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

THE EFFECT OF EARLY MOBILIZATION ON Taylor Clevinger FUNCTIONAL OUTCOMES

IMMA HURT ¡ 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

INJURIES FROM MVA Pelvic Fracture—Ortho on ¡ Injuries cont.: board, s/p OR with ortho § Subarachnoid Hemorrhage—NSGY consulted, repeat HCT only if § Displaced fracture of the decline left superior pubic ramus § Right Pneumothorax—s/p chest and likely non-displaced tube, daily CXR fracture of the left § Left Pneumothorax—s/p chest inferior pubic ramus. tube, daily CXR Likely fracture of the left § Left Diaphragm Injury—s/p repair in OR, daily CXR sacral ala. § Splenic Injury, G4—s/p removal in § Acute displaced fracture OR of the left femoral neck. § Hepatic Laceration—monitor for The left femur distal to SIRs the fracture appears § L2-L4 Transverse process fracture— internally rotated. no intervention § No right hip fracture or dislocation.

SURGERY ¡ Exploratory laparotomy, where the abdomen is surgically cut open 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

PATIENT HISTORY ¡ 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.

PT INITIAL EVALUATION Weight- We Or Orientation/ Se Sensation ion ROM RO Strength St Ba Balance Pa Pain bearing be g Behavior Beh statu sta tus NWB A&O x4 N/A WFL At least Pt able to sit 3/10 3+/5 in EOB under bilateral LE supervision 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)

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

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

PT INTERVENTION WEEK 1 ¡ 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 Shoulder Abduction Band Ex. 3x10 Bicep Curls (0.5 lb. food can) 3x10 Tricep extensions 3x10 Straight leg raises on R (p! 3x10 on L) Quad sets 3x10 Ankle Pumps 3x10 ¡ **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.

RE-EVALUATION (DAY 9) ¡ TT TTWB ON R LE LE Mobility Mo ty ROLL LEFT SUPERVISION ROLL RIGHT SUPERVISION SUPINE TO SIT MOD ASSIST SCOOTING TO EOB MINIMAL ASSIST TRANSFER BED/CHAIR MINIMAL ASSIST ¡ ** ** 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 (due to chest tubes). (d ). ¡ La Last day I I saw patien ent

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 •

CLINICAL QUESTION 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?

EA EARLY EX EXER ERCISE E IN CR CRITICALL ALLY Y ILL LL PA PATIENTS ENHANCES SHORT-TE SH 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

METHODS ¡ 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 5 th 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).

EXCLUSION CRITERIA

RESULTS ¡ 6MWD, SF-36, and quadriceps force in treatment group BETTER at hospital discharge than control group. BE ¡ 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%)

p + <0.01 p*<0.05

CONCLUSION ¡ 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

HOW DOES THIS RELATE TO IMMA? ¡ 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 onal ou outcom omes es at disc scha harge ge from rom hosp hospital.

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

METHODS ¡ 142 consecutive patients started, ended study with 52 (over 30 months) § 2 nd 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 (0 à 5) and Handgrip Application (dynamometer)

ADDITIONAL INFO ¡ 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