Amitha Kalaichandran
Amitha Kalaichandran
Even short hospital ICU stays can cause lasting problems for patients. Can early mobility and exercise help?
SAPNA KUDCHADKAR still remembers the morning in 2010 that shaped the trajectory of her scientific research. She was in the midst of a medical fellowship, listening carefully to the hospital’s overnight staff, as they summarized the progress of each child in the pediatric intensive care unit. The staff would comment on how well the patients had slept the night before. “In that moment, I realized that we weren’t really talking about sleep, per se, but really sedation,” says Kudchadkar.
While the terms are sometimes used interchangeably in intensive care, she says, they are not the same. Among other things, real sleep is restorative; upon waking, patients feel energized. The disruptive effects of sedation, Kudchadkar suspected, could have lasting implications for a person’s recovery and long-term health.
Knowing that physical activity enhances sleep, Kudchadkar wondered: Would her young patients do better if they were encouraged to move during their stay in intensive care? At the time, this question was already being investigated in adults, but had largely been avoided in pediatrics due to concerns about patient safety. The intensive care unit (ICU), after all, is widely viewed as a place of rest for the acutely ill or for those recovering from major surgery. And some ICU patients rely on breathing tubes, which are cumbersome and often require sedation to prevent the body from reflexively trying to remove the tubing. Getting exercise broadly into the ICU, then, would require research demonstrating that it is both effective and safe.
Two multi-year initiatives — one directed by Kudchadkar at Johns Hopkins School of Medicine, and one based at McMaster University in Canada — are now providing that kind of evidence for patients of all ages. These initiatives are part of a broader trend toward “ICU liberation.” While intensive care has improved dramatically over the decades, resulting in higher survival rates, there is now a broad recognition that survivors are not walking away unscarred. The ICU liberation movement seeks to reduce the negative effects of intensive care, which can linger for decades, and include everything from lowered muscle strength to depression and anxiety. One way to do this is to decrease sedation and encourage patients to move far sooner than they have in the past.
As with any major culture change, though, “there was some pushback early in the process,” Kudchadkar wrote in an email. Some of her colleagues worried that the new initiative might push sick patients to perform beyond their physical abilities. So she and her team worked to reassure colleagues that patients’ goals would be individualized. “There was a collective sigh of relief that we weren’t trying to get every kid out of bed walking regardless of their acuity of illness,” Kudchadkar recalls. Still, she adds, “illness doesn’t mean stillness,” the program’s catchphrase. That view, according to Kudchadkar, is now shared by a growing number of intensive care specialists across the country.
SEDATION STANDARDS for intensive care units can be traced back to the 1980s, when operating room procedures began being applied in other settings. Sedation causes the brain to take on a semi-conscious or unconscious state, and the drugs include propofol and benzodiazepines. Additional drugs called paralytics are often added to prevent the body from moving. At that time, the focus was largely on using sedation to keep a patient comfortable and able to tolerate pain, without as much regard for the negative long-term effects of prolonged sedation, says Yahya Shehabi, a professor and director of critical care research at Monash University School of Clinical Sciences in Australia.
A pivotal change came in 2000, with a New England Journal of Medicine article that discussed the benefits of interrupting sedation for a brief period each day. Over time, additional research would show that sedation has its own side effects. For one, it has been linked to cognitive issues, typically memory deficits. Additionally, bed rest can lead to muscle deconditioning. A 2014 study found, for example, that each day of ICU bed rest lowered a person’s muscle strength between 3 and 11 percent. Over one third of ICU patients were discharged from the hospital with muscle weakness, and that weakness was associated with substantial impairments in physical function lasting months, and in some cases years.
New research also points to the benefits of physical activity for people dealing with an array of conditions. In August, a systematic review and meta-analysis found that adding physical exercise to standard care may improve quality of life in everything from multiple sclerosis to Parkinson’s disease. When it comes to children, a study in the Journal of the American Medical Association showed that children and adolescents with a concussion may benefit from light activity earlier than traditionally advised. And in June of last year, a systematic review of 15 studies reported that exercise can improve attention and social behavior in children with attention deficit hyperactivity disorder, or ADHD.
Still, Shehabi issues a word of caution regarding the introduction of physical activity into critical care: “Patients who are able to mobilize usually self-select as they get better to achieve ICU liberalization,” he wrote in an email. “As such, many patients will not be able to mobilize before they have recovered substantially from critical illness.” Lakshman Swamy, a pulmonary and critical care fellow at Boston Medical Center, echoes this point: “Early mobilization is critical but difficult — and potentially dangerous without the proper systems and support.” Sick patients may be connected to medical tubes, lines, and drains, all of which can be displaced and serve as major fall risks, says Swamy. “Even one fall can be catastrophic.”
KUDCHADKAR’S INITIAL one-year study, which ended in 2015, was designed to assess the safety of a program that encourages young ICU patients to walk and play. Sydney Pearce was two-and-a-half years old and recovering from open-heart surgery when her parents agreed to let her participate. Within 24 hours of the operation, she was up and walking and driving a cozy coupe car around the ICU. “We had no idea about what the program could do,” said her mother, Ashley. While Sydney was initially reluctant to move about, the young girl soon became determined to try everything she had enjoyed before.
That study, published in 2016 in the journal Pediatric Critical Care Medicine, indicated that the mobility program was safe and appropriate for follow-up testing. As a next step, Kudchadkar is helping lead a multicenter randomized controlled trial to look at the protocol’s effectiveness. It will measure outcomes such as duration of mechanical ventilation, exposure to sedative medications, and length of stay. Johns Hopkins All Children’s Hospital in Florida, Boston Children’s Hospital, Advocate Health Care in Illinois, and Our Lady of the Lake Children’s Hospital in Louisiana are participating in the trial.
Researchers at McMaster University in Canada are also studying ICU mobility. In particular, they are examining whether “in-bed cycling” can help improve outcomes among adult ICU patients. The results of a pilot randomized controlled trial involving seven ICUs, led by Michelle Kho, a physical therapist and professor, were published last year. A larger trial involving 17 ICUs across Canada, the U.S., and Australia, now aims to compare whether adding early in-bed cycling to routine physical therapy among adults in the ICU improves physical function, mental well-being, and mortality, among other factors.
As part of the McMaster-led study, bike pedals mounted on a platform, are wheeled into the patient’s room. A physical therapist then guides the patient — who remains in bed — to use cycling as a strength and rehabilitation program. If patients are physically able, they can pedal the bike unassisted. For patients who are too sedated or weak, the motorized bike passively moves the patient’s legs. Each session typically lasts 30 minutes. “In a lot of ICUs people are on bedrest, which can lead to muscle weakness and general deconditioning,” says Kho. But thanks to the in-bed cycle’s motor, even patients who are sedated and receiving life support can participate.
Physical therapist Kristy Obrovac, who is based at a McMaster-affiliated hospital, St. Joseph’s Health Care, recalls one adult patient who used the in-bed cycle after complex thoracic surgery. The experience provided “an opportunity to focus on something positive,” she says, while offering “a sense of control in the recovery during a very challenging time.”
The in-bed cycling sessions are conducted by physical therapists and engaging them at other hospitals will be key to ensuring that the program can be replicated in different settings, says Kho. “We aren’t looking at the effect of exercise per se, but more at breaking up sedentary behaviors, and the impact that could have for ICU patients, which includes the opportunity to regain some control and hope,” says Kho.
While these new efforts are promising, it may be a few years before the field of intensive care medicine adapts to more formally include them. One challenge could be purely logistical. During the day, ICU patients undergo a range of tests, procedures, and imaging studies, plus they often have visitors. So it could be hard to find a time when clinicians and patients are ready to work on mobility, says Swamy.
Still, he views research like Kudchadkar’s and Kho’s as part of a necessary and important shift in ICU care more generally: “The way we practice medicine needs to be radically reimagined to put the patient — and patient mobility — at the center of the care plan.”
**Originally published in Undark magazine**
The secret to sticking with your resolutions may be having a coach to help strategize and cheer you on.
My teenage patient looked nervous as I reviewed her glucose readings from her glucometer and her glucose logbook, which people with diabetes use to track their blood-sugar test results. There were a lot of high levels — ranges in the 12’s and 14’s, when the goal was around 7 or 8. The peaks were mostly in the middle of the day and on weekends. (This was in Canada; blood glucose readings of 12 to 14 are equivalent to 216 to 250 mg/dL in the United States.)
“What do you usually eat at home?” I asked. She said that her mother was careful to make her a breakfast that balanced carbohydrates with protein. Her dinners were similar.
“What do you usually eat at lunch?” I asked. My patient started tearing up. She ate whatever her friends were eating in her high school’s cafeteria that day — like spaghetti, hamburgers or pizza, and something like a cupcake for dessert. This was probably what led to her readings being so high.
She had met with diabetes educators before, and she knew what uncontrolled glucose does to a person with diabetes, from speeding up nerve damage in the feet to hastening blood vessel damage in the back of the eyes and the kidneys, to increasing her risk of heart disease.
I knew she could have told me all of that, so lecturing her wasn’t going to help.
Instead my patient needed empathy and the tools to help her make healthier decisions, and part of that required understanding what was important to her, specifically “fitting in” with her friends in high school, the ones who didn’t have a chronic disease. It also would have involved helping her find the motivation within herself to make the change.
But my skill set for helping her was limited, especially on top of everything else I had to cover within our allotted time of 45 minutes.
Research suggests that behavioral and lifestyle factors are a big part of what contributes to chronic disease. In medical training, we learn a lot about the body and how to prevent and treat disease, but little about how we can motivate a patient to change old habits or even stick with a current management plan.
It struck me that what my patient really needed was a coach. At this time of year when many of us have made resolutions to get healthier, working with a health coach might be one way to reach those goals.
A health coach is someone trained in behavior change, who primarily uses an interview style called “motivational interviewing” to help patients see their ability to make change. While some may have clinical training in fields like nursing or medicine, they hail from a wide variety of disciplines or train in health coaching as a secondary career.
As a relatively young field, it’s still finding its footing — for instance, a systematic review found that the definitions of “health coaching” varied widely, though the authors recommended that health coaches take a patient-centered approach to help with goal setting while encouraging self-discovery and accountability.
The evidence that health coaching may spur general lifestyle changes is mounting. A 2018 study looked at clinical trials for coaching for nutrition and weight management and found that over 80 percent of these studies found improvement. And a 2017 study found that coaching can lead to increased physical activity in older adults. Studies suggest that health coaching may also provide benefits for conditions such as obesity and diabetes as well as attention deficit hyperactivity disorder, chronic pain, hypertension and high cholesterol. A recent review found that health coaching can improve quality of life and reduce hospital admissions among patients with chronic obstructive pulmonary disease, and it may help patients to become more engaged in the health care system.
It may even improve health outcomes through encouraging patient adherence to medication.
“Health coaching recognizes that we cannot help people by expecting them to act if that person is not ready to act,” said Leila Finn, a health coach based in Atlanta. “We help people take big goals and break them down into accessible, bite-size pieces — not by telling clients what to do but by helping clients figure out what will work for them.”
Health coaching gets to the heart of what providing good health care is about: acceptance, partnership, compassion, and helping patients feel respected and understood.
Though my clinical training is in pediatric medicine, inspired by what I had read, I recently completed a certificate in health coaching myself. The experience was eye-opening and humbling. I learned new ways of communicating with my patients, specifically ways to encourage them to see their own ability to make lifestyle changes while setting manageable goals. I also learned ways to cheer them on when they reach their goals, without shaming them if they relapse: Both pieces are critical to the process of making sustainable change.
While research is beginning to show the value of health coaching, the principles of communicating with the intent to inspire and motivate are transferable to all health professions — and could reap dividends if taught early on in the training of nursing students, medical students, pharmacy students, and other allied health professionals.
And when I think back to my teenage patient with diabetes, while I was empathetic, that was only half of the solution. The second half could have involved coaching her to see which small changes she could begin to make moving forward. I’m hoping that choosing my words more effectively, even within the pressures of time, may make all the difference for my other patients.
**Originally published in the New York Times**
Surf therapy programs often focus on children with autism or anxiety, or groups like veterans or cancer survivors.
Agatha Wallen’s son, Mason, has autism, and when he was 7, she heard about an initiative in San Diego aimed at children with special needs. It involved an unlikely tool: a surf board.
She wasn’t sure how it would work for her son, who struggled with behavioral and sensory issues. “Even getting the wet suit on was difficult for him because it was a brand-new sensory sensation,” she recalled. “From the beach I could see the surf instructors calmly speaking to him, and his whole body seemed to change and relax,” Ms. Wallen said. “He was able to stand up and catch a wave, with a big smile on his face, and ran up to shore and said ‘Mommy, I want to do it again.’”
Mason has been surfing for five years, and now his younger brother, Trevor, 9, is also an active participant in the same program, A Walk on Water. It is a California-based surf therapy nonprofit that primarily focuses on children with special needs — mostly with neurological disabilities. Ms. Wallen serves as an ambassador for the program, helping explain surf therapy to other parents.
“In the ocean there are no cars or planes or people shouting or things buzzing around,” she said.
“It might be the calmness of the waves, but it’s also being with instructors that he could trust and who were patient with him as well.”
A Walk on Water’s executive director, Sean Swentek, points to the importance of serving the whole family, including the child’s siblings, while also offering respite for parents.
“Surf therapy often provides bonding time for them, and our events are meant to be a full day of healing for the whole family,” Mr. Swentek said. The group recently released a short documentary about the role of surf therapy in the lives of three children with special needs.
“In a nutshell, surf therapy is a structured method of surfing utilizing elements of ocean and using its therapeutic benefits for those in need,” said Kris Primacio, the chief executive of the International Surf Therapy Organization, which acts as an umbrella organization to bring together surf therapy programs and researchers. “We tend to focus on underserved populations and exposing surf therapy to those who wouldn’t otherwise have access to an instructor.”
Each surf therapy organization develops its own program. In general, groups meet on the sand before a surf lesson, discuss ocean safety and often discuss mental health struggles as a form of group therapy. They then surf for a few hours and have a debriefing session.
In Britain, children with referrals for anxiety can participate in a free six-week program called The Wave Project. The program, which has received National Health Service funding in the past, gathers data before and after through questionnaires using the Stirling Children’s Well-being Scale and the Rosenberg Self-Esteem Scale.
“We focus on children who have anxiety disorders or are at risk of developing issues. Some may have autism or A.D.H.D. and are at risk of developing more series mental health problems, and most of these children feel isolated,” said Joe Taylor, the program’s chief executive. “Our approach is similar to an occupational therapy approach, and we don’t see ourselves as an alternative to support for care, but part of a package of mental health care.”
In 2014, John Newkirk started Salt Water Therapy L.A., which emphasizes mindfulness as well as surfing. As a certified drug and alcohol counselor with his own history with addiction, Mr. Newkirk wanted to share a mindfulness practice while also structuring the program with ocean safety and surf instruction.
“What happens with mental struggles, including addiction, is that there is an element of self-medicating. Surfers have called it ocean therapy for decades, because of the spiritual benefits. It’s a high with dopamine, but a safer healthier kind,” Mr. Newkirk said.
Surf therapy is not a substitute for medical care, and surfers can still struggle with mental illness. Indeed, the surf legend Sunny Garcia talked about his depression and has been hospitalized since attempting suicide this spring.
However, the evidence for surf therapy seems to validate what we know about movement and exercise, therapeutic effects of water and mindfulness. For instance, two years ago, a paper out of California State University described that just one 30-minute surf session improved mood, but the researchers didn’t distinguish the impact of surfing compared to other sports.
A qualitative study of 22 youths participating in The Wave Project, published in June in the International Journal of Environmental Research and Public Health, noted that surf therapy may work through offering a safe physical and emotional space, peer mentoring and positive reinforcement. Similarly, in 2017 a British study looked at the effectiveness of a three-month surfing program for youth and found that some elements of self-reported well-being improved. However neither study matched participants with a control group.
In June, research with 74 active duty military personnel from the Naval Health Research Center in San Diego found that depression, anxiety and PTSD symptoms decreased after surf therapy, but all participants were simultaneously receiving another form of therapy, making it hard to measure the impact of surfing alone.
Naturally, surfing is not without dangers: drowning, rip currents, sharks, just to name a few.
“The ocean is unpredictable, but leading organizations try to mitigate the risks by making sure staff are C.P.R.-certified and know how to prevent and deal with emergencies,” Mr. Swentek told me. “I think part of the reason it’s so powerful is because of those risks. It is not easy to do, so when these kids for instance are able to surf a wave and overcome their fear, there’s huge growth.”
Is the trend of surf therapy meaningfully different from exercise or mindfulness techniques? The evidence isn’t quite there. But its popularity is a sign of broader interest in a variety of tools that might improve mental fitness. Notably, a Los Angeles-based study from 2014 found that surfing may have a positive effect when delivered in combination with other forms of exercise, medication if needed, and group or individual therapy.
In Jon Kabat-Zinn’s book on mindfulness “Wherever You Go, There You Are,” he writes, “You can’t stop the waves, but you can learn to surf.” Dr. Kabat-Zinn, a physicist by training, was one of the first academics to standardize and research mindfulness approaches. In surfing, much of the challenge involves facing a real wave and pushing forward anyway, even when the easy thing to do is back away.
When I reached out to Dr. Kabat-Zinn to say that one of his best-known sayings was being taken quite literally, he replied in an email:
“The beauty of mindfulness is that you can bring it into anything, and then everything becomes your mindfulness teacher and contributes to waking you up fully. Surfing is no exception. When you are really present, the world (and the wave) can wake you up, and bring you into the timeless present moment, even in the midst of complex, unpredictable, dynamical circumstances.”
**Originally published in the New York Times**
