Physical Function after ICU

A/Prof Carol Hodgson PhD FACP PT

Deputy Director ANZIC-RC, Melbourne, AustraliaChair TEAM Study, PREDICT Study and EXCEL Study Management Committee (ANZICS CTG)

WHO: International Classification of Functioning

Physical and mental / cognitive baseline status

Acute illness

Organ function - impairment

Activity - functional limitation

Participation - disability

Quality of life

WHO conceptual model

International Classification of Functioning (WHO)

World Health Organization. International Classification of Functioning, Disability and Health. Geneva; 2001

Physical Function

1. Should we measure physical function after ICU?

2. How do we measure it?

3. What are risk factors for poor physical function?

4. Can we improve it?

The scope of the problem

1. Should we measure physical function after ICU?

2. How do we measure it?

3. What are risk factors for poor physical function?

4. Can we improve it?

5 Year Outcome of ARDS Survivors

CorePhysical functionHealth-related quality of lifeCognitive functionReturn to work/prior activitiesMuscle and/or nerve functionMental healthSurvival

SometimesFatiguePulmonary functionPain

Research AgendaFamily impactResource utilizationSocial roles/relationshipsFinancial impact

Hodgson, Needham et al, Phys Ther 2017Core Domains Evaluating Patient Outcomes

The scope of the problem

1. Should we measure physical function after ICU?

2. How do we measure it?

3. What effects physical function?

4. Can we improve it?

Long Term Outcomes Research (1970-2013) Turnbull et al, 2016

425 peer-reviewed papers

• Outcomes assessed using 250 differentmeasurement instruments

• 6% measured physical function

11

www.improveLTO.com

improveLTO@jhmi.edu

ANZICS CTG Trials Jack Iwashyna

Aim: to determine what the ANZICS CTG has used in clinical trials to measure long-term follow-up

Physical and mental / cognitive baseline status

Acute illness

Organ function - impairment

Activity - functional limitation

Participation - disability

Quality of life

WHO conceptual model

International Classification of Functioning (WHO)

World Health Organization. International Classification of Functioning, Disability and Health. Geneva; 2001

Domains SF-36 EQ5D

Physical status

Psychological status

Cognitive status

Activities and behaviours

Physical zone of comfort & activity

Interactions and relationships with others

Perceptions & responses to life

Personality

Appearance

Clothing

Place of residence

Finances

Captured by questionnaireInconsistently / infrequently captured by questionnaireNot captured by questionnaire

HRQoL in Critical Care Lim et al, 2016

Physical and mental / cognitive baseline status

Acute illness

Organ function - impairment

Activity - functional limitation

Participation - disability

Quality of life

WHO conceptual model

International Classification of Functioning (WHO)

World Health Organization. International Classification of Functioning, Disability and Health. Geneva; 2001

Function

BaselineFunction

Physical and mental / cognitive baseline status

Acute illness

Organ function - impairment

Activity - functional limitation

Participation - disability

Quality of life

WHO conceptual model

International Classification of Functioning (WHO)

World Health Organization. International Classification of Functioning, Disability and Health. Geneva; 2001

Function

BaselineFunction

Missing information:

- Impairment e.g. MMT / grip

- Activity e.g. IADL / 6MWD

- Disability e.g. RTW / WHODAS

Measuring Physical Function

In person

• Expensive

• Difficult in multi-center

Telephone

• Cheaper

• Hospital based or central

Wearable

Devices

• Readily available & relatively cheap

• Minimal patient interruption

Case et al, JAMA 2015

Loss to follow-up is a significant problem!

16 studies used IADL dependency

• Variable definitions of dependency

• IADL dependency persists months-yrs

• Longitudinal data is sparse

• Inconsistent risk factors

• Poor baseline measure of IADL

Annals ATS, 2017

The scope of the problem

1. Should we measure physical function after ICU?

2. How do we measure it?

3. What are the risk factors for poor physical function?

4. Can we improve it?

ICU Acquired Weakness – not just prolonged bedrest

Batt et al, AJRCCM, 2013

Date of download: 6/3/2015Copyright © 2015 American Medical

Association. All rights reserved.

From: Acute Skeletal Muscle Wasting in Critical Illness

JAMA. 2013;310(15):1591-1600. doi:10.1001/jama.2013.278481

Acute Skeletal Muscle Wasting

ICU Acquired Weakness & Patient Outcome

0.0

00

.25

0.5

00

.75

1.0

0

48 42 40 40Yes46 46 45 45No

Number at risk

0 30 60 90Days

No Yes

Logrank p=0.016

Kaplan-Meier survival estimates

of ICUAW

P=0.016

TEAM Study Investigators, Crit Care, 2015 Hermans et al, AJRCCM, 2014

N= 166 ARDS, multicenter

86% experience a decline in physical function

Pfoh et al, ICM 2016

Muscle StrengthMMT

Exercise Capacity6mWT

HRQoLSF-36

Physical Functioning

Risk factors included:- Age - Comorbidities (strength and ex cap)- SOFA (strength)

• Prospective, longitudinal, cohort study

• 13 ICUs with N=222 survivors of ARDS

• MMT, hand grip, respiratory muscle strength, 6MWT and SF-36

• Measured at 3, 6, 12 & 24m

Fan et al, CCM

• MMT increased to normal over 24m

• 6MWT and SF-36 improved but not back to normal

• Duration of bed rest was associated with muscle weakness

The Recover Program, AJRCCM, Herridge et al, 2016

N = 391 ≥ 1 week MV

Mean age 58Mean APACHE II 25

FIM associated with- Age- LOS

FIM at D7 after ICU predicts functional trajectory at 12M

Comparing outcome of MV versus hospitalisation

Barnato, AJRCCM, 2011

• Medicare beneficiaries 65y and older

• Significant decrease in function after MV

• Elderly may not chose this intervention if they are going to have ongoing disability

• Outcomes of prolonged MV are worse than expected by the family and ICU staff

ADL

Mobility

MV

MV

Disability after ICU - WHODAS Hodgson et al, ICM, 2017

N=262, 5 ICUsDisability WHODAS > 25%

Disability was highest in the areas of physical activity e.g. walking

Multivariable analysis: Predictors of disability

Predictor Odds Ratio P Value

History of anxiety / depression 1·65 [1·22, 2·23] <0·001

Separated or divorced 2·88 [1·35, 6·08] <0·001

Mechanical ventilation days 1·04 [1·01, 1·08] 0·027

Disability-free survival at 6 months was 57%

Hodgson et al, ICM, 2017

Trajectory of recovery Iwashyna AJRCCM, 2012

Six minute walk test as primary outcome

Denehy et al., 2013 Puthucheary & Denehy, 2015

Pre-ICU Healthy - 50% difference in 6MWD at 3m

Pre-ICU Chronic Disease- no difference in 6MWD at 3m

Physical Function After ICU. Hodgson & Denehy, ICM 2017

The scope of the problem

1. Should we measure physical function after ICU?

2. How do we measure it?

3. What effects physical function?

4. Can we improve it?

Early ICU Interventions – ANZ Studies:

Mobilisation – TEAM

Sedation – SPICE

Nutrition – TARGET

Effect of EM on ICUAW and mobilizing without assistance

Favours early rehab N =299P= 0.02

EM doubles the odds of mobilizing

without assistance at hospital

discharge,

n = 189, 2 studies

OR 2.13, 95% CI 1.19–3.83, p = 0.01

TEAM RCT

• N=750 multicentre, phase III RCT

• ~35 sites ANZ, Germany, Ireland, UK

• NHMRC funded

• ANZICS CTG endorsed

carol.hodgson@monash.edu

Conclusions @chodgsonANZICRC

• Survival is only part of the story

• Physical function is important to all stakeholders

• Include physical function (activity & participation) alongside HRQoL

• Follow-up is hard - can be done by phone!

carol.hodgson@monash.edu