Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients

Article Reviews
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Read Full Text for Free: 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 (Free)
Journal: Intensive Care Medicine
Year Published: 2014
Ranked 10th on our 2014-2019 list of the 50 most influential articles

Article overview for OT practitioners

Cognitive impairment is common in the ICU, and it can be debilitating for the patients that experience it.

Since early mobility has been shown to be beneficial to ICU patients, the question becomes whether early cognitive therapy could also be beneficial when combined with physical rehabilitation.

This article sought to establish whether a cognitive therapy program is feasible and safe for ICU patients. It did not, however, seek to establish whether this type of program actually works.

The study found that the cognitive therapy protocol is, in fact, both feasible and safe.

Unfortunately, the outcome measures that they did track didn’t show the functional benefit of the cognitive therapy. However, the study was not large enough to really explore efficacy anyway, so more research is needed.

About the ICU patients

87 patients from the medical and surgical intensive care units at Vanderbilt University Medical Center were included in this study. Patients were all 18 years or older and had undergone one or more of the following:

  • Respiratory failure
  • Septic, cardiogenic, or hemorrhagic shock

Those who had been critically ill for longer than 72 hours were excluded. Please see the article for more details on inclusion.

The patients were divided into three groups:

  • Usual care
  • Early physical therapy only
  • Early cognitive therapy plus physical therapy (note that there was not a group of patients that received cognitive therapy without the PT component).

About the cognitive therapy protocol

Patients on the cognitive therapy protocol received cognitive therapy sessions twice daily, which began within 24 hours of inclusion in this study. Keep in mind that this cognitive therapy was delivered in addition to receiving physical therapy once per day.

Per the protocol, research nurses and physicians delivered the cognitive therapy sessions.

Cognitive tasks were designed to address:

  • Orientation
  • Memory
  • Attention
  • Delayed Memory
  • Problem Solving
  • Processing Speed

The cognitive exercises included:

  • Orientation exercises
  • Digit span forward
  • Matrix puzzles
  • “Real world” exercises
  • Pattern recognition
  • Digit span reverse
  • Noun list recall
  • Paragraph recall
  • Letter-number sequences

Once discharged home, patients with lingering cognitive and functional deficits continued cognitive therapy for 6 sessions over 12 weeks using Goal Management Training (GMT).

To see a full breakdown of the protocol:

A Combined Early Cognitive and Physical Rehabilitation Program for People Who Are Critically Ill: The Activity and Cognitive Therapy in the Intensive Care Unit (ACT-ICU) Trial (Free)

Assessments

Possible documentation

The study “Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients” (2014) provided evidence that conventional ICU rehab programs can safely be extended to include cognitive therapy. In the absence of a formal cognitive therapy program in this facility, OT has derived key functional cognition components from an established protocol. As this patient demonstrates cognitive deficits, it is this therapist’s belief that early cognitive interventions delivered via OT are an integral part of the rehabilitation process.

Key take-aways

1.) Early functional cognition is an important consideration for OTs in the ICU. It is my personal opinion that occupational therapists are better poised than research nurses and physicians to address cognition in the ICU.

The protocol included in this study provides a great starting point for anyone looking to incorporate cognitive interventions into their ICU care. GMT also seems to be a good option for OTs seeking to address cognition in the outpatient setting.

2. The exact details of which type(s) of cognitive therapy should be utilized, when it should be delivered, and who should manage this type of care are still undetermined. From what I can tell, this protocol has not progressed on to the stage of efficacy testing. And, as I mentioned above the outcome measures, albeit from a small sample, did not not scream that this exact protocol as delivered by the research nurses and physicians is the most effective treatment. We all know how important cognition is in the ICU so I would expect more research and exploration of this topic.

3. Personal note: I’m annoyed by the use of physical therapy in this article. The protocol upon which this feasibility trial was based refers to “physical rehabilitation,” and couples OT and PT as that physical rehabilitation team throughout the article. This article, on the other hand, only uses physical therapy in the title instead of mentioning both professions.

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What questions/thoughts does this article raise for you?

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Lol. I love your personal thoughts on this article. It seems that so often we are linked with PT, starting with how orders are “checked” even. In home health, we often have the same box for OT/PT with it literally being printed like this for the MD to mark. How do we begin advocating for this separation? What are thoughts on this?

On a more direct note, I am not surprised by some of these findings. What comes to mind is something released by AOTA on cognition, emphasizing the need to make it functional and engaging, not merely rote and isolated to specific skills (ie using lists).

I am taking more interest in the ACL and find it very helpful in home health (and have WAAAAY more to learn still, too). I am SO glad that OT is included and agree on the need for OT to address cognition in the ICU. It seems that there are more occupation-based ways to address (and assess it) thought. Perhaps this would fall under more “real world” exercises.

I’d love to hear from an OT in ICU about what is most helpful for building and assessing these skills on such a dynamic unit for OT. It also makes me think of a cognitive kit for cognitive rehab. I wonder if any OTs in ICU use one with “real world” props in it. Or what would YOU put in a cognitive kit for improving cognition?

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What a tricky place to do a study like this hey? Focussing on the cognitive issues: why do people recovering from the ICU have cognitive issues in the first place? I’d imagine there are many reasons, and each case is different so the population is already highly heterogenous when it comes to their cognitive function. Sarah, you and Monika both bring up good points about the challenge in differentoating PT and OT in acute medical settings as well as the importance of actual occupation rather than rote cognitive tasks.

I think a big part of the confusion with PT/OT in acute medicine is that we are used as PTs. Actually the example OT note you made Sarah about the patient with carpal tunnel issues is a great example. While it’s not in an acute setting, reading the description of intervention I would not be able to tell if it was a PT note or an OT one. Occupation has to be what we use to differentiate ourselves otherwise we look just like PT.

So, in acute settings how do we do that? I wonder if it begins with helping people do real things like make some phone calls, check their emails, read, learn something new, do some work related tasks, get some group stuff going with other patients somehow, etc… I bet that would be more stimulating and meaningful to most people and have a better outcome. Plus it would be occupation based.

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Hey @monika! I’m linking the AOTA article that I bet you are referring to!

I love your idea of a cognition kit. I’ve also been thinking about working with the patient/client to identify cognitive tasks that they have a previous established baseline on, like checking their email, writing to-do lists or even if they have a favorite game to play on their phone. For example, I know my little sister has a well-established baseline on several games on her phone and would consider those some of her top leisure activities!

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Hey @DevonCochrane! Yes, the more research I read the more convinced I am that treatment needs to occupational therapy based and meaningful. For example, if I was in acute care I would want my therapist to help me get back to leisure ready, writing a daily to-do list, and checking my email.

I also like your feedback on the example note that I wrote: https://club.otpotential.com/t/example-outpatient-occupational-therapy-eval-carpal-tunnel-release/147/3

If any hand therapists stumble into this thread, I would love tips for making it more occupation based.

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Completely agree with your comments, Sarah. I work primarily in ICU and address cognition frequently. It is especially important in determining discharge recommendations. Occupation based treatment sessions highly the patient’s strengths and needs in such a more meaningful way than mobilization or exercise alone. Although the environment itself is limited, there are many ways to include occupation based interventions, grade them up or down and incorporate occupations of meaning from patient’s lives. Although I have considered the idea of a “cognition kit” I have not yet developed one due to concerns of infection control and difficulty with customization. However, that is the beauty of OT, we are creative and able to problem solve to make the best of what is available!

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