Activin A level is associated with physical function in critically ill patients.

BACKGROUND: Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels. OBJECTIVES: The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital. METHODS: Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU. RESULTS: High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures. CONCLUSIONS: Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness. STUDY REGISTRATION: ACTRN12615000047594.

Development of a performance standard for physiotherapists delivering exercise and mobilisation to the critically ill: A modified Delphi consensus study.

BACKGROUND: The provision of early mobilisation to critically ill patients has the potential to improve long term outcomes, but, is complex to deliver. There is minimal literature detailing the training and expertise required to deliver these interventions safely and effectively. OBJECTIVE: The objective of this study was to determine the key elements of a performance standard for assessment of physiotherapists delivering exercise and mobilisation interventions to the critically ill. METHOD: This is a modified eDelphi expert consensus study. Fifty-one physiotherapists from Australia and New Zealand with relevant clinical, educational, or research experience were included on the expert panel. Background information and the initial pool of items were developed from review of relevant literature. Five survey rounds were administered across two study phases to determine the elements, performance criteria, and assessment scale of the performance standard. Items were modified, amalgamated, and added based upon panel comments. RESULTS: Consensus was achieved for 69 mandatory, and two supplementary performance criteria which were arranged under 15 elements encompassing knowledge, assessment, analysis, intervention, and professional behaviours. A 3-point rating scale was selected to assess item achievement and global performance. CONCLUSION: Binational expert consensus was reached to define the assessment criteria for physiotherapists delivering exercise and mobilisation interventions to the critically ill. This standard can be utilised in clinical, educational, and research practice environments to guide training, assessment, and skill recognition in critical care physiotherapy.

The utility of short-term goal achievement as an early indicator of discharge destination in people admitted to neurological rehabilitation with severe functional deficits.

PURPOSE: This study investigates whether short-term goal achievement in the early phase of neurological rehabilitation is an accurate indicator of discharge destination in patients with severe disability in comparison to change in scores in the motor domain of the Functional Independence Measure (FIM motor). METHOD: A prospective observational cohort study. PARTICIPANTS: A consecutive sample of 53 patients admitted to rehabilitation with a neurological diagnosis and FIM motor score below 47.Measures: Short-term goal achievement and FIM motor change in the first 2 weeks following admission and discharge destination. RESULTS: Short-term goal achievement showed good prognostic utility [area under the curve (AUC) of 0.75; 95% confidence intervals (CI) 0.6, 0.89] for discharge destination, dichotomized as home or semi-independent living versus nursing home care, similar to that demonstrated by change in FIM motor scores (AUC of 0.69; 95% CI 0.55, 0.84), p = 0.55. A cut-off was established for short-term goal achievement at more than half of goals achieved, with an AUC of 0.73 (95% CI 0.58, 0.87); sensitivity 71.4% and specificity 74.4%. CONCLUSIONS: Short-term goal achievement in the early phase post-admission is a good indicator of the person's potential to return home.Implications for RehabilitationShort-term goal setting should be a key practice feature of neurological rehabilitation.Goal achievement is an indicator of a person's potential to return home or to semi-independent living in people with severe neurological deficits.Evaluation of short-term goal achievement may inform the ongoing rehabilitation program and discharge planning.

Physical Rehabilitation in the ICU: A Systematic Review and Meta-Analysis.

OBJECTIVES: Significant variability exists in physical rehabilitation modalities and dosage used in the ICU. Our objective was to investigate the effect of physical rehabilitation in ICU on patient outcomes, the impact of task-specific training, and the dose-response profile. DATA SOURCES: A systematic search of Ovid MEDLINE, Cochrane Library, EMBASE, and CINAHL plus databases was undertaken on the May 28, 2020. STUDY SELECTION: Randomized controlled trials and controlled clinical trials investigating physical rehabilitation commencing in the ICU in adults were included. Outcomes included muscle strength, physical function, duration of mechanical ventilation, ICU and hospital length of stay, mortality, and health-related quality of life. Two independent reviewers assessed titles, abstracts, and full texts against eligibility criteria. DATA EXTRACTION: Details on intervention for all groups were extracted using the template for intervention description and replication checklist. DATA SYNTHESIS: Sixty trials were included, with a total of 5,352 participants. Random-effects pooled analysis showed that physical rehabilitation improved physical function at hospital discharge (standardized mean difference, 0.22; 95% CI, 0.00-0.44), reduced ICU length of stay by 0.8 days (mean difference, -0.80 d; 95% CI, -1.37 to -0.23 d), and hospital length of stay by 1.75 days (mean difference, -1.75 d; 95% CI, -3.03 to -0.48 d). Physical rehabilitation had no impact on the other outcomes. The intervention was more effective in trials where the control group received low-dose physical rehabilitation and in trials that investigated functional exercises. CONCLUSIONS: Physical rehabilitation in the ICU improves physical function and reduces ICU and hospital length of stay. However, it does not appear to impact other outcomes.

Clinical Practice Guidelines for Early Mobilization in the ICU: A Systematic Review.

OBJECTIVES: To evaluate the methodological quality and thematic completeness of existing clinical practice guidelines, addressing early mobilization of adults in the ICU. DATA SOURCES: Systematic review of Medline, Embase, CINAHL, Cochrane, and grey literature from January 2008 to February 2020. STUDY SELECTION: Two reviewers independently screened titles and abstracts and then full texts for eligibility. Ten publications were included. DATA EXTRACTION: A single reviewer extracted data from the included publications and a second reviewer completed cross-checking. Qualitative data were extracted in five categories relating to the key factors influencing delivery of early mobilization to critically ill patients. DATA SYNTHESIS: Methodological quality was appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Appraisal of Guidelines for Research and Evaluation II scores for applicability were low. Median quality scores for editorial independence, rigor of development, and stakeholder engagement were also poor. Narrative synthesis of publication content was undertaken. All publications supported implementation of early mobilization. Most documents agreed upon seven topics: 1) early mobilization is safe and may reduce healthcare costs, 2) safety criteria should be provided, 3) a protocolized or structured approach should be used, 4) collaborative teamwork is required, 5) staff require specific skills or experience, 6) patient and family engagement is important, and 7) program evaluation and outcome measurement are a key component of implementation. There was no consensus on dosage and patient selection. The areas of team culture and leadership were poorly addressed. CONCLUSIONS: Despite significant variation in the methodological quality of clinical practice guidelines for early mobilization, there were important consistencies in recommendations internationally. Future research should address gaps related to patient selection, dosage, team culture, and expertise. Future clinical practice guidelines in this area should focus on engagement of patients and families in the development process and provision of resources to support implementation based on the consideration of known barriers and facilitators.