Increasing post-ICU physical therapy does not improve functional status [RECOVER trial]

1. In this trial, increasing the frequency and intensity of physical, occupational, speech and language, and dietetic therapies during the post-intensive care unit (ICU) period did not improve the functional status or the health-related quality of life for the patients compared to the usual care already in place.

2. This intervention also had no appreciable impact on the length of stay, anxiety, depressive, and post-traumatic symptoms, though patients in the intervention group did report higher satisfaction.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Intensive care unit (ICU) related illnesses impart a significant amount of morbidity, even once the initial illness has resolved. Muscle weakness, cognitive impairment, and post-traumatic stress disorder have all been reported. There have been reports that initiating targeted post-ICU rehabilitation can help decrease this burden. This prospective, randomized study was conducted to evaluate the effectiveness of targeted rehabilitation for the post-ICU period of patient’s hospital stay. The results suggested that increasing the frequency and intensity of physical, occupational, speech and language, and dietetic therapies during the post-ICU period did not have any significant impact on the functional status or the health-related quality of life for the patients compared to the usual care already in place. This intervention also had no appreciable impact on the length of stay, anxiety, depressive, and post-traumatic symptoms, though patients in the intervention group did report higher satisfaction.

The strength of this study lay primarily in the study design and the pre-defined, measureable outcomes. Even though the therapy was heterogeneous across the usual care group, there was an appreciable increase in the level of therapy provided to the intervention group, which does help validate the results. The primary end point, the Rivermead Mobility Index, is validated for stroke patients, not the ICU population, so that decreases the reliability of the conclusion. This study does show that significant work still remains in decreasing the morbidity associated ICU admissions.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Rehabilitation interventions for postintensive care syndrome: a systematic review

In-Depth [randomized controlled trial]: This prospective, parallel group, randomized clinical trial took place in two hospitals in Scotland. Inclusion criteria were a minimum of 48 hours of mechanical ventilation. Exclusion criteria included predominant neurologic injury, palliative care, and long-term ventilatory need. The monitoring period included the three months immediately post-ICU discharge, at which point outcomes were assessed. The usual care group included physical and occupational therapy, speech and language therapy, and dietetics as per the discretion of the primary team. The intervention group received therapy from the same type of therapists. However, the therapy was more intense, frequently re-evaluated and targeted, and had an additional rehabilitation assistant (RA) involved who assessed the patients daily and provided targeted therapy.

The primary outcome was the Rivermead Mobility Index (RMI), which assesses functional mobility in gait, balance, and transfers, at three months after ICU discharge. In the final analysis, there were a total of 240 participants included. After three months, the mean change in RMI was 7.7 in the usual care group and 7.9 in the intervention group, with a difference of -0.2 (95% CI, -1.3 to 0.0; p = 0.71). There were also no significant differences found in the length of stay, health-related quality of life, anxiety, depressive, or post-traumatic symptoms. There were also no differences at the longer follow-up periods of 6 and 12 months.

Image: PD

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