Response from author musculoskeletal, neurological as well as in surgical patients. However, mobility design is underused in cardio-thoracic setup mainly in intubated patients. Recently published prospective repeated measure study, focused aptly on positive effects of exercise in intubated adults in ICU with extensive methodological consideration (Winkelman et al., 2012). We applaud the researchers for utilising a large data to record all patient related measures such as severity of illness, type, duration of exercise, etc. However, apart from these measures, we also feel that the level of consciousness may also be considered. This is because of consciousness would have an impact on the subjects’ exercise performance. Hence, we would suggest the above measures may be adapted in future studies. Similarly, regarding the exercise programme, it was mentioned that in-bed exercises, assisted and out-of-bed exercises were given. In this study methodology also, we would like to recommend that along with these protocols tilt table programme also can be considered as a mobilisation programme, as tilt table practice provides evidence in terms of improved ventilation, early extubation and mobility (Hashim et al., 2012). Apart from that, we support the author’s views that both surgical and medical patients were included for the study as this would create difference in the study results. Oxidative stress involves increase in the level of circulating interleukins. Hence, any effect that modifies or reduces oxidative stress may reduce biochemical inflammatory markers in the body. In the present study, increase of IL-6 following exercise at day 7, is not well understood and it can be debated. IL-6 is released from the skeletal muscles. There are recent research reports which even depict decrease in the level of IL-6 in the sputum of the individuals even after 2 hours of exercise (Davidson et al., 2012). In conclusion, this is a magnificent article which picked up the issue of exercise in individuals who are intubated in the critical care setup. The authors and the editor need to be applauded for highlighting such innovative treatment schemes applied on the intubated patients.
Funding None.
Contributions Both VM, HSE and SD read and commented on the article.
Conflict of interest The authors have no conflict of interest.
References Davidson WJ, Verity WS, Traves SL, Leigh R, Ford GT, Eves ND. Effect of incremental exercise on airway and systemic inflammation in patients with COPD. J Appl Physiol 2012, April 12, http://dx.doi.org/10.1152/japplphysiol.01615.2011.
319 Hashim AM, Joseph LH, Embong J, Kasim Z, Mohan V. Tilt table practice improved ventilation in a patient with prolonged artificial ventilation support in intensive care unit. Iranian J Med Sci 2012;37(1):54—7. Winkelman C, Johnson KD, Hejal R, Gordon NH, Rowbottom J, Daly J, et al. Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study. Intensive Crit Care Nurs 2012;28(6):307—18.
Vikram Mohan Department of Physiotherapy, Faculty of Health Sciences, Universiti Teknologi MARA, 42300, Puncak Alam, Malaysia Ho Siew Eng Department of Nursing, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Chears, 56000 Kuala Lumpur, Malaysia Srijit Das ∗ Department of Anatomy, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abd Aziz, 50300 Kuala Lumpur, Malaysia ∗
Corresponding author. Tel.: +60 3 92897263x7874; fax: +60 3 26989506. E-mail address:
[email protected] (S. Das)
doi:10.1016/j.iccn.2012.06.001
Response from author Thank you for your thoughtful comments. You raise a number of important points and we would like to share some additional details about our intervention and plans for future investigations. We agree cognition is an important factor in progressive mobility exercises. We use a measure of cognition in our intervention to guide the intensity of exercise. Specifically we us a protocol developed by Peter Morris in which patients follow the majority of five (i.e., 3/5) directions to progress to standing or perform a pivot transfer to chair (Morris et al., 2008). We do not have access to tilt tables in the 5 ICUs where data were collected but we agree that upright positioning is an important strategy to challenge and sustain cardiovascular and pulmonary responses to exercise. We typically raise the head of bed 60—90◦ or, when this manoeuvre is clinically contraindicated, use reverse Trendelenburg at 45◦ (i.e., the maximum tilt provided by most of bed frames used in patient care at our study sites) when subjects are in bed during exercise and encourage clinicians to do the same. The interactions between oxidative stress and cytokine synthesis are essential for muscle health and cell turnover but problematic when sustained or present in excess. We hope to examine additional biomarkers exploring these relationships in future studies. We appreciate your additional insights and, like you, remind clinicians there is great value in providing exercise to intubated and critically ill patients.
DOI of refers to article: http://dx.doi.org/10.1016/j.iccn.2012.06.001
320
Conflict of interest None.
Reference Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensive care unit mobility in the treatment of acute respiratory failure. Crit Care Med 2008;36(8):2238—43.
C. Winkelman et al. Chris Winkelman ∗ Case Western Reserve University, 2121 Emergency Drive, Cleveland, OH 44106-4904, United States ∗ Tel.: +1 216 368 0700; fax: +1 216 368 3542. E-mail addresses:
[email protected],
[email protected]
doi:10.1016/j.iccn.2012.06.004
