​​​Michelle Kho, PT, PhD, monitors a patient who is using an in-bed cycle (credit: Courtesy of The Research Institute of St. Joe’s Hamilton).

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By: Mike Beattie

From robotic surgery that reduces procedure and healing times, to new approaches for treating addictions and managing schizophrenia, clinical research at St. Joseph's Healthcare Hamilton (St. Joe's) plays a pivotal role in the evolution of care to deliver better patient outcomes.

St. Joe's clinician-scientists have built a robust physiotherapy research program within the hospital's intensive care unit (ICU). Their work aims to combat muscle weakness and improve physical functioning, such as walking, after a critical illness and discharge from hospital.

Critically ill patients can lose up to 2 per cent muscle mass per day in the ICU. Since leg muscles account for 75 per cent of skeletal muscle mass, they are most vulnerable to weakness causing functional impairment. 

Michelle Kho, PT, PhD, is a St. Joe's physiotherapist and professor in the School of Rehabilitation Science at McMaster University. As a clinician-scientist, Kho has led the CYCLE research program at St. Joe's for over ten years.

Kho's interdisciplinary team has been studying the safety and efficacy of in-bed cycling to help critically ill patients combat muscle deterioration and weakness.

St. Joseph's Healthcare Foundation has been a key early partner in growing the CYCLE research program.

“Our first in-bed cycle machine for the CYCLE research program was purchased through donor funding from St. Joe's Foundation and was critical to the start of our research," said Kho. “By kickstarting our early work with seed investments from our Hospital and Foundation, we had more leverage to apply for grants with external funders, including the CIHR Accelerating Clinical Trials Consortium and the Canadian Frailty Network."

The CYCLE team performed numerous studies over the years in conjunction with the Canadian Critical Care Trials Group. This includes research in the preparation phase to phase II and phase III randomized trials, as well as an economic evaluation and a pandemic response study, among others.

Today, the CYCLE team has grown to include 16 hospitals across 3 countries and has produced numerous publications. In Ontario, partner sites include Hamilton General and Juravinski Hospitals, Niagara Health (St. Catharine's), Brantford General Hospital, Ottawa Civic and Ottawa General Hospitals, St. Michael's Hospital, London Health Sciences (Victoria), and Kingston General Hospital.

Support from the physiotherapy department, ICU physiotherapists, and physiotherapy assistants in partially embedding CYCLE into the hospital system was a major contributor to the research program's success.

The CYCLE team published two major papers in 2024 in the journal NEJM Evidence. The first focused on the CYCLE randomized controlled trial, which found that while there was no difference in physical function scored at 3 days post-ICU discharge, some patients who received additional cycling reported better function at hospital discharge. This was evident based on their improved performance – patients who cycled could walk farther, had less frailty, and had fewer cases of ICU-acquired weakness.

The second 2024 paper – a systematic review led by Heather O'Grady, PhD – analyzed data from nearly 3,300 patients and found that in-bed cycling therapy, when used in the ICU with critically ill patients, is safe and leads to better physical function. It also found that patients who cycled spent an average of 1 day less in the ICU, and 1.5 days less in hospital overall, freeing up an important bed sooner.

“Considering all of the evidence, in-bed cycling can offer patients more variety to have a head start at recovery upon hospital discharge," said Kho.

By engaging nearly 400 professionals – ICU physiotherapists, outcomes accessors, research personnel – the CYCLE trial built a network with the capacity to conduct future large-scale, hospital-based physiotherapy research projects.

“Our network is one of our greatest resources," said Lehana Thabane, vice president of research at St. Joe's. “In Hamilton, we have access to a large patient population, many of whom are eager to be part of research. We have close affiliations with post-secondary institutions, including the world-renowned McMaster University. And we have an ever-growing community of clinician-scientists who have contributed to building a culture of collaboration, education, and discovery – inspired by our foundational principle of Health and Humanity for All."

St. Joe's ranked 22 in Canada's Top 40 Research Hospitals for 2023 and 2024. In the most recent survey, published by Research Infosource, St. Joe's also ranked first in research hospital spending growth in the medium-sized hospitals category for 2024 – leaping from fifth place in 2023 – representing an increase of nearly 31 per cent in spending growth.

“Our physiotherapy researchers have accomplished so much in these last 10 years," said Thabane. “We're excited to see what they can achieve over the next decade and beyond."