Cognitive and physical rehabilitation of intensive care unit survivors: results of the RETURN randomized controlled pilot investigation

Abstract

Background: Millions of patients who survive medical and surgical general intensive care unit care every year experience newly acquired long-term cognitive impairment and profound physical and functional disabilities. To overcome the current reality in which patients receive inadequate rehabilitation, we devised a multifaceted, in-home, telerehabilitation program implemented using social workers and psychology technicians with the goal of improving cognitive and functional outcomes.

Methods: This was a single-site, feasibility, pilot, randomized trial of 21 general medical/surgical intensive care unit survivors (8 controls and 13 intervention patients) with either cognitive or functional impairment at hospital discharge. After discharge, study controls received usual care (sporadic rehabilitation), whereas intervention patients received a combination of in-home cognitive, physical, and functional rehabilitation over a 3-month period via a social worker or master's level psychology technician utilizing telemedicine to allow specialized multidisciplinary treatment. Interventions over 12 wks included six in-person visits for cognitive rehabilitation and six televisits for physical/functional rehabilitation. Outcomes were measured at the completion of the rehabilitation program (i.e., at 3 months), with cognitive functioning as the primary outcome. Analyses were conducted using linear regression to examine differences in 3-month outcomes between treatment groups while adjusting for baseline scores.

Results: Patients tolerated the program with only one adverse event reported. At baseline both groups were well-matched. At 3-month follow-up, intervention group patients demonstrated significantly improved cognitive executive functioning on the widely used and well-normed Tower test (for planning and strategic thinking) vs. controls (median [interquartile range], 13.0 [11.5-14.0] vs. 7.5 [4.0-8.5]; adjusted p < .01). Intervention group patients also reported better performance (i.e., lower score) on one of the most frequently used measures of functional status (Functional Activities Questionnaire at 3 months vs. controls, 1.0 [0.0 -3.0] vs. 8.0 [6.0-11.8], adjusted p = .04).

Conclusions: A multicomponent rehabilitation program for intensive care unit survivors combining cognitive, physical, and functional training appears feasible and possibly effective in improving cognitive performance and functional outcomes in just 3 months. Future investigations with a larger sample size should be conducted to build on this pilot feasibility program and to confirm these results, as well as to elucidate the elements of rehabilitation contributing most to improved outcomes.

Conflict of interest statement

Dr. Hoenig received an AFAR Beeson Award. The remaining authors have not disclosed any potential conflicts of interest.

Figures

Figure 1. Intervention Timeline

CT = cognitive therapy (GMT), ET = exercise training, FT = functional training, O/E = Orientation/Exercise, TC = therapy consultation. ET and FT interventions were delivered in tandem and cognitive therapy was generally delivered in a stand-alone fashion. Therapy consultations were done exclusively on the telephone and occurred between “in person” sessions, which a focus on providing support and reinforcement and on fostering treatment compliance with a focus on daily functioning.

Figure 2. Flow chart of recruitment and study participation

Other exclusions: 2 discharged to hospice, 2 could not be reconsented due to unavailability of study staff, 2 were not consented for the parent study (BRAIN) prior to discharge, 1 patient was uncooperative and refused assessments, 1 patient was violent and transferred to a psychiatric hospital, 1 patient lived in an environment unsafe for home visits.

Figure 3. Comparison of Tower Test Scores at Enrollment vs. 3-Month Follow-Up

Higher scores reflect better executive functioning ability. The graph reflects the findings that intervention patients characteristically improved in their Tower Test performance of executive function as compared to control patients, as shown in Figure 3 (P

Figure 4. Comparison of FAQ Scores at Enrollment vs. 3-Month Follow-Up

Lower scores reflect better instrumental activities of daily living ability (IADLs). The graph reflects the findings that while statistically significant as shown in Figure 4 (P=0.04), the differences in improvement in IADLs in treatment versus control patients are modest and not consistent in all patients. In the legend, patients in the treatment group are represented by black lines and patients in the intervention group are represented by gray lines. In the legend, the Frequency notation indicates that all thin lines represent scores from individual patients, while the single thick gray line represents 3 patients who had identical scores at enrollment and 3 months in the intervention group. The p-value for treatment is from a linear regression models with three-month FAQ score as its outcome and treatment group as an independent variable, adjusting for baseline FAQ score.