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. 2022 Jan 20;9(2):34. doi: 10.3390/jcdd9020034

Table 2.

Modalities of exercise training, proposed protocols, and suggested candidates.

Modality of Exercise Proposed Exercise Protocol * Suggested Candidates
Prehabilitation
  • -

    Airway clearance techniques

  • -

    Ventilation in prone and supine position

  • -

    In-bed active-assisted range-of motion exercises:

    • Sitting at the bedside;
    • Standing balance and tolerance;
    • Rolling;
    • Stretching;
    • Positioning in bed;
    • Strengthening and reconditioning exercises in the supine position including ankle pumps, heel slides and upper extremity stretching;
    • Bedside cycling (passive/active) for 15 min (3 sets of 5–10 min with 1 min recovery);
    • Inspiratory muscle training;
    • Out-of-bed activities;
    • Standing at the bedside;
    • Strength of standing force;
    • Sitting on the edge of the bed;
    • Transfer from bed to chair;
    • Exercises in the sitting position on the edge of the bed including leg lifts, ankle rolls, and arm lifts (strength training);
    • Aerobic training (cycle ergometer/treadmill) for 10–20 min;
    • Inspiratory muscle training.

Proposed duration: 60 min per session, daily while on ECMO.
  • Patients with severe acute or end-stage respiratory failure on ECMO support as a bridge to lung transplantation.

  • Patients with severe acute or end-stage heart failure on ECMO support as a bridge to heart transplantation.

Early mobilization Awake patients with level of consciousness
  • 1 to 3 sets of 8 to 10 repetitions of 5 active range of motion and resistance exercises such as leg press, squats from sitting position;

  • 15–30 min of active cycling with moderate to slightly high intensity;

  • Mobilization in a standing position and walking;

  • Respiratory rehabilitation and breathing exercises for 2 sets of 10 min per set;

  • Functional electrical stimulation of the lower limb muscles;

  • Inspiratory muscle training.

Unconscious patients
  • Passive mobilization via stretching, splinting and passive movements;

  • Continuous passive motion;

  • Functional electrical stimulation of the lower limb muscles;

  • Passive cycling for 20 min.


Proposed duration: 60 min per session, 5 times per week while on ECMO.
  • Patients with severe acute or end-stage respiratory failure on ECMO support as a bridge to lung transplantation.

  • Patients with severe acute or end-stage heart failure on ECMO support as a bridge to heart transplantation.

  • Patients with respiratory or heart failure on ECMO support as a bridge to recovery.

NMES
  • -

    Functional electrical stimulation cycling in quadriceps, hamstrings, and buttocks bilaterally;

  • -

    30-min active NMES per session;

  • -

    Biphasic, symmetric impulses of 45–75 Hz, with 300–400 μs pulse duration, 6 s on and 12 s off (intensity to a maximum of 140 mA).

Proposed duration: 30 min per session, daily while on ECMO.
All patients on ECMO support, especially patients with lower level of consciousness.

* Selection of exercises (in-bed or out-of-bed, passive or active) should be individualized for each patient according to his/her consciousness level, functional status and disease severity. Workload, number of repetitions and number of sets in strength training depend on the physical status of each patient: 1 to 3 sets of 8 to 10 repetitions of 5 active range for patients with better physical status and 3 to 5 sets of 8 to 10 repetitions of 5 passive range for patients with worse physical status or disability for active rehabilitation is suggested. Workload should be based on the 1 RM test for active exercises (40–60% of the 1 RM test) if feasible. Moderate intensity of aerobic exercise training, either on a cycle ergometer or a treadmill, aimed for 12–13 on the Borg scale is suggested for prehabilitation or early mobilization in patients with higher severity and lower functional capacity while moderate to slightly high intensity is suggested for early mobilization in patients with better functional status. Inspiratory muscle training should be prescribed once or twice daily, with 3–5 sets of 6 inspiratory efforts at the intensity of 30–60% of maximum inspiratory pressure progressively increased. ECMO, extracorporeal membrane oxygenation; NMES, neuromuscular electrical stimulation; ICU-AW, intensive care unit acquired weakness; MAP, mean arterial pressure; SAP, systolic arterial pressure; HR, heart rate.