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What happens to the body at the cellular, neurological, pulmonary, musculoskeletal, and cardiovascular levels when it remains supine for days to weeks? What is verticalization therapy and what does current research reveal about its benefits during critical illness? Verticalization experts, Phillip Gonzalez, MOT, OTR/L, BCPR, Nikki Stephens, DNP, APRN, FNP-C, and Jenna Hightower, PT, DPT, CCS dive deep into the science and beauty of verticalization therapy.

Episode Transcription

Kali Dayton 0:03
Okay, welcome everybody. We have three experts on verticalization. With us. We have Jenna Hightwoer. We have Phillip Gonzalez, and we have Nikki Stephens with us. Go ahead and introduce yourself, guys.

Phillip Gonzalez, OTR, MOT 0:16
Yeah, I’ll go ahead and get started. So hi, everybody. My name is Phillip Gonzalez. I’m an occupational therapist, by trade. I’ve been an OT for about the last nine years graduate of Texas Tech over in Lubbock. I’m a OTA board certified in physical rehabilitation. I have a background in exercise science.

For the majority of my career, I’ve worked in the ICU as a critical care rehab specialist. Mostly because I love the patient population, TBI burns, STIs, heart and lung transplants, trauma, you name it, everything you see in the ICU is something that I love to do and work toward to get those patients better. I also do a few guest lectures at different OT programs. SCCM presenter on disorders of consciousness and I also serve as a clinical specialist for Vitalgo Systems.

Jenna Hightower, PT, DPT, CCS 1:03
Hi, everybody, I’m Jenna Hightower. I’m a critical care physical therapist by trade and a board certified cardiovascular and pulmonary physical therapy clinical specialists is a mouthful. But I have a special passion for working with patients on various forms of mechanical circulatory support, and mechanical ventilation, as well as patients with an organ failure pre and post heart and lung transplant.

I’ve been a PT for six years now, which is hard to believe. And I have a couple of recent publications on mobility in the ICU. I like to guest lecturer and a lot of different DPT programs. I currently still work part time in patient care here in Atlanta, Georgia, and currently serve as the Director of Clinical Strategy for Vitalgo systems, the inventor of the total lift bed.

Nikki Stevens, DNP, APRN, FNP-C 1:58
Hi everyone I’m Nikki Stevens, I’m a doctorally prepared and published nurse practitioner, have been that certified for eight years. I’ve been an RN for 17 years with experience in a number of roles, including, you know, in the hospital setting, in the emergency department, urgent care, family practice, dermatology, aesthetics, a little bit of everything in the nursing field.

But more specifically, I have been in the healthcare industry in the medical device industry for 15 years, and have served as a mobility evangelist, champion and advocate for all things mobility. And so currently, I’m serving in the role as Vice President of Clinical Operations for Kreg therapeutics.

Kali Dayton 2:42
And this is so exciting. So we’ve got physical therapy, occupational therapy and nursing represented giving different takes and insights into all things verticalization, which many are some of our listeners, verticalization, maybe a new word, a new concept, a new topic, and I’m finding at the bedside when I’m saying hey, what about a verticalization bed? I’m getting blank looks. So let’s zoom out and talk about what is verticalization therapy?

Phillip Gonzalez, OTR, MOT 3:13
Yeah, so verticalization therapy or verticalization. In general, like Kali mentioned is such a nuanced word, there’s not really a good clear definition for what that actually means. So we came up with one, I’m gonna go ahead and just read it verbatim just because I think how we wrote it makes really good sense.

Verticalization therapy: a concept under the early mobility umbrella. Verticalization therapy is a therapeutic approach using equipment, manual assistance, or other various technologies to gradually tilt a patient from supine to 90 degrees in a slow and controlled manner, traditionally accomplished without any hip flexion using tilt tables.

Verticalization can also refer to bring in the body in an upright position where the head and upper body is placed in a position higher than the lower body in a vertical plane. Importantly, verticalization therapy is often used as a therapeutic modality by the interdisciplinary care team in the hospital setting and other settings to aid in the recovery and rehabilitation of various medically complex patients who are unable to achieve that upright position without assistance and need for close monitoring of autonomic and hemodynamic responses consciousness and musculoskeletal and neuromuscular responses.

Nikki Stevens, DNP, APRN, FNP-C 4:27
You just add to that, Kali, Sorry, I’ll just add to that, you know, verticalization is another name for like tilting, and reverse Trendelenburg. They’re all you know, all kinds of different, you know, synonyms you can use to define that or to search those terms. And it’s not new.

And so I just wanted to add it not only is it not new, but in 1996 there was a consensus consensus document published by the American College of Cardiology, that spoke about you utilizing tilting for a test of syncope, right looking at the heart rate and blood pressure to see what what our patients going to do when we change their position. So just wanted to bring that up.

And then also to complement what Philip just read is that you know, verticalization be both passive and active. So those patients who are sedated and paralyzed, may not be able to actively engage from, you know, therapeutic standpoint, however, I think Jenna is going to touch on, like barrel receptors and things like that. So there are benefits, whether it’s passive or active. And I just wanted to point that out.

Kali Dayton 5:27
Yeah, when you when I say it’s a bed that can do what a tilt table does, people say, “Oh, tilt table, I’ve heard of that. Physical Therapy uses it on some patients in the past, few patients…” like they have just a very vague concept of, “We have a tilt table somewhere in our hospital collecting dust,” right? So but it’s not new. And then when it comes to the ICU, it can be a new concept to use verticalization therapy use this kind of tilt table technology, which we’ll talk about, into now our critical care patients. So what kind of patients benefit from verticalization. And why?

Jenna Hightower, PT, DPT, CCS 6:10
I also want to add that verticalization is more than just early mobility. You know, early mobility is such a hot topic right now, and has been for some time, because there’s tons of research saying that early mobility is beneficial. However, in the literature, early mobility is very poorly defined. So what encompasses early mobility and verticalization can be a form of early mobility. However, there’s so many more benefits to verticalization than just the mobility aspect, which we’re going to get into as well. But I’ll let us get into the specific patient populations from here.

Kali Dayton 6:45
Love that. Yeah,

Nikki Stevens, DNP, APRN, FNP-C 6:47
I love that. Jenna, thanks for pointing that out, too. I just I’m so passionate about it. It’s like Kali, you do all these podcasts on, you know, that ABCDEF bundle, right, and liberating patients and how do we do that? And mobility as part of that E. You’re right, Jenna, that there’s so many studies that talk about mobility, but how do we mobilize, right?

That’s not clearly defined, but the kind of patients that can benefit from verticalization may what we’ve seen is respiratory failure, or dare I say mechanically ventilated, before the respiratory failure, you know, especially in the ARDS during COVID, there were so many really great outcomes realized from that ARDS patient population due to COVID.

But specifically, you know, when you get into that bariatric patients can fall on this spectrum, whether or not they’re in arts or just simply because of their body habitus, surgical patients transplants have seen, you know, really great outcomes from a both a, what I call prehab, and then rehab from the, you know, post transplant phase, then large wounds, you know, where they cannot maybe engage their core, whether it’s abdominal, or you know, just lower extremities.

You know, just any, any reasons that they cannot engage their cores, or their core strength, and then significant pain. So those patients are in excruciating pain. They just maybe can’t find the, you know, gumf, if you will, to get up and move and those patients can benefit from this as well.

Phillip Gonzalez, OTR, MOT 8:19
To add to that, so I think, Kali, I’ve been on your podcast before, a lot of things that I’ve talked about before were traumatic brain injuries and disorders of consciousness. So TBIs, delirium ,disorders of consciousness, the spinal cord injury patients at my hospital that I’ve worked part time that in our pediatric population, we see the tilt bed or the verticalization bed being utilized for young spinal cord injury patients, any type of acquired brain injury and any type of progressive neuromuscular disorder where we’re really trying to facilitate continuous neuromuscular responses so that they don’t lose that nerve muscle connection as well as create a environment for muscle atrophy because now you’re working against a neuromuscular impairment but also muscle fiber deficiency as well.

Kali Dayton 9:09
Wow, I hadn’t thought about that.

Jenna Hightower, PT, DPT, CCS 9:11
Yeah, they add that even more, the ICU acquired weakness population. Now, us as ICU revelate. revolutionists Kali, we strongly believe that we shouldn’t even get to that point, there’s so many things that we can avoid. However, the realization is there is still a huge ICU acquired weakness population out there from prolonged sedatives or just patients that are profoundly unstable for a long period of time.

And, and the concept of verticalization is to be able to get them weightbearing multiple times a day to load their system more than just the few times that PT or OT may be in the room. And a lot of times this ICU acquired weakness population, they can only tolerate you know 5, 10, 15 minutes of mobility at a time. And we spend all of this time to set up the room transfer them over or get them to the edge of the bed. And they can only stand or, you know, sit there for maybe five minutes supported. And then we got to put them back down and the staff workload to accomplish that is a lot.

Whereas verticalization can really augment their therapy program, in order to really help them make progress and accelerate their rehabilitation process process. Another great population is cardiogenic shock, or orthostatic intolerance. So a lot of the surgical population that Nikki mentioned a lot of them and end up with orthostatic intolerance after surgery, or just your cardiogenic shock population, where they can’t tolerate a whole lot of load to their system. So a slow controlled, like titratable activity is really important for that population. And virtualization is a tool to be able to accomplish that.

And it’s safe, because if they don’t tolerate, you just put them back down and start over, or you back down to the degree that they can tolerate, and you work from there. And that can look different from day to day with that population. So really having the the safe environment to challenge those patients. Especially patients with mechanical circulatory support, which we’ll get into some more, it’s a really sick patient population.

And it really can be very scary patient population to move, where there’s a lot of research coming out on all the benefits of mobility on those patient populations, and especially improving mortality with that patient population. And giving us the tools to to do that safe safely, but also, to do it more. So even these programs that are really mobility strong with their mechanical circulatory support, they walk their patients on ECMO, they’re up in the chair.

However, it takes a whole big team to do that. And verticalization therapy is another instance where we can get those patients weight bearing axial loading multiple times a day outside of just the once with the whole entire team and nurse can do it by themselves at the click of a button, which is pretty incredible. And then lastly, burns, which we’ll talk about all of the benefits to burn down a little bit.

But burns can be a very complex patient population to mobilize, they can be very tenuous, you know, their bodies in this chronic state of inflammation, they have all these volume shifts, they are in excruciating amounts of pain, they have very strict wound protocols. And actually verticalization therapy is part of the standard of care for burn patients, but traditionally with a tilt table. And so we can talk about some of the benefits to the verticalization bed outside of that. But a great population that benefits from verticalization therapy or the the large burn patient population.

Phillip Gonzalez, OTR, MOT 12:50
I think I think it’s interesting. You mentioned the ICU acquired weakness and the cardiogenic shock and Nikki and both in orthostatic intolerance that you and Nikki talked about, because as therapists we know, the patients that we get in the ICU that we are going to see for the first time they have been sedated paralyzed for an extended period of time, my evaluation or my intervention session is probably going to be less than 10 minutes, most of time because we’ll go try and sit them up edge of the bed, I anticipate they’re probably going to go orthostatic I’m checking that I’m being very highly aware of that attune to that.

And if I’m lucky, and the patient’s tolerating well, then we’ll progress as appropriate. But almost nine times out of 10, we have that high acuity patient that hasn’t been mobilized, hasn’t done anything has been sedated has been paralyzes on the vet, I expect they’re not going to tolerate if there’s been no opportunity to be in an upright position prior to that. And so therapy sessions in the ICU can be as short as active therapy being five minutes because they didn’t tolerate and then that’s all they get for the day. So imagine the opportunity of being able to be in an upright position with safe equipment, and how that can really start to benefit these patients for an autonomic retraining purpose, as well as just being able to be upright multiple times. Yeah.

Jenna Hightower, PT, DPT, CCS 14:06
And speaking to that, you know, a lot of these patients in the ICU or on pressors, and I know tropes and multiple, you know, invasive drips, so to speak. And we don’t want that to deter us from mobilization. And especially patients on multiple drips, verticalization therapy can be a safe way to progress and really assess their tolerance to see what they can tolerate, as well as what do they need to be able to tolerate upright. So having your you know, being able to have your nurses titrate, you know, to the physician order of our goal map and whatnot to be able to tolerate activity rather than just saying, “Oh, they didn’t tolerate put him back down.” What can we do to optimize their their vitals in their system to be able to tolerate the maximum amount of mobility since that’s the end goal because that’s where we see all the outcomes?

Kali Dayton 14:59
Now you have confidence that you’re gonna be able to progress safely that, you know, you have a better idea of where they’re at, what they can tolerate, especially when they’ve been down for a long time, or they are more tenuous, right? Patients that usually would be off limits for early mobility…. now there’s the option!

Jenna Hightower, PT, DPT, CCS 15:15
Right.

Nikki Stevens, DNP, APRN, FNP-C 15:16
I was gonna say, I’ll just add to that, and I know we’re gonna get into this. And then in a little bit, Kali, but you know, we’re sort of the conversation is just sort of organic. And I just want to jump in to say that as, as I travel across the nation, and even around the globe, but more specifically in America, what I find is, it’s like some places, it’s like mobilities, led by nursing, some places, it’s, it’s led by physical therapy, occupational therapy, and it’s like, why aren’t we working together and collaborating?

Because as a nurse, I should be…. as soon as I do that, I’m the one who does the admission assessment, right. And I’m doing my assessments every shift. And as I’m assessing you, I’m also assessing your mobility potential and your level. And so who better to start that mobilization in the earliest infancy phases than the nurse right before we call our colleagues in to come and say, occupational therapy, physical therapy, come do your thing, right?

I mean, the nurse should really step up and be leading that. And, um, if you can’t tell, I’m just so passionate about it. And I’m like, like I said, it’s one of the things it’s so puzzling when I traveled to just different institutions. And you’re here, oh, that’s, you know, we got a physical therapy, you know, they assess their level, and then, you know, they’ll come in and do XYZ, or physical therapy and occupational therapy, they can’t come in until they can bill and I’m like,

“Okay, that’s that makes sense. Sorta, but, but why are you mister or missus, nurse? Why aren’t you leading this, this, you know, this mobility initiative?” Because, who better to do it, right? And now we have this wonderful technology that can allow you to do it. Dare I say, alone, but safely and pretty much independently.

Phillip Gonzalez, OTR, MOT 17:03
I love that you said that Nikki, my biggest champion is I like to bridge the gap between nursing and rehab world. Our languages are sometimes so different. So two things: talking to Jenna’s point about pressors- bridging that gap. One of the things that I always ask the nurses are, “Do you have ability to titrate their pressors? Does the order allow you to do that?” Or, “Do you have ability to re initiate pressors?” because if I go see a patient that was just taken off pressors, but hasn’t been thought of it, going back to what I said earlier than being orthostatic.

I expect they’re not going to tolerate it. So having that ability to communicate, understand each other’s roles and the background of knowledge that we bring to the table is super important. And then to comment on what you said therapy is a consult service. So we don’t know what patients are not mobilizing until we get that consultation.

Jenna Hightower, PT, DPT, CCS 17:51
And there’s only a few of us.

Phillip Gonzalez, OTR, MOT 17:54
Nurses are doing their assessment and saying, “Hey, these patients can’t move.” We’re not going to see that consult. But there’s been plenty times where I’ve gone into a patient and got them up out of bed or asked the nurse initially, “Hey, have you mobilized this patient at all?” They’re like, “No, we’re waiting for therapy.”

Well, patient on the vent, got them up. Sat edge of bed was transferred to a commode standing at the window, whatever. And the nurse is like, “Well, how’d you do that?” I’m like, “Well, I just got them up, they were able to do it.”

Jenna Hightower, PT, DPT, CCS 18:22
You asked them to do it.

Phillip Gonzalez, OTR, MOT 18:24
So there’s that gap between confidence in mobilizing in the ICU. And I think that’s a big part of it, where both of us working are all all of us working for institutions where we’re at the forefront of the ICU revolution and early mobility and bringing different things to the table, an agenda Nikki and I bringing the equipment to do it safely with these patients is super important. And I think that leads really well into why do we do it?

Kali Dayton 18:54
I think part of the gap is that from the nursing side, I personally as I’ve been doing this journey in this podcast, I’ve been astounded by what I’ve learned. And I constantly am asking myself, “Why didn’t I know this before? Why did I work in the ICU for 10 years without knowing this?” Because there’s so much information that’s essential to our ability to critically think through and optimize care for each individual patient. So let’s just again, zoom out, zoom in. What are the benefits of verticalization? If there are so many ways to apply it, why should it be applied?

Nikki Stevens, DNP, APRN, FNP-C 19:29
Right? Well, I’ll kick us off on just physical benefits or benefits that come along with mobility in general, but specifically verticalization and the top of mind is pulmonary. So when we look at pulmonary you know there’s there’s so many things that I want to cover. And Jenna and Phillip I would say jump in at any point in time when you have something to add.

Truly, when we look at, you know, position… position matters as it relates to respiratory so we look at things like aspiration risk. So what puts us at risk for that, and you know, as patients are on mechanical ventilation or just decreased mobility due to whatever, even if they’re not on a ventilator, but but just diving into what puts them at risk for aspiration. Knowing that aspiration puts us at high risk for ventilator associated or ventilator acquired pneumonia.

But so if we get down to even the cellular level, you know, our mucociliary elevator that those little hairy fibers are cells that take the mucus and have into the larger airways from the smaller airways into the larger airways, and help us to excrete, or, you know, get rid of the secretions that we don’t need that may be hindering oxygenation, that process is impaired, first of all, by your disease state, but second of all, once they go into the hospital, it is impaired by medicines and other things that happen sedation put, you know, paralyzes…

Kali Dayton 21:04
Propofol! Propofol paralyzes the cilia.

Nikki Stevens, DNP, APRN, FNP-C 21:07
Right! So I mean, you know, when we look at that as like, Okay, so now, we know that if we have a mechanically ventilated patient that are on these, all of these medications, and specifically propofol, right, it is impaired hugely, grossly, maybe even to the point where it’s stagnant, not moving.

So what happens to those secretions? They stay in the lungs, they dropped to the bases or, you know, to where we can’t excrete them. And it is just an environment that harbors the growth of bacteria. So inevitably, growth of bacteria, you’re going to get, you know, some type of an infusion, and that just sort of exacerbates the whole cycle of inspiratory expiratory excursion.

Minimizes chest recoil, I mean, you know, decreases lung recruitment, which, you know, creates atelectasis. I mean, it’s just like, it’s almost like these embers that are burning on a fire, and the more you add to it, the more the fire grows, and it’s like, you know, those those things? How do we stop them? Or how do we mitigate them, I don’t want to say that we can prevent them completely.

But how do we mitigate the negative effects that go along with all of these things, the fact that not only is the medication slowing things down from a from an, you know, excretion secretion perspective, but also, when you think about it, the patient has a tube down their throat, right, they cannot actually aspirate those secretions on their own.

So then if you don’t have someone standing there with a, you know, a suction apparatus, they can’t then effectively get those out those secretions out. So that’s one part of it, then when you go on and look to like, your volumes, on your lung volumes, there’s so many things that go into that, you know, when you’re when you’re in the position of even at a head of bed, 30 degrees.

you know, I think oftentimes the diaphragm is overlooked. And like one of the main things that one of the main muscles that actually helped with that inspiratory expiratory cycle, and if the if the diaphragm cannot drop to allow that thoracic cavity to them in, you know, take in the oxygen at optimal levels, then you’re left with, you know, decreased excursion decrease recoil decreased that whole inspiratory cycle.

And so what happens is, is that now, you’re you definitely have decreased alveolar recruitment, you’re now probably at high risk of developing atelectasis, which impaires gas exchange. And you know, when we get into like the V Q mismatching, just to assuming that, you know, some people might not understand what V Q matching is:

the V is for ventilation and the Q is perfusion ratio. So the mismatch of that ventilation perfusion ratio ratio is like the common cause of hypoxemia. And respiratory failure or distress that leads to failure is caused by hypoxemia.

A number of variables can impact that, like I said, if you have a pleural effusion, that then decreases the ability of the lungs to potentially expand. And, you know, I mean, it’s just a vicious cycle, decreased recruitment, you know, the new lead to atelectasis this and, and then, none of which is like the least of these is the diaphragm atrophy.

Again, it’s a muscle and as you’re on mechanical ventilation, you can develop just like any other muscle in your body atrophy. And as you atrophy, your ability to then come off or be weaned from mechanical ventilation, your ability is now decreased. And so you know, the longer you’re on mechanical ventilation, the moral law likely you are to experience a number of related negative events.

And I would just say that ventilator associated or acquired pneumonia is one of the top most common hospital acquired infections that occur not only in an adult, but also it’s the second most common hospital acquired infection in pediatric population. And so like I said, it’s a vicious cycle. And position matters.

A study from Gan et al. in 2023, early passive orthostatic training prevents diaphragm atrophy, they proved in that the… it’s a retrospective case control study. And they proved in that study that patients that they put on a verticalization protocol from zero degrees to 90 degrees for 30 minutes most days, they had good success with preventing the diaphragm from atrophying and in that protocol of the 30 minutes of verticalization 15 minutes was spent on moving the patient and what I call low and slow to see how they acclimate and, and how fast they can titrate them to the highest level.

But at the last 15 minutes, they went aggressive to try to see with positional changes what that meant to the diaphragm and overall oxygenation. So I would just say position matters. And then going back to like the secretion, the body produces 30 to 100 milliliters of mucus daily in a healthy individual, so 30 to 100 cc’s of mucus in a healthy person.

Well, if you think about in an abnormal situation with disease process in, in play, it can be up to probably like six or 800 CC’s. And the capacity of one lung, in volume can be up to six liters. So you can do the math, if you’re up to an abnormal disease process where you’re getting like 600 cc’s of mucus that you cannot then clear, you multiply that out.

And within two days, you’re over a liter of mucus sitting in those lungs that you’re not able to secrete. And so we’re already behind the mark when they come in, and then we ventilate them because of their disease process, then we’re throwing all these medications on board. And then if we’re not moving them, they absolutely cannot clear those secretions on their own. So again, position matters.

There’s another study that I wanted to point out, that actually looked at supine, you know, seated, if you will, head of bed at 30 or 45, and then standing. And then you know, at the conclusion of that study, you know, it was pointed out that standing provided the optimal position for oxygenation because of that whole a&p

Where your diaphragm is dropping, allowing the thoracic cavity to expand in the most optimal position. But in health care, we know that the seated position is utilized, mostly because we’re afraid of syncope or a fall related to a near syncopal event. So you know, there are plenty of studies that show standing, if you will, is is optimal as it relates to our anatomy and facilitating the most optimal oxygenation position. It’s a lot.

Jenna Hightower, PT, DPT, CCS 28:27
Especially with any patients that have any sort of abdominal girth, which is a lot of the US patient population, especially ones that are hospitalized. So the sitting position is great, yes, we want them up out of bed. But when you’re sitting, you’ve got all that abdominal girth, just sitting on their diaphragm, so that’s restricting their breathing even more. Whereas in standing gravity just gently offloads that for us. So that’s even more excursion that you’re getting.

Kali Dayton 28:53
Ironically, Jenna I was just with a team that had a large patient that was on there for aspiration pneumonia. So his lungs were bad. But he’s on people 16 and 100%. And they were trying to explain that they were deeply sedated him because of his ventilator settings, which there’s no evidence to support that. But posed the question, when is his peep going to come down? If he’s just laying there with about 350 pounds? When is his PEEP going to come down to a level that you subjectively feel comfortable with? Unless he gets up? Unless he actually clears that aspiration from his lungs? When is it going to actually get better if we don’t do the things that will help it get better or anatomically and logically makes sense for him?

Jenna Hightower, PT, DPT, CCS 29:32
Yeah, I actually just had a chest physician or a physician at CHEST, the conference earlier this month, come up to me and say, “Oh my gosh, we love this bed so much for our bariatric patient population, because we will extubate them in the standing position so that they are more successful.” And I was like, “I’m just curious what your settings are. He was like we’ll have them minimally on minimal oxygen settings, but a lot of times their PEEP is still 15 or 16. Because of all of the abdominal girth and whatnot on their diaphragm.” And he was like, “and this just helps us be able to bring it down so that we can safely extubate them.”

So, just like you said, you know, physicians are seeing that out in the field. Actually, when I was in residency here in Atlanta, we did the same thing, we would extubate our bariatric patients in the standing position, you know, on a tilt bed, because it just made them that much more successful.

So we can leave them verticalized for a good 30 minutes or an hour or longer if they could tolerate after being extubated, so that it gave them even more time for them to acclimate, you know, to breathing off the ventilator without all the extra pressure on their diaphragm. And not to mention patients that are have increased weight.

Once they lose their ability to bear their own weight, it is so much harder for them to build that back up, because it’s not like your your little 90 pound grandma that me as a PT can just pick up and put in a chair or hold up to stay until they’re strong enough to do it. You know, you have to have mechanical assistance to help them rehab.

And often it’s a long and costly rehab process, and often that they end up with tracheostomies. Because of that, and it’s really hard for them to ever get that tracheostomy out because they require such a high peep. And so in this instance, I can think of one individual we started tilting him as soon as he got put on the ventilator.

We had him off sedation in two days, and he was going through alcohol withdrawal. So we’re able to have him off sedation despite withdraws because of the verticalization. And even on high vent requirements. He was on 80% PEEP of 15, worked with him throughout his whole 10 days of mechanical ventilation. Had him walking, literally the day, you know, he was off the vent.

And in the hallway, we walked him on the ventilator also. But just so that he could be verticalized with nursing staff multiple times throughout the day kept his strength up that he literally went home two days after he got out of the ICU.

And I feel like with somebody that is over 400 pounds, that is just unheard of. Like if they end up on a ventilator, they’re often in the hospital for a very long time, end up going to like an LTACH or something like that, because they they end up on the vent for a long time. And it’s really sad and such a disservice to this patient population.

But one other study, I wanted to point out while we’re on the pulmonary topic, we had a physician in France who really wanted to look at the benefits of verticalization compared to proning. In the arms patient population. And we’re looking at the definition of ARDS, a lot of how we characterize the severity of our does by P F ratio. And severe ARDS is considered P F ratio less than 150.

And all that is is comparing how much oxygen is showing up in their blood gas compared to how much oxygen we’re giving them without that your PF ratio. So he looked at the physiological effects and safety of bed verticalization in patients with acute respiratory distress syndrome. And this was Dr. Lewis Bouchard, and his critical care team out of Clermont Ferrand, France, I’m probably not pronouncing that correctly.

But he took 30 patients, and he compared outcomes of hemodynamics via a PA catheter, all the various VIP parameters, arterial and venous blood gases in exploratory lung volumes, esophageal pressures. And then he also went a step further and looked at their lungs with electrical impedance tomography and looked at the expansion of the lungs, which is really cool. And he compared outcomes at 30 degrees, 60 degrees, 90 degrees for 30 minutes at each angle.

And he basically just wanted to look at preliminary results, one, just see if it did show any results. But also if it was safe, because often these patients are septic, they’re on multiple pressors. They’re on paralytics. So if you think if someone’s not actively contracting their muscles, and you tilt them up, you think they’re going to be vasopalegic and orthostatic. And he actually found with this patient population that they weren’t, so they didn’t really have to titrate much on their hemodynamic drugs.

They had no serious side effects. And these were all patients that were on paralytics because their disease process was so severe, which was a massive negative five as well. And in exploratory lung volumes, for predicted body weight were increased significantly, there was significantly lower alveolar strain, which is a really big problem in the arts patient population, their lungs get really scarred from all of the pressure that we’re having to give them to the ventilator to keep their lungs open and oxygenate them effectively transpulmonary shunt was significantly lower.

So showing that better VQ matching is much better Less physiologic deadspace from the disease. And then as a result of all of that improved PF ratios. So showing a good way that we track how our ARDS patients are getting better is watching those PF ratios are they’re actually getting oxygen diffused into their body. And this study showed that they work.

So that’s really exciting that these outcomes were showing similar effects to pruning, because we know and we found out through COVID, that pruning is really detrimental to patients like to touch on that a little bit. Yeah, you know, all of the side effects from becoming, you know, prone and paralyzed and sedated for so long are just terrible. I mean, patients go blind, they end up with nerve injuries, facial edema, pressure, injuries and injuries. Yeah. Oh, it’s so bad. I mean, I’ve had patients where their faces are just completely black, and it’s just terrible.

Kali Dayton 35:53
Not to mention obviously, the delirium and ICU acquired weakness, right?

Jenna Hightower, PT, DPT, CCS 35:56
Just the rehab process is just months and months and months. And not to mention the long term effects on top of that, which we could talk about for hours.

Kali Dayton 36:05
We have a whole podcast on this- preaching to the choir here.

Nikki Stevens, DNP, APRN, FNP-C 36:09
But I want to share to Jenna is, um, there are two case studies that, you know, one was out of Northwestern, and then actually it’s a cohort series that actually talked about exactly what you’re, you’re touching on, but I mean, I think one that cannot be, you know, I guess over highlighted in is the one from Northwestern, a 31 year old female with no significant medical history came to an at, you know, a lower tertiary level of care at at a house outside hospital, but she was intubated and transferred to Northwestern, and placed on, you know, vv ECMO along transplant, list, all the things.

And what I would highlight about that particular study that was just published this year, is that, you know, they had tried everything, right, all the traditional care, antibiotics, you name it, they’re like, oh, maybe we need to change her cannula with her, her VV ECMO. So they change the cannula, and tried all the things and you know, at the end of the day, her SATs, they could not get them above 88%, no matter what they try, they even tried proning.

So I’ll just wanted to sort of, you know, tag on what you were talking about, is they tried proning multiple times and couldn’t get her SATs up, they start to verticalized. Her, and after they did her SATs stayed up beyond 90% for three hours and beyond. And they’re like, Hey, there, they were onto something. So they were like, keep this going. They kept it going for a month and the patient kept her lungs. I think that’s significant. You know, I always say is, is verticalization a silver bullet?

I’m not trying to make that claim. But what I am saying is that, again, if we go back to the studies that show that position matters, when you’re talking about how do we get the lungs to a or the body to an optimal position to facilitate, you know, oxygenation, at at the optimal levels. I mean, again, common time we see standing is preferred to seated or if even supine, you know, like I said that one study was pretty significant

. And then, you know, I would just mention that Rush University Medical Center, they did a study, and there it was, during that COVID time, they had a ton of ECMO patients, where, you know, of course, during that time, there weren’t enough staff members to produce every patient, right, these patients were sick. And so they did a study on retrospectively on 62 patients, and 34 of them had COVID origin related to COVID.

And what I would say on that study was that they that what they highlight was their primary outcome was survivability. 85% of those patients survived. And what I would also then say is almost 30% of those patients were then discharged to home, not even to a rehab, but to home. And I mean, just like what you were saying earlier, Jenna, is we cannot overstate the importance of those patients, not even having to go to a rehab, just going home to their family. You know, that’s, at the end of the day. That’s what they want.

Kali Dayton 39:04
You know, this is so validating, and I just feel vindicated. Because when I started this podcast in 2020, these kinds of studies, we’re not quite yet, right. These are very recent studies where we’re looking at verticalization the effect of verticalization, and so people are saying, “You’re crazy.”

And I’m trying to articulate, “No, these patients do really well. I had a patient- Megan Wakely- I interviewed her. We proned her, and she actually did better walking and she did proned. And people did not believe that because proning is the ultimate magic bullet right, quote, unquote. And I’m like, “But I this is what I’m seeing. I’m seeing as my own eyes.

She does better walking.” And during COVID, very few patients really had to be prone and paralyzed in the awake and walking COVID ICU. They were upright, they were sitting in their chairs, they were walking, they were doing things and again, the evidence wasn’t there to articulate why and capture why that was so much better other than, obviously to delirium or to quit weakness, things like that, but be upright. It made sense to me. But we just didn’t have the evidence.

Now I’m saying okay, this is now it makes sense because they were vertical. They were upright, their diaphragms were intact, they were able to clear the secretions, they didn’t have the evaporates, they became mismatch was better, improve shunting, like everything was better because they were upright, we were just doing what we knew had always worked for our patients with acute respiratory failure, applied it to COVID. And it worked. Almost most of those patients walked out the doors and went home. So finally, we know this works for ARDS, acute respiratory failure, all these patients, but then it’s not just the lungs. It gets there. It gets better than that. I’m better but there’s more right? Hit it Phillip. Tell us about the musculoskeletal benefits.

Phillip Gonzalez, OTR, MOT 40:47
Absolutely. So before being an OT, I had a background in exercise physiology as a college athlete, and I love just the science of exercise in general. So a lot of my rehab, even though I’m ot ADL based functional activity based goes back to that. As an athlete, our bodies are designed to be athletes, our bodies are designed to be upright.

So way back in the 90s, it started out with research being done with astronauts returning home from space, why when they would get home, they would get off the ship, get off the rocket, be dizzy, lightheaded, have poor balance, be orthostatic not really be able to tolerate tolerate upright activity. And the question was, why was this happening?

Well, so they did research on it. And it’s hard to recreate a gravity eliminated environment in a world that has gravity. So what the studies did was they actually had these astronauts or study subjects be in a bed rest position for a prolonged period of time and ironically, bed rest position with a slight Trendelenburg. And what they found was that that position alone created a huge opportunity for days of leisure created a huge opportunity for muscle tissues for muscle wasting, because it wasn’t being loaded on by gravity created a huge opportunity for remodeling of the bone to not happen.

So what they found was that, in that bed rest position, you lost bone mineral density, you lost muscle protein, muscle mass, you actually lost responsiveness from an electrolyte efficiency of getting the ions into the muscle fibers to perform that contraction in efficient manner, to actually respond in an appropriate time to do the task that you need to.

You can mess with your hormones, your endocrine system, and mess with regulating that so that they weren’t actually being able, the body wasn’t producing the growth hormone that it needed to sustain status quo. And then even later on in the early 2000s, and 1000s and 10s, more studies came out of the table, why is that happening?

And really, it comes down to our bodies here on earth are designed to be able to operate against gravity. in a supine position, gravity is going through our plane in a horizontal position. So not many muscles, bones are being involved from that in an upright position, and gravity is going from our head down to our feet.

So now you get that axial loading through our spine, you get joint proprioception, you get muscle activation from each individual muscle fiber at each individual joint to support that upright position, you get barrel receptor response to be able to support blood pressure in that upright position. I could go on and on about this, honestly. Because that’s something I really am passionate about.

Kali Dayton 43:40
But we’re not thinking about right? We don’t most of us don’t look at a patient that’s resting in bed with their eyes closed, and see what’s happening on the cellular level. But that’s what you see. And that’s what the evidence supports. And so finally, we’re tying it together. I mean, this is like decades in the making. And how does this all tie in?

Phillip Gonzalez, OTR, MOT 44:01
So when we’re in a supine position, we’re not encouraging our body to have that neuromuscular response to actually do really anything. So you start to have a disuse, you start to have the muscle fiber becoming lazy, our muscles like to be lazy, if they’re given an opportunity to be lazy they’re going to be so when you start having that disuse.

Then you start to have type one fibers which are quick Twitch force production fibers switching over to type two fibers, which are more of a slower twitch longer endurance type fiber, but can’t generate the force for the functional transfers, can’t generate the force to push ourselves up edge of bed push ourself up to standing to be able to perform those functional transfers appropriately.

Excuse me, and then you start to lose that strength and it goes all the way down to these patients not even be able to have that contraction velocity and that force production to be able to lift a finger. We’ve seen it we’ve had patients post COVID. And now we’ve referred to COVID a couple of times.

But even prior to that we’re into patients that had ours that were intubated, sedated, paralyzed for a long period of time, they’re coming out, they’re starting to become more awake, we’re finally allowed consultation. Like we said earlier, we don’t know that we need orders for these patients earlier, unless nurses are advocating for us doctors or advocating for us that hey, let’s go in and we’ve gotten patients where they can’t even lift a finger.

Well, that’s because their muscles, their nerve conduction, the electrolyte imbalance, all cascades on top of each other, to where the now they can’t create the force, have the speed of the force, have the speed of the conduct contraction, perform the task, as well as even coordinate that together to do whatever they wanted to do. It could be your legs, your arms, your back your head.

I mean, I jokingly say wrestle in bed with my ICU patients sometimes because I’m physically behind them, holding them up, holding their head up courageous, don’t have the muscle strength to do it. Whether it’s a neuromuscular issue, whether it’s a musculoskeletal strength issue, it all cascades on top of each other.

Jenna Hightower, PT, DPT, CCS 46:07
I mean, can you imagine just being trapped in your own body, like people that are claustrophobic that are listening, like I just I can’t imagine what that it’s like, you know, just being trapped in your own body not being able to lift your head up off the pillow, like not being able to reposition yourself when you’re uncomfortable.

Like it’s, terrible what we do to these patients, and it’s not intentional, but it is important to talk about in that detail so that we we can fix it and know that we have these tools to fix it. And then going into that further, other things get lazy right fill up, our neuro system gets lazy. Our vestibular system gets lazy. So if you want to talk about those two.

Kali Dayton 46:48
Those are different pathology, but we create jamborees patients, and a lot of ways, right.

Phillip Gonzalez, OTR, MOT 46:55
Yeah, so from a neuro standpoint, being in that upright position, and I’ve said this for cognition, which we’ll talk about as well. But from a neuro muscular standpoint, being in that upright position has such a profound sensory input through our ARs are activating reticular, or ascending reticular activating system or through the thalamus and the thalamus within the cerebral cortex, where all that sensory processing information happens to then go back out to the efferent pathways to have that muscular response.

So when we don’t have that, you’re not stimulating the cerebral cortex to then say, hey, the body needs to respond in an appropriate manner to maintain that strength, not coordination, like Jenna mentioned with the head in an upright position. If you’re not encouraging the head to be upright, you’re not activating the inner ear, you’re not activating those efferent pathways in the inner ear to show “Hey, we need to start to prepare our body to tolerate this upright position.”

So from a sensory input standpoint, from the inner ear to moving upright, as well as a barrel receptor response from the stretch reflex from being upright, our body would not be prepared to tolerate upright and would likely like I had mentioned earlier, go orthostatic. So those are things that I’m doing my initial evaluation that I’m preparing for in my head knowing, “Okay, is this a sensory issue? Is it a cardiogenic response issue? Is it a muscular wasting issue? Is it a combination of all of it, that is really going to affect this patient?” Yeah.

Jenna Hightower, PT, DPT, CCS 48:25
I mean, I’ve had patients that end up with vestibular hypofunction, because they’ve just been for so long, their body just isn’t used to moving around. So when they do move around, they’re dizzy. And, and the physicians or the medical team can’t come up with any other explanation. They’re like, “Oh, their blood pressure’s good. Their blood sugar’s good, all the other things are taken care of.” And I’m like, “I think that they have a vestibular hypofunction. And the only way to get over that is to let them be dizzy them around.”

Kali Dayton 48:50
It lasts long after the ICU as well, I mean, there’s, they are vestibular rehabilitation specialists, because the patient’s their their gates off they’re fall risks. And it’s, it’s all on the air like it’s, but it’s because of what we did to them in the ICU, right?

Phillip Gonzalez, OTR, MOT 49:06
A lot of times we’ll get that’s where it’s sometimes our start of our console will be as “Oh, the patient is dizzy.” And it’s BPPV. Well, no, it’s not BPPV. It’s just because of a hypofunction response, because they’ve been in bed for too long.

Jenna Hightower, PT, DPT, CCS 49:18
Right

Phillip Gonzalez, OTR, MOT 49:18
Then, unfortunately, just as you would with hypersensitivity to destimulate that with the hyposensitivity or hyporesponse, you have to stimulate it, which means you have to allow their brain to learn to reprocess that position.

And then going into my next one functional cognition and delirium. Sensory stimulation is huge for patients with disorders of consciousness, whether that be from an acquired brain injury, whether it traumatic or stroke, or whether that be from delirium, that sensory stimulation is so important to be able to get these patients to start to move from…

if it’s a brain injury, that vegetative, minimally conscious state to aroused, or to confuse and then arouse, or if it’s a delirious patient to be able to get them to engage with their environment so that they can start processing that information.

A lot of new evidence is coming out that shows that sensory stimulation itself dependent on the sensory stimulation that is being given, allows us to engage with the patient at a much deeper level, other than just us as healthcare providers providing interventions.

How are we providing this intervention? What is the mechanism going into the intervention that’s been provided? If it’s a sensory stimulation specifically, as a therapist, if I get a patient that’s comatose, that I want it to get upright or get moving? How am I going to do that? Is it just going to be me going up doing it not engaging with the patient? No.

I like to incorporate a bunch of factors in that I want to engage the family, have family give commands so that they’re able to hear family’s voice, I get them upright so that our body gets that sensory input along the, as I mentioned earlier, the ascending reticular activating system, so that now we’re not engaging just the bones, the muscles that joints were engaged in the central nervous system were engaged in the cerebral cortex, so that you’re getting both the a fair and the efferent pathways working at the same time.

How many times a day am I doing this? I’m going through, and as a therapist, unfortunately, we’re only able to be there one time of the day, most likely, but what education like giving to the nurses to be able to do this with the verticalization bed, “hey, this is something you can do it safe. Where they’re strapped in safely, you can get them in an upright position. If they’re non ICU, you’re able to train family to be able to do that. If you’re not worried too much about their hemodynamic response.

That way, they’re getting that emotional component of it as well. And then we talked about in our last conversation, one of the personal stories that I always go back to always remember is TBI patient that I had a young gentleman severe motor vehicle accident, got him in an upright position, in this case, it was sitting under the bed. But yes, he was responding to that verticalized position, as I would expect, he was thrashing. He was in pain, not really processing information.

But the moment we incorporated his favorite music with that verticalized patient piece to it, he melted like butter in my arms, because I was having to hold him because he was thrashing. He instantly went to just kind of a rhythmic rocking just to self soothe. And it allowed him to now start to engage eyes open looked around in his environment. So being upright showed that yes, that’s one portion of it. But what else are we doing? And how are we delivering that upright position?

Nikki Stevens, DNP, APRN, FNP-C 52:50
Yeah, I was going to add to that. So Philip, this great. Just a great piece of conversation here. And thank you for educating us, all of us on, you know, the benefits as far as it relates to neuro. But I would also take that and say that I have seen patients when they become upright, as opposed to just sitting instead of as a provider looking down on the patient, but being able to see them eye to eye, what that does for their emotional, their psyche, and that cognitive stimulation, because now they feel alive.

You know, I mean, that cannot be overstated, as is that part of it? It seems so minimal, but I mean, being in the hospital setting for days and weeks, and then you know, always looking talking down to you down to you telling you what to do. You know what what, you know, here’s what you’re planning to curious, but now you feel more like you’re a part of it.

Phillip Gonzalez, OTR, MOT 53:42
You know, that’s one of the biggest things. Yeah, so one of the biggest things I do like ot intervention, because there’s still often a debate of okay, well, what’s OTS role in the ICU? Is it just for functional cognition? Do we have a mobility component to it? Is it just ADLs? Well, what ADLs can you do in the ICU when they’re connected to mechanical circulatory support the event and everything else in between?

What is our role? Well, I mean, personally, Jenna knows this because we practice together for years now. But I’m a mobility, heavy OT, I like to incorporate some components of mobility, early mobility, verticalizationm upright activity into whatever I’m doing. And working with the tilt bed to total lift bed, it completely changed how I practice in the ICU.

And this was even long before I worked with Vitalgo of what I was able to do in the ICU. I would do simple ADL washing face attempting to brush teeth self suctioning for the pulmonary benefit, but I would do it with a tilt bed in an upright position for that not only the sensory stimulation, but as you mentioned, the psychological benefit of just being upright.

It makes you feel human again, it increases your mood, your attention, your concentration, these patients that I’ve worked with would be able to sustain attention for the activity that we’re doing for a much longer period of time versus if we We’re just doing it supine in bed or just doing range of motion.

And then finally, one of my favorite memories is getting the patient in an upright position, and then they’ve just been able to hug their family member. I mean, somebody that is so sick that you don’t think can do that even family, like you said, is looking down on them trying to hug them saying “It’s okay, they’ll get better.”

Now they’re in an upright position, they’re able to initiate those things, that has such a profound cognitive benefit to move through cycles of delirium, but also even benefit for the care providers and the family members involved to see their loved one who is thick, still engaged, that’s often the battle we as therapists fight is how are you going to do therapy when they’re this sick, there’s always something that we can do.

Jenna Hightower, PT, DPT, CCS 55:45
Kali always talks about that, that will to live, that will to get better, you can’t, you can’t will that for them, we have to create an environment where they want that as well. And this is just one of the many benefits of being upright and, and to speak to the ADLs. I mean, we do all of our ADLs in real life and upright so why would we change that in the hospital?

Kali Dayton 56:11
Well, how does that play into how you approach awakening trials?

Jenna Hightower, PT, DPT, CCS 56:15
Um, oh, yes. Um, yes, my favorites. Yes, at at my hospital, we initiate the verticalization therapy, even before we start weaning sedation as a mode to help them we infer from sedation, it’s particularly beneficial in those patients that are a little harder to wean from sedation, especially, you know, patients that are fighting other other things like alcohol withdrawal, or opiate withdrawal, or whatever it may be some of our metabolic induced delirium such as patients with liver failure, or kidney failure.

The upright position, as Philip has talked about all of those benefits, really help in weaning that sedation and doing it in a calm and controlled manner. Because I mean, how terrifying is it for you to wake up in a hospital bed with all of this stuff around you and attached to you and you can’t see anything of it. And you can’t control what you’re doing versus being upright and being able to see your room, see your environment, see your healthcare providers talk, you know, engage with them, you may not be able to talk depending on what devices you have.

But interacting and having that sensory input is extremely beneficial in weaning sedation, and preventing delirium as well. So that’s one tool that we use use at my hospital a lot. But also on the neuro topic wanted to discuss, we’re starting to see some new stuff in the literature in the neuro ICU, which is really exciting, because I feel like the neuro population is so such grossly under utilized with verticalization therapy, but it can be one of the most beneficial.

So not only from a sensory stimulation standpoint, and weight bearing, but some of these tools as as we can use it as an intervention to treat some of their neuro issues. So Nikki, if you want to touch on the case study that came out last year?

Nikki Stevens, DNP, APRN, FNP-C 58:13
Yeah, I would love to. So University of Maryland medical center actually did. It was a case series on six patients that had refractory intracranial pressure. So in addition to all of the conventional treatments, they were having refractory ICP. And so what they did is they implemented verticalization.

And of course, everybody that knows your brain, in case you don’t know, your brain, if you look at your brain and your stem down here is where your heart rate respiratory center is. So if you herniate when I tell the staff at Kreg, if you aren’t a that brainstem, it’s over, right? So it is like critical to maintain that pressure inside of the head, the cranium, because if you still if you herniate, it’s lethal.

So they want you to put the patient up into the vertical position, they stay there to maintain those pressures as long as it takes. So this study looked at those six patients, they put them up for 24 hours, and then they documented or they you know, got some data. And out of that data, what they found that was pretty significant is the overall mean ICP decreased from eight to 12 millimeters of mercury that is substantial, because again, when you’re looking at that’s a tiny threshold that you can have that can cause that brainstem to herniate.

So decreased mean ICP, the decreased number of ICP spikes that decreased the total medical interventions the need for that also decrease you know, your man atolls and things like that, that the need for that decreased and then just a total therapy intensity level score with verticalization also decreased so you know, again

There’s a lot of important applications and populations that benefit from verticalization, or upright positioning. And neuro is definitely at the top of the list again, because of, you know, your brain is one of your major organs that tells your body what to do. Right. So that is a really significant case series that was put out by Maryland.

Kali Dayton 1:00:22
I was just had a meeting the other day with the team that I’m working with. And they were talking about a patient with an EVD that they’re having a really hard time weaning sedation off of so patient had a real indication for sedation. Now that the pressures are a little bit tenuous, like they’re fine, when he’s down but when they take off sedation, he gets agitated, and the pressures start to spike.

And they have a relationship with a company that where they have access to a vertical verticalization bed, they’re just not used to using it. So I said, “This would be the opportunity, the perfect patient to use a verticalization bed.” They’re also worried about with the agitation having access to his EVD, right? There’s like, how do we keep the EVD safe, keep the pressures within range, but we’re also worried about him now having delirium, and being agitated, we understand why this is a problem.We just don’t know how to get there.”

So that was my “aha moment” where I thought this would be such a powerful tool because they can’t just pop him out of bed and mobilize him.

Jenna Hightower, PT, DPT, CCS 1:01:21
Right.

Kali Dayton 1:01:22
But if he was upright, could that help his delirium, agitation, the pressures, all of that, would that help get him on the right course, because they were saying, “This is the kind of patient that we would just keep sedated for another few weeks? Probably.” Which right now, I don’t want to do

Phillip Gonzalez, OTR, MOT 1:01:34
Which would be so detrimental, because then you’re just prolonging the delirium for even longer. On the flip side of it, looking at the comatose side of things, there’s two studies, one in 2013, out of Germany, from Kramer et al., that was wanting to check verticalization, and patients that were in the vegetative state and the minimally conscious state, versus verticalization, with the Arago, which Ergo is a basically a verticalization table or a tilt table with the reciprocal stepping trainer built into it, to see what showed better efficacy and recovery and long term.

So what this study did was they took 50 patients 30 patients that were either quantified in that vegetative state or minimally conscious state, and for four weeks, at the initial phase, they had 10, one hour, till concessions over the course of three weeks, 25 were just verticalized and 25, were verticalized with the reciprocal trainer, but the stepping trainer, and what they ironically ended up finding out was adding the era go on top of that that reciprocal trainer, these patients only showed a two point increase in the coma recovery scale, which is the gold standard for monitoring a patient’s recovery through the comatose state after a brain injury.

Whereas verticalization alone, the patients that didn’t have the additional reciprocal stepping trainer in it showed a five point increase in their coma recovery scale. And so there was a lot of discussion as to why is that because this is championed as Okay, well, the more sensory stimulation we want, the better. And it goes back to what I was mentioning earlier.

Yes, the sensory stimulation is important, but how are you delivering it? Well, so verticalization provides that sensory stimulation in a controlled manner. It allowed these patients to start to auto calibrate, I like to say, of tolerate something in a position that was still passive, they weren’t becoming habituated to it. And it was still safe to do.

And so the discussion was is was the reciprocal stepping train or just to overstimulation for these patients to move them through. Even beyond at the six month mark. The patients that were just verticalized still showed greater improvement than both the verticalization and the reciprocal stepping trainer. I think the big takeaway from that study is the key factor is verticalization.

Both groups showed improvement. Both groups were verticalized. The only difference was one added reciprocal trainer on top of it, but verticalization alone show the better outcome. And I think that’s huge to help move these patients through the coma recovery scale so that they’re more awake, participatory and ultimately recover from a brain injury.

And then looking at it more recently in 2003 Out of the Journal of Neurology. They did the same thing. They wanted to look at it again. So they took 47 patients over a four week period 16 sessions. This time they split them up into three groups. They did verticalization they did the reciprocal stepping trainer alone and then they did the reciprocal stepping trainer with electrical stimulation on top of it to see if that facilitated any greater response or recovery.

They looked at their level of consciousness, they looked at their fins. So which is a ADL measurement of how they’re able ADL and mobility measurement of how they’re able to complete tasks, they looked at EEGS. And what they found is that verticalization, again, still proved to be the key factor in having a greater positive, correlated recovery in all of these patients across all three groups.

And I think that is just super, super important to say is that even though we’re adding all these additional things, because us as therapists, Jenna and I, both we know the benefits of being upright, that’s what we’re trying to do. That’s our background and our schooling. But how we’re delivering that service is super, super important.

And being conscious of sometimes more isn’t always better, too, because I always take that back and say, “Okay, well, what exactly are we doing? How are we delivering it? What is the premise of what we’re doing? And what is the ultimate outcome?”

And I think having access to like you mentioned, the facility for management of ICPs, letting these hospitals that deal with traumatic brain injuries know, we have access to the equipment to be able to accomplish this upright position in a safe manner, that show into be just as efficient and showing just as good outcomes as all this additional equipment is so beneficial.

Jenna Hightower, PT, DPT, CCS 1:06:21
I feel like oftentimes, it’s it’s, it’s more the under utilization for these patient populations than anything is is like you said, we have this appointment, we’re not using it, which is really unfortunate, especially I feel like in this in this particular patient population is another grossly underutilized, we often we often don’t even get consulted. And that’s another caveat we can talk today.

But like from a therapy standpoint, we don’t even get consulted, because the nurses say, “Oh, they’re not following commands.” when there is things that we could be doing to improve their outcomes potentially, and especially for that, like neuro remodeling is so important early on, but often we don’t get consulted for many, many, many weeks, which is really unfortunate.

Kali Dayton 1:07:06
I have a picture with like a railroad tracks, and there’s a path of sedation and mobility, declaring my declared weakness, infections, death, whatever. The other path is no sedation, awake, mobile, blah, blah, blah. But not every patient can get on the right track right away, you know. Intracranial hypertension is a good example of where they’re already on a separate track, they have all these complications waiting for them. And it’s like verticalization, just suddenly puts a fork in the road. And it diverts the track back to being on course, and you can do it sooner with this kind of technology than we’ve been able to do before, which is really powerful. And we’re talking about pulmonary benefits, musculoskeletal, neurological, and it doesn’t stop there is there are even cardiovascular benefits.

Jenna Hightower, PT, DPT, CCS 1:07:53
Yes. So talking about cardiovascular benefits. And so we’ve talked kind of touched on it, the stimulation of bear receptors, so those little receptors that sit in our blood vessels that tell our body, whether we are upright, we are flat, we are sitting, we’re standing, we were walking, and it helps our our heart regulate our heart rate and blood pressure to increase demand for whatever activity that we’re doing. And when we are flat for too long, those get lazy and they lose the ability to do that.

But also, we can get vaso, please yeah, so our vessels have muscles in them too. And if we don’t use them, they get weak as well. And so when you’re upright and your bear receptors aren’t working, and you are vaso, pelagic, you’re going to be orthostatic. Because your heart rate and blood pressure aren’t regulating appropriately, but also your vessels have gotten lazy. So they’re just dumping into your extremities.

So that’s where muscle contraction and being upright is very important. So improving our circulation also decreases our risk for blood clots. That’s a big big issue in in the ICU is we have those lovely SCDS that we wear that squish our our calves and help us do that passively. But what would be even better is active muscle contraction in verticalization to help decrease that risk. But then also just increasing our cardiac endurance and just tolerance to upright in general is very important.

And patients that become severely deconditioned with ICU acquired weakness, also lose their ability lose that cardiac endurance and respiratory endurance as well to that increased demand. And then along that topic, we have mechanical circulatory support. And I feel like we save this kind of for last on purpose because I feel like it’s the more common use of verticalization therapy.

It’s is is a real hot topic right now is verticalization therapy with mechanical circulatory support. So the big one is ECMO, there’s lots of growing research that the more we move our ECMO patients, the better their outcomes are, the more they survive, and the less complications that they have. However, mobilizing these patients can be extremely challenging, especially for those newer centers that maybe don’t have the experience to do it. Or maybe they’re just starting to get the staff to do it.

And the acuity level of the patient, the configuration of the ECMO, that type of ECMO, what organ systems are involved staffing, limitations, competency requirements, equipment limitations, that can all be it, there’s a lot of barriers to mobilizing ECMO patients, and a well oiled machine of, of a team of people that does, it usually takes a minimum of four to five people to mobilize an ECMO patient out of the bed safely.

And like I said before, usually, you know, even if you have a facility that’s doing that really well, they’re still only getting mobilized once per day. And that’s just not enough. It’s not enough to maintain our strength and all of the other systems that we’ve involved, you know, we, we even on a sick day at home, you know, we’re a healthy person, and you’re sick at home for the day, how often do you get up and move around your house to go to the bathroom to get a drink of water to get food, it’s multiple times a day, and we put these patients in the hospital and we only move on once a day with PT or OT, like for 15 minutes, it’s just not enough.

So giving these the nurses the tools to be able to get these patients upright and weight bearing more than just once when the whole team is required to be there. But also for those newer programs that are learning to mobilize. This is a good stepping tool to get your your competency programs in place to have a safe environment to get started to figure out what tools What team members you need, what protocols do you need in place to be able to accomplish this safely? A great stepping stone, stepping stone is a verticalization bed to be able to do that. As you can tell I’m very passionate about- I know I’m preaching to the choir here we’re all like, yes, nodding your heads.

Kali Dayton 1:11:56
You can’t see everyone at once, but we’re all nodding their heads. And like putting their hands in the air and just loving this.

Jenna Hightower, PT, DPT, CCS 1:12:01
Yes. And then going along with mechanical circulatory support. Another popular Hot Topic is patients with femoral intra aortic balloon pumps. So traditionally, these patients are on strict strict bed rest, they’re not able to bend their hip greater than 30 degrees, it’s completely contraindicated. So that of course prevents you from sitting on the edge of the bed getting out of bed like normal, because of the risk involved.

So an intra aortic balloon pump, for those that don’t know is a balloon that sits up in your ascending aorta. And it inflates during diastole, which is that relaxation phase of your heart and it pushes blood flow back into our coronary arteries. And then when it deflates, it has a little bit of a suction effect and can help our cardiac output as well. So some facilities use it to increase blood flow before maybe a cabbage surgery.

And then some facilities use it as a mechanical circulatory support device or bridge to transplant. So helping with that cardiac output until that patient can get the organ that they need. Now those patients would be in bed for a long time, you know, you can wait on an organ transplant list for months on end. I mean we’ve we know people that have I’ve waited for over a year.

So that would be a really long time to be on bed rest and then your complication rate is going to be just extraordinary. Your body. If you’ve been on bedrest for months on end, or even just a couple of weeks, your body is not prepared to accept that organ successfully. There’s just too many research shows, the more frail you are going into a transplant surgery, the worse your outcomes are going to be greater complication rate you’re going to have. We know that already.

And so a colleague and mentor of mine, Steven Ramsey, said, “Well, how come we can’t walk these people? And we just, you know, walk them off a tilt table or walk them off a tilt bed. And so he started doing that.”

And so the team at Piedmont Atlanta hospital where I am now did a study on it, and they beautifully published their protocol. So it’s all strictly written out for you. If you’ve never seen it, it’s a great reference point. Bring it to your physicians is something you can start at your facility. Because you can imagine the outcomes are just night and day when you take a patient that has been on bedrest going into surgery and a patient that has been walking around every day.

There’s just no comparison. And to read some of the stats, I mean, they had over 300 ambulation sessions, and no major complications. So they had over 70 patients when they published this was published in 2020. So it’s been probably triple or quadruple that now because we have probably 10 patients with balloon pumps at any given time right now.

And not all of them are candidates to walk but all of them at least get a verticalization bed so that they are weight bearing and Steven does nicely where he outlines who’s had can help you clinically judge who is more appropriate to walk based on like their previous ambulation status. They have to be cognitively intact hemodynamically stable, you know. But out of the 323 sessions that they did, they only had 11 complications. So that is a 3% complication rate and they were all considered minor.

So they had a couple of balloons migrate just three migrations, three infections, and then three patients that had hematoma at the insertion site. But actually, when compared to their patients that were on bedrest, the bedrest patients had actually more complications with their balloon pumps than the patients that actually were up and walking. So they didn’t really attribute the complications to walking, they just attributed to having a balloon pump.

So that is, is really cool. And they’re starting to translate that also into patients with femoral impellers. So the impeller 5.5 is a device that goes up through a vessel, it can go in the, the axillary, or the groin, but we’re seeing a lot in the groin. And it goes through your aortic valve and sits in your aortic valve. And it’s a percutaneous ventricular assist device. And so it’s an artificial heart pump, if a temporary, you know, artificial heart pump.

And again, if that were to move while it’s active, it could, you know, shred your aortic valve, which would be very detrimental to the patient. So again, extreme caution and mobilizing these patients, but we’re finding if we can limit that hip flexion still mobilize them, it can be done safely. So some more I’m sure research to come on that as well. But definitely seeing a lot in the field for those patients as well.

Phillip Gonzalez, OTR, MOT 1:16:45
Before you start into the next one, I just have a comment on some of that was at an institution not too long ago. And like Jenna mentioned, they use the balloon pump in preparation for cabbages while this patient was in the hospital, waiting for his cabbage, I think it was pushed out for a week because surgeons weren’t available.

And he was on strict bed rest. And this is a patient had a chronic back pain patients that traditionally needed to be upright to alleviate his pain. Well couldn’t get up, right, because he had the balloon pump, but can’t deal with his pain because he can’t be upright. So now you’re caught between a rock and a hard place. Well, what do you do, the facility at the time didn’t have access or a means or think about getting him upright in a way that was safe, using either a tilt table or verticalization bed.

So the patient himself asked for the balloon pump to be removed so that he could get up and get moving to deal with his pain. And this is a patient that came in with a STEMI he needed the cabbage for life sustaining purposes. He needed the balloon pump for life sustaining purposes. And they educated him and educated him like this isn’t safe to do. But there was such a point where he was so miserable being in bed because of his severe chronic back pain that he opted to have the balloon pump removed.

Well, unfortunately, things went as you would expect, he ended up coding and passing away, they had they had opportunity to get them in an upright position to offload that back from the bed to be able to minimize some of that pain, just like we know is done through the Ramsey protocol. It’s safe, it’s feasible, you’re able to do it. Now you look at we have an additional opportunity to minimize pain for these patients to our bodies aren’t designed to be flat. Our bodies are designed to be upright.

Jenna Hightower, PT, DPT, CCS 1:18:27
Yeah, absolutely. And I mean, and so many patients are on mechanical circulatory support waiting for transplant, and we put them put them on these devices to save their lives. But then if we aren’t mobilizing them, then we’re risking their lives because then they’re not candidates for transplant anymore. And it happens so often.

I mean, I’ve had, I’ve had people reach out to me on LinkedIn, and say, you know, “mM mom or my brother in law is on ECMO, I see that you have experienced with this, what did your facility do? Oh, now, they’re so weak, they’re not a candidate for transplant anymore.”

And that’s heartbreaking to hear. When this is something we can really impact. We have a case when we were working together, Philip and I at Mayo that post COVID patient and I ended up publishing this case in the Journal of safe patient handling and mobility because it was so profound. He was prone and paralyzed at an outside facility for a long time over a month, they finally came to ECMO or came to our facility got cannulated for ECMO was kind of that last ditch effort.

However, at that point, his lungs were so scarred that he just he had no recovery at that point. And he was extremely weak. So they got to the point where he needed a lung transplant however, he couldn’t even lift his fingers off the bed. And so we decided to put him on a verticalization bed to initiate his therapy and We had a very aggressive approach, we had the schedule for verticalization, plus our sessions plus nursing tilting, so that he was getting that four to five times of verticalization in a day that he could tolerate.

And we actually had him standing at the edge of the bed in three weeks. And he was able to get listed for transplant, which is just crazy, because typically somebody that’s that week, it’s a minimum of three months before I can get them standing with a traditional mobility program, because they’re only getting that 20 minutes per day. So I mean, just crazy that we were able to get over 1000 minutes of weight bearing time in three weeks to get him strong enough to standing and be listening for transplant so that he could get a transplant.

And he did. And he got a simultaneous CABG, and he ended up walking out of the hospital and going home, after all of that he went home and not a rehab hospital, which is just incredible. So it just speaks volumes of what, you know, a therapy like this can do for patients, not only with mechanical circulatory support, but you know, with ICU acquired weakness, he had delirium, he had all the things, and we were able to overcome some of those barriers.

And he’s just a great patient, he’s very near and dear to our hearts. We still in contact, I just sent him pictures of my baby yesterday. But lastly, I wanted to touch on burn management. And I know we’ve been talking for a long time. But it’s just such an extensive topic of us, greatly underutilized service in our healthcare system to be able to reach every patient with mobility. And last is is burns.

So as I talked about burns healing process is very, extremely complex, timely, costly, very painful. Mobility is often very delayed because of the pain because of the fluid imbalances. Because of very strict wound healing protocols with skin grafts and whatnot, works for the or Yeah, back and forth to the O R, and they have respiratory failure from smoke, inhalation, all kinds of things. And verticalization is a way to overcome all those things to be able to initiate that weight bearing and mobility way earlier in a safe way in a controlled way, it’s titratable.

So that if they’re not tolerating you can go back down, you can, you know, figure out what meds they need, if they need more volume, whatnot, that parameters everything to help them through that healing process earlier on, without having to transfer them on and off to a tilt table multiple times a day. So just like any other patient, these patients need to be upright multiple times a day to be able to make progress.

And not to mention those transfers are painful for patients. And even if you’re using a mechanical ceiling lift, you still get a lot of shearing from the lifts on those skin grafts. And that itself can be very painful for the patient. So verticalization therapy, especially on a tilt bed, or verticalization bed is very much more efficient for not only the staff members, but in order to be able to get the patient that therapy that they need and deserve to make progress. And it just saves a lot of time and resources.

Phillip Gonzalez, OTR, MOT 1:23:16
In the long run. Tilting upright has been the standard of care for burn patients for as long as I’ve been a therapist and even longer. But like Jenna mentioned having to go back and forth from the tilt table to the bed can cause injury, staff injury, patient injury, wound sharing graft side injury. So these hospitals now have access to a tool to be able to minimize the amount of transfers back and forth. Because these patients are already transferring back and forth to and from the or table or the burn tank to get cleaned to get prepped to get graph sides done like so the more we can minimize that the better we can facilitate their wound healing. Yeah,

Nikki Stevens, DNP, APRN, FNP-C 1:23:55
I would just add two points to that is, you know, in that cardiovascular population, you know, the venous return that you get with the upright position, right is just, you know, feeding into that. So when you’re talking about like healing, whether it’s skin or whatever, and that’s one organ, the largest organ we didn’t even touch on.

But I mean, we could just go on and on. I’m sure the three of us the four of us are very passionate about mobility, and especially being upgraded verticalization but like the just the, the prevention and the maintenance of the skin, which is the largest organ of our body, and these burn patients. I mean, we’ve seen so many success stories with the offloading at you know, from shipping and the weight without that sharing on the graph sites or just on skin in general and reducing the potential for pressure injuries and just saving the skin. It cannot be overstated. It’s very important. And we know that with verticalization again with venous return and challenge with the cardiovascular population. It’s just super beneficial.

Kali Dayton 1:25:00
So I mean, this is just so profound. Obviously, it doesn’t make sense to not have verticalization tools and technology in our hospitals. But even when we have it, we’re not fully utilizing it. So what? How should this technology be used? What’s the real objective of all of this?

Nikki Stevens, DNP, APRN, FNP-C 1:25:17
Yeah, I mean, I can kick us off, I think, you know, as we spoke about at the beginning of this podcast, Kali is, you know, again, it’s to provide mobility for like, the most complex patients, the most, you know, the sickest patients that to date have seemed to be excluded from that mobilization, for whatever reason, can’t bend, bend at the hips, or, you know, move my legs and, and things like that.

But I would even go so far as to say, why is verticalization not a standard of care a standard in the mobility arena, that would be where I would really like the goal of it, and what I’d like to see it go to, and so, you know, we should be including verticalization, in every part of mobility, like I said, from the sickest patient to start, you know, and then when they’re able to come off of that bed and move to another modality, then so be it. But I would love to see this available for every single patient.

That way, we’re not excluding any patient from mobilization in the in the benefits of mobility. And I think I can’t remember if it was Jen, or Philip that sort of pointed out even the lowest tilt angle, if that’s all they could tolerate for the benefits of neuro and, and pulmonary and cardiovascular and, you know, all the things, you know, low and slow starting out in that mobility arena. Again, it should be it should be equitable, right? Access to access to verticalization. For everybody. That’s like my, my, my charge.

Phillip Gonzalez, OTR, MOT 1:26:44
Oh, I think you had mentioned it really well, early on to it. And oftentimes, we experienced it in the field as practicing therapists, still, that mobility is often left at the PT and OT. And what the objective of having a verticalization bed does is it allows it to not just be therapy to get these patients upright, it allows it to not just be nurses that get these patients of bright, it allows it to be the interdisciplinary care team.

We’re all healthcare providers, we’re all able to check vitals as we’re doing a session respiratory physicians and pas physician’s assistants, really competency RNAs in the ICU, we can assess a patient’s ability to be upright, what better way to do it in a tool where we’re protecting staff, but also protecting the patient that they’re not capable of holding that upright position on their own.

Nikki Stevens, DNP, APRN, FNP-C 1:27:40
Yeah, yep.

Jenna Hightower, PT, DPT, CCS 1:27:42
Especially patients population were a little hesitant on to move like, that’s where this is a big tool. And like, I like to say, “If you have to have ICU beds in the ICU anyways, why not have some that were why not have ones that stand?” You know, like, why would you not? It’s just a tool, that is, it should be there.

Also just increasing the frequency of uprights, so not only capturing every patient, but increasing their frequency. Like I said before, it has to be multiple times a day to be able to get that benefit, obviously, one time would be better than none. But to be able to do it easily multiple times a day, and to be able to decrease the workload for the staff because of that. So like all the patients that require so many hands to mobilize, that maybe we’re still mobilizing with that team, you know, in an ideal world, but also getting them weight bearing and upright just more than once, where that requires the whole team is super important.

Kali Dayton 1:28:40
And I love that you’re bringing up that this is an additional tool and increasing the frequency. I’m going to do a whole nother episode later on how equipment can actually be a barrier sometimes or impede our culture of early mobility. So what do you want people that understand about what the bed is and is not?

Phillip Gonzalez, OTR, MOT 1:28:57
I think first first and foremost, I’ll say is it’s not a replacement for being out of bed. It’s not a replacement for those out of the importance of walking out of bed, getting up to a chair, being able to get up to a commode. I think what we can sometimes forget as healthcare providers based off of time and access to staff access to equipment is these patients don’t need to move.

We’ve said it multiple times throughout this podcast is our bodies designed to be upright our bodies designed to be moving. Yes, the verticalization that allows us to be upright more, but it doesn’t allow us necessarily to move to do all the extra things that our bodies are designed to do. It is important that it is a stepping stone. It’s something that allows us to augment our ability to practice in the ICU to be able to progress these patients functionally and allow them to perform the more aggressive tasks.

One thing I like to champion too as a therapist is it allows nurses to get up patients upright safely. So the Jenna and I as therapists can do the harder stuff so that we’re able to magically walk a patient into the bathroom, as some nurses have said before, how did you get them there when I couldn’t even stand up? When they’re appropriate to do that, and allows us to be able to prepare those patients to be able to do that?

Nikki Stevens, DNP, APRN, FNP-C 1:30:19
Yeah, I would add to that Philip is what it is not as it’s not a replacement to stand a pivot 100% agree with you. But what I would say is, is that we have to have a building block, I think you pointed that out to be able to get to that point. And, you know, it’s not that but what it is, is it is a risk decrease, or if you will, and instead of having to slide that patient over from another, you know, from surface to surface or equipment to equipment, you have one piece of equipment that is optimal, that can do all the things right, plus keep it’s you know, the skin cannot be again overlooked.

Keeping the skin safe is is one of the main things. And one of the things that hospitals get penalized. If you create a an issue with that, then, you know, you create a whole different set of issues and your reimbursement is, is affected.

Kali Dayton 1:31:13
We love checklists, right? So when we’re looking at the A to F bundle dashboard, we’re like early mobility, that’s only looking at charting, right, so I don’t want this bed to be seen as checking off the charting only. Sometimes that might be the highest level of mobility someone can do. But if it’s not the highest level of mobility, we could use that bet and still get that check done. But are we really optimizing early mobility? Are we doing the highest level mobility for that patient, so I’d invite people to continue to use critical thinking, again, we’re titrating, and we’re increasing frequency, but we’re not replacing patients highest level of mobility.

Jenna Hightower, PT, DPT, CCS 1:31:47
Yeah, and I would like to add to it, that it is a a tool where the patient can still be active. You know, oftentimes, we have these beautiful ceiling lifts that are just so nice. And hospital, this hospital rooms now and a lot of hospitals have one in every room, and the nurse will say “Oh, I lifted my patient to the chair, I got them out of bed,” when the patient can literally walk to the chair.

You know, and it’s just because that’s the easiest way to do it, maybe you know, with all the lines or they’re just don’t want to, you know, take the risk of the patient falling. And so you know, or they’re just, it’s sometimes it’s strictly out of habit. And it’s not to say anybody’s doing these things on purpose. It’s just, sometimes that’s how it goes. And so this is a means for the patient to actively be using their muscles with a safe patient handling tool versus a passive lift into a chair or whatever.

Kali Dayton 1:32:43
So once the entire team understands the why behind it, how to apply it. What is everyone’s role? This is why I brought all three representatives here. Nursing, ot PT, how do you use this?

Nikki Stevens, DNP, APRN, FNP-C 1:32:57
Yeah, I’ll start since nursing, like I said earlier is like that we are the eyes, we are the assessment assessors from the very beginning. So as a nurse, I can say to my colleagues, this should be something that we work into inter collaboratively on. But we should be spearheading, we should be starting that mobilization cascade, you know, ourselves.

So even with the most minimal movements, getting them prepared for when Jenna and Philip come in to then do further activities, that should be the nurses responsibility. So I really feel strongly that nurses should be leading this, we shouldn’t be doing it in a silo, we shouldn’t be doing it alone, we should be collaborating and that we should be starting. And we should know how to assess our patients on the level of mobility and what pieces of tools or equipment are then at our disposal to then bring in to the room to start that patient down a successful mobilization pathway. So that’s what I would say for nurses. That’s where I think we we can start this.

Kali Dayton 1:34:04
It’s exciting that they can do it without needing other help. One of the concerns was the time that it might take monitoring, what do we how do you speak to that? And how can we make this really time efficient for nurses?

Nikki Stevens, DNP, APRN, FNP-C 1:34:16
Yeah, that is a great question. I’m sorry, Philip, I was gonna answer from the perspective of a nurse. I mean, we’re in there already having to, you know, with our computers, now, they they’re all wills, right? And so we’re in the room doing other things, whether it’s a med pass or a med, you know, to the to the IV, or if they’re able to take it orally, crush it, put it in a peg, whatever the case may be, we’re in there doing other things. It is our responsibility to do q2 turns.

We’re in there doing those things. And I always say it’s not just the term right, more than that. It’s not just the term that matter. We’re turning them to assess their skin to make sure that hey, if we have you know, on non bleachable, your thema we’re offloading it we have we have tasks to do interventions to do while we’re in the room. Um, so what I’m always coaching nurses on is come in, have your patient to tilt them 510 degrees again, it doesn’t have to be, you know, 75 or 90, you can do slow things with your critically ill patients, while you’re in the room and your your, your, as you know, assessing their pain score while you’re documenting those types of things, maybe you’re giving them a bath or those nursing activities on the daily that we should be and are doing.

And then you’re documenting, do it in the room so that way you’re with the patient, it’s a one to one activity, when they’re critically ill maybe two if you have a Philip or Jenna. But um, but you know, we’re documenting while we’re in the room. So those things it’s not, we’re not asking them to do more, we’re asking them to do something while they’re in the room that would extend or improve the outcome of their patient.

Phillip Gonzalez, OTR, MOT 1:35:50
I think that’s a fantastic point. Because one of the biggest questions that we get is how do we build it into our daily care? How do we know when how do we? How do nurses or therapists know when to implement it? And how do we build it into our daily care? So Jen, and I had recently did a presentation on the B mat and the VA MSST this tool that nursing used to assess their patients.

And how does that translate to therapists language, like I’ve mentioned, the very beginning, nursing language and therapy, language and mobility is sometimes very different. Well, the equipment solutions in the B mat and the VA, MSST, don’t include options for verticalization. But it’s lifts its power, its Ceiling lifts, it’s powered lifts, it’s non powered, lifts, standing aids, and staff assist and DMA.

Well, now we have an additional tool that can be utilized in the first three levels of the be mat, that helps to move the patient along the continuum of care in the continuum of recovery. So that now they’re able to mobilize now they’re able to do things that they weren’t able to do when they were considered total care. And then it’s not something from building it into nursing care that we’re asking you to do, in addition to what you’re already doing.

The point that you brought up that it’s something that you can do, while you’re doing your other things while you’re preparing the patient for meds while you’re preparing the patient for tube feeds, Peg feeds, whatever the case may be, while you’re getting them set up to do skin checks, do a bath, whatever you may be. It’s not something that you’re going to just do on its own and then have to sit there watch them while they’re tilted, and not do anything. No, do it while you’re doing everything else. Because now you done what our bodies are used to doing is doing multiple things at once.

Jenna Hightower, PT, DPT, CCS 1:37:36
I like to add into is like giving the patient an opportunity and upright to be a member have their own care team. Like you know, I feel like sometimes all health care providers as a PTA do it as well, but but nurses and care partners with with things like baths, like they oftentimes will bait the patient just because to get it done bathe whatnot, well, this is an opportunity for the patient to bathe themselves. Like sometimes I’ll joke with my nurses and say, are their hands broken?

Why are they not helping with their bath? Why are they not assisting you. So quit doing these things for the patient that they can do for themselves, you know, help them to be an advocate. And this is just an another opportunity that while you’re in the room doing other things, you can allow the patient to do some of these things for themselves with your supervision so that they’re safe, but still allowing them to be a member of their own care team.

Kali Dayton 1:38:28
I wish that I had this vision of having our patients be vertical during rounds. Yes. And they’re standing in rounds with us rounding on themselves.

Jenna Hightower, PT, DPT, CCS 1:38:37
Yeah, yeah.

Phillip Gonzalez, OTR, MOT 1:38:38
I’m so glad you brought up. As an OT, obviously, I’m ADL-focused. But that’s literally my one of my favorite interventions to do with ICU patients, getting the warm wipes, have them either in a verticalized position or a bed or whatever they’re capable of doing. But oftentimes with those high acuity patients, it’s on the verticalization, that is having them do a bath in a standing position and then taking charge of it.

It’s something humanizing about that you no longer feel like a subject, you no longer feel like a patient, you no longer feel as if you’re totally impaired and incapable. You’re able to do these things on your start to do these things on your own with assistance. And then it also is profound for the family members to see their loved one, doing these things on their own or initiating starting to do these things.

It starts to change the psychological mentality in the entire room of okay, we’re starting somewhere, we’re going somewhere they start to see that proverbial finish line of where we possibly can go, which as therapists were often asked me to be their biggest cheerleaders of saying, this is where you are, this is how we’re going to get there. But oftentimes, we walk in and family members are so confused as to where we even start.

Nikki Stevens, DNP, APRN, FNP-C 1:39:55
Yeah, I love that you brought up as a part of rounds. Kaylee actually made that simple gestion just like a couple of weeks ago, you know, when you’re in one to one, you know, nurse to patient ratios, and you do have your team rounding? Why not? Why not? That’s the time to see, you know, so the physicians can see for themselves if they’re going to be successful on a weaning, you know, why not? Why not incorporate in that in the that into the bigger sort of scheme of things that that bigger realms so that we, as a team are assessing together? What that patient whether or not there’s a date, you know, there’s a nation, weaning, or whatever, but be able to, to assess how they’re responding?

Phillip Gonzalez, OTR, MOT 1:40:37
Absolutely, if they’re ready to titrate, down their pressors, let’s get them up, right, and actually see before you turn it off.

Jenna Hightower, PT, DPT, CCS 1:40:43
Same with in with those vent parameters as well.

Nikki Stevens, DNP, APRN, FNP-C 1:40:47
Yes.

Kali Dayton 1:40:47
And Jenna, what do you do as a physical therapist? I mean, how do you I mean, we’re imagining I think patients standing there, right? Or, being tilted to some angle. But what else do you do to make this more active mobility? What how do you set this up as a physical therapist?

Jenna Hightower, PT, DPT, CCS 1:41:01
So again, I like to bring up that I use the verticalization bed as an augmentation, a way to augment my treatment sessions, not my entire plan of care. So that’s something I always, you know, enforce with therapy teams, and I’m educating is, is you want it to be a tool to augment, but not be your entire plan of care. So you’re still working on those functional mobility goals and those strengthening goals and whatnot.

But, you know, verticalization therapy may be an additional therapy to add to their treatment plan in order to accelerate their rehab process. So it just depends on where the patient is where they fall on the mobility spectrum, and where they are from a hemodynamic standpoint and all of their support on what I can do and use the verticalization bed as a tool. So with the ICU acquired weakness, patient population that might be their only, you know, treatment session is vertical arising and being able to tolerate that.

Now oftentimes, when I do have a patient, up right on the bed, I am adding an exercises, so many squats, I’ll have them do heel lifts, and you know, alternating upper extremity, lower extremity, I’ll tie their bands to the bed, I’m having them do leg presses, things like that, if they’re, you know, devices allow. But those are all all tools that you can use the bed in order to augment your plan of care.

And then sometimes, you know, as a therapist, we are so short staffed just like everyone else in the healthcare field. But you know, for some perspective, at my hospital, we have one therapist for all five ICUs on the weekends. Now, imagine if none of the ICU patients got out of bed, only when PT came like, they just wouldn’t get moved on the weekends like that. I mean, realistically, I can maybe see seven patients in a day and eight hour day, and that’s a really good day in the ICU. So this is a tool that, you know, I am helping bridge that gap with nursing.

So I’m saying “These are the things that I’m working on with this patient, these are the things that you can do to help me with that, or that when I’m not there, these are things that they can be doing.” Or I may have like a short amount of time, and I don’t want to spend my whole time just doing the verticalization therapy, I need to spend it on working on sitting balance, working on things on the edge of the bed. So I may do that.

And then put them in a virtualized position at the end of my session and leave them with nursing to monitor for the next 1520 minutes as a way to really optimize my time in the room. So those are all like tools are, you know, I guess pointers as a therapist that you can do. But really maximizing that upright time is how I like to, you know, build it into my plan of care.

Kali Dayton 1:43:50
This is an amazing information. I hope that this is shared with every hospital, every ICU clinician, right, I think, again, the blank looks that I get from people when I talk about this, just rebuild it. There is a lot of work we need to do in making this standardized. And in every hospital again, like Jenna said, “If you have a bed, might as well make it a bed that will help patients get better.”

Not a bed that exacerbates all the complications that we’re trying to fight might as well increase the frequency and make it titratable for each individual patient so that it there is equity throughout all of our patient populations. I mean, we’re talking about a very broad critical care world. But a tool that works for probably every patient that is very rare and it’s a win for the hospital, huge return on investment win for the staff decreases staff workload decreases ventilators that you’re using improves bed flow.

I’m sure it improves the morale, the connection, the humanity within your profession. And obviously as we’ve explained, it’s vastly beneficial for our patients, which is what we’re all really prioritizing. In our careers. So thank you so much for everything that you’ve shared any last thoughts?

Phillip Gonzalez, OTR, MOT 1:45:05
No, obviously, thank you for having us all, all of us who are passionate about early mobility in the ICU and all of us who are passionate about getting our patients upright, I think you brought together some awesome thought leaders to be able to express our own unique perspectives, have it in areas that are very pertinent to our specialties, but how it all collaborates together to really build that interdisciplinary care model and ultimately, what’s best for the patient.

Kali Dayton 1:45:29
It takes the entire team and you guys are an amazing team of experts. I’ll put your contact information in with the transcript and all the citations. Guys, they shared a lot of research, a lot of published case studies, so go check it out, read it for yourself, share it with your teams, let’s move the goalposts on our liability and get this technology standardized.

Jenna Hightower, PT, DPT, CCS 1:45:51
I do have something to add really quick. I just often hear that, “Oh, I’m just a PT or Oh, I’m just a nurse, I don’t make decisions on purchasing. I don’t know how to get access to equipment like this. I don’t make these decisions.”

That’s what we’re here for. So you know, I brought this bed into my hospital into a very big hospital that is really hard to get stuff into as a PT. So like, you can do it too. That’s why we’re here contact us we can help you we know who to talk to we know that you know what to talk about. So if you if you really think you know I would love to have this at my facility. I just don’t know how to go about it. Contact us. That’s why we’re here to help and we’re all over the country. All three of us are so just don’t hesitate to reach out to me, or Kali.

Kali Dayton 1:46:35
anything I’ve learned from it revolutionists. No one is “just a nurse or just a PT just an OT”. I am seeing people down to the dieticians not that they’re a minor part. But when it comes down to mobility, that’s not who you initially think of. No, I’m seeing dieticians bringing this in. So everyone can make an impact. And we are community we’re here to help you advocate for your patients and revolutionize your team. But you don’t have to do it alone.

Nikki Stevens, DNP, APRN, FNP-C 1:47:02
Yes, yeah, absolutely. Absolutely. Thank you for bringing that up. Jenna. Yeah, contact us. I’m always available. Also help. I’m here to help with protocols, policies, anything like that to get this up and going up and off the ground so that you don’t have you’re not in a silo don’t have to do it alone. Thank you so much, Kali.

Kali Dayton 1:47:20
Thank you

Transcribed by https://otter.ai

 

Contact Information:

Phillip Gonzalez, MOT, OTR, BCPR
Critical Care Occupational Therapist
AOTA Board Certified in Physical Rehabilitation
Clinical Specialist, VitalGo Systems
Phone: (915) 422-4835
https://www.vitalgosys.com

Jenna Hightower, PT, DPT, CCS
Critical Care Physical Therapist
ABPTS Cardiovascular & Pulmonary Specialist
Director of Clinical Strategy, VitalGo Systems
Phone: (252) 945-8426
https://www.vitalgosys.com

Nikki SanMiguel-Stephens, DNP, RN, APRN, FNP-C, NE-BC
Vice President of Clinical
Kreg Therapeutics, LLC
Mobile 615-586-0662 /  nstephens@kreg.us
https://vimeo.com/user119646792/catalyst?share=copy

 

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