Does enhanced physical rehabilitation following intensive care unit discharge improve outcomes in patients who received mechanical ventilation? A systematic review and meta-analysis

Shunsuke Taito, Kota Yamauchi, Yasushi Tsujimoto, Masahiro Banno, Hiraku Tsujimoto, Yuki Kataoka, Shunsuke Taito, Kota Yamauchi, Yasushi Tsujimoto, Masahiro Banno, Hiraku Tsujimoto, Yuki Kataoka

Abstract

Objective: We aimed to determine whether enhanced physical rehabilitation following intensive care unit (ICU) discharge improves activities-of-daily-living function, quality of life (QOL) and mortality among patients who received mechanical ventilation in the ICU.

Design: Systematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Data sources: MEDLINE, Embase, CENTRAL, PEDro and WHO International Clinical Trials Registry Platform searched through January 2019.

Eligibility criteria for selecting studies: We included randomised controlled trials assessing the effect of post-ICU rehabilitation designed to either commence earlier and/or be more intensive than the protocol employed in the control group. Only adults who received mechanical ventilation for >24 hours were included.

Data extraction and synthesis: Two independent reviewers extracted data and assessed risk of bias. Standard mean differences (SMDs) with 95% CIs were calculated for QOL, and pooled risk ratios (RRs) with 95% CIs are provided for mortality. We assessed heterogeneity based on I² and the certainty of evidence based on the GRADE approach.

Results: Ten trials (enrolling 1110 patients) compared physical rehabilitation with usual care or no intervention after ICU discharge. Regarding QOL, the SMD (95% CI) between the intervention and control groups for the physical and mental component summary scores was 0.06 (-0.12 to 0.24) and -0.04 (-0.20 to 0.11), respectively. Rehabilitation did not significantly decrease long-term mortality (RR 1.05, 95% CI 0.66 to 1.66). The analysed trials did not report activities-of-daily-living data. The certainty of the evidence for QOL and mortality was moderate.

Conclusions: Enhanced physical rehabilitation following ICU discharge may make little or no difference to QOL or mortality among patients who received mechanical ventilation in the ICU. Given the wide CIs, further studies are needed to confirm the efficacy of intensive post-ICU rehabilitation in selected populations.

Prospero registration number: CRD42017080532.

Keywords: critical illness; exercise; mortality; post-intensive care syndrome; quality of life; rehabilitation.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Preferred Reporting Items for Systematic reviews and Meta-Analyses flow diagram.
Figure 2
Figure 2
Forest plot for quality of life and mortality.

References

    1. World Health Organization. International classification of functioning, disability and health (ICF). 2001. [Accessed 24 May 2018].
    1. Hodgson CL, Udy AA, Bailey M, et al. . The impact of disability in survivors of critical illness. Intensive Care Med 2017;43:992–1001. 10.1007/s00134-017-4830-0
    1. Fan E, Dowdy DW, Colantuoni E, et al. . Physical complications in acute lung injury survivors: a two-year longitudinal prospective study. Crit Care Med 2014;42:849–59. 10.1097/CCM.0000000000000040
    1. Hermans G, Van Mechelen H, Clerckx B, et al. . Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis. Am J Respir Crit Care Med 2014;190:410–20. 10.1164/rccm.201312-2257OC
    1. Naidech AM, Beaumont JL, Rosenberg NF, et al. . Intracerebral hemorrhage and delirium symptoms. Length of stay, function, and quality of life in a 114-patient cohort. Am J Respir Crit Care Med 2013;188:1331–7. 10.1164/rccm.201307-1256OC
    1. National Institute for Health and Care Excellence. Rehabilitation after critical illness. 2008. [Accessed 24 May 2018].
    1. Major ME, Kwakman R, Kho ME, et al. . Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge. Crit Care 2016;20:354 10.1186/s13054-016-1508-x
    1. Prescott HC, Angus DC. Enhancing recovery from sepsis: a review. JAMA 2018;319:62–75. 10.1001/jama.2017.17687
    1. Chao PW, Shih CJ, Lee YJ, et al. . Association of postdischarge rehabilitation with mortality in intensive care unit survivors of sepsis. Am J Respir Crit Care Med 2014;190:1003–11. 10.1164/rccm.201406-1170OC
    1. Connolly B, Salisbury L, O’Neill B, et al. . Exercise rehabilitation following intensive care unit discharge for recovery from critical illness. Cochrane Database Syst Rev 2015:CD008632 10.1002/14651858.CD008632.pub2
    1. Connolly B, Thompson A, Douiri A, et al. . Exercise-based rehabilitation after hospital discharge for survivors of critical illness with intensive care unit-acquired weakness: a pilot feasibility trial. J Crit Care 2015;30:589–98. 10.1016/j.jcrc.2015.02.002
    1. Walsh TS, Salisbury LG, Merriweather JL, et al. . Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial. JAMA Intern Med 2015;175:901–10. 10.1001/jamainternmed.2015.0822
    1. McWilliams DJ, Benington S, Atkinson D. Outpatient-based physical rehabilitation for survivors of prolonged critical illness: a randomized controlled trial. Physiother Theory Pract 2016;32:179–90. 10.3109/09593985.2015.1137663
    1. Patsaki I, Gerovasili V, Sidiras G, et al. . Effect of neuromuscular stimulation and individualized rehabilitation on muscle strength in intensive care unit survivors: a randomized trial. J Crit Care 2017;40:76–82. 10.1016/j.jcrc.2017.03.014
    1. McDowell K, O’Neill B, Blackwood B, et al. . Effectiveness of an exercise programme on physical function in patients discharged from hospital following critical illness: a randomised controlled trial (the REVIVE trial). Thorax 2017;72:594.1–5. 10.1136/thoraxjnl-2016-208723
    1. Taito S, Yamauchi K, Tsujimoto Y, et al. . Systematic review and meta-analysis of physical rehabilitation following intensive care unit discharge. 2018. [Accessed 24 May 2018].
    1. Higgins JPT, Green S, eds Cochrane handbook for systematic reviews of interventions, version 5.1.0. 2011. [Accessed 24 May 2018].
    1. Liberati A, Altman DG, Tetzlaff J, et al. . The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009;6:e1000100 10.1371/journal.pmed.1000100
    1. Moher D, Liberati A, Tetzlaff J, et al. . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097 10.1371/journal.pmed.1000097
    1. Guyatt GH, Oxman AD, Vist GE, et al. . GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924–6. 10.1136/
    1. Guyatt G, Oxman AD, Akl EA, et al. . GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011;64:383–94. 10.1016/j.jclinepi.2010.04.026
    1. Jones C, Skirrow P, Griffiths RD, et al. . Rehabilitation after critical illness: a randomized, controlled trial. Crit Care Med 2003;31:2456–61. 10.1097/01.CCM.0000089938.56725.33
    1. Cuthbertson BH, Rattray J, Campbell MK, et al. . The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial. BMJ 2009;339:b3723 10.1136/bmj.b3723
    1. Elliott D, McKinley S, Alison J, et al. . Health-related quality of life and physical recovery after a critical illness: a multi-centre randomised controlled trial of a home-based physical rehabilitation program. Crit Care 2011;15:R142 10.1186/cc10265
    1. Salisbury LG, Merriweather JL, Walsh TS. The development and feasibility of a ward-based physiotherapy and nutritional rehabilitation package for people experiencing critical illness. Clin Rehabil 2010;24:489–500. 10.1177/0269215509360639
    1. Batterham AM, Bonner S, Wright J, et al. . Effect of supervised aerobic exercise rehabilitation on physical fitness and quality-of-life in survivors of critical illness: an exploratory minimized controlled trial (PIX study). Br J Anaesth 2014;113:130–7. 10.1093/bja/aeu051
    1. Shelly AG, Prabhu NS, Jirange P, et al. . Quality of life improves with individualized home-based exercises in critical care survivors. Indian J Crit Care Med 2017;21:89–93. 10.4103/ijccm.IJCCM_433_16
    1. Tipping CJ, Harrold M, Holland A, et al. . The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med 2017;43:171–83. 10.1007/s00134-016-4612-0
    1. Fuke R, Hifumi T, Kondo Y, et al. . Early rehabilitation to prevent postintensive care syndrome in patients with critical illness: a systematic review and meta-analysis. BMJ Open 2018;8:e019998 10.1136/bmjopen-2017-019998
    1. Girard TD, Alhazzani W, Kress JP, et al. . An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Rehabilitation protocols, ventilator liberation protocols, and cuff leak tests. Am J Respir Crit Care Med 2017;195:120–33. 10.1164/rccm.201610-2075ST
    1. Greening NJ, Williams JE, Hussain SF, et al. . An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomised controlled trial. BMJ 2014;349:g4315 10.1136/bmj.g4315
    1. AVERT Trial Collaboration Group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 2015;386:46–55. 10.1016/S0140-6736(15)60690-0
    1. Bernhardt J, Churilov L, Ellery F, et al. . Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT). Neurology 2016;86:2138–45. 10.1212/WNL.0000000000002459
    1. Stevens RD, Dowdy DW, Michaels RK, et al. . Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med 2007;33:1876–91. 10.1007/s00134-007-0772-2
    1. Iwashyna TJ, Ely EW, Smith DM, et al. . Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010;304:1787–94. 10.1001/jama.2010.1553
    1. Ramsay P, Huby G, Merriweather J, et al. . Patient and carer experience of hospital-based rehabilitation from intensive care to hospital discharge: mixed methods process evaluation of the RECOVER randomised clinical trial. BMJ Open 2016;6:e012041 10.1136/bmjopen-2016-012041
    1. Corner EJ, Murray EJ, Brett SJ. Qualitative, grounded theory exploration of patients' experience of early mobilisation, rehabilitation and recovery after critical illness. BMJ Open 2019;9:e026348 10.1136/bmjopen-2018-026348

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