Does enhanced physical rehabilitation following intensive care unit discharge improve outcomes in patients who received mechanical ventilation? A systematic review and meta-analysis

Abstract

ObjectiveWe aimed to determine whether enhanced physical rehabilitation following intensive care unit (ICU) discharge improves activities-of-daily-living function, quality of life (QOL) and mortality among patients who received mechanical ventilation in the ICU.DesignSystematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.Data sourcesMEDLINE, Embase, CENTRAL, PEDro and WHO International Clinical Trials Registry Platform searched through January 2019.Eligibility criteria for selecting studiesWe included randomised controlled trials assessing the effect of post-ICU rehabilitation designed to either commence earlier and/or be more intensive than the protocol employed in the control group. Only adults who received mechanical ventilation for >24 hours were included.Data extraction and synthesisTwo independent reviewers extracted data and assessed risk of bias. Standard mean differences (SMDs) with 95% CIs were calculated for QOL, and pooled risk ratios (RRs) with 95% CIs are provided for mortality. We assessed heterogeneity based on I² and the certainty of evidence based on the GRADE approach.ResultsTen trials (enrolling 1110 patients) compared physical rehabilitation with usual care or no intervention after ICU discharge. Regarding QOL, the SMD (95% CI) between the intervention and control groups for the physical and mental component summary scores was 0.06 (–0.12 to 0.24) and −0.04 (−0.20 to 0.11), respectively. Rehabilitation did not significantly decrease long-term mortality (RR 1.05, 95% CI 0.66 to 1.66). The analysed trials did not report activities-of-daily-living data. The certainty of the evidence for QOL and mortality was moderate.ConclusionsEnhanced physical rehabilitation following ICU discharge may make little or no difference to QOL or mortality among patients who received mechanical ventilation in the ICU. Given the wide CIs, further studies are needed to confirm the efficacy of intensive post-ICU rehabilitation in selected populations.PROSPERO registration numberCRD42017080532.

Home‐Based Combined Activity and Cognitive Intervention for Post‐Intensive Care Syndrome: A Pilot Randomised Controlled Trial

“…Physically, the overall trajectory of recovery in all groups was consistent with the natural functional gains typically seen in the overall trajectory of physical recovery, in which many ICU survivors experience spontaneous gains in functional capacity during the first months following discharge [29]. Exercise trials and systematic reviews have reported similar patterns, with significant within-group increases in 6MWT distance and physical function in both intervention and attention control groups, but only small or inconsistent between-group differences [6,7]. A 2023 systematic review of nine RCTs evaluating post-discharge rehabilitation programs confirmed this pattern: while both intervention and control groups showed improvements over time in functional capacity and 6MWT distance, most studies failed to demonstrate statistically significant between-group differences, suggesting that accelerated recovery rather than absolute benefit may be the primary effect of structured rehabilitation [27].…”

Home‐Based Combined Activity and Cognitive Intervention for Post‐Intensive Care Syndrome: A Pilot Randomised Controlled Trial

“…Physically, the overall trajectory of recovery in all groups was consistent with the natural functional gains typically seen in the overall trajectory of physical recovery, in which many ICU survivors experience spontaneous gains in functional capacity during the first months following discharge [29]. Exercise trials and systematic reviews have reported similar patterns, with significant within-group increases in 6MWT distance and physical function in both intervention and attention control groups, but only small or inconsistent between-group differences [6,7]. A 2023 systematic review of nine RCTs evaluating post-discharge rehabilitation programs confirmed this pattern: while both intervention and control groups showed improvements over time in functional capacity and 6MWT distance, most studies failed to demonstrate statistically significant between-group differences, suggesting that accelerated recovery rather than absolute benefit may be the primary effect of structured rehabilitation [27].…”

Factors associated with functional recovery after intensive care unit discharge in patients with mechanical ventilation: A multi-centre prospective observational study

“…The definition of rehabilitation intensity after ICU discharge has not been clearly established so far. 4,5 Since rehabilitation time was found to be associated with recovery in ADL after ICU discharge in this study, therefore time was suggested to be an important factor in defining rehabilitation intensity. Second, the results were limited to short-term follow-up.…”

Rehabilitation to enable recovery from COVID-19: a rapid systematic review

“…One high quality RCT [50] involving patients on a general hospital ward after transfer from ICU found no difference in outcomes although reported overall hospital costs were lower for those who received the intervention. Taito and colleagues [45] found no difference in the SF-36 physical and mental components scales, respectively (SMD 0.06, 95% CI −0.12 to 0.24; −0.04, −0.20 to 0.11).…”

“…No summary data on participants. Improved ICU-AW with early rehabilitation (Odds ratio 0.71, 95% CI 0.53 to 0.95); more likely to return home Taito et al 2019 [45] Meta-analysis Post ICU (hospital and community) Adults discharged from ICU Activity limitation; HRQoL; adverse events SF36 physical and mental component scores, ADL function and mortality (1 month and 6 months) Protocolised rehabilitation following ICU discharge earlier than/more intensive than usual care 10 RCTs; 1110 mixed medical/surgical patients. Mean/median age raged from 40.5 to 68.5 years.…”

Home‐Based Combined Activity and Cognitive Intervention for Post‐Intensive Care Syndrome: A Pilot Randomised Controlled Trial

“…Physically, the overall trajectory of recovery in all groups was consistent with the natural functional gains typically seen in the overall trajectory of physical recovery, in which many ICU survivors experience spontaneous gains in functional capacity during the first months following discharge [29]. Exercise trials and systematic reviews have reported similar patterns, with significant within-group increases in 6MWT distance and physical function in both intervention and attention control groups, but only small or inconsistent between-group differences [6,7]. A 2023 systematic review of nine RCTs evaluating post-discharge rehabilitation programs confirmed this pattern: while both intervention and control groups showed improvements over time in functional capacity and 6MWT distance, most studies failed to demonstrate statistically significant between-group differences, suggesting that accelerated recovery rather than absolute benefit may be the primary effect of structured rehabilitation [27].…”

Factors associated with functional recovery after intensive care unit discharge in patients with mechanical ventilation: A multi-centre prospective observational study

“…The definition of rehabilitation intensity after ICU discharge has not been clearly established so far. 4,5 Since rehabilitation time was found to be associated with recovery in ADL after ICU discharge in this study, therefore time was suggested to be an important factor in defining rehabilitation intensity. Second, the results were limited to short-term follow-up.…”

Rehabilitation to enable recovery from COVID-19: a rapid systematic review

“…One high quality RCT [50] involving patients on a general hospital ward after transfer from ICU found no difference in outcomes although reported overall hospital costs were lower for those who received the intervention. Taito and colleagues [45] found no difference in the SF-36 physical and mental components scales, respectively (SMD 0.06, 95% CI −0.12 to 0.24; −0.04, −0.20 to 0.11).…”

“…No summary data on participants. Improved ICU-AW with early rehabilitation (Odds ratio 0.71, 95% CI 0.53 to 0.95); more likely to return home Taito et al 2019 [45] Meta-analysis Post ICU (hospital and community) Adults discharged from ICU Activity limitation; HRQoL; adverse events SF36 physical and mental component scores, ADL function and mortality (1 month and 6 months) Protocolised rehabilitation following ICU discharge earlier than/more intensive than usual care 10 RCTs; 1110 mixed medical/surgical patients. Mean/median age raged from 40.5 to 68.5 years.…”

Home‐Based Combined Activity and Cognitive Intervention for Post‐Intensive Care Syndrome: A Pilot Randomised Controlled Trial

“…Physically, the overall trajectory of recovery in all groups was consistent with the natural functional gains typically seen in the overall trajectory of physical recovery, in which many ICU survivors experience spontaneous gains in functional capacity during the first months following discharge [29]. Exercise trials and systematic reviews have reported similar patterns, with significant within-group increases in 6MWT distance and physical function in both intervention and attention control groups, but only small or inconsistent between-group differences [6,7]. A 2023 systematic review of nine RCTs evaluating post-discharge rehabilitation programs confirmed this pattern: while both intervention and control groups showed improvements over time in functional capacity and 6MWT distance, most studies failed to demonstrate statistically significant between-group differences, suggesting that accelerated recovery rather than absolute benefit may be the primary effect of structured rehabilitation [27].…”

Factors associated with functional recovery after intensive care unit discharge in patients with mechanical ventilation: A multi-centre prospective observational study

“…The definition of rehabilitation intensity after ICU discharge has not been clearly established so far. 4,5 Since rehabilitation time was found to be associated with recovery in ADL after ICU discharge in this study, therefore time was suggested to be an important factor in defining rehabilitation intensity. Second, the results were limited to short-term follow-up.…”

Rehabilitation to enable recovery from COVID-19: a rapid systematic review

“…One high quality RCT [50] involving patients on a general hospital ward after transfer from ICU found no difference in outcomes although reported overall hospital costs were lower for those who received the intervention. Taito and colleagues [45] found no difference in the SF-36 physical and mental components scales, respectively (SMD 0.06, 95% CI −0.12 to 0.24; −0.04, −0.20 to 0.11).…”

“…No summary data on participants. Improved ICU-AW with early rehabilitation (Odds ratio 0.71, 95% CI 0.53 to 0.95); more likely to return home Taito et al 2019 [45] Meta-analysis Post ICU (hospital and community) Adults discharged from ICU Activity limitation; HRQoL; adverse events SF36 physical and mental component scores, ADL function and mortality (1 month and 6 months) Protocolised rehabilitation following ICU discharge earlier than/more intensive than usual care 10 RCTs; 1110 mixed medical/surgical patients. Mean/median age raged from 40.5 to 68.5 years.…”