Passive limb movements for patients in an intensive care unit: A survey of physiotherapy practice in Australia

Abstract

Purpose

This study aimed to investigate physiotherapists' clinical practice regarding passive limb movements for adult patients in Australian intensive care units (ICUs).

Materials and Methods

A prospective survey using a purpose-designed questionnaire was mailed to the senior physiotherapist working in each Australian level 3 (tertiary) adult ICU.

Results

Of 65 questionnaires sent, 51 (78%) were returned. A minority of respondents (35%) undertook routine assessment of passive limb range of movement (ROM) for all ICU patients. Instead, most based the need for assessment on criteria such as length of stay, reason for admission, and medical history. A minority (14%) provided passive limb ROM exercises on a routine basis for all patients, instead most intervened only for high-risk patients or those with loss of ROM. The most frequently used interventions were manually applied passive limb ROM exercises, positioning, and mobilization, and the actual exercise prescription varied markedly. Respondents thought contracture was uncommon in ICU patients, was multifactorial in origin, and caused moderate problems. Personal experience and colleagues' advice were the factors most influencing clinical practice.

Conclusions

Although selective passive limb ROM assessment and intervention formed a part of most physiotherapists' clinical ICU practice, considerable variability was found in its application between respondents.

Introduction

The number and complexity of patients admitted to intensive care units (ICUs) have substantially increased over recent years, with 124 557 adult admissions to Australian ICUs during 2005/2006, representing 4% of hospital admissions [1], [2]. The survival rate of patients admitted to the ICU has also increased, largely attributable to advances in general ICU care [2], [3], [4]. In addition, there is a higher incidence of adverse sequelae associated with ICU stay, such as residual organ compromise, neuromuscular disorders, neurocognitive or psychiatric conditions, and reduced quality of life and function [5], [6], [7], [8], [9]. Indeed, because of the underlying nature of their critical illness and the medical and pharmacological interventions used in their management, all patients admitted to an ICU are at an increased risk of adverse neuromuscular sequelae such as weakness, reduced mobility, soft tissue contracture, and reduced joint range of movement (ROM) [5], [7], [8], [9], [10], [11], [12]. These sequelae can, in turn, have a major impact on patients' functional ability and health-related quality of life. Therefore, management aimed at preventing or reducing the neuromuscular complications of ICU patients, both during and after admission to ICU, has become particularly important [5], [12], [13], [14]. The interventions that may be used by physiotherapists to prevent/reduce neuromuscular complications include passive limb ROM exercises, positioning, strengthening exercises, and mobilization (ie, activities such as standing and walking) [13], [15]. Passive limb ROM exercises are usually defined as consisting of repeated movement of a joint within the available limits (range) of that joint [13].

Although there has been a considerable amount of research evaluating the effectiveness of respiratory physiotherapy techniques for patients admitted to ICUs, fewer studies have evaluated clinical physiotherapy practice in ICUs [16], [17], [18], [19], [20]. These studies found that there was considerable variability in physiotherapy staffing levels and that the interventions most often provided by physiotherapists were mobilization, positioning, and manual respiratory techniques [16], [17], [18], [19]. Although a recent task force recommended that interventions such as active or passive mobilization and muscle training be instituted early for ICU patients to preserve joint mobility and muscle length, these recommendations were reported as being based on low-level evidence [5]. Morris et al [21] found that, compared with usual care, a mobility protocol (involving interventions such as early passive limb movements, active exercises, sitting on the edge/out of the bed) resulted in a shorter time to first sit out of bed and reduced length of stay in the ICU and hospital. We were unable to identify any other studies involving ICU patients that evaluated the effectiveness of specific interventions, such as passive limb movements, that are primarily aimed at the neuromuscular rather than the cardiorespiratory system. This is an important oversight in view of the increasing importance of this aspect of the management of ICU patients.

In particular, we were interested in evaluating clinical practice with respect to passive limb movements for ICU patients because their provision can be time-consuming and previous studies involving other patient groups have questioned the effectiveness of interventions that involve passive limb movement and stretching [22], [23], [24], [25], [26], [27], [28]. In the population with spinal cord injury, well-designed clinical research has shown that passive stretching (ie, 30 minutes' duration, 3-7 days a week for up to 12 weeks) is not effective at increasing ankle mobility [22], [23] or hamstring extensibility [24]. Furthermore, for 20 patients with chronic tetraplegia, passive movements (10 minutes, 10 times a week, for 6 months) resulted in only small effects on ankle joint ROM that were of questionable clinical importance [25]. In other patient groups, the ability of passive movements (administered by a continuous passive motion machine) to achieve clinically important improvements in ROM is questionable [26], [27], [28].

Therefore, the overall aim of our study was to clarify current practice with respect to the use of passive limb movements for patients in the ICU. We did this by investigating the clinical practice of physiotherapists (in terms of passive limb movements) for adult patients admitted to an Australian ICU. As well as benchmarking Australian physiotherapy clinical practice, these data could be used for comparison in future studies to identify international variation in practice and also to assist in the design of future clinical trials. Specifically, we aimed to investigate the patterns of physiotherapy assessment and intervention with passive limb movements and the clinical rationale for these services.