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Visualize a tall, elderly, frail man in the first few days of his ICU stay, and on a ventilator.  He is awake and alert. Now add large headphones connected to an MP3 player and his legs in straps with an in-bed bicycle. Now think about how this would look for 30 minutes.  At the end of 30 minutes, you note that he cycled 7 kilometres.  7 kilometres!  This observation sold me on the fact that in-bed cycling in the ICU was more than research; it was a tool that could help get patients going sooner.  What I didn’t expect was how this research project helped improve our physiotherapy profile and teamwork in the ICU.

TryCYCLE1 was a 33-patient research study conducted in the ICU at St. Joseph’s Healthcare Hamilton. We wanted to see if it was safe and feasible to start in-bed cycling with patients for 30 minutes within the first 4 days of mechanical ventilation.  As one of the physiotherapists in the ICU during the study, I watched the evolution of TryCYCLE and the variety of staff/patients/families touched by the study. Initially, we (the PTs) were concerned about the amount of time cycling would take and whether we would still be able to fit the rest of our caseloads into our days. The entire team was concerned about the patients’ ability to participate due to their medical acuity. That initial fear and disbelief melted away as we enrolled more patients.  Since we were the first in Canada to have the RT 300 supine bike in our ICU, we received some media coverage.  This attracted a lot of attention inside and outside the ICU for our patients, the ICU, and the PT profession. It was surprising to see the interest from patients and families, and exciting to see the eagerness of the staff to learn more about it.

 

Let’s get people moving!

Immobility is not a good thing for our ICU patients.  We know that patients’ leg muscles can atrophy by >10% within the first week of bedrest.  However, how and when is best to get people going is still undetermined. TryCYCLE brought a new tool to try with our ICU patients, and because of the collaboration this tool required with the team, it seemed to bring the importance of mobility to the forefront. The bike used for in-bed cycling has its own motor that pedals for the patient until the patient can use their own power and allows the patient to watch their progress on a screen. The bike fits over the bed so that the patient can remain in a comfortable position while their legs are secured into the pedal system.  The staff came to see how the bike worked and asked questions. There were lots of jokes about whether staff could use it while they slept and say they exercised.  Following local TV and newspaper coverage about the bike, we received questions from families and staff members, and even had some calls come from other PTs in Canada. The technology was stirring up quite a bit of excitement.

Yikes! Can we do this?

I was excited for this new treatment option. How amazing to have something for patients to actively do that would have a visual incentive! But the biggest question was: could we do this research study? Our staffing was changing as people were going on maternity leaves and others coming back. The ICU was busy, and there were other demands on our time. Setting up a machine and running it for half an hour, then taking it down seemed like it would take over our day. But with Dr. Michelle Kho’s guidance and enthusiasm, we took a leap of faith and gave it a try. We were able to do it because we learned to be a stronger physiotherapy team. When we enrolled a cycling patient on study, other PTs would help us with our caseload. We learned to communicate and share our caseloads smoothly and seamlessly. We also became much more efficient with set up and take down the more we used the bike. Turns out this new treatment option was indeed feasible for us to administer.  We also learned it was safe to bike early in a patient’s ICU stay, with very few safety events.

 

What we learned…

Our hard work appears to have paid off!  Most patients seemed to enjoy the activity if they were awake.  We learned a few things that we didn’t expect.  First, we were surprised to see that sedated patients could intermittently cycle actively above the set motor speed (something none of us had previously noted with range-of-motion activities).  And some ‘awake’ patients got competitive!  We had one patient cycle 7 kilometres in one session.  Another patient decided to beat that record and cycled for 9 kilometres. Some patients were competitive with themselves and wanted to cycle a greater distance each time they biked.  

We also learned that families liked seeing their loved ones on the bike. I don’t think it was just the act of biking that got them excited, I think that it was the feeling of hope. If their family member was participating in a physical activity, maybe there was hope they could get better. In addition, families and patients could SEE this intervention. Much of what happens in the ICU is behind the scenes or is not easily visible – with this bike, patients and families could SEE the progress; they could SEE what they had signed up for.

And, outside of the research study, we started seeing nurses help patients out of bed more frequently - even before we did our first assessments.  Mobility became something that the ICU team owned, and wasn’t just the responsibility of physiotherapists.  ICU staff would seek us out for more complex patients and help us organize equipment for transfers. They would also ask if their patient would be appropriate for the bike, and if so, whether we would have capacity to provide the intervention.  

 

So what’s next?

The excitement on the faces of the families when their family member actively cycled or the look of determination on a patient’s face when they set a distance goal was well worth the learning curve that this equipment required. Although our primary focus was the patient, we also ended up with a much stronger interdisciplinary team in the ICU which was a huge and unexpected benefit of the TryCYCLE study. Now that we know we can administer the treatment, it’s time to figure out just how much this intervention benefits patients. Our next step is to see if it is possible to do a cycling study in other ICUs in Canada in the form of a pilot randomized trial.  We will collaborate with ICUs who have members in the Canadian Critical Care Trials group, and we look forward to sharing what we learned with them.  CYCLE Pilot RCT2 here we come!

By Magda McCaughan, MScPT, Hamilton District, OPA President

 

References:

  1. Kho ME, Molloy AJ, Clarke F, Ajami D, McCaughan M, Obrovac K, Murphy C, Camposilvan L, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Zanni JM, Mourtzakis M, Piraino T, Cook DJ, and the Canadian Critical Care Trials Group. TryCYCLE: A prospective study of the safety and feasibility of early in-bed cycling in mechanically ventilated patients. PLoS One, 11(12):e0167561. doi:10.1371/journal.pone.0167561. Dec 2016
  2. Kho ME, Molloy AJ, Clarke F, Herridge MS, Koo KKY, Rudkowski J, Seely AJE, Pellizzari JR, Tarride JE, Mourtzakis M, Karachi T, Cook DJ and the Canadian Critical Care Trials Group. CYCLE Pilot: A Protocol for a Pilot Randomized Study of Early Cycle Ergometry Versus Routine Physiotherapy in Mechanically Ventilated Patients. BMJ Open, 6, e011659. 2016

 

More information:

Winnipeg Free Press

http://www.winnipegfreepress.com/opinion/analysis/cycling-in-icu-optimizes-recovery-for-critically-ill-412375973.html

Huffington Post

http://www.huffingtonpost.ca/michelle-kho/in-bed-exercise-frail-patients_b_14631992.html

 

Comments

Excellent to read, thank you

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