PHYSICAL THERAPY PRACTICE IN INTENSIVE CARE UNIT: A SURVEY

AMONGST PHYSICAL THERAPIST

A SYNOPSIS SUBMITTED TO

INSTITUTE OF PHYSICAL MEDICINE AND REHABILITATION

DOW UNIVERSITY OF HEALTH SCIENCES

For the partial fulfilment of the degree of

DOCTOR OF PHYSICAL THERAPY

DATE OF SUBMISSION: 24/5/2016

RESEARCHERS:
ABDUL HAMEED (student of DPT)

Signature:
UROOJ HAMID (student of DPT)

Signature:
SUPERVISOR:
Dr. RABAIL RANI SOOMRO (PT)
Asst. Professor (Physiotherapy)
Institute of Physical Medicine and Rehabilitation (IPMR)
Dow University of Health Sciences (DUHS)

Signature:

pg. 1
 PHYSICAL THERAPY PRACTICE IN INTENSIVE CARE UNIT: A SURVEY

AMONGST PHYSICAL THERAPIST

ABSTRACT

INTRODUCTION:

Physiotherapy is an essential component for patient management in ICU as Physical therapists

work with the multi-disciplinary team. Due to delayed immobilization the patients face many

difficulties as neuromuscular problems, respiratory complications, musculoskeletal issues etc.

There has not been any study done to see the awareness and guidelines of critical care

management in Pakistan as far as the author’s knowledge is concerned.

OBJECTIVE: To assess the physical therapy practices in intensive care unit amongst

physical therapist in Karachi.

METHODOLOGY: Study will be conducted through questionnaire based survey among

physical therapists working in ICU’s. Informed consent will be taken prior fulfilling the

questionnaire.

STUDY DESIGN: A Cross Sectional Survey

SAMPLING TECHNIQUE: Convenience Sampling Technique

SAMPLE SIZE: Estimated sample size will be 97.

STUDY DURATION: 3 Months after approval of synopsis

STUDY SETTING: Physiotherapist of Civil hospital Karachi, Dow University Hospital Ohja

campus, Institute of physical medicine and rehabilitation (IPMR), Dr Zia Uddin hospital, Hill

Park General Hospital, Jinnah postgraduate medical centre, Patel Hospital, and Ashfaq

Memorial Hospital.

pg. 2
DATA ANALYSIS: Data will be entered in SPSS Version 20. Frequencies and percentages

will be taken out for all categorical variables. Chi-square test will be applied as test of

significance to find association between two categorical variables. P-value less than 0.05 will

be considered significant.

KEY WORDS:

Physical therapy practice, intensive care unit.

pg. 3
INTRODUCTION

Physical therapists are recommended in ICU to deal with critically ill patient, which being a

challenge requires thorough background knowledge related to pathophysiology of disease,

field expertise and fine skills.

Physical therapy plays an essential role for patient management in intensive care unit as a

participant of the multidisciplinary team in dealing the problems and to continue the functional

skills. Physical therapists duty in the ICU is specific considerably varies from one entity to the

next, reliant on aspects like Educational levels, Physical therapy training and proficiency [1].

In some areas of Europe like Netherlands, Sweden, Switzerland, and in Australia Physical

Therapist are involved hardly with patients to wean off from mechanical ventilator (MV), in

contrast to it more than 50% of physical therapists in Portugal and Belgium usually contribute

in weaning patients from mechanical ventilator (MV). [2]The patients on mechanical

ventilation (MV) have decreased muco-ciliary airway clearance, in combination with decreased

expiratory flow, results in collection of secretions. [3]

Approx. 56% of the time, mobilization out of bed was used as an intervention stated by

Canadian Physical therapists. 100% of the time in Saskatchewan and 33% of the time in Nova

Scotia was applied locally. In Germany community hospitals, as compared to university and

university-affiliated hospitals greater numbers of patients were mobilised out of bed. With

regard to training, 29% of European physical therapists stated postgraduate speciality in ICU

therapy, and 43% reported postgraduate specialization in respiratory therapy, the greatest

extent from the United Kingdom as well. [2]

It is apparent that early rehabilitation and chest physical therapy is everyday job of a physical

therapist in the ICUs. Many elements may impact physical therapy practice in ICUs in India,

when contrasted to ICUs in developed nations, such as awareness about the method,

pg. 4
accessibility of the apparatus, training or instruction of the physical therapist, availability of

respiratory physical therapist. Other important factors such as patient proportion, state of mind

of other medical experts toward physical therapy, medical administration of the patient, (for

example, sedation practices, methods of ventilation preferred, inclination for initial

tracheostomy), proof based practice concerns , case-mix of unit, and open versus shut ICUs.

[4]

Patients in Intensive Care Units (ICU) are regularly presented to delayed immobilization,

which can assume an important part in creating neuromuscular problems linked with expanded

length of hospital stay and higher mortality and with debilitated useful status that can be

identified years after hospital discharge, negotiating patients’ excellence of life. [5]

Many patients in ICU need invasive ventilator support to help and subsequently subject not

just to pick up benefits from the institution of that backing, for example, decreased work of

breathing and maintain gaseous exchange. The procedure of chest compression alone is not

generally effective. Chest compression combined with a 10-cmH2O increase in baseline

inspiratory pressure on pressure support ventilation in relation with that of aspiration alone, in

eliminating secretions, maintaining hemodynamic, and in patient with mechanical ventilator

support enhance respiratory mechanics. [3]

Early mobilization have been accounted to enhance functional mobility, support weaning from

mechanical ventilator (MV), and decreases risk of readmissions are the services provided by

physical therapist in ICUs. [2]

The purpose of physical therapy techniques in ICUs mean to improve muco-ciliary clearance

and consequently avoid bronchial obstruction brought about by accumulation of secretions.

Together with alteration of ventilator settings, can bring about more improvement in clearing

the secretions. [3]

pg. 5
There has not been any study done to see the awareness and guidelines of critical care

management in Pakistan as far as the author’s knowledge is concerned. The aim of this study

is to highlight the level of training and awareness of the physical therapy guidelines of critical

care management.

RATIONALE OF THE STUDY:

As ICU based rehabilitation services include most challenging task, performed by the physical

therapist, there is need to assess the practice of physical therapist regarding knowledge, skills

and attribute to work in ICU so that the barrier could be identified in utilization of evidence

based physical therapy practice.

SIGNIFICANCE:

The findings of this study will provide awareness to the present physical therapy practice being

implemented in ICUs. These findings will help physical therapists in ICU to enhance their

training and developing approaches to ensure adequate ICU rehabilitation services according

to evidence based services. The study is being held to check the awareness and guidelines of

physical therapy in ICU in Karachi, Pakistan. The study will make base for further studies to

be conducted in Pakistan.

pg. 6
OPERATIONAL DEFINITIONS:

Muco-cilairy airway clearance:

Muco-ciliary clearance is a type of defence mechanism of the respiratory tract protecting it

from foreign bodies.

Invasive ventilation

Ventilation given through an endotracheal tube injected into the patient’s nose or mouth, or

over a tracheostomy.

Mechanical ventilation

It is a technique which delivers gas towards the lungs and out from the lungs through and

external device directly connected to the patient.

Sedation

It is a relaxed, calm or sleepy state caused by a drug for relaxing a patient.

Tracheostomy

It is a surgical opening into trachea through neck for allowance of entry of air.

Evidence based practice

It is the utilization of clinical decision making for patient administration taking into account

research proof, clinical aptitude, understanding patient values and preferences and clinical

circumstances.

pg. 7
OBJECTIVE OF THE STUDY:

To assess the physical therapy practices in intensive care unit amongst physical therapist in

Karachi.

MATERIAL & METHODS

A self-administered questionnaire will be distributed among the individuals those who fulfil

the inclusion criteria after clarifying the purpose behind the study and informed consent will

be taken prior fulfilling the questionnaire.

SAMPLE DESCRIPTION:

Inclusion Criteria:

 Physical therapist doing practice in ICU and wards (both male and female)

 Physical therapist having experience of working in ICU for at least six months

Exclusion Criteria:

 Physical therapist who do not have experience to work in ICU.

 Physical therapist students

 Physical therapist technicians

RESEARCH DESIGN:

Cross-sectional self-reported questionnaire survey design.

SAMPLING TECHNIQUE:

It is a convenience sampling technique.

pg. 8
STUDY SETTING:

Physical therapist of:

 Civil Hospital Karachi

 Dow University Hospital Ohja Campus

 Institute of Physical Medicine and Rehabilitation (IPMR)

 Jinnah Postgraduate Medical Centre

 Dr Zia Uddin Hospital

 Patel Hospital

 Hill Park General Hospital

 Ashfaq Memorial Hospital

STUDY PERIOD:

3 months after the approval of synopsis.

SAMPLE SIZE:

Sample size of 97 calculated through Open Epi version 3.0 with a hypothesized frequency of

92%, confidence limits of 5%, data effect of 1% and confidence level 97%. [4]

DATA COLLECTION:

A self-administered questionnaire will be circulated among the individuals after explaining the

motivation of the study and consent will be taken from all participants.

Questionnaire Design:

A self-administered questionnaire includes 10 mix questions (open and closed ended) derived

from the literature. A pilot study will be directed to guarantee that members would have the

capacity to comprehend the inquiries. It will be accepted that if the members fill the survey

pg. 9
then this would be considered as assent for support in the study. The Questionnaire will be

partitioned into 2 sections, one will survey the demographic points of interest of the member

keeping in mind other one evaluates the awareness of physical therapy practice.

ETHICAL CONSIDERATION:

Informed consent will sought from Head of departments of all selected departments and

randomly selected students.

DATA ANALYSIS/ STATISTICAL TECHNIQUES:

Data will be analysed using SPSS Version 20. Frequencies and percentages will be taken out

for all categorical variables. Chi-square test will be applied as test of significance to find

association between two categorical variables. P-value less than 0.05 will be considered

significant.

SPECIALITY OF INVESTIGATORS AND THEIR CONTRIBUTION:

CHIEF INVESTIGATORS:

ABDUL HAMEED (student of DPT)

UROOJ HAMID (student of DPT)

SUPERVISORS:

Dr. RABAIL RANI SOOMRO (PT)

Asst. Professor (Physiotherapy)

Institute Of Physical Medicine and Rehabilitation (IPMR)

Dow University of Health Sciences (DUHS)

pg. 10
REFERENCES

1. Tadyanemhandu c, manie. Profile of patients and physiotherapy patterns in intensive

care units in public hospitals in Zimbabwe: a descriptive cross-sectional study .BMC

A. 2015; 15:136.

2. Malone D, Ridgeway K, Craft AN, Moss P. Schenkman M, Moss M. Physical Therapist

Practice in the Intensive Care Unit: Results of a National Survey. APTA. 2015 October;

95(10):1335-44.

3. Nave WS, Forgiarini Junior LA, Dias AS, Vieira SRR. Chest compression with a higher

level of pressure support ventilation: effects on secretions removal, hemodynamic and

respiratory mechanics in patients on mechanical ventilation. JBP.2014; 40(1):55-60.

4. Bhat A, Chakravarthy K, Rao BK. Chest physiotherapy techniques in neurological

intensive care unit of India: A survey. IJCCM.2014 June; 18(6):363-68.

5. Santos LJD, Lemos FDA, Bianchi T, Sachetti A, Acqua AMD, Nave WDS, et’ol. Early

rehabilitation using a passive cycle ergometer on muscle morphology in mechanical

ventilated critically ill patients in intensive care unit (move ICU study): study protocol

for a randomized controlled trail.BMC.2015 August 28; 16:383.

pg. 11
 INFORMED CONSENT
You are invited to take part in research “Physical Therapy Practice in Intensive Care Unit:
A Survey Amongst Physical Therapist”. This research is being conducted by the students of
DPT, Institute of Physical Medicine and Rehabilitation, DUHS. We want you to read this form
before agreeing to be a part of the research.

PURPOSE:
The purpose of the research is to evaluate the Physical therapy practice in Intensive Care Unit.

PROCEDURES:
If you agree to be in this research, and sign this consent form, we ask that you fill out a
questionnaire. The questionnaire should take only 5-10 minutes of your time.

RISKS AND BENEFITS:

You will be asked to answer questions which may be personal, but the information will not be
shared with anyone else. You may refuse to answer any questions on the form. We will not
share with anyone, the specific details you tell us.

The benefit of this study is that as students will get to know their stress levels they may be able
to figure out the coping mechanism in accordance to their hectic environment.

CONFIDENTIALITY:
The records of this study will be kept confidential. Anything you tell us will remain
confidential. In any sort of report of the study, we will not include any information that will
make it possible to identify you. The surveys will be kept in a locked file; only the researchers
for this study will have access to the records.

VOLUNTARY NATURE OF STUDY:

Your decision whether or not to participate in this research is voluntarily. Even if you sign the
consent form, you are free to stop doing the survey at any time.

I have read the above information and understand that this survey is voluntary and I may
stop at any time. I consent to participate in the study.

SIGNATURE OF PARTICIPANT

SIGNATURE OF RESEARCHER

pg. 12
 INFORMATION SHEET

You are invited to take part in research “Physical Therapy Practice in Intensive Care Unit:
A Survey Amongst Physical Therapist”. This research is being conducted by the students of
DPT, Institute of Physical Medicine and Rehabilitation, DUHS. We want you to read this form
before agreeing to be a part of the research.

PURPOSE:

The purpose of the research is to evaluate the Physical therapy practice in Intensive Care Unit.

PROCEDURES:

If you agree to be in this research, and sign this consent form, we ask that you fill out a
questionnaire. The questionnaire should take only 5-10 minutes of your time.

RISKS AND BENEFITS:

You will be asked to answer questions which may be personal, but the information will not be
shared with anyone else. You may refuse to answer any questions on the form. We will not
share with anyone, the specific details you tell us.

The benefit of this study is that as students will get to know their stress levels they may be able
to figure out the coping mechanism in accordance to their hectic environment.

CONFIDENTIALITY:

The records of this study will be kept confidential. Anything you tell us will remain
confidential. In any sort of report of the study, we will not include any information that will
make it possible to identify you. The surveys will be kept in a locked file; only the researchers
for this study will have access to the records.

VOLUNTARY NATURE OF STUDY:

Your decision whether or not to participate in this research is voluntarily. Even if you sign the
consent form, you are free to stop doing the survey at any time.

I have read the above information and understand that this survey is voluntary and I may
stop at any time. I consent to participate in the study.

pg. 13
 RESEARCH TOPIC :

PHYSICAL THERAPY PRACTICE IN INTENSIVE CARE UNIT: A SURVEY

AMONGST PHYSICAL THERAPIST

Read the following questions and tick the relevant answers according to your practice.

Name Age Gender

HOSPITAL __________________________ Qualification: ______________
Experience working in ICU: __________________ Contact number (optional) ___________

1. What kind of hygiene routine you use while dealing with patients?
You can tick as many as apply
Gloves Face Mask Head Cover Gown
2. Do you check GCS before every physiotherapy session in critically ill patients?
Yes No
1. Do you think physical inactivity in critically ill patient may result in the development
of neuro muscular weakness and delayed weaning from mechanical ventilation?
Yes No
2. Which physical therapy intervention you mostly use in ICU patient?
Mobilization PROM and AROM exercises Chest physical therapy
Postural Drainage Other ______________________
3. According to guidelines 20 mins mobilization is recommended to improve functional
performance for how much time you mobilize patient?
05 mins 10 mins 15 mins 20 mins
4. Which physical therapy technique you use for expectorating out secretions in critically
ill patients?
Suctioning chest compression huffing and coughing positioning
5. Which physical therapy technique do you use to increase lung compliance?
Incentive spirometry thoracic expansion exercises blowing exercise
6. Do you think aggressive chest physical therapy is needed after weaning off patient from
mechanical ventilation?
Yes No
If yes; which therapy you prefer for aggressive chest physical therapy?

7. Do you use mechanical chest physical therapy in ICU?

pg. 14
 Yes No
If yes; which modality you prefer?

8. Which physical therapy intervention you mostly use in ICU patient?

Mobilization PROM and AROM exercises Chest Physical therapy
Postural Drainage Other ______________________
9. Which physical therapy do you use to increase lung compliance?
Incentive spirometry thoracic expansion exercises blowing exercise
ACBT’s IDT’s Others_________
10. Do you prefer positioning as a treatment plan for patients admitted in ICU with bed
sores?
Yes No
If Yes, after how many hours?

pg. 15