NURS 8710 Week 8 Thematic Synthesis Paper Example

Making the Trials Argue: A Thematic Synthesis of Early Mobilization in Ventilated Adults Across Baseline, Dose and Time Horizon

Student Name

College of Nursing, Walden University

NURS 8710: Doctoral Seminar I

Instructor Name

Month Day, Year

Making the Trials Argue: A Thematic Synthesis of Early Mobilization in Ventilated Adults Across Baseline, Dose and Time Horizon

Purpose

This synthesis draws the eleven studies in the review into an argument about when early active mobilization helps ventilated adults and when it does not. It is organized around three themes that emerged from the synthesis matrix: what the comparison group received, how much mobilization was added and when outcomes were measured. No paragraph is devoted to a single study. Where studies disagree, the synthesis tries to explain the disagreement rather than report it. The central paragraph is printed twice, once as a listing and once as a synthesis, so the difference between the two can be seen directly.

Theme 1: What the Comparison Group Received

The trials that found clear benefit compared structured early mobilization with very little. In two university hospitals, the control arm got therapy only if someone ordered it, and the intervention group was far more likely to return to independent function by discharge (Schweickert et al., 2009). In surgical ICUs, an algorithm-guided approach raised the level of mobilization patients reached and improved functional mobility at discharge against standard care (Schaller et al., 2016). A nonrandomized cohort in a medical ICU showed the same kind of contrast in process, with therapy starting in the ICU for most protocol patients and for few usual care patients (Morris et al., 2008). In each case the comparison was close to the absence of structured mobilization.

The trials that found no benefit compared an intervention with something more active. The largest trial defined usual care as the mobilization each ICU normally provided and measured almost nine minutes of active mobilization a day in that arm (TEAM Study Investigators, 2022). Two further trials compared an intensive program with a standard one that itself included therapy (Moss et al., 2016; Wright et al., 2018). The first theme, then, is that the effect of mobilization depends heavily on the baseline it is added to.

Theme 2: How Much Is Added

The listing version, for contrast. Moss et al. (2016) delivered 408 minutes of therapy against 86 and found no difference. Wright et al. (2018) delivered 161 minutes against 86 and found no difference. The largest trial delivered 20.8 minutes a day against 8.8 and found no difference, with more adverse events (TEAM Study Investigators, 2022). Schweickert et al. (2009) found a benefit.

The synthesis version. Three dose comparisons found no added benefit from more mobilization, and the pattern suggests why. In each, the extra therapy was layered on top of a comparison arm that already received a meaningful amount: in one trial about 86 minutes of therapy over the stay (Moss et al., 2016), in another a similar median in the ICU (Wright et al., 2018), and in the largest about nine minutes of active mobilization every day (TEAM Study Investigators, 2022). The trial showing a large benefit started from a much lower baseline (Schweickert et al., 2009). If benefit follows a curve, rising steeply from none to some and then flattening, these results are what one would expect: moving from little to some helps, and moving from some to more does not. The explanation has a weakness that should be stated. The trials differ in other ways too, including population, setting and the outcome measured, and the largest dose trial counted days alive and out of hospital over six months rather than measuring function at discharge. Dose alone cannot be separated from those differences with eleven studies. What the pattern does support is that the evidence for doing more is weak in settings that already mobilize patients, and that the largest dose trial also found more adverse events at the higher dose.

The two versions use the same facts. The listing reports four findings and leaves the reader to notice the pattern. The synthesis names the pattern, offers an explanation, tests it against the trials' other differences and says what survives.

Theme 3: When the Outcome Was Measured

The third theme concerns time. Benefits in the review cluster at ICU or hospital discharge: independence in daily activities, walking distance, quadriceps strength and functional mobility scores all improved at that point in the trials that measured them (Burtin et al., 2009; Schweickert et al., 2009; Schaller et al., 2016). By six months and later, most trials found no difference in physical function (Denehy et al., 2013; Moss et al., 2016; Wright et al., 2018). Two trials found partial benefits at six months, in self-reported physical function and in performance measures, but not in strength or in their primary outcome (Kayambu et al., 2015; Morris et al., 2016).

Two readings are possible. Early gains may fade as patients recover after discharge, with usual care patients catching up over months. Or the later trials, being different studies with different comparisons, may simply not have produced early gains to begin with. Few studies measured both time points, so the set cannot decide between these readings. Loss to follow-up adds uncertainty, since one dose trial had outcome data at six months for well under half of those randomized (Wright et al., 2018), and the patients well enough to come back for testing are probably not typical of everyone enrolled.

The timing theme also changes how the first two themes should be read. Because the benefits cluster at discharge and the null results cluster at six months, a reader could mistake a difference in timing for a difference in dose or baseline. The low-baseline trials mostly measured early, and the dose trials mostly measured late, so the three themes are entangled in this set of studies. A trial that compared a low baseline with a moderate one and measured function both at discharge and at six months would be needed to pull them apart.

What the Synthesis Supports

Taken together, the themes support a qualified conclusion. Structured early mobilization improves short-term function when the alternative is little or no mobilization. Adding more mobilization on top of an already active baseline has not been shown to improve longer-term outcomes and was associated with more adverse events in the largest trial. Whether early gains last is not settled. For a unit deciding what to do, the most important fact may be one the studies cannot supply: how much mobilization its own patients currently receive.

References

Burtin, C., Clerckx, B., Robbeets, C., Ferdinande, P., Langer, D., Troosters, T., Hermans, G., Decramer, M., & Gosselink, R. (2009). Early exercise in critically ill patients enhances short-term functional recovery. Critical Care Medicine, 37(9), 2499-2505. https://doi.org/10.1097/CCM.0b013e3181a38937

Denehy, L., Skinner, E. H., Edbrooke, L., Haines, K., Warrillow, S., Hawthorne, G., Gough, K., Vander Hoorn, S., Morris, M. E., & Berney, S. (2013). Exercise rehabilitation for patients with critical illness: A randomized controlled trial with 12 months of follow-up. Critical Care, 17(4), Article R156. https://doi.org/10.1186/cc12835

Kayambu, G., Boots, R., & Paratz, J. (2015). Early physical rehabilitation in intensive care patients with sepsis syndromes: A pilot randomised controlled trial. Intensive Care Medicine, 41(5), 865-874. https://doi.org/10.1007/s00134-015-3763-8

Morris, P. E., Berry, M. J., Files, D. C., Thompson, J. C., Hauser, J., Flores, L., Dhar, S., Chmelo, E., Lovato, J., Case, L. D., Bakhru, R. N., Sarwal, A., Parry, S. M., Campbell, P., Mote, A., Winkelman, C., Hite, R. D., Nicklas, B., Chatterjee, A., & Young, M. P. (2016). Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: A randomized clinical trial. JAMA, 315(24), 2694-2702. https://doi.org/10.1001/jama.2016.7201

Morris, P. E., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., Ross, A., Anderson, L., Baker, S., Sanchez, M., Penley, L., Howard, A., Dixon, L., Leach, S., Small, R., Hite, R. D., & Haponik, E. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 36(8), 2238-2243. https://doi.org/10.1097/CCM.0b013e318180b90e

Moss, M., Nordon-Craft, A., Malone, D., Van Pelt, D., Frankel, S. K., Warner, M. L., Kriekels, W., McNulty, M., Fairclough, D. L., & Schenkman, M. (2016). A randomized trial of an intensive physical therapy program for patients with acute respiratory failure. American Journal of Respiratory and Critical Care Medicine, 193(10), 1101-1110. https://doi.org/10.1164/rccm.201505-1039OC

Schaller, S. J., Anstey, M., Blobner, M., Edrich, T., Grabitz, S. D., Gradwohl-Matis, I., Heim, M., Houle, T., Kurth, T., Latronico, N., Lee, J., Meyer, M. J., Peponis, T., Talmor, D., Velmahos, G. C., Waak, K., Walz, J. M., Zafonte, R., & Eikermann, M. (2016). Early, goal-directed mobilisation in the surgical intensive care unit: A randomised controlled trial. The Lancet, 388(10052), 1377-1388. https://doi.org/10.1016/S0140-6736(16)31637-3

Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G. A., Bowman, A., Barr, R., McCallister, K. E., Hall, J. B., & Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. The Lancet, 373(9678), 1874-1882. https://doi.org/10.1016/S0140-6736(09)60658-9

TEAM Study Investigators and the ANZICS Clinical Trials Group. (2022). Early active mobilization during mechanical ventilation in the ICU. New England Journal of Medicine, 387(19), 1747-1758. https://doi.org/10.1056/NEJMoa2209083

Wright, S. E., Thomas, K., Watson, G., Baker, C., Bryant, A., Chadwick, T. J., Shen, J., Wood, R., Wilkinson, J., Mansfield, L., Stafford, V., Wade, C., Furneval, J., Henderson, A., Hugill, K., Howard, P., Roy, A., Bonner, S., & Baudouin, S. (2018). Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC): A multicentre, parallel-group, randomised controlled trial. Thorax, 73(3), 213-221. https://doi.org/10.1136/thoraxjnl-2016-209858