Early mobilisation has been shown to improve the outcome of ventilated patients in intensive care units. But what are the effects of a subsequent intensive rehabilitation programme after discharge to the regular therapy ward? So far there is no consensus on this. A Japanese working group led by Shunsuke Taito investigated this question.

“Our goal was to determine whether a reha­bili­tation programme after discharge from the ICU improves the activities of daily life (ADL), quality of life (QOL) and mortality of patients who were ventilated in the ICU,” Taito and colleagues explain.

In a systematic review with meta-analysis, they investigated the effects of rehabilitation for ventilated patients after their discharge from intensive care. “We have included randomised controlled trials that evaluate the effect of post-intensive care rehabilitation. For this purpose, the therapy either started earlier and/or was more intensive than in the control group. Only adults who were mechanically ventilated for more than 24 hours were included.”

Two independent experts extracted the data and assessed the risk of possible bias. Standard mean differences (SMD) with 95% confidence intervals (CI) were calculated for the QOL, and pooled risk ratios (RR) with 95% CI were specified for mortality. “We evaluated heterogeneity on the basis of I² and the quality of evidence on the basis of the GRADE approach,” the researchers explain in their work.

Ten studies with a total of 1,110 patients compared an early/intensive rehabilitation pro­gramme with standard care or no intervention after discharge from intensive care. With regard to quality of life, the standardised mean difference (SMD) (95% CI) between the intervention group and the control group was 0.06 (-0.12 to 0.24) and -0.04 (-0.20 to 0.11) for the physical and mental components respectively. Rehabilitation did not significantly reduce long-term mortality (RR 1.05, 95% CI 0.66 to 1.66). The studies analysed did not report on ADL. The quality of evidence for quality of life and mortality was moderate.

Improved rehabilitation after discharge from the ICU therefore makes little or no difference to quality of life or mortality in patients who were previously ventilated in the ICU. Given the broad range of CIs, further studies are needed to confirm the effectiveness of intensive rehabilitation after discharge from intensive care.

I²: The effects of several studies can only be meaningfully summarised if the differences between the individual studies are not too great, e.g. in terms of the measurement methods applied or the patient populations. The studies should therefore be as homogeneous as possible. Heterogeneity is often evaluated with the measure I². It is assumed that the variability of results is based on systematic differences between the studies on the one hand and random deviations on the other. The smaller the value for I², the more likely that differing study results are due to random variations; the larger the value, the more likely that differing results are due to differences between studies. I² can adopt values between 0 and 100%.

Comments

The positive effects of early mobilisation, which can be performed, for example, using a bed bicycle in the intensive care unit while patients are still in bed and on artificial ventilation, are undisputed. Numerous high-quality studies have proven this in recent years. It appears that these effects can no longer be achieved at a later point in time, or only to a much lesser extent, even if follow-up rehabilitation on a normal therapy ward begins earlier than usual and is more intensive than in the conventional setting. The results underline the need for early mobilisation in intensive care units.