The case for early exercise intervention for ICU patients

In-bed cycling in critical care units could be a way to improve patient health and save money
Michelle Kho, Evidencenetwork.ca
March 07, 2017
By Michelle Kho, Evidencenetwork.ca
Frail and critically ill patients can safely bike in the intensive care unit, even early in their ICU stay. These are the exciting findings from an in-bed cycle program that aims to get hospital patients – even in intensive care units – pedalling as soon as possible with therapeutic bicycles, so they are functioning better by the time they leave hospital.

Why throw in a fitness plan for patients who already have so many critical medical issues? The reason is because patients who are stuck in bed are precisely the patients who need in-bed cycling the most.

Anyone who's tried hitting the gym or recovered from injury knows that muscles can take weeks to gradually strengthen. But did you know that muscles only take days to quickly deteriorate?

For example, after only seven days of lying in a critical care bed, one study noted that patients' muscle strength was four times weaker than in healthy controls. After 10 days of critical care with mechanical ventilation, patients' leg muscles decreased in size by almost 18 percent.

In fact, many previously active patients are unable to walk when they are discharged from critical care due to profound muscle weakness. In new research, my colleagues and I show how we start to think of rehabilitation, very early in a patient's ICU stay to help prevent or minimize this weakness.

What is in-bed cycling?

The in-bed cycle involves a specialized exercise bike that rolls over patients' beds. These cycles have a motor, can move patients' legs for them or allow patients to cycle on their own. Patients stay on their back while their lower legs and feet are secured into slings and pedals while their legs move in a cycling motion. The in-bed cycle also has video screen that helps motivate more alert patients with animation of their virtual ride.

In-bed cycling is an especially promising early exercise intervention because it targets the legs, particularly hip flexors, which are most vulnerable to muscle atrophy and weakness during bed rest.

Cycle therapy can also safely begin right after resuscitation, while patients are still attached to life support, whether patients are awake or sedated. That's right, patients can be pedalling even before they wake up.

We recently conducted a study with frail and critically ill patients connected to machines to help them breathe to see if they could start cycling very early in their ICU stay. Our study found cycle-therapy safe because there were very few times where patients stopped cycling early due to medical concerns – and feasible, because over 90 per cent of patients or substitute decision makers who were approached agreed to participate in the study.

So far, our team has trained eight ICU facilities and over 45 physiotherapists across Ontario to provide in-bed cycling in our ongoing research. The rest of the country is still waiting for cycle therapy.

Here's why hospitals should review and expand their approach to rehabilitation across the country.

Patients in critical care are rigged up to all sorts of specialized equipment, including machines to support breathing, medication pumps and monitors. Despite all this investment, few critically ill patients receive exercise, which is key to their recovery.

Studies from the ICU show that exercise is more effective than changes in nutrition or different ways of providing mechanical ventilation for improving long-term physical function in critically ill adults.

But critically ill and frail patients are often perceived as 'too sick' for physical therapy. Rehabilitation in the ICU can be infrequent and, when provided, may occur late in a patient's ICU stay.

Without rehabilitation, physical strength quickly deteriorates and patients wind up leaving ICU with new weaknesses acquired in the ICU. This in turn can result in longer hospital stays, higher risks of mortality and more health care costs.

Canada's population is aging and Canadians over 65 years of age account for 78 per cent of the three most expensive types of hospitals stays by diagnosis: cardio-pulmonary disease, pneumonia and heart failure without angiogram. These are all conditions that require some time in ICU.

It's time to change the way we view exercise for frail and critically ill patients. As soon as we resuscitate, we need to think of starting rehabilitation interventions, even in the ICU, to optimize their recovery.

Early in-bed cycling is one creative therapeutic approach for critically ill patients, for supporting our aging population, and for potentially saving significant health care dollars down the road.

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Michelle Kho is an assistant professor in the School of Rehabilitation Science at McMaster University, physiotherapist at St. Joseph's Healthcare Hamilton, and network investigator with Canadian Frailty Network. She holds a Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation.

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