Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial

Abstract

Purpose: Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness.

Methods: We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%).

Results: Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up.

Conclusions: This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.

Figure 1

Inpatient intervention protocols began within 24 hours of study enrollment and continued until hospital discharge for the cognitive therapy intervention or until the patient had independently ambulated more than 200 feet and required no assistance in performing activities of daily living (ADLs) on two consecutive study days for the physical/occupational therapy intervention. The study protocol has been described in detail previously.[9] Briefly, cognitive therapy was delivered in 20-minute sessions, twice each day. We chose exercises that targeted neurocognitive domains commonly impaired in survivors of critical illness including orientation (e.g., orientation exercises), memory/attention (e.g., digit span forward, digit span reverse, noun recall, paragraph recall and letter-number sequences), delayed memory (e.g., digit span reverse), and problem solving/processing speed (e.g., matrix puzzles, ‘real world’ exercises and pattern recognition). Physical therapy was delivered in a single session each day. RASS, Richmond Agitation-Sedation Scale; ROM, Range of Motion; ADL, Activities of Daily Living

Figure 2

Screening, randomization, and participant follow-up ^a Unable to physically complete any follow-up testing (i.e., could not move discs for the Tower Test or hold a pencil to complete MMSE testing) ^b CAM-ICU positive on the day of hospital discharge ICU = intensive care unit

Figure 3

Proportion of hospitalized, alert (RASS −1 to +1) patients meeting cognitive therapy milestones on each of the first 10 days of the study. Each of the shaded areas represent the proportion of patients who performed at least one problem correctly for each milestone exercise on a given study day