Mind-body interventions utilized by an occupational therapist in a medical intensive care unit: An exploratory case study

Abstract

Patients in the medical intensive care unit (MICU) face life-threatening conditions leading to physical and psychological stress, and decreased occupational engagement. Mind-body interventions include techniques based on connecting the mind, body, brain, and behavior to positively influence health. The purpose of this study was to explore the use of mind-body interventions as a tool for use by occupational therapists (OT) to improve health and occupational performance. This was an exploratory case study completed with the patient, “Ann” in a MICU. Ann was a 57-year-old female who was admitted to the MICU for abdominal pain and later diagnosed with septic shock. Two mind-body sessions were completed with Ann and her responses were assessed via multiple variables, including: respiratory rate; blood pressure; heart rate; oxygen saturation; and anxiety. Ann stayed within normal ranges for all variables. This study demonstrates it was feasible to elicit mind-body interventions in this setting, with this patient.

Keywords

Occupational therapy complementary and integrative health mind-body holistic occupational performance

1 Introduction

The intensive care unit (ICU) presents a challenging environment within the health care arena. The ICU provides care for persons who are critically ill and medically complex and nearly 39% of patients are mechanically ventilated [1, 2]. There are many types of ICUs, including but not limited to: surgical ICU; cardiovascular ICU; neurological ICU; burn ICU; and medical ICU (MICU) [3]. This study took place in a MICU. The MICU differs from other ICUs in medical conditions and diseases treated, which may include: pulmonary disease; kidney, liver, and gastrointestinal complications; multi-organ failure; sepsis; and drug or alcohol overdose [4].

Patients in the ICU are confronted with life-threatening illness or injuries that inevitably lead to physical and psychological stress. Patients are at risk for occupational deprivation, which occurs when people are not afforded opportunities to participate in desired occupations [5]. Occupational deprivation is potentially due to a lack of opportunities for purposeful movements and activities, and thus occupations, which negatively impacts health [6, 7]. Barriers contributing to occupational deprivation include: immobility; sensory deprivation and overload; mechanical ventilation; ICU-acquired weakness; agitation; stress; and delirium [6, 7]. There are also many machines, sensors, and devices used to keep the patient alive, but make the ICU a difficult environment, further hindering occupational performance [8]. The primary goal for occupational therapy (OT) in the treatment of adults who are critically ill in the ICU is to address threats to life and loss of function [9]. Examples of OT interventions in the ICU include: participation in self-care tasks; early mobilization; cognitive retraining; use of positioning devices; splinting; and education and training [7 , 10].

There has been a recent influx of literature regarding early rehabilitation for patients in the ICU, focused on establishing the efficacy of early mobilization and delirium management [7 , 11–16]. Researchers demonstrated early mobility for patients in the ICU is safe, feasible, and may improve short and long-term physical and psychological outcomes. However, a gap remains regarding how patients in the ICU may participate in purposeful movements and activities through occupations. Mind-body interventions may be a potential modality for use by OT as preparatory methods to enhance occupational performance in the ICU. Mind-body interventions are a subset of complementary and integrative health (CIH) approaches and include a diverse group of techniques, such as yoga, Tai Chi, deep breathing, guided imagery, and progressive muscle relaxation [17]. In general, mind-body interventions focus on the mind-body connection and its impact on behavioral, emotional, spiritual, and mental aspects of health and well-being [17].

There is little literature regarding OT interventions in the ICU, including the use of mind-body approaches. There is however, a plethora of research documenting the perceived benefits of CIH approaches to improve health and well-being in other settings and populations. Some of these patient populations include: traumatic brain injury; stroke; chronic pain; cardiovascular and pulmonary conditions; anxiety; and cancer [18–22 , 28]. The settings for these studies were in outpatient and inpatient settings of hospital, but none were in the ICU. Only two of the CIH studies included the use of OT [22, 28]. This case-study begins to address the lack of evidence-based interventions for OT in the ICU, and the use of CIH approaches for patients in the ICU.

There is significant evidence suggesting mind-body interventions have positive effects on psychological functioning and quality of life in adults with and without disability [18 –21]. Schmid et al. looked at adding yoga, a mind-body CIH intervention, to inpatient rehabilitation two times per week in addition to regular therapy [28]. Schmid et al. demonstrated patient perceived improvements in: breathing; management of frustrations; stress; worry; anxiety; and pain. Participants also believed yoga helped enhance their overall recovery. Mind-body interventions have previously been shown to provide benefits such as: reduced stress and anxiety; increased oxygen saturation; enhanced breathing; and decreased blood pressure [18 –22]. These physiological benefits of mind-body interventions may later translate to improved cognitive functioning, enhanced mobility, and enhanced occupational performance. Despite their promise, mind-body interventions are infrequently used by OT in ICU settings. Given the novel nature of this intervention for this population, the objective of this case study was to explore the use of mind-body interventions, delivered by an OT in a MICU.

2 Methods

2.1 Design

This single case study with patient “Ann” includes data from two mind-body sessions, administered by an OT who is a registered yoga teacher in a MICU. Approval was obtained from the Colorado Multiple Institutional Review Board (IRB) and the Colorado State University IRB.

2.2 Recruitment

Ann met the following inclusion criteria: MICU patient; English speaking; ≥18 years old; referral for OT; and able to make decisions and provide consent [determined by a medical doctor (MD)]. Exclusion criteria included: pregnancy; ≤ 18 years old; prisoners; individuals who lack decision-making capacity (decided by MD) (i.e. proxy is consenting for medical and surgical procedures); and ventilator settings >10 Positive End-Expiratory Pressure (PEEP), and fraction of inspired oxygen (FiO₂) >60%. PEEP is the pressure in the airway at the end of expiration exceeding atmospheric pressure [4]. PEEP is applied through mechanical ventilation to prevent alveolar collapse. FiO₂ is the percentage of oxygen in the air [9]. Patients with trouble breathing receive oxygen-enriched air via mechanical ventilation. FiO₂ ranges from 21% (room air) to 100%.

2.3 Occupational profile of patient in this case study

Ann was a high-school educated 57-year-old female admitted to the MICU due to abdominal pain. Upon admission to the MICU, Ann’s primary diagnoses were septic shock, acute kidney injury, and weakness and numbness of the lower extremities. Ann had a history of alcohol and tobacco abuse, depression with a recent suicide attempt, anxiety, and panic attacks. Ann was bedbound for the previous six months due to abdominal pain, and unable to walk for the last month due to neuropathy in lower extremities. She required assistance from her significant other for all activities of daily living and instrumental activities of daily living. Upon the initial examination by the OT, Ann was alert and oriented to person, place, and time. Ann’s mood, affect, insight, and judgement were intact. She demonstrated limited mobility due to abdominal discomfort, and reported generalized anxiety. Ann requested interventions to help control her anxiety because this hospitalization exacerbated her symptoms. Ann reported she had previously, but infrequently practiced meditation to manage anxiety and panic attacks.

2.4 Outcome measures

Data were collected by the OT and included measures that were part of usual OT care in the MICU. Responses to the mind-body sessions were assessed via Ann’s physiological and mental responses. All variables were measured before, during, and after the mind-body sessions. Percent change (T1-T2/T1×100) was calculated for each variable. As is standard practice for OT in the MICU, the mind-body session was ended if Ann became medically unstable. Ann could ask to stop the intervention at her discretion.

2.4.1 Physiological variables

Heart rate, or the number of time the heart beats in one minute, was continuously measured by a pulse oximeter placed on the patient’s finger or toe. Criteria for medical instability is a heart rate <40 or >130 beats/min. Blood pressure (BP) was recorded using mean arterial pressure (MAP). MAP is an average measure of blood pressure over several heartbeats, and is considered a comprehensive measurement [23]. Criteria for medical instability is a MAP <65 mmHg. Oxygen saturation is the amount of oxygen circulating in the blood [24] and was continuously measured using a pulse oximeter placed on the patient’s finger or toe. Criteria for medical instability is an oxygen saturation <88%. Respiratory rate, or the number of breaths per minute, was measured by inspiratory expansion and expiratory contraction of the chest [25]. Criteria for medical instability is a respiratory rate <5 or >40 breaths/min.

2.4.2 Mental status variables

The Richmond Agitation - Sedation Scale (RASS) is a 10-point scale used to measure observation of agitation, sedation, and level of alertness in the ICU [26]. Scoring ranges from +4, combative, to -5, unarousable. Levels +1 to +4 denotes the extent of agitation or anxiety, level 0 denotes a calm and alert stage, and levels -1 to -5 denotes the extent of sedation. The RASS has been shown to have strong reliability and validity for the adult ICU population [26]. Criteria for medical instability is a RASS score of ≥+3 (very agitated) or -4 or -5 (deep sedation, unarousable). Mental status was also assessed using the Mental Status Examination (MSE). The purpose of the MSE was to describe the patient’s psychological functioning via direct patient observation [27]. The MSE has 11 domains, we included two domains, mood and affect, and thought content as these were the most indicative of the patient’s psychological functioning in the MICU setting. To assess mood and affect, the OT observed and recorded the appropriateness, stability, and range of the patient’s affect. To assess thought content, the OT observed and recorded the patients’ thoughts, including abnormalities, such as delusions, ruminations, or obsessions. The OT observed for expressions of anxiety, documented as low, moderate, or high.

2.5 Intervention

During her stay at the MICU, Ann completed two mind-body sessions that were approximately 15 minutes in length. An OT with 9.5 years of experience as an OT and 3.5 years as a registered yoga teacher, administered the mind-body sessions. Each mind-body session utilized a patient-directed and semi-structured format. The mind-body sessions involved components of breathwork, postural alignment, and meditation. The OT focused on Ann’s positioning for alignment and comfort. Ann was supine in bed with the head of bed elevated 30–45 degrees for both sessions. There were eight mind-body techniques utilized and were chosen based on Ann’s needs, abilities, and preference (see Table 1). The OT described these mind-body techniques to Ann and allowed her to choose which techniques to use. In session one, Ann chose Gratitude/Resourcing, Mindful Check-In/Body Scanning, and Scanning the Environment. In session two, Ann chose Gratitude/Resourcing, Three Part Breath, and Mindful Check-In/Body Scanning.

Table 1
Description of Specific Mind-Body Techniques

Mind-Body Technique Description of Techniques

1. Three Part Breath Deep and calming breaths with attention to sensation of the breath moving in and out of the abdomen, rib cage, and upper chest (in this order).

2. Progressive Muscle Relaxation (PMR) A systematic procedure of tensing and relaxing of muscle groups combined with structured breathing.

3. Gentle movement/stretching with breath This is similar to PMR, but sequence and focus will be based on specific patient needs.

4. Sensing Well-being Attention that is brought to the body and bodily sensations with a focus towards what feels pleasant or neutral.

5. Gratitude/Resourcing Mental effort is encouraged to focus on identifying something or someone that brings a sense of joy or gratitude, well-being, or security.

6. Self-Compassion Adoption of an attitude of gentleness and care towards oneself.

7. Mindful Check-In/ Body Scanning Bringing awareness to one’s internal self and noticing what areas are seeking one’s attention with encouragement to do so with a sense of curiosity and non-judgment. This could be guided or the person could perform this more freely.

8. Scanning the Environment Using all the senses a person is encouraged to notice five things in their environment.

Mind-Body Technique	Description of Techniques
1. Three Part Breath	Deep and calming breaths with attention to sensation of the breath moving in and out of the abdomen, rib cage, and upper chest (in this order).
2. Progressive Muscle Relaxation (PMR)	A systematic procedure of tensing and relaxing of muscle groups combined with structured breathing.
3. Gentle movement/stretching with breath	This is similar to PMR, but sequence and focus will be based on specific patient needs.
4. Sensing Well-being	Attention that is brought to the body and bodily sensations with a focus towards what feels pleasant or neutral.
5. Gratitude/Resourcing	Mental effort is encouraged to focus on identifying something or someone that brings a sense of joy or gratitude, well-being, or security.
6. Self-Compassion	Adoption of an attitude of gentleness and care towards oneself.
7. Mindful Check-In/ Body Scanning	Bringing awareness to one’s internal self and noticing what areas are seeking one’s attention with encouragement to do so with a sense of curiosity and non-judgment. This could be guided or the person could perform this more freely.
8. Scanning the Environment	Using all the senses a person is encouraged to notice five things in their environment.

Note: ^*PRM = progressive muscle relaxation.

3 Results

Ann was within normal ranges for all physiological and mental status variables during both mind-body sessions. There were no adverse events during either of the mind-body sessions, and the intervention did not have to be stopped. Due to continuous monitoring of patient’s vital signs in the MICU, Ann’s baseline physiological variables were collected prior to initiation of mind-body sessions and included: respiratory rate: 31 breaths/minute; BP: 77/45 mmHg, which equates to a MAP of approximately 56 mmHg; heart rate: 80 beats/minute; and oxygen saturation: 96%. Regarding the physiological response during both mind-body sessions, Ann’s heart rate, BP, oxygen saturation, and respiratory rate remained relatively stable (see Table 2). Of note, in session one, Ann’s respiratory rate decreased from 26 to 20 breaths/min (23.1% change), and in session two, decreased from 23 to 17 breaths/min (26.1% change). Ann’s BP (MAP) in session one increased from 72 to 77 mmHg (6.9% change). A MAP of 77 mmHg is within normal limits. In session two, Ann’s BP decreased from 65 to 63 mmHg (3.1% change). Lastly, in session two Ann’s heart rate decreased from 91 to 88 beats/min (3.3% change).

Table 2
Physiological and Mental Status Variables from Sessions 1 and 2

Before After % Change

Session 1

Time 13:25 13:46

Heart Rate (beats/min) 78 79 1.3%

Blood Pressure (MAP) (mmHg) 72 77 6.9%

Oxygen Saturation (%) 98 99 1.0%

Respiratory Rate (breaths/min) 26 20 23.1%

RASS 0 0

Affect Attentive, stable, even Attentive, stable, even

Attitude toward OT Welcoming, interactive Appreciative, eager

Specific mood or feelings Anxious Hopeful

Anxiety level Moderate Low

Session 2

Time 13:45 14:05

Heart Rate (beats/min) 91 88 3.3%

Blood Pressure (MAP) (mmHg) 65 63 3.1%

Oxygen Saturation (%) 99 97 2.0%

Respiratory Rate (breaths/min) 23 17 26.1%

RASS 0 0

Affect Calm, talkative Even, relaxed

Attitude towards OT Welcoming Appreciative

Specific mood or feelings Calm, content, tangential Relaxed, asleep

Anxiety level Low Low

	Before	After	% Change
Session 1
Time	13:25	13:46
Heart Rate (beats/min)	78	79	1.3%
Blood Pressure (MAP) (mmHg)	72	77	6.9%
Oxygen Saturation (%)	98	99	1.0%
Respiratory Rate (breaths/min)	26	20	23.1%
RASS	0	0
Affect	Attentive, stable, even	Attentive, stable, even
Attitude toward OT	Welcoming, interactive	Appreciative, eager
Specific mood or feelings	Anxious	Hopeful
Anxiety level	Moderate	Low
Session 2
Time	13:45	14:05
Heart Rate (beats/min)	91	88	3.3%
Blood Pressure (MAP) (mmHg)	65	63	3.1%
Oxygen Saturation (%)	99	97	2.0%
Respiratory Rate (breaths/min)	23	17	26.1%
RASS	0	0
Affect	Calm, talkative	Even, relaxed
Attitude towards OT	Welcoming	Appreciative
Specific mood or feelings	Calm, content, tangential	Relaxed, asleep
Anxiety level	Low	Low

Note: *OT = occupational therapist *MAP = mean arterial pressure, mmHg = millimeter of mercury. RASS = Richmond-Agitation and Sedation Scale.

Ann scored a 0 on RASS before and after the both mind-body sessions, indicating an alert and calm state was maintained throughout (see Table 2). In the beginning of session one, Ann’s affect was considered attentive; stable, or not likely to change; and even, or having little variation in quality. Ann was also welcoming and interactive with the OT. She demonstrated moderate anxiety, related to her frequent coughing and her MICU stay. At the completion of session one, Ann was appreciative and eager for another mind-body session. Her anxiety about coughing had subsided, and she reported feeling hopeful for her recovery. In session two, Ann was welcoming, and upon entrance of the OT, the Ann stated, “oh here’s my motivational therapist!” Ann’s affect was initially calm, peaceful, and talkative. She demonstrated low anxiety throughout this mind-body session. At the completion of session two, Ann’s affect was even and was relaxed.

4 Discussion

Overall, Ann maintained normal ranges for all physiological and mental status variables during the mind-body interventions. Therefore, it appears it was feasible for an OT with proper training and credentials to elicit mind-body interventions (breathwork, postural alignment, and meditation) in this setting with this patient. Additionally, the results in this case-study demonstrated mind-body interventions may potentially be useful to reduce stress and anxiety related symptoms, both frequently experienced by patients in the ICU.

Hardison & Roll recently conducted a scoping review about mindfulness interventions in rehabilitation and the implications for use in OT [29]. Hardison & Roll stated that further research is needed to determine the effectiveness of CIH interventions among a wider variety of conditions within the realm of physical rehabilitation. Our case study begins to fill this gap. The patient in our case study successfully completed the intervention during the OT treatment time. Such treatment interventions allow the OT to holistically treat the individual, by focusing on physical, mental, and emotional needs; which are foundational aspects of OT.

Chugh-Gupta et al. conducted a systematic review regarding the use of yoga by OT to reduce anxiety in adult populations with varying diagnoses and conditions, but none of the studies in Chugh-Gupta et al.’s review took place in the ICU [22]. Chugh-Gupta et al. concluded that yoga is a feasible tool for OT to use to address anxiety. Chugh-Gupta et al. discussed the unique ability of OT to conduct such interventions given their holistic focus on the mind and body, and connection to meaningful occupations. The patient in our case study demonstrated similar benefits to this study, which were improved breathing (reduced respiratory rate), and reduced anxiety.

AOTA recently published a position paper regarding OT scope of practice and CIH [30]. AOTA stated that CIH can be used as preparatory methods to increase engagement in occupations to improve overall health. This aligns with our rationale, that mind-body interventions be used as preparatory methods to reduce barriers that result in occupational deprivation, to increase occupational performance while in the ICU.

4.1 Limitations

This case-study has several limitations. First, due to the nature of a single case study and predominately urban population, results cannot be generalized. Second, implementation of certain CIH and mind-body interventions require training beyond general education for OT for implementation, this may mean that most OT cannot utilize these techniques until further training is obtained. Third, due to the extent of the patients’ illnesses and inability to consent, recruitment was difficult, and substantially limited eligible patients.

4.2 Future research

Future research should more rigorously address the safety, benefits, and feasibility of utilizing mind-body interventions in the ICU. Additionally, the impact of mind-body interventions on occupational performance and participation both in the ICU, and after ICU discharge should be explored. Due to the short length of stay in the MICU (approximately 3.8 days) and the clinical nature of the patient’s diagnoses, the MICU may not have been the best setting for this study. ICUs with longer lengths of stay, such as the burn ICU, which has average length of stay approximately eight days, might be a more feasible setting [31]. Barriers to implementing this type of research study included: short length of stays; scheduling around patients’ surgeries or procedures; pharmaceutical sedation; impaired cognitive status; and high mortality rate. Future researchers should carefully examine exclusion criteria, as this appeared to be the main limiting factor for recruitment.

5 Summary

Mind-body interventions may be a powerful tool for OT to include in their sessions for patients in the MICU, or any ICU, who experience stress, anxiety, and difficulty engaging in occupations. Mind-body interventions should only be used by trained OT who have prior training in CIH. CIH approaches should be client-centered, supportive of patient goals, and incorporated into their overall care plan [30]. In summary, the outcomes of this case study substantiated the need for additional research to ascertain the safety, benefits, and feasibility of mind-body interventions by OT in an ICU. There are currently few evidence-based interventions for OT to use in the ICU, and our study begins to address this gap. Mind-body interventions have the potential to increase occupational performance while in the ICU to enhance recovery and health. OT are distinctly suited to provide these interventions because of their holistic frames of reference, and understanding that the mind and body share an intimate connection that impacts occupational engagement and subsequent health andwell-being.

Conflict of interest

The authors declare they do not have any conflicts of interest.

Footnotes

Acknowledgment

The authors wish to thank the patient and her family who participated in this study. We also wish to thank Colorado State University and the University of Colorado Hospital for providing the facilities needed to conduct this research. Lastly, we thank the nurses of the MICU for their assistance and patience during the study.

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