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Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial

Summary Background Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical an... Full description

Journal Title: The Lancet (British edition) 2009, Vol.373 (9678), p.1874-1882
Main Author: Schweickert, William D, MD
Other Authors: Pohlman, Mark C, MD , Pohlman, Anne S, MSN , Nigos, Celerina, RN , Pawlik, Amy J, PT , Esbrook, Cheryl L, OTR/L , Spears, Linda, PT , Miller, Megan, OTR/L , Franczyk, Mietka, PT , Deprizio, Deanna, OTR/L , Schmidt, Gregory A, Prof , Bowman, Amy, BSN , Barr, Rhonda, PT , McCallister, Kathryn E, BS , Hall, Jesse B, Prof , Kress, John P, Dr
Format: Electronic Article Electronic Article
Language: English
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Quelle: Alma/SFX Local Collection
Publisher: Kidlington: Elsevier Ltd
ID: ISSN: 0140-6736
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title: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
format: Article
creator:
  • Schweickert, William D, MD
  • Pohlman, Mark C, MD
  • Pohlman, Anne S, MSN
  • Nigos, Celerina, RN
  • Pawlik, Amy J, PT
  • Esbrook, Cheryl L, OTR/L
  • Spears, Linda, PT
  • Miller, Megan, OTR/L
  • Franczyk, Mietka, PT
  • Deprizio, Deanna, OTR/L
  • Schmidt, Gregory A, Prof
  • Bowman, Amy, BSN
  • Barr, Rhonda, PT
  • McCallister, Kathryn E, BS
  • Hall, Jesse B, Prof
  • Kress, John P, Dr
subjects:
  • Abridged Index Medicus
  • Activities of Daily Living
  • Adult
  • Aged
  • Artificial respiration
  • Bed Rest - adverse effects
  • Biological and medical sciences
  • Blood pressure
  • Care and treatment
  • Chicago
  • Conscious Sedation - adverse effects
  • Conscious Sedation - methods
  • Critical care
  • Critical Care - methods
  • Critical Illness - rehabilitation
  • Critically ill
  • Delirium - etiology
  • Delirium - prevention & control
  • Diseases of the osteoarticular system. Orthopedic treatment
  • Dosage and administration
  • Early Ambulation - methods
  • Exercise Therapy - methods
  • Female
  • General aspects
  • Health aspects
  • Hospitals
  • Humans
  • Hypnotics
  • Illnesses
  • Intensive care
  • Internal Medicine
  • Intervention
  • Iowa
  • Kaplan-Meier Estimate
  • Logistic Models
  • Male
  • Medical sciences
  • Middle Aged
  • Mobility Limitation
  • Occupational therapy
  • Occupational Therapy - methods
  • Patient outcomes
  • Patients
  • Physical therapy
  • Proportional Hazards Models
  • Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects)
  • Respiration, Artificial - adverse effects
  • Respiration, Artificial - methods
  • Sedatives
  • Single-Blind Method
  • Statistics, Nonparametric
  • Subacute care
  • Therapeutics, Physiological
  • Time Factors
  • Treatment Outcome
  • Usage
  • Ventilation
ispartof: The Lancet (British edition), 2009, Vol.373 (9678), p.1874-1882
description: Summary Background Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care. Methods Sedated adults (≥18 years of age) in the ICU who had been on mechanical ventilation for less than 72 h, were expected to continue for at least 24 h, and who met criteria for baseline functional independence were eligible for enrolment in this randomised controlled trial at two university hospitals. We randomly assigned 104 patients by computer-generated, permuted block randomisation to early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n=49) or to daily interruption of sedation with therapy as ordered by the primary care team (control; n=55). The primary endpoint—the number of patients returning to independent functional status at hospital discharge—was defined as the ability to perform six activities of daily living and the ability to walk independently. Therapists who undertook patient assessments were blinded to treatment assignment. Secondary endpoints included duration of delirium and ventilator-free days during the first 28 days of hospital stay. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov , number NCT00322010. Findings All 104 patients were included in the analysis. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0·02; odds ratio 2·7 [95% CI 1·2–6·1]). Patients in the intervention group had shorter duration of delirium (median 2·0 days, IQR 0·0–6·0 vs 4·0 days, 2·0–8·0; p=0·02), and more ventilator-free days (23·5 days, 7·4–25·6 vs 21·1 days, 0·0–23·8; p=0·05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony. Interpretation A strategy for whole-body rehabilitation—consisting of interruption of sedation and physical and occupational therapy in the ea
language: eng
source: Alma/SFX Local Collection
identifier: ISSN: 0140-6736
fulltext: fulltext
issn:
  • 0140-6736
  • 1474-547X
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creatorSchweickert, William D, MD ; Pohlman, Mark C, MD ; Pohlman, Anne S, MSN ; Nigos, Celerina, RN ; Pawlik, Amy J, PT ; Esbrook, Cheryl L, OTR/L ; Spears, Linda, PT ; Miller, Megan, OTR/L ; Franczyk, Mietka, PT ; Deprizio, Deanna, OTR/L ; Schmidt, Gregory A, Prof ; Bowman, Amy, BSN ; Barr, Rhonda, PT ; McCallister, Kathryn E, BS ; Hall, Jesse B, Prof ; Kress, John P, Dr
creatorcontribSchweickert, William D, MD ; Pohlman, Mark C, MD ; Pohlman, Anne S, MSN ; Nigos, Celerina, RN ; Pawlik, Amy J, PT ; Esbrook, Cheryl L, OTR/L ; Spears, Linda, PT ; Miller, Megan, OTR/L ; Franczyk, Mietka, PT ; Deprizio, Deanna, OTR/L ; Schmidt, Gregory A, Prof ; Bowman, Amy, BSN ; Barr, Rhonda, PT ; McCallister, Kathryn E, BS ; Hall, Jesse B, Prof ; Kress, John P, Dr
descriptionSummary Background Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care. Methods Sedated adults (≥18 years of age) in the ICU who had been on mechanical ventilation for less than 72 h, were expected to continue for at least 24 h, and who met criteria for baseline functional independence were eligible for enrolment in this randomised controlled trial at two university hospitals. We randomly assigned 104 patients by computer-generated, permuted block randomisation to early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n=49) or to daily interruption of sedation with therapy as ordered by the primary care team (control; n=55). The primary endpoint—the number of patients returning to independent functional status at hospital discharge—was defined as the ability to perform six activities of daily living and the ability to walk independently. Therapists who undertook patient assessments were blinded to treatment assignment. Secondary endpoints included duration of delirium and ventilator-free days during the first 28 days of hospital stay. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov , number NCT00322010. Findings All 104 patients were included in the analysis. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0·02; odds ratio 2·7 [95% CI 1·2–6·1]). Patients in the intervention group had shorter duration of delirium (median 2·0 days, IQR 0·0–6·0 vs 4·0 days, 2·0–8·0; p=0·02), and more ventilator-free days (23·5 days, 7·4–25·6 vs 21·1 days, 0·0–23·8; p=0·05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony. Interpretation A strategy for whole-body rehabilitation—consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness—was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care. Funding None.
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languageeng
publisherKidlington: Elsevier Ltd
subjectAbridged Index Medicus ; Activities of Daily Living ; Adult ; Aged ; Artificial respiration ; Bed Rest - adverse effects ; Biological and medical sciences ; Blood pressure ; Care and treatment ; Chicago ; Conscious Sedation - adverse effects ; Conscious Sedation - methods ; Critical care ; Critical Care - methods ; Critical Illness - rehabilitation ; Critically ill ; Delirium - etiology ; Delirium - prevention & control ; Diseases of the osteoarticular system. Orthopedic treatment ; Dosage and administration ; Early Ambulation - methods ; Exercise Therapy - methods ; Female ; General aspects ; Health aspects ; Hospitals ; Humans ; Hypnotics ; Illnesses ; Intensive care ; Internal Medicine ; Intervention ; Iowa ; Kaplan-Meier Estimate ; Logistic Models ; Male ; Medical sciences ; Middle Aged ; Mobility Limitation ; Occupational therapy ; Occupational Therapy - methods ; Patient outcomes ; Patients ; Physical therapy ; Proportional Hazards Models ; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects) ; Respiration, Artificial - adverse effects ; Respiration, Artificial - methods ; Sedatives ; Single-Blind Method ; Statistics, Nonparametric ; Subacute care ; Therapeutics, Physiological ; Time Factors ; Treatment Outcome ; Usage ; Ventilation
ispartofThe Lancet (British edition), 2009, Vol.373 (9678), p.1874-1882
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0Schweickert, William D, MD
1Pohlman, Mark C, MD
2Pohlman, Anne S, MSN
3Nigos, Celerina, RN
4Pawlik, Amy J, PT
5Esbrook, Cheryl L, OTR/L
6Spears, Linda, PT
7Miller, Megan, OTR/L
8Franczyk, Mietka, PT
9Deprizio, Deanna, OTR/L
10Schmidt, Gregory A, Prof
11Bowman, Amy, BSN
12Barr, Rhonda, PT
13McCallister, Kathryn E, BS
14Hall, Jesse B, Prof
15Kress, John P, Dr
title
0Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
1The Lancet (British edition)
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descriptionSummary Background Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care. Methods Sedated adults (≥18 years of age) in the ICU who had been on mechanical ventilation for less than 72 h, were expected to continue for at least 24 h, and who met criteria for baseline functional independence were eligible for enrolment in this randomised controlled trial at two university hospitals. We randomly assigned 104 patients by computer-generated, permuted block randomisation to early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n=49) or to daily interruption of sedation with therapy as ordered by the primary care team (control; n=55). The primary endpoint—the number of patients returning to independent functional status at hospital discharge—was defined as the ability to perform six activities of daily living and the ability to walk independently. Therapists who undertook patient assessments were blinded to treatment assignment. Secondary endpoints included duration of delirium and ventilator-free days during the first 28 days of hospital stay. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov , number NCT00322010. Findings All 104 patients were included in the analysis. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0·02; odds ratio 2·7 [95% CI 1·2–6·1]). Patients in the intervention group had shorter duration of delirium (median 2·0 days, IQR 0·0–6·0 vs 4·0 days, 2·0–8·0; p=0·02), and more ventilator-free days (23·5 days, 7·4–25·6 vs 21·1 days, 0·0–23·8; p=0·05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony. Interpretation A strategy for whole-body rehabilitation—consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness—was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care. Funding None.
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0Abridged Index Medicus
1Activities of Daily Living
2Adult
3Aged
4Artificial respiration
5Bed Rest - adverse effects
6Biological and medical sciences
7Blood pressure
8Care and treatment
9Chicago
10Conscious Sedation - adverse effects
11Conscious Sedation - methods
12Critical care
13Critical Care - methods
14Critical Illness - rehabilitation
15Critically ill
16Delirium - etiology
17Delirium - prevention & control
18Diseases of the osteoarticular system. Orthopedic treatment
19Dosage and administration
20Early Ambulation - methods
21Exercise Therapy - methods
22Female
23General aspects
24Health aspects
25Hospitals
26Humans
27Hypnotics
28Illnesses
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31Intervention
32Iowa
33Kaplan-Meier Estimate
34Logistic Models
35Male
36Medical sciences
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38Mobility Limitation
39Occupational therapy
40Occupational Therapy - methods
41Patient outcomes
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43Physical therapy
44Proportional Hazards Models
45Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects)
46Respiration, Artificial - adverse effects
47Respiration, Artificial - methods
48Sedatives
49Single-Blind Method
50Statistics, Nonparametric
51Subacute care
52Therapeutics, Physiological
53Time Factors
54Treatment Outcome
55Usage
56Ventilation
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titleEarly physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
authorSchweickert, William D, MD ; Pohlman, Mark C, MD ; Pohlman, Anne S, MSN ; Nigos, Celerina, RN ; Pawlik, Amy J, PT ; Esbrook, Cheryl L, OTR/L ; Spears, Linda, PT ; Miller, Megan, OTR/L ; Franczyk, Mietka, PT ; Deprizio, Deanna, OTR/L ; Schmidt, Gregory A, Prof ; Bowman, Amy, BSN ; Barr, Rhonda, PT ; McCallister, Kathryn E, BS ; Hall, Jesse B, Prof ; Kress, John P, Dr
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16Delirium - etiology
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21Exercise Therapy - methods
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46Respiration, Artificial - adverse effects
47Respiration, Artificial - methods
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52Therapeutics, Physiological
53Time Factors
54Treatment Outcome
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6Spears, Linda, PT
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issn0140-6736
eissn1474-547X
codenLANCAO
abstractSummary Background Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care. Methods Sedated adults (≥18 years of age) in the ICU who had been on mechanical ventilation for less than 72 h, were expected to continue for at least 24 h, and who met criteria for baseline functional independence were eligible for enrolment in this randomised controlled trial at two university hospitals. We randomly assigned 104 patients by computer-generated, permuted block randomisation to early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n=49) or to daily interruption of sedation with therapy as ordered by the primary care team (control; n=55). The primary endpoint—the number of patients returning to independent functional status at hospital discharge—was defined as the ability to perform six activities of daily living and the ability to walk independently. Therapists who undertook patient assessments were blinded to treatment assignment. Secondary endpoints included duration of delirium and ventilator-free days during the first 28 days of hospital stay. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov , number NCT00322010. Findings All 104 patients were included in the analysis. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0·02; odds ratio 2·7 [95% CI 1·2–6·1]). Patients in the intervention group had shorter duration of delirium (median 2·0 days, IQR 0·0–6·0 vs 4·0 days, 2·0–8·0; p=0·02), and more ventilator-free days (23·5 days, 7·4–25·6 vs 21·1 days, 0·0–23·8; p=0·05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony. Interpretation A strategy for whole-body rehabilitation—consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness—was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care. Funding None.
copKidlington
pubElsevier Ltd
pmid19446324
doi10.1016/S0140-6736(09)60658-9