Cycling through intensive care: Researchers help critically ill older patients get stronger with in-bed bicycling

Even if a person is quite mobile before an illness or injury lands them in intensive care, there’s a serious risk they will not be getting around too easily by the time they leave. In fact, research shows that 60 per cent of people who are able to walk before an ICU stay are unable to walk seven days after they leave.

“People in the ICU are on life support… they can become very weak, losing 17 per cent of their thigh muscle mass after seven days of bed rest,” notes Dr. Michelle Kho, associate professor in the School of Rehabilitation Sciences at McMaster University in Hamilton, Ontario. “For older people, who may already be compromised, the impact on their physical function, independence and quality of life can be devastating.”

As a physiotherapist and Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation, Dr. Kho wants to help ICU patients maintain as much strength as possible during their stay. Based on a study from Belgium that started in-bed cycling two weeks after a patient was admitted to ICU, she determined that this technology could be just the tool to help patients maintain muscle mass and mobility, even while on mechanical ventilators in the ICU. Her next step was to find funding.

With [CFN] support, we were able to get started with a feasibility and safety study in four centres in Ontario—three in Hamilton, one in Toronto—then add more centres when we received additional funding.

“The Canadian Frailty Network was the first to come on board with the critical cornerstone funding that allowed us to start the research,” remarks Dr. Kho. “With their support, we were able to get started with a feasibility and safety study in four centres in Ontario—three in Hamilton, one in Toronto—then add more centres when we received additional funding.”

The feasibility study was a resounding success. “We showed it is possible to start to use in-bed bicycles in seven ICUs and trained physiotherapists in six new centres how to use them,” notes Dr. Kho. “Eighty-five per cent of the patients we approached agreed to take part, which is a very high participation rate, and we were able to recruit hospital physiotherapists to conduct blinded assessments of patients’ strength and physical function at hospital discharge.”

The success of the CFN-funded pilot paved the way to a major advance. In 2018, the Canadian Institutes of Health Research (CIHR) awarded Dr. Kho and her team of collaborators from the Canadian Critical Care Trials Group $1.98 million to launch a large-scale clinical trial of in-bed cycling involving 360 patients in 17 centres in Canada, Australia and the United States. Read more about how Dr. Kho’s initial funding has been leveraged for greater impact.

“We’re comparing physical function of patients who do 30 minutes of in-bed cycling a day, along with routine physiotherapy, to that of patients who receive routine physiotherapy alone during their ICU stay,” Dr. Kho says. “If patients in the cycling group score higher than the physio-only group, this technology could change rehabilitation in critical care.”

The multi-centre study will also shed light on another important issue. The Canadian Frailty Network has provided funding for a PhD student, Heather O’Grady, to dig into the data to learn just what constitutes “routine physiotherapy” in the ICU. “There are no standard guidelines or protocols,” notes Dr. Kho. “This effort will shed light on how different centres approach physiotherapy in critical care, so we can learn from each other.”

Another PhD student, Julie Reid, is shaping her PhD thesis around the in-bed cycling research, with supervision from Dr. Kho. An experienced physiotherapist, Reid works directly with patients doing the in-bed cycling in the ICU at the Hamilton General Hospital.

“Even patients who are doubtful at first get excited when we show them the device and let them give it a try,” says Reid. “Many of them haven’t cycled since they were kids, so it’s quite a novelty and they enjoy it.”

It motivates them, they see they are able to pedal farther every day.

Cycling in bed is not as boring as it sounds, because the in-bed cycles are equipped with a video screen showing an avatar taking a virtual spin around town. Plus, as Reid explains, she and the other physiotherapists involved in the study have created maps that allow participants to trace how far they have travelled around their own hometowns. “It motivates them, they see they are able to pedal farther every day.”

Even very ill patients who are mostly non-responsive due to sedation are able to use the in-bed cycles, which are motorized to allow for passive cycling. As they become stronger, patients contribute more of their own energy, but in the meantime they are able to participate in low-intensity physical activity with minimal effort.

“This is the first study to introduce in-bed cycling so early,” notes Reid. “We start the intervention within four days of mechanical ventilation… the ability to calibrate the equipment to match the patient’s ability allows us to do this.”

The researchers are eagerly anticipating the results of the multi-site study, which is one of very few in the world to include rehabilitation of older people in the ICU.

“As the wave of baby boomers continues to age, the demand for intensive care is only going to increase,” says Dr. Kho. “In fact, it’s projected to increase by 80 per cent between 2020 and 2026. It’s vitally important that we help people recover as quickly as possible after their critical illness.”

A stay in the ICU can be frightening for patients and families, who worry about the chances of survival and what life will look like after the ICU. For Dr. Kho, in-bed cycling offers a positive prospect for people facing down despair.

“By offering a rehabilitation study to patients in the ICU, we are offering them and their family members hope,” says Dr. Kho. “It’s very rewarding to me, my collaborators and our teams, to work with patients in the ICU as they get better and stronger in preparation to return home.”