SAPNA Kudchadkar still remembers the morning in 2010 that shaped the trajectory of her scientific research. She was in the midst of a medical fellowship, listening carefully to the hospital’s overnight staff, as they summarized the progress of each child in the pediatric intensive care unit. The staff would comment on how well the patients had slept the night before. “In that moment, I realized that we weren’t really talking about sleep, per se, but really sedation,” says Kudchadkar.
While the terms are sometimes used interchangeably in intensive care, she says, they are not the same. Among other things, real sleep is restorative; upon waking, patients feel energized. The disruptive effects of sedation, Kudchadkar suspected, could have lasting implications for a person’s recovery and long-term health.
Knowing that physical activity enhances sleep, Kudchadkar wondered: Would her young patients do better if they were encouraged to move during their stay in intensive care? At the time, this question was already being investigated in adults, but had largely been avoided in pediatrics due to concerns about patient safety. The intensive care unit (ICU), after all, is widely viewed as a place of rest for the acutely ill or for those recovering from major surgery. And some ICU patients rely on breathing tubes, which are cumbersome and often require sedation to prevent the body from reflexively trying to remove the tubing. Getting exercise broadly into the ICU, then, would require research demonstrating that it is both effective and safe.
Two multi-year initiatives — one directed by Kudchadkar at Johns Hopkins School of Medicine, and one based at McMaster University in Canada — are now providing that kind of evidence for patients of all ages. These initiatives are part of a broader trend toward “ICU liberation.” While intensive care has improved dramatically over the decades, resulting in higher survival rates, there is now a broad recognition that survivors are not walking away unscarred. The ICU liberation movement seeks to reduce the negative effects of intensive care, which can linger for decades, and include everything from lowered muscle strength to depression and anxiety. One way to do this is to decrease sedation and encourage patients to move far sooner than they have in the past.
As with any major culture change, though, “there was some pushback early in the process,” Kudchadkar wrote in an email. Some of her colleagues worried that the new initiative might push sick patients to perform beyond their physical abilities. So she and her team worked to reassure colleagues that patients’ goals would be individualized. “There was a collective sigh of relief that we weren’t trying to get every kid out of bed walking regardless of their acuity of illness,” Kudchadkar recalls. Still, she adds, “illness doesn’t mean stillness,” the program’s catchphrase. That view, according to Kudchadkar, is now shared by a growing number of intensive care specialists across the country.
Sedation standards for intensive care units can be traced back to the 1980s, when operating room procedures began being applied in other settings. Sedation causes the brain to take on a semi-conscious or unconscious state, and the drugs include propofol and benzodiazepines. Additional drugs called paralytics are often added to prevent the body from moving. At that time, the focus was largely on using sedation to keep a patient comfortable and able to tolerate pain, without as much regard for the negative long-term effects of prolonged sedation, says Yahya Shehabi, a professor and director of critical care research at Monash University School of Clinical Sciences in Australia.
A pivotal change came in 2000, with a New England Journal of Medicine article that discussed the benefits of interrupting sedation for a brief period each day. Over time, additional research would show that sedation has its own side effects. For one, it has been linked to cognitive issues, typically memory deficits. Additionally, bed rest can lead to muscle deconditioning. A 2014 study found, for example, that each day of ICU bed rest lowered a person’s muscle strength between 3% and 11%. Over one third of ICU patients were discharged from the hospital with muscle weakness, and that weakness was associated with substantial impairments in physical function lasting months, and in some cases years.
New research also points to the benefits of physical activity for people dealing with an array of conditions. In August 2019, a systematic review and meta-analysis found that adding physical exercise to standard care may improve quality of life in everything from multiple sclerosis to Parkinson’s disease. When it comes to children, a study in the Journal of the American Medical Association showed that children and adolescents with a concussion may benefit from light activity earlier than traditionally advised. And in June of 2019, a systematic review of 15 studies reported that exercise can improve attention and social behavior in children with attention deficit hyperactivity disorder, or ADHD.
Still, Shehabi issues a word of caution regarding the introduction of physical activity into critical care: “Patients who are able to mobilize usually self-select as they get better to achieve ICU liberalization,” he wrote in an email. “As such, many patients will not be able to mobilize before they have recovered substantially from critical illness.” Lakshman Swamy, a pulmonary and critical care fellow at Boston Medical Center, echoes this point: “Early mobilization is critical but difficult — and potentially dangerous without the proper systems and support.” Sick patients may be connected to medical tubes, lines, and drains, all of which can be displaced and serve as major fall risks, says Swamy. “Even one fall can be catastrophic.”
Kudchadkar’s initial one-year study, which ended in 2015, was designed to assess the safety of a program that encourages young ICU patients to walk and play. Sydney Pearce was two-and-a-half years old and recovering from open-heart surgery when her parents agreed to let her participate. Within 24 hours of the operation, she was up and walking and driving a cozy coupe car around the ICU. “We had no idea about what the program could do,” said her mother, Ashley. While Sydney was initially reluctant to move about, the young girl soon became determined to try everything she had enjoyed before.
That study, published in 2016 in the journal Pediatric Critical Care Medicine, indicated that the mobility program was safe and appropriate for follow-up testing. As a next step, Kudchadkar is helping lead a multicenter randomized controlled trial to look at the protocol’s effectiveness. It will measure outcomes such as duration of mechanical ventilation, exposure to sedative medications, and length of stay. Johns Hopkins All Children’s Hospital in Florida, Boston Children’s Hospital, Advocate Health Care in Illinois, and Our Lady of the Lake Children’s Hospital in Louisiana are participating in the trial.
Researchers at McMaster University in Canada are also studying ICU mobility. In particular, they are examining whether “in-bed cycling” can help improve outcomes among adult ICU patients. The results of a pilot randomized controlled trial involving seven ICUs, led by Michelle Kho, a physical therapist and professor, were published in 2019. A larger trial involving 17 ICUs across Canada, the US, and Australia, now aims to compare whether adding early in-bed cycling to routine physical therapy among adults in the ICU improves physical function, mental well-being, and mortality, among other factors.
As part of the McMaster-led study, bike pedals mounted on a platform, are wheeled into the patient’s room. A physical therapist then guides the patient — who remains in bed — to use cycling as a strength and rehabilitation program. If patients are physically able, they can pedal the bike unassisted. For patients who are too sedated or weak, the motorized bike passively moves the patient’s legs. Each session typically lasts 30 minutes. “In a lot of ICUs people are on bedrest, which can lead to muscle weakness and general deconditioning,” says Kho. But thanks to the in-bed cycle’s motor, even patients who are sedated and receiving life support can participate.
Physical therapist Kristy Obrovac, who is based at a McMaster-affiliated hospital, St Joseph’s Health Care, recalls one adult patient who used the in-bed cycle after complex thoracic surgery. The experience provided “an opportunity to focus on something positive,” she says, while offering “a sense of control in the recovery during a very challenging time.”
The in-bed cycling sessions are conducted by physical therapists and engaging them at other hospitals will be key to ensuring that the program can be replicated in different settings, says Kho. “We aren’t looking at the effect of exercise per se, but more at breaking up sedentary behaviors, and the impact that could have for ICU patients, which includes the opportunity to regain some control and hope,” says Kho.
While these new efforts are promising, it may be a few years before the field of intensive care medicine adapts to more formally include them. One challenge could be purely logistical. During the day, ICU patients undergo a range of tests, procedures, and imaging studies, plus they often have visitors. So it could be hard to find a time when clinicians and patients are ready to work on mobility, says Swamy.
Still, he views research like Kudchadkar’s and Kho’s as part of a necessary and important shift in ICU care more generally: “The way we practice medicine needs to be radically reimagined to put the patient — and patient mobility — at the center of the care plan.”
Amitha Kalaichandran, MHS, MD, is a physician and writer based in Toronto, Canada. Follow her on Twitter at @DrAmithaMD.