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.
Open accessAbstract
PurposeCognitive 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.MethodsWe 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 (%).ResultsEarly 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.ConclusionsThis 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.
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Palliative care interventions had no significant impact on family satisfaction with care, ICU length of stay, hospital length of stay, or mortality.
“Palliative care interventions had no significant impact on family satisfaction with care, ICU length of stay (543, 545-548), hospital length of stay (543, 545, 548), or mortality (543, 545, 548).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [543]
The Results (Follow-up Outcomes; page unavailable) report no between-group differences in ICU length of stay, hospital length of stay, or mortality. But this trial tested cognitive and physical therapy, not palliative care, and the Methods (Follow-up Outcomes Assessment; page unavailable) do not list family satisfaction as an outcome. The cited paper therefore supports only the reported findings for those three outcomes in a different intervention. (LLM, conf=0.89)
Experimental — accuracy not yet measuredNeither study demonstrated an effect of interventions on mortality.
“Neither study demonstrated an effect of interventions on mortality.”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [543]
Carson et al. found an increase in PTSD symptoms in family surrogate decision makers with palliative care consultation.
“In contrast, Carson et al. found an increase in PTSD symptoms in family surrogate decision makers with palliative care consultation (543).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [543]
The Results and Discussion sections address cognitive and physical therapy for critically ill patients, not palliative care consultation or PTSD symptoms in family surrogate decision makers. Searches for Carson and for the claimed PTSD and palliative-care outcome found no passage addressing it in our copy. (LLM, conf=0.78)
Experimental — accuracy not yet measuredStudies have evaluated palliative care interventions in the ICU but not specifically in patients with sepsis.
“Studies have evaluated palliative care interventions in the ICU but not specifically in patients with sepsis (543,(545)(546)(547)(548).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [543]
The Methods (Study Procedures; page unavailable) describe early physical and cognitive therapy in ICU patients, and the Eligibility Criteria include patients with septic shock among a broader population. Neither those passages nor the Introduction addresses palliative care interventions or whether such studies specifically enrolled patients with sepsis; searches for palliative care and sepsis-related terms found no passage establishing the claim. (LLM, conf=0.75)
Experimental — accuracy not yet measuredIn an analysis of older adults with severe sepsis, one study found that the combination of early home health care and a visit with a medical provider was associated with a reduced readmission risk.
“In an analysis of older adults with severe sepsis, one study found that the combination of early home health care and a visit with a medical provider was associated with a reduced readmission risk (631).”
From Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. (2021) · cites this paper as [631]
The Methods sections describe ICU cognitive and physical therapy for adults with critical illness, followed in some cases by in-home cognitive therapy. The Follow-up Outcomes section does not assess readmission. Searches for home health care, medical-provider visits, and readmission risk found no passage addressing the claimed association in older adults with severe sepsis. Page numbers were unavailable in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Some small single centre studies tested specific early cognitive therapies to enhance cognitive and overall functional recovery after critical illness.
“Some small single centre studies tested specific early cognitive therapies to enhance cognitive and overall functional recovery after critical illness [634, 635].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [634]
A proof-of-concept single-centre pilot study found the multi-faceted early cognitive intervention feasible and safe, but underpowered and inconclusive regarding clinical effects on cognitive function and health-related quality of life at 3 months.
“The results demonstrated that the intervention was feasible and safe, but the study was underpowered and therefore inconclusive regarding its clinical effects on cognitive function and health-related QoL outcomes at 3-month follow-up.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [634]
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.
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- Authors
- Brummel, N. E., Girard, T. D., Ely, E. W., Pandharipande, P. P., Morandi, A., Hughes, C. G., Graves, A. J., Shintani, A., Murphy, E., Work, B., Pun, B. T., Boehm, L., Gill, T. M., Dittus, R. S., & Jackson, J. C.
- Affiliations
- Vanderbilt University (US)
- Vanderbilt University Medical Center (US)
- Yale University (US)
- Corresponding author
- Brummel, N. E.
- ORCID
- Venue
- Intensive Care Medicine
- Published
- 2013-11-21
- Volume
- 40
- Issue
- 3
- Pages
- 370-379
- ISSN
- 0342-4642 (ISSN-L)
- 1432-1238
- PMC
- PMC3943568
- OpenAlex
- W2019032950
- Semantic Scholar
- 39969e708d7eb3dcedde2b4641c39b2125d820aa
- Cited by
- 256
- References
- 47
- Citations by year
- 2026: 15 · 2025: 16 · 2024: 16 · 2023: 22 · 2022: 22 · 2021: 36 · 2020: 18 · 2019: 29 · 2018: 22 · 2017: 18 · 2016: 13 · 2015: 20 · 2014: 9
- FWCI
- 12.34
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Intensive Care Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Institutional Research Information System (Università degli Studi di Brescia) (submittedVersion)
- Funders
- U.S. Department of Veterans Affairs
- Vanderbilt University (UL1‐TR000445)
- Vanderbilt University Medical Center (UL1TR000445)
- National Institutes of Health (UL1TR000445)
- Clinical Science Research and Development
- Geriatric Research Education and Clinical Center
- National Institute on Aging (R03AG045095, K24AG021507, K07AG043587, R01AG035117, K23AG031322, K23AG034257, R01AG027472, P30AG021342)
- National Heart, Lung, and Blood Institute (R01HL111111, T32HL087738)
- NIH Clinical Center
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Intensive Care Unit Cognitive Disorders
- Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
- Keywords
- cognitive therapy, physiotherapy, early rehabilitation, critical illness, cognitive impairment, intensive care unit patients, respiratory failure, shock, feasibility, safety, health-related quality of life, functional outcome
- MeSH terms
- Adult, Aged, Exercise Therapy, Feasibility Studies, Female, Humans, Intensive Care Units, Male, Middle Aged, Occupational Therapy, Pilot Projects, Quality of Life, Surveys and Questionnaires, Cognitive Behavioral Therapy, Critical Illness, Treatment Outcome, Cognitive Dysfunction
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