The Physical Function in ICU Test-Scored (PFIT-S)

PFIT Instructions July 2103 L Denehy

The Physical Function in ICU Test-scored (PFIT-s)

The PFIT was developed as an outcome measure to evaluate and prescribe rehabilitation in patients who are critically ill. Patients are often too unwell and the environment unsuitable to perform functional measures such as the six minute walk test (6MWT) or timed up and go test (TUG) and unable to answer specific questions such as in the Barthel index. We have modified the initial PFIT to reduce the number of components and score the test.

References: Skinner E, Berney S, Warrillow S, Denehy L (2009): Development of a new physical function outcome measure (PFIT) and a pilot exercise training protocol for use in intensive care. Critical Care and Resuscitation 11 (2): 110-115.

A New Physical Function Test For Use In The ICU: Validity And Responsiveness Of The Pfits Linda Denehy, Elizabeth Skinner, Sue Berney, Lara Edbrooke, Kimberley Haines, Stephen Warrillow, Ian Gordon, 2011: A2644, 10.1164/ajrccm-conference.2011.183.1_MeetingAbstracts.A2644

New Components of the PFIT:

 Assistance (sit to stand)  Cadence (steps/minute)  Shoulder (flexion strength)  Knee (extension strength)

Test Performance- general

The test can be performed once the patient is alert enough to co-operate. De Jonghe Criteria can be used to assess awakeness as follows

Ask the patient in a loud clear voice to do the following activities:

1. Open / close your eyes

2. Look at me

3. Poke out your tongue

4. Nod your head

5. Raise your eyebrows

Each one that is performed correctly mark as 1 point. The criterion is out of five. A minimum of 3 out of 5 for the patient to be deemed awake.

If the patient can sit or be sat out of bed, this is the position that should be used for the components of the test.

If they cannot, they can be tested sitting over the edge of the bed. If they are unable to do any of this their strength can be tested in bed, but they would be unable to be tested and scored on sit to stand or marching on the spot. PFIT Instructions July 2103 L Denehy

The rating of perceived exertion (RPE) via the modified BORG scale (0-10), oxygen saturation (SP02), heart rate and mean arterial blood pressure are monitored during testing and training.

Test Preparation

PATSLIDE or assist patient out of bed (OOB) if possible Sit patient upright in a chair near the bed

Patients are instructed that:

This test is designed to record your maximum exercise ability. Plese do the most you can for each of the 4 components of the test. We will start with asking you to stand up from sitting, the ask you to march in place (on the spot) and then test the strength in your arms and legs while you are seated. . Give standardised encouragement every 10 seconds during each exercise component “Keep going for as long as you can”, “You’re doing well”, “Well done”.

Test Components

1. Sit to stand component (performed first)

 If the patient is unable to sit OOB the patient can sit to stand from the edge of the bed. To standardise the test the height of the chair/bed should be adjusted so the patient’s feet are flat on the floor with their knees flexed to 90 degrees. Distance from seat/bed to floor and use of arm rests should be recorded.  Ask the patient to stand up. No assistance should be given unless the patient is unable to perform this movement alone  One person should then assist, and if this is insufficient, the second person should then assist to transfer into the standing position.  The level of assistance required to transfer from sitting to standing should be recorded.

2. Marching on the spot (MOS) component

 Once the patient has been assisted into the standing position, the MOS component of the PFIT should be recorded as soon as possible.  Instruct the patient that when you tell them to ‘Start’, you want them to march on the spot as long as they possibly can as you discussed prior to standing.  Instruct the patient to ‘Start’ MOS and record the number of steps taken (1 step = when the patient’s foot (left or right) contacts the ground) and the total time that the patient continues to march (in seconds).  Once the patient stops for longer than two seconds (i.e. no new steps in two seconds) or if the patients feet do not completely clear the floor at each step (on 6 steps) the test should be ceased and the patient assisted (as required) to return to the sitting position in the chair.  Record patient’s RPE at completion of MOS component. PFIT Instructions July 2103 L Denehy

3. Upper Limb and Lower Limb strength test

 Once the patient has returned to the sitting position, bilateral shoulder flexion and bilateral knee extension strength testing should be performed once the patient has had ample time to rest.  Bilateral shoulder flexion should be performed first. Free active movement should be assessed first, and then resistance applied through range, resisted at the elbow where resistance is required. Muscle strength should be recorded for each arm.  Knee extension should be resisted at the ankle where resistance is required for assessment. Muscle strength should be recorded for each leg.

Grading scale for assessment of muscle strength

Each muscle will be assessed using the Oxford scale (Oxford range 0-5) which is the traditional scale as shown below. Isometric testing is commonly performed

Resources:

http://www.jov e . com/video/2632/manual-muscle-testing-a-method-of-measuring extremity-muscle-strength-applied-to-critically-ill-patients-

Oxford Grading Scale

0 No visible contraction

1 Flicker of contraction (no movement of limb)

2 Active movement with gravity eliminated

3 Active movement against gravity

4 Active movement against gravity and resistance

5 Normal strength PFIT Instructions July 2103 L Denehy

Scoring the test (PFITs)

An ordinal score is obtained out of 12 (ie. adding scores out of 3 for the 4 items) as per table 1.

PFIT Score 0 1 2 3 Total

Assistance Unable Assist x2 Assist x1 No assist

Cadence (steps/min) Unable >0 - 49 50 -<80 80+

Shoulder (grade) 0,1 or 2 3 4 5

Knee (grade) 0,1 or 2 3 4 5

Table 1. PFIT scoring

The PFITs (interval score) is then obtained from the Rasch analysis algorithm (see table 2). The conversion to an interval scoring scale is required in order for parametric statistics to be used in data analyses.

Ordinal 0 1 2 3 4 5 6 7 8 9 10 11 12 score /12

Interval 0 2.0 3. 3.9 4.4 4.9 5.4 5.9 6.4 7.1 7.9 8.8 10 PFIT 2 score /10

Table 2. PFIT ordinal and interval scale scoring. PFIT Instructions July 2103 L Denehy

PFIT RECORDING SHEET

1. Heart Rate (beats per Pre:______Post:______minute)

2. SpO2 (%) Pre:______Post:______

3. Sit – stand assistance

(circle) 0 1 2 unable

Chair/bed height (distance ______to floor, cm)

Chair arms used? Yes No

4. MOS

4.1 RPE (pre) ______

4.2 Able? (circle) Yes No

4.3 Steps (no.) ______

4.4 Time (sec) ______

4.5 RPE (post) ______

5. Strength Left Right

5.1 Shoulder Flexion ______

5.2 Knee Extension ______