THE EFFECT OF EARLY MOBILIZATION ON Taylor Clevinger FUNCTIONAL - - PowerPoint PPT Presentation

Taylor Clevinger

THE EFFECT OF EARLY MOBILIZATION ON FUNCTIONAL OUTCOMES

¡ 18 year old female ¡ Senior in high school ¡ Works at an appliance store in hometown after school ¡ Single ¡ Lives with her mother, father, brother and sister in a 2-level home with 3 steps to enter. §Her bedroom/bathroom is on the first level/ground level. ¡ She will have supervision/assistance from her family. ¡ Father is building a ramp

IMMA HURT

Pelvic Fracture—Ortho on board, s/p OR with ortho

§ Displaced fracture of the left superior pubic ramus and likely non-displaced fracture of the left inferior pubic ramus. Likely fracture of the left sacral ala. § Acute displaced fracture

• f the left femoral neck.

The left femur distal to the fracture appears internally rotated. § No right hip fracture or dislocation.

¡Injuries cont.:

§ Subarachnoid Hemorrhage—NSGY consulted, repeat HCT only if decline § Right Pneumothorax—s/p chest tube, daily CXR § Left Pneumothorax—s/p chest tube, daily CXR § Left Diaphragm Injury—s/p repair in OR, daily CXR § Splenic Injury, G4—s/p removal in OR § Hepatic Laceration—monitor for SIRs § L2-L4 Transverse process fracture— no intervention

INJURIES FROM MVA

¡ Exploratory laparotomy, where the abdomen is surgically cut

• pen to examine abdominal organs for possible injury

¡ Splenectomy, where her spleen was removed. ¡ Primary repair of left diaphragm injury. ¡ Ortho—

§ Left dynamic hip screw with single derotation cannulated hip screw, § Low anterior pe pelvic ex external fixator, this was surgically placed to help heal the fractured pelvis. § Left sacroiliac screw.

¡ Admitted to the Surgical Trauma ICU

SURGERY

¡ No previous surgeries ¡ No family history of diseases or conditions ¡ No co-morbidities ¡ No alcohol, tobacco or illicit substance use ¡ Active and healthy prior to MVA ¡ Oxycodone for pain during PT sessions while she was in the STICU.

PATIENT HISTORY

PT INITIAL EVALUATION

We Weight- be bearing g sta statu tus Or Orientation/ Beh Behavior Se Sensation ion RO ROM St Strength Ba Balance Pa Pain NWB A&O x4 N/A WFL At least 3+/5 in bilateral LE Pt able to sit EOB under supervision 3/10 Mo Mobility ty Roll Left: MODERATE ASSIST Roll Right: MODERATE ASSIST Supine to Sit: MAX ASSIST Sit to Supine: MAX ASSIST Transfer Bed/Chair: TOTAL ASSIST (used Maxi-move)

¡ Imma’s deficits § Balance, Bed mobility, Endurance, Strength, Transfer, Wheelchair mobility. ¡ Discharge Planning § Home with Home Health Physical Therapy ¡ Pr Prognosis § Due to her independent functional status prior to the car accident and her young age, she will have a good prognosis.

INITIAL EVALUATION CONT.

¡ ROLLING R and L: SUPERVISION ¡ SUPINE to SIT: SUPERVISION ¡ BED to CHAIR: SUPERVISION ¡ Propel wheelchair 150 feet using bilateral Upper Extremities with SUPERVISION.

INITIAL PT GOALS

¡ No pain ¡ Return to previous function ¡ Return to school and work ¡ Walk across the stage at graduation

IMMA’S GOALS

¡ Day 2 post-op:

§ NWB § Mobility

§ Supine to sit: MOD ASSIST with cues to help with bed mobility. § Lateral transfer from bed to wheelchair with MOD ASSIST (assist x 2) § Pt able to sit EOB for 10 minutes

PT INTERVENTION WEEK 1

¡ Imma was given UE and LE strength exercises day 4 post-op ¡ Perform 2x/day ¡ **Imma performed most of the exercises, except for shoulder abduction and straight leg raises on the left due to pain on left side (chest and pelvic region). ¡ **Later, Imma reported that she only did them the day given.

PT INTERVENTION WEEK 1

Shoulder Abduction Band Ex. 3x10 Bicep Curls (0.5 lb. food can) 3x10 Tricep extensions 3x10 Straight leg raises on R (p!

• n L)

3x10 Quad sets 3x10 Ankle Pumps 3x10

¡TT TTWB ON R LE LE

¡ ** ** Im Imma us used a slid lidin ing board to get from bed to wheelc lchair ir. ¡ Pr Propel elled ed 200 ft. . in wheel eelchair under er super ervision from PT PT (d (due to chest tubes). ). ¡ La Last day I I saw patien ent

RE-EVALUATION (DAY 9)

Mo Mobility ty ROLL LEFT SUPERVISION ROLL RIGHT SUPERVISION SUPINE TO SIT MOD ASSIST SCOOTING TO EOB MINIMAL ASSIST TRANSFER BED/CHAIR MINIMAL ASSIST

NEW GOALS

SUPINE TO SIT SUPERVISION BED TO CHAIR SUPERVISION WHEELCHAIR PROPULSION SUPERVISION, 600 FT. INDEPENDENT WITH HOME EXERCISE PROGRAM

• Continue PT 3 x per week

Does early mobilization affect the functional outcome of an eighteen- year-old female patient with an externally fixated fractured femur and superior/inferior pubic rami presenting with polytrauma in the surgical trauma ICU?

CLINICAL QUESTION

EA EARLY EX EXER ERCISE E IN CR CRITICALL ALLY Y ILL LL PA PATIENTS ENHANCES SH SHORT-TE TERM FU FUNCTIO IONAL AL RECOVE VERY

Burton, C., Clerckx, B., Robbeats, C., Ferdinande, P., Langer, D., Troosters, T., Hermans, G., Decramer, M., Gosselink, R. (2009). Early exercise in critically ill patients enhances short-term functional recovery . Society of Critical Care Medicine, 37(9), 2499-2505. doi:10.1097/CCM.0b013e3181a38937

¡ Randomized Control Trial ¡ 90 critically ill patients (avg. age: 56) in the ICU at University Hospital Gasthuisberg in Leuven, Belgium ¡ Patient Eligibility

§ Patients judged on the 5th day of ICU stay § At least a prolonged stay of 7 more days in ICU

¡ Control group

§ Respiratory physical therapy and AROM (or PROM if sedated)

¡ Treatment group

§ In addition to control group, CYCLE ERGOMETER for 20 min, 4x/week

§ Outcome Measures:

§ Short Form 36 Health Survey questionnaire (SF-36), 6-min walking distance (6MWD), Berg Balance (sit to stand), Functional Ambulation Categories and quadriceps force (using handheld dynamometer).

METHODS

EXCLUSION CRITERIA

¡ 6MWD, SF-36, and quadriceps force in treatment group BE BETTER at hospital discharge than control group. ¡ Berg Balance and Functional Ambulation Categories

§ No difference between groups at ICU and hospital discharge

¡ At hospital discharge, 6MWD was correlated with quadriceps force (r= .40, p= .002) and SF-36 PF score (r= .55, p< .001) ¡ Patients who could walk independently at hospital discharge tended to be higher in the training group (73% vs. 55%)

RESULTS

p+<0.01 p*<0.05

¡ Early mobilization/exercise training in prolonged ICU stay

§ enhance recovery of functional exercise capacity § Increased self-perceived functional status § Increased quadriceps force

¡ Limitations

§ More males than females § Treatment group was given 20 extra minutes of daily physical activity § Max exercise intensity on cycle ergometer

CONCLUSION

¡ ICU patient ¡ Imma would have been excluded from this study (pelvic fx) ¡ Other early mobilization exercises (UE) or arm cycle ergometer could benefit Imma ¡ Good to know for future ICU patients, early mobilization/early exercise (i.e. cycle ergometer) wi

will impro rove e functi tion

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es at disc scha harge ge from rom hosp hospital.

HOW DOES THIS RELATE TO IMMA?

Eleftherios Karatzanos, Vasiliki Gerovasili, Dimitrios Zervakis, et al., “Electrical Muscle Stimulation: An Effective Form of Exercise and Early Mobilization to Preserve Muscle Strength in Critically Ill Patients,” Critical Care Research and Practice, vol. 2012, Article ID 432752, 8 pages, 2012. doi:10.1155/2012/432752

EL ELEC ECTRICAL MUS USCLE E STIMUL ULATION ON: AN AN EFFECTI TIVE VE FORM RM OF EX EXER ERCISE E AND EA EARLY MO MOBILIZATION TO PRESERVE MU MUSCLE STRENGTH IN CR CRIT ITIC ICALL LLY Y IL ILL PATIE IENT NTS

¡ 142 consecutive patients started, ended study with 52 (over 30 months)

§ 2nd day after admission in ICU of Evangelismos Hospital (Greece) § acute physiology and chronic health evaluation (APACHE) II score ≥ 13

¡ Patients randomly assigned to a control or intervention group (EMS) ¡ Daily EMS of both lower extremities for 55 min in addition to regular ICU care until ICU discharge

§ vastus lateralis, vastus medialis, and peroneus longus

¡ Exclusion Criteria: <18 y.o, pregnancy, obesity, pre-existing neuromuscular disease, other precautions to EMS (i.e. cardiac pacemaker, BO BONE FRACTURES, cancer, open wounds) ¡ Outcome measures: MRC (Medical Research Council) muscle strength scale (0à5) and Handgrip Application (dynamometer)

METHODS

¡ Intensive Care Acquired Weakness (ICU-AW)

§ Neuromuscular complication seen in survivors of acute critical illness § Characterized by:

§ 1. Profound muscle weakness § 2. Delayed weaning from mechanical ventilation

¡ Leads to poor functional outcomes due to muscle wasting and increased length of stay in ICU ¡ ICU-AW for Eleftherios et al., MRC cut off score of <48.

§ 12 combined muscle groups tested with a score lower than a “4”

¡ W. D. Schweickert and J. Hall, “ICU-acquired weakness,” Chest,

• vol. 131, no. 5, pp. 1541–1549, 2007

ADDITIONAL INFO

¡ EMS group

§ Significantly higher MRC of wr wris ist fle lexion ion, , hip ip fle lexion ion, , knee extension ion, , an and an ankle dorsiflexion.

¡ The overall MRC score was significantly higher in patients assigned to the EMS group in comparison to the control group (58 (51–60) versus 52 (40– 58), P = 0.04) (Figure 2). ¡ Handgrip strength (dynamometer)

§ Significant difference between patients diagnosed with ICU-AW in comparison to those without an ICU-AW diagnosis (6.6 ± 4.4 versus 23.4 ± 8.9 kg, P < 0.01) § Correlated with MRC strength values for UE, LE, and overall MRC

§ Systemic effect

RESULTS

FIGURE 2. ARMS, LEGS AND OVERALL MRC SCORES FOR EMS AND CONTROL GROUPS

¡ EMS used as an early mobilization technique ¡ Resulted in preserved strength of directly stimulated muscles

• f LE and also non-stimulated muscle groups of the UE

§ MRC scale

¡ Systemic effect in UE

§ Pathophysiological mechanisms involved in ICU-AW

¡ EMS prevents ICU-AW development ¡ Leads to improved functional outcomes (i.e. walking, ADLs) ¡ Limitations

§ Number of patients after 30 months (142à 52) § Sham EMS was not applied to control group § MRC strength scale as a means of testing criteria

CONCLUSION

¡ ICU ¡ Increased muscle weakness (ICU-AW?) ¡ FR FRACTU TURED PELVIS S (& extern rnal fixator) r)

§ Can’t receive EMS treatment to LE as of right now § However… systemic effect?? If EMS of UE

¡ Compared to Burton et al., if if inc increase qu quad force streng ngth (E (EMS)àen enhance e rec ecover ery of functional exer ercise e ca capa paci cityàim improve fu functi tional outc tcomes (i. i.e wa walking, ADL ADLs) s)

HOW DOES THIS RELATE TO IMMA?

¡ Imma is very medically complex

§ Pelvic fracture, weight bearing restrictions, external fixator § 3x chest tube § In addition to transfers and bed mobility, was given strength treatment plan, but sufficient enough?

HO HOWEVER In future patients seen in the ICU or acute/inpatient rehab: ¡ EA EARLY Y MOBILIZATION/EX EXER ERCISE E IS KEY EY ¡ Leads to improved functional outcomes and self perceived functional status at discharge from hospital ¡ Including, walking and ADLs that are specific to the patient

LESSONS LEARNED

Burton, C., Clerckx, B., Robbeats, C., Ferdinande, P., Langer, D., Troosters, T., Hermans, G., Decramer, M., Gosselink, R. (2009). Early exercise in critically ill patients enhances short-term functional recovery . Society of Critical Care Medicine, 37(9), 2499-2505. doi:10.1097/CCM.0b013e3181a38937 Eleftherios Karatzanos, Vasiliki Gerovasili, Dimitrios Zervakis, et al., “Electrical Muscle Stimulation: An Effective Form of Exercise and Early Mobilization to Preserve Muscle Strength in Critically Ill Patients,” Critical Care Research and Practice, vol. 2012, Article ID 432752, 8 pages, 2012. doi:10.1155/2012/432752

• W. D. Schweickert and J. Hall, “ICU-acquired weakness,” Chest,
• vol. 131, no. 5, pp. 1541–1549, 2007

REFERENCES

QUESTIONS??