Anne Moseley talked to Ms Amy Pawlik (University of Chicago Medicine, USA) whose trial evaluating early therapy in critically ill patients is one of the most significant trials in physiotherapy.
Anne: Could you explain what you did in the study
Amy: We divided patients who had recently been placed on a ventilator into two groups. One group underwent physical and occupational therapy when we would have typically seen them at that time, when the breathing tube was removed or a more permanent breathing tube was placed. The other group received physical and occupational therapy as early as possible after they had been placed on the ventilator. Patients in both groups received optimal nutrition, blood glucose control and a protocol that is used to reduce the usage of sedative medications. Both groups received physical and occupational therapy which included activities such as sitting in the chair, walking and participating in their own bathing and dressing. The difference between groups is that one group underwent physical and occupational therapy much earlier and while still requiring a ventilator and a breathing tube. At the time of the study, completing various out of bed activities such as standing, walking, and self-care tasks with patients on a ventilator with a breathing tube was not a common intervention.
Anne: What was the main finding?
Amy: Physical and occupational therapy were initiated much sooner in the early group; an average of 1.5 days after being placed on the ventilator versus 7 days with the standard group. The patients who received early physical and occupational therapy were able to come off the ventilator sooner, were better able to stand and walk independently when they were discharged from the hospital and experienced 50% fewer days of delirium, a state of confusion that is also associated with serious complications for patients who have been very ill. More patients were able to return immediately home after hospitalization as opposed to going to an alternate rehabilitation facility.
Anne: Why do you think your study is important?
Amy: There are many known long-lasting strength and cognition complications for patients who are in bed for days, weeks and even just hours. The study demonstrated that it is safe and possible to engage patients who need to be on a ventilator and while they are quite ill in aggressive physical and occupational therapy including out-of-bed activity very early in their hospital stay and that the patients who did so showed superior outcomes related to activities that are important to having a positive quality of life. It’s not enough to only help people recover medically from a serious illness; we need to do everything we can to ensure that, once a patient survives, he or she can return to the activities that allow the patient to be independent and enjoy life. This study helped change the way we manage patients with critical illness and this intervention is becoming the standard of care both in the United States and internationally.
Anne: What lead you to do the study?
Amy: Historically, patients with respiratory failure who were placed a ventilator were given medications to keep the patient calm, sedated, and immobile. We knew from earlier studies that when the sedative medications were not used, or used less, patients remained comfortable and were able to get off the ventilator sooner. However, often times these patients were still having chronic weakness and cognitive deficits which impair their day to day tasks. Our study built on this concept. We considered the possibility that, if the patients are safe and comfortable when awake on the ventilator and had improved outcomes, they might do even better if they did not remain confined to the bed but, instead, were engaged in activity to stimulate both the body and mind.
Anne: What studies are you conducting now?
Amy: Our study followed the patients until they left the hospital. But, it did not tell us what happened in the long run. We are replicating the original study but following the patients after they leave the hospital to see if the improvements we had noted in the first study hold up over time.
Anne: Amy, thank you for making such a valuable contribution to physiotherapy.