活動介入方案對重症病人之成效

Abstract

背景：重症後虛弱症（intensive care unit - acquired weakness, ICU-AW）是重症病人常見的症狀，是指發生在重症之後，除了重症疾病的因素之外，找不到其他會造成無力的原因，約有33~55%的重症病人會發生重症後虛弱症的情形，會影響病人呼吸器的脫離，延長住院天數，對於病人的身體活動功能狀態及生活品質都有影響。重症後虛弱症的預防除了積極治療敗血症、維持正常血糖之外，許多研究顯示減少臥床不動及盡早開始運動是有效的，不僅可減少重症後虛弱症的發生，也可改善病人的活動功能狀，進而減少呼吸器使用天數、降低住院天數，但是目前對於重症病人活動的強度、時間及頻率仍缺乏實證基礎。 目的：本研究的目的在於探討重症後虛弱症的發生率，並透過活動介入方案的實施，了解其對重症病人的成效。 研究方法：採隨機控制之研究設計，研究對象為某醫學中心之綜合加護病房所有入住之病人，年齡20歲以上，非預期即將死亡，且生命徵象穩定者，以隨機決定收治對照組或實驗組個案。研究之介入措施為活動介入方案，對照組接受常規照護，實驗組除常規照護外，還接受活動介入方案，活動之內容依其困難度分為六個等級，每日評估病人可執行的活動等級，每次活動約30分鐘，每週五天，活動前、中、後觀察病人生命徵象及任何不適狀況，並紀錄不良事件的發生，活動介入由入住第一天至病人轉出加護病房，或至多三週為止。成效指標包括肌力、握力、關節活動角度、身體組成及呼吸參數的測量。統計方式採用廣義估計方程式（generalized estimating equation, GEE）進行資料分析。 研究結果：研究共收案72位，實驗組35位，對照組37位，以男性、老年患者居多，兩組個案基本資料無統計上之差異，研究結果顯示重症後虛弱症的發生率為22.86%，兩組個案在肌肉力量、雙手握力及呼吸參數均無顯著差異，關節活動角度方面，雙手腕關節伸展、雙腳膝關節屈曲、雙腳踝關節蹠屈及右腳踝關節背屈之關節角度，實驗組的改善情形較對照組多，但未達統計顯著差異，身體組成參數方面，對照組在BMI（body mass index, Wald χ2 = 7.833, p = 0.005）、RMR（resting metabolic rate, Wald χ2 = 5.413, p = 0.020）、FFM（fat free mass, Wald χ2 = 5.722, p = 0.017）、TBW（total body water, Wald χ2 = 6.951, p = 0.008）、ECW（extracellular water, Wald χ2 = 5.569, p = 0.018）、ICW（intracellular water, Wald χ2 = 7.098, p = 0.008）、glycogen（Wald χ2 = 5.753, p = 0.016）、Dry Weight（Wald χ2 = 5.232, p = 0.022）、ECF（extracellular fluid, Wald χ2 = 5.627, p = 0.018）、plasma fluid（Wald χ2 = 5.617, p = 0.018）和body volume（Wald χ2 = 4.280, p = 0.039）等參數的下降情形顯著高於實驗組。若依介入時間30分鐘為切點共分為三組進行劑量-反應分析，結果顯示右手肘關節屈曲肌力及左手腕關節屈曲角度有顯著差異，其餘肌力、握力、關節活動角度、身體組成及呼吸參數各項指標均無顯著差異。 討論與結論：研究結果顯示多數結果指標無統計上的顯著差異，經分析可能原因為：（1）個案數過少，統計檢力不足；（2）活動介入強度多為被動運動，缺少主動之抗阻力運動，對肌力的恢復較無幫助；（3）欠缺介入措施執行完整性的檢討與改善機制；（4）其他如自然病程進展、其他有違研究目的之照護活動、環境因素之霍桑效應等情形有關。本研究之限制在於（1）研究樣本數過少，難以推論至其他族群；（2）隨機控制研究設計於研究場所易產生霍桑效應；（3）研究工具指標可能受到病人因素等影響測量結果。建議未來可以增加收案之樣本數、採其他研究設計方式以減少兩組個案的霍桑效應、並且持續監督及檢討研究執行狀況。

Background: Intensive care unit-acquired weakness (ICU-AW) is a common symptom among critically ill patients. It refers to a clinical diagnosis of weakness experienced by approximately 33% to 55% of critically ill patients for which there is no alternative etiology other than critical illness. Implications of ICU-AW include delayed weaning of the ventilator, prolongation of hospitalization, physical activity impairment, and compromised quality of life of the patient. In addition to the active treatment of sepsis and the maintenance of a normal blood sugar level, multiple studies have indicated that reducing bed rest and starting exercise immediately are effective in preventing ICU-AW. These measures mitigate ICU-AW incidence and improve the patient's functional status, thereby shortening the length of both respirator use and hospitalization. However, currently, there is, insufficient empirical evidence on the intensity, time, and frequency of critically ill patients' appropriate activities. Purpose: This study aims to explore the incidence rate of ICU-AW, and through the implementation of activity intervention program to investigate its effectiveness on critically ill patients. Methods: This study included all patients admitted to an intensive care unit (ICU) of a medical center, who were over 20 years of age, were not expected to die, and demonstrated stable vital signs using a randomized control design. These patients were subsequently divided into a control group and an experimental group randomly. During the study, the control group received routine care only. Alternatively, in addition to routine care, the experimental group also participated in a physical activity intervention. The intervention was categorized into six levels according to difficulty. Further, patients in the experimental group were assigned an appropriate activity level according to the daily assessment. The frequency of the intervention was five days a week, each with a length of 30 minutes. Patients' vital signs, discomfort, and any adverse incidences were recorded before, during, and after the intervention. The intervention started as soon as the patient was admitted and was concluded either when the patient left the ICU or completed a maximum of three weeks. Outcome indicators included muscle strength, grip strength, range of motion (ROM), and body composition and respiratory parameters. Statistical analysis was conducted using the generalized estimating equation (GEE). Results: The study recruited 72 patients—35 in the experimental group and 37 in the control group. Most participants were male and elderly patients, with no statistical differences between the two groups' basic data. Results revealed that the incidence rate of ICU-AW was 22.86%, and suggested that while there were no significant differences between the muscle strength, grip strength, and respiratory parameters of the two groups, the experimental group displayed improved ROM. Including degrees in both wrists' extension/flexion, both knees' flexion, both feet's plantar flexion, and the dorsiflexion of the right ankle, although the difference was not statistically significant. In addition, in terms of body composition parameters, the control group showed a considerably larger drop in body mass index (BMI) (Wald χ2 = 7.833, p = 0.005), resting metabolic rate (RMR) (Wald χ2 = 5.413, p = 0.020), fat free mass (FFM) (Wald χ2 = 5.722, p = 0.017), total body water (TBW) (Wald χ2 = 6.951, p = 0.008), extracellular water (ECW) (Wald χ2 = 5.569, p = 0.018), intracellular water (ICW) (Wald χ2 = 7.098, p = 0.008), glycogen (Wald χ2 = 5.753, p = 0.016), Dry Weight (Wald χ2 = 5.232, p = 0.022), extracellular fluid (ECF) (Wald χ2 = 5.627, p = 0.018), plasma fluid (Wald χ2 = 5.617, p = 0.018), and body volume (Wald χ2 = 4.280, p = 0.039), compared with the experimental group. Subsequently, the control group and the experimental group were further divided into three subgroups according to the intervention's length with a cut-off of 30 minutes for dose-response analysis. Results indicated the right hand elbow MRC score and degree of left wrists’ extension were significant differences; and no significant differences in other muscle strength, grip strength, ROM, body composition, and respiraotry parameters among these three groups. Discussion and conclusion: Our results suggested that most outcome indicators were not significantly different between the control and experimental groups. Possible reasons include: (1) the sample size was small, which could lead to an inadequate statistical power; (2) the implemented physical activity intervention primarily comprised passive ROM rather than active resistance exercises, which could not be helpful for the recovery of muscle strength; (3) lack of process evaluation for intervention integrity; and (4) other factors, such as the natural progression of the disease, care activities that violated purposes of the research, and environmental factors, such as the Hawthorne effect, could have contributed to this insignificance. Limitations of this study include: (1) the sample size was small, limits the generalizability of the findings; (2) the adopted randomized control design was prone to the Hawthorne effect; and (3) the outcome indicators could be affected by the patient and other factors. It is recommended that for future studies, the number of samples should be increased, different research methods should be utilized to minimize the Hawthorne effect between the control and the experimental groups, and the intervention's implementation should be continuously monitored and reviewed.