Frequency of physical and occupational therapy in the ICU for patients with cognitive motor dissociation: a retrospective cohort study

Supportive care is the primary focus of ICU management for unconscious patients early after severe acute brain injury. While benefits of early physical and occupational therapy are generally recognized, it remains uncertain how early therapy can begin and what patients most benefit form intensive, early therapy. Brain activation to motor commands detected by EEG also known as cognitive motor dissociation (CMD) is a predictor of recovery seen in up to 25% of patients. The purpose of this study was to determine if CMD patients that undergo early, intense physical and occupational therapy are particularly responsive to the treatment.

In this retrospective analysis of prospectively collected data from 119 ICU patients with acute, severe brain injury who were assessed using the Coma Recovery Scale-Revised (CRS-R). CMD was detected applying machine learning to EEG recorded during verbal command presentation. Time from admission, type, and frequency of physical/occupational therapy, and pre-defined adverse events were recorded. Glasgow Outcome Scale-Extended (GOS-E) at discharge, 3, 6, and 12 months were the primary outcome. Investigators were blinded to CMD status. Outcomes were compared in relation to CMD status and therapy characteristics applying Wilcoxon signed-rank tests and ordinal regression.

CMD was detected in 16 (13%) patients and not associated with demographics or clinical factors. No therapy-related complications were observed. Between admission and discharge, GCS improved for all patients. Median delta GCS was the highest for CMD patients who received high-frequency therapy (OR 4.1 [1.1-16.3], p = 0.03). GOS-E was 4 or above in 26 (26%) by 12 months after the injury. CMD patients who received high-frequency therapy had larger increases in GOS-E at 6 and 12 months after discharge compared to those without CMD and those who did not receive frequency therapy (OR 10.7 [2.5,48.8] p = 0.001).

Physical and occupational therapy can be applied in the ICU using a safety protocol and CMD patients may be particularly responsive to early, intense therapy. Multicenter trials integrating CMD status should determine optimal timing and dosage of rehabilitation to support the allocation of this limited resource.