Physical Function after ICU - Critical Care Canada Forum · ICU Acquired Weakness & Patient Outcome...
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Physical Function after ICU A/Prof Carol Hodgson PhD FACP PT Deputy Director ANZIC-RC, Melbourne, Australia Chair TEAM Study, PREDICT Study and EXCEL Study Management Committee (ANZICS CTG)
Transcript of Physical Function after ICU - Critical Care Canada Forum · ICU Acquired Weakness & Patient Outcome...
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
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
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!
