Effectiveness of physical exercise and neuromuscular electrical stimulation interventions for preventing and treating intensive care unit-acquired weakness: A systematic review of randomized controlled trials

Risk factors for acquired weakness in intensive care unit patients: An umbrella review

OBJECTIVE

This umbrella review aims to summarize and synthesize the evidence on risk factors related to intensive care unit-acquired weakness in systematic reviews to create prevention strategies and intervention measures for intensive care unit-acquired weakness.

METHODOLOGY

Eight databases were searched systematically from inception to 1st November 2023. Two researchers independently screened and extracted data based on predefined inclusion and exclusion criteria. The methodological quality, risk of bias and certainty of evidence of reviews included were evaluated using version 2 of the Measurement Tool for Evaluation System Review (AMSTAR-2) and the Risk of Bias in Systematic Reviews (ROBIS), and the Grading of Recommendations Assessment, Development and Evaluation(GRADE) respectively.

RESULTS

This review included 10 systematic reviews, reporting a total of 42 factors and 22 associations with meta-analysis. Overall, among these associations, the methodological and evidence quality of the majority ofstudies was rated as low or extremely low. Most systematic reviews and/or meta-analyses exhibited a high risk of bias.

CONCLUSION

This umbrella review comprehensively summarized the risk factors related to intensive care unit-acquired weakness and evaluated the methodological quality, risk of bias, and evidence quality of reviews included. Future studies with high-quality research such as cohort studies are needed, to better update and synthesize the risk factors of intensive care unit-acquired weakness.

IMPLICATIONS FOR CLINICAL PRACTICE

Inconsistent or even contradictory findings exist among multiple systematic reviews regarding intensive care unit-acquired weakness. The present study offers a comprehensive and readily comprehensible overview of the risk factors linked to intensive care unit-acquired weakness, which is conducive to develop assessment tools for the condition and identify intervention targets.

Impact of sarcopenia and obesity on mortality in older adults with SARS-CoV-2 infection: automated deep learning body composition analysis in the NAPKON-SUEP cohort

INTRODUCTION

Severe respiratory infections pose a major challenge in clinical practice, especially in older adults. Body composition analysis could play a crucial role in risk assessment and therapeutic decision-making. This study investigates whether obesity or sarcopenia has a greater impact on mortality in patients with severe respiratory infections. The study focuses on the National Pandemic Cohort Network (NAPKON-SUEP) cohort, which includes patients over 60 years of age with confirmed severe COVID-19 pneumonia. An innovative approach was adopted, using pre-trained deep learning models for automated analysis of body composition based on routine thoracic CT scans.

METHODS

The study included 157 hospitalized patients (mean age 70 ± 8 years, 41% women, mortality rate 39%) from the NAPKON-SUEP cohort at 57 study sites. A pre-trained deep learning model was used to analyze body composition (muscle, bone, fat, and intramuscular fat volumes) from thoracic CT images of the NAPKON-SUEP cohort. Binary logistic regression was performed to investigate the association between obesity, sarcopenia, and mortality.

RESULTS

Non-survivors exhibited lower muscle volume (p = 0.043), higher intramuscular fat volume (p = 0.041), and a higher BMI (p = 0.031) compared to survivors. Among all body composition parameters, muscle volume adjusted to weight was the strongest predictor of mortality in the logistic regression model, even after adjusting for factors such as sex, age, diabetes, chronic lung disease and chronic kidney disease, (odds ratio = 0.516). In contrast, BMI did not show significant differences after adjustment for comorbidities.

CONCLUSION

This study identifies muscle volume derived from routine CT scans as a major predictor of survival in patients with severe respiratory infections. The results underscore the potential of AI supported CT-based body composition analysis for risk stratification and clinical decision making, not only for COVID-19 patients but also for all patients over 60 years of age with severe acute respiratory infections. The innovative application of pre-trained deep learning models opens up new possibilities for automated and standardized assessment in clinical practice.

Efficacy of neuromuscular electrical stimulation with modern rehabilitation techniques in the treatment of acute ischemic stroke patients with post-motor dysfunction

BackgroundAcute ischemic stroke (AIS) refers to a sudden loss of blood flow in a region of the brain, which leads to a loss of neurological function.PurposeTo unveil the efficacy of neuromuscular electrical stimulation (NMES) with modern rehabilitation techniques in AIS patients with post-motor dysfunction.Material and MethodsA total of 200 AIS patients with post-motor dysfunction were divided into groups A, B, C, and D (n = 50). Patients in the four groups were routinely treated with medicine, on this basis: group B received NMES treatment; group C received modern rehabilitation technology treatment; and group D was treated with NMES and modern rehabilitation technology. Rehabilitation effect, cerebral hemodynamic indices, neurological function recovery, Fugl-Meyer Assessment (FMA) and Motor Assessment Scale (MAS) scores, self-care, and quality of life were compared.ResultsAfter treatment, the total effective rate of group D was 96% higher than that of group A (64%), group B (82%), and group C (84%). Bilateral middle cerebral artery Vm and Vs and scores of FMA, MAS, functional independence measure, and modified Barthel index increased; RI and NHISS scores decreased; and all group D improved significantly versus groups A, B, and C, and both groups B and C improved significantly versus group A.ConclusionNMES with modern rehabilitation technologies synergistically treat motor dysfunction after AIS with ideal rehabilitation effect, improving cerebral hemodynamics, neurological and limb motor function recovery, and self-care ability and quality of life.

Effects of in-bed cycling in critically ill adults: A systematic review and meta-analysis of randomised clinical trials

BACKGROUND

Impairments in intensive care unit (ICU) survivors can last up to 5 years post-discharge. Finding effective treatments to palliate and prevent them is essential, and in-bed cycling is a way to palliate the effects of prolonged immobilisation.

OBJECTIVE

To evaluate the effects of in-bed cycling in critically ill adults regarding recovery status, mortality, physical performance and quality of life.

METHODS

We followed PRISMA 2020 guidelines. The search was conducted in Cinahl, Medline, Scopus and Web of Science from their inception to October 2024. We included randomised clinical trials with critically ill adults who performed in-bed cycling alone or with another treatment while in ICU, compared to no intervention, placebo, rehabilitation or standard care, assessing recovery status, mortality, physical performance or quality of life. Methodological quality and risk of bias were evaluated. A meta-analysis was performed.

RESULTS

Thirty-two studies were included in the review, and 22 studies in the meta-analysis. A total of 3,052 participants (≥18 years old) admitted to different types of ICUs were included. Results showed significant differences regarding ICU length of stay (n = 1,564; MD -0.93; 95 % CI -1.64 to -0.21; P = 0.01) and hospital length of stay (n = 1,189; MD -1.78; 95 % CI -3.16 to -0.41; P = 0.01), mechanical ventilation duration (n = 1,024; MD -0.51; 95 % CI -0.92 to -0.11; P = 0.01) and functional status (n = 400; MD 44.88; 95 % CI 3.11-86.65; P = 0.04) favouring in-bed cycling plus rehabilitation compared to rehabilitation. However, no significant differences were found regarding mortality, muscle strength, ICU-acquired weakness or quality of life. Different programme duration did not significantly affect hospital length of stay.

CONCLUSION

In-bed cycling plus rehabilitation significantly reduced ICU and hospital length of stay, mechanical ventilation duration and improved functional status compared to rehabilitation. Further research is needed to analyse long-term effects and standardise interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022309311; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022309311.

Muscle Dysfunction and Physical Recovery After Critical Illness

During critical illness, patients experience significant and rapid onsets of muscle wasting and dysfunction with loss of strength, mass, and power. These deficits often persist long after the ICU, leading to impairments in physical function including reduced exercise capacity and increased frailty and disability. While there are numerous studies describing the epidemiology of impaired muscle and physical function in the ICU, there are significantly fewer data investigating mechanisms of prolonged and persistent impairments in ICU survivors. Additionally, while several potential clinical risk factors associated with poor physical recovery have been identified, there remains a dearth of interventions that have effectively improved outcomes long-term among survivors. In this article, we aim to provide a thorough, evidence-based review of the current state of knowledge regarding muscle dysfunction and physical function after critical illness with a focus on post-ICU and post-hospitalization phase of recovery.

Current Rehabilitation Practices of Physiotherapists in Intensive Care Units in the UAE: A National Survey

Background

Intensive care units (ICUs) are essential for patient recovery, but prolonged stays often result in complications like reduced mobility and muscle weakness.

Aims

This study examines current ICU rehabilitation practices in the United Arab Emirates (UAE) through a web-based cross-sectional survey involving 80 physiotherapists from both public and private sectors.

Methods

The questionnaire, validated by experts with a Cronbach's alpha of 0.84, explored various rehabilitation strategies. Most participants held bachelor's degrees and had 2-5 years of experience.

Results

Over 96% required physician referrals for ICU physiotherapy sessions, and 75% noted that hospitals provided development programs to enhance skills. Respiratory therapy, joint mobilization, and electrical stimulation were the most commonly used interventions, while massage, continuous passive motion machines, and taping were less frequently applied. Among neonatal ICU patients, 85.7% of physiotherapists regularly performed passive range of motion exercises, and 69% consistently involved parents in the treatment plan. The results indicate a variety of practices among ICU physiotherapists in the UAE, with no clear adherence to standardized protocols. This lack of consistency may negatively affect patient care quality.

Conclusion

The study underscores the importance of implementing standardized rehabilitation protocols and enhancing patient education to improve outcomes in ICU settings.

The Effect of Electrical Stimulation Strength Training on Lower Limb Muscle Activation Characteristics During the Jump Smash Performance in Badminton Based on the EMS and EMG Sensors

This study investigates the effects of electrical stimulation (EMS) combined with strength training on lower limb muscle activation and badminton jump performance, specifically during the "jump smash" movement. A total of 25 male badminton players, with a minimum of three years of professional training experience and no history of lower limb injuries, participated in the study. Participants underwent three distinct conditions: baseline testing, strength training, and EMS combined with strength training. Each participant performed specific jump tests, including the jump smash and static squat jump, under each condition. Muscle activation was measured using electromyography (EMG) sensors to assess changes in the activation of key lower limb muscles. The EMS intervention involved targeted electrical pulses designed to stimulate both superficial and deep muscle fibers, aiming to enhance explosive strength and coordination in the lower limbs. The results revealed that the EMS + strength condition significantly improved performance in both the jump smash and static squat jump, as compared to the baseline and strength-only conditions (F = 3.39, p = 0.042; F = 3.67, p = 0.033, respectively). Additionally, increased activation of the rectus femoris (RF) was observed in the EMS + strength condition, indicating improved muscle recruitment and synchronization, likely due to the activation of fast-twitch fibers. No significant differences were found in the eccentric-concentric squat jump (F = 0.59, p = 0.561). The findings suggest that EMS, when combined with strength training, is an effective method for enhancing lower limb explosiveness and muscle activation in badminton players, offering a promising training approach for improving performance in high-intensity, explosive movements.

Heart rate variability biofeedback for critical illness polyneuropathy: a randomized sham-controlled study

BACKGROUND AND PURPOSE

Critical illness polyneuropathy (CIP) has been linked to neurocardiac dysfunction mediated by autonomic nervous system dysregulation, which increases mortality. We aimed to assess if heart rate variability (HRV) biofeedback could improve neurocardiac function in CIP.

METHODS

We randomly allocated (1:1) patients with electrophysiologically confirmed CIP undergoing early inpatient neurological rehabilitation to additional HRV or sham biofeedback over 14 days. We evaluated neurocardiac function via standard deviation of normal-to-normal intervals (SDNN) as the primary outcome, as well as HRV frequency domains, sympathetic cutaneous sudomotor and vasomotor functions and disability at baseline, post intervention and 4 weeks later. The study is registered on the German Clinical Trials Register (DRKS00028911).

RESULTS

We included 30 patients with CIP (40% females, median [interquartile range] age 64.6 [56, 72] years). We observed an increase in SDNN and the predominantly parasympathetic high frequency domain post intervention (ß = 16.4, 95% confidence interval [CI] 0.2, 32.6 [p = 0.047] and ß = 1179.2, 95% CI 119.9, 2158.5 [p = 0.018]), which was sustained at the 4-week follow-up (ß = 25.7, 95% CI 6.0, 45.4 [p = 0.011] and ß = 25.7, 95% CI 6.0, 45.4 [p = 0.011]). Patients who underwent HRV biofeedback displayed a higher adjusted Barthel index, indicating less severe disability 4 weeks after the intervention compared to those in the sham group (ß = 23.3, 95% CI 5.5, 41.1 [p = 0.014]). Low frequency and sympathetic skin functions did not differ between groups (p = nonsignificant).

CONCLUSIONS

Our study provides pilot data suggesting that, in patients with CIP, HRV biofeedback can improve neurocardiac function with a predominant effect on the parasympathetic nervous system and has a beneficial effect on functional recovery.

The knowledge, attitude and behavior of ICU nurses regarding ICU-acquired weakness: a cross-sectional survey

BACKGROUND

Intensive care unit-acquired weakness (ICU-AW) is very common in ICU patients. It is important to understand the status quo of knowledge, attitude and behavior of ICU nurses about ICU-AW. This survey aimed to investigate the knowledge, attitude and behavior of ICU nurses about ICU-AW, to provide useful implications for clinical care.

METHODS

ICU nurses from two tertiary hospitals in China from October 10 to November 15, 2023 were included. The ICU-AW knowledge, attitude and behavior questionnaire of ICU nurses with 31 items were used for survey. SPSS24.0 statistical software was used for data analysis.

RESULTS

A total of 364 ICU nurses were included for survey. The ICU-AW knowledge of ICU nurses was 21.96 ± 5.72 (< 50% of the total knowledge score), the ICU-AW attitude of ICU nurses was 30.24 ± 5.05(< 75% of the total attitude score), the ICU-AW behavior of ICU nurses was 26.77 ± 5.81(< 75% of the total behavior score), the total score was 79.21 ± 12.69(< 75% of the total score). Nurses' ICU-AW knowledge, attitude and behavior were all correlated (all P < 0.05). Multiple linear regression analyses indicated that age, years of ICU work experience, professional ranks and titles, had received the training about the ICU-AW were the influencing factors of knowledge, attitude and behavior of ICU nurses about ICU-AW (all P < 0.05).

CONCLUSIONS

The knowledge, attitude and behavior of ICU nurses' ICU-AW needs to be improved, and there are many influencing factors. Hospital nursing administrators should strengthen the training of nurses' ICU-AW knowledge and improve the cognitive and practical ability of ICU nurses on ICU-AW, so as to reduce the occurrence of ICU-AW.

Photobiomodulation therapy (red/NIR LEDs) reduced the length of stay in intensive care unit and improved muscle function: A randomized, triple-blind, and sham-controlled trial

CONTEXT

Photobiomodulation therapy (PBMT) has been widely used to improve strength, fatigue resistance and increase muscle mass in healthy individuals. These effects could help critically ill patients admitted to intensive care units (ICUs) who show reduced mobility and muscle strength. ICU-acquired weakness lessens overall health and increases the patient's length of stay in the ICU.

OBJECTIVE

This study evaluated the effects of PBMT using low intensity light-emitting diodes (LEDs) on the mobility and muscle strength (functional capacity) and length of stay of patients admitted to hospital ICU.

METHODS

This randomized, triple-blind, sham-controlled trial was conducted in a hospital ICU. Sixty patients were randomly assigned to two equal groups: (a) PBMT and (b) Sham. PBMT was applied daily to patients until their discharge from the ICU, using a flexible neoprene array of 264 LEDs (120 at 635 nm, 1.2 mW each; 144 at 880 nm, 15 mW each) for 90s (207.36 Joules) at each site. Ten sites were located bilaterally on the thighs, legs, arms, and forearms ventrally and dorsally, 15 min totaling 2,073.6 Joules per session. Outcomes were length of stay (in h) until discharge from the ICU, muscle strength by the Medical Research Council (MRC) score and handgrip dynamometry (HGD), patient mobility by Intensive Care Unit Mobility Scale (IMS) and the Simplified Acute Physiology Score 3 (SAPS 3) for predicting mortality of patients admitted to the ICU.

RESULTS

PBMT reduced the average length of stay in the ICU by ~30% (p = 0.028); increased mobility (IMS: 255% vs. 110% p = 0.007), increased muscle strength (MRC: 12% vs. -9% p = 0.001) and HGD (34% vs. -13% p < 0.001), and the SAPS3 score was similar (p > 0.05).

CONCLUSION

The results suggest that daily PBMT can reduce the length of stay of ICU patients and increase muscle strength and mobility.

Effect of neuromuscular electrical stimulation and early physical activity on ICU-acquired weakness in mechanically ventilated patients: A randomized controlled trial

BACKGROUND

Intensive care unit-acquired weakness (ICU-AW) is common in critically ill patients and increases the duration of mechanical ventilation (MV) and weaning time. Early mobilization, range of motion (ROM) exercises, and neuromuscular electrical stimulation (NMES) can prevent ICU-AW by maintaining muscle mass. However, studies highlighting the effects of combining NMES with early physical activity in ICU patients are limited.

AIM

To evaluate the effect of NMES and early physical activity on ICU-AW in mechanically ventilated patients.

STUDY DESIGN

A single-blinded randomized controlled trial was conducted in Alexandria, Egypt. Patients were randomly assigned to one of four groups: NMES, ROM, combined therapy (ROM + NMES), or conventional care (control group). The Medical Research Council (MRC) scale was used to assess the ICU-AW for the study patients over a 7-day period. The duration of the patient's MV and ICU stays were recorded.

RESULTS

Of the 180 patients who were assessed for eligibility, 124 were randomly assigned to one of four groups: 32 patients in ROM exercises, 30 in NMES, 31 in combined therapy (ROM + NMES), and 31 in the control group. On day 7, ROM + NMES and NMES groups showed higher MRC scores than ROM and control groups (50.37 ± 2.34, 49.77 ± 2.19, 44.97 ± 3.61, and 41.10 ± 3.84, respectively). ANOVA test results indicated significant differences (p < .001) across the four groups. ICU-AW occurred in 0% of the ROM + NMES group, 60% of the ROM group, 13% of the NMES group, and 100% of the control group (p < .001). The MV duration (in days) in the ROM + NMES group was shorter (12.80 ± 3.800) than in the ROM, NMES, or control groups (21.80 ± 4.460, 18.73 ± 4.748, and 20.70 ± 3.932, respectively). ICU-LOS was shorter in the ROM + NMES group (17.43 ± 3.17 days) compared with the ROM group (22.53 ± 4.51 days), the NMES group (21.10 ± 5.0 days), and the control group (21.50 ± 4.42 days) with significant differences (p < .001) between the four groups.

CONCLUSION

Daily sessions of NMES and early physical activity were well tolerated, preserved muscle strength, prevented ICU-AW, and decreased the duration of the MV and ICU stay.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study support the use of NMES and early physical exercises by critical care nurses as part of routine care for critically ill patients.

Construction and evaluation of acquired weakness nomogram model in patients with mechanical ventilation in intensive care unit

Objective

The incidence of intensive care unit acquired weakness (ICU-AW) has shown an increasing trend with still a lack of effective treatment options. The early assessment of the risk of developing ICU-AW can provide patients with targeted interventions. This study aimed to determine the independent risk factors of ICU-AW in patients receiving mechanical ventilation (MV) and develop a nomogram and verify its predictive efficacy.

Methods

This observational study included patients receiving MV therapy in the ICU of our hospital between January 2020 and January 2023. They were divided into the ICU-AW and non-ICU-AW groups. The training cohort (n = 264) and the validation cohort (n = 143) were constructed. Multivariate logistic regression analyses were used to select the risk factors, and a nomogram model was established. Calibration, receiver operating characteristic (ROC), and decision curves were used to evaluate the effectiveness of the model.

Results

The MV duration (OR = 1.24, 95%CI[1.11, 1.38]), APACHE II score (OR = 1.34, 95%CI[1.20, 1.50]), SOFA score (OR = 1.36, 95%CI[1.21, 1.53]), age (OR = 1.05, 95%CI[1.00, 1.10]), nerve blockers (OR = 3.26, 95%CI[1.34, 7.92]), and diabetes mellitus (OR = 3.12, 95%CI[1.10, 8.87]) were independent risk factors for ICU-AW. The nomogram had good predictive efficacy for both the training (area under the curve (AUC) = 0.950, 95%CI [0.93, 0.97]) and validation cohorts (AUC = 0.823, 95%CI [0.75, 0.89]).

Conclusion

The MV duration, APACHE II, SOFA, age, use of nerve blockers, and diabetes mellitus are independent risk factors for ICU-AW. The nomogram model based on them had good predictive efficacy and may be clinically useful.

The effects of early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis

Background

The effects of early mobilization (EM) on intensive care unit (ICU) patients remain unclear. A meta-analysis of randomized controlled trials was performed to evaluate its effect in mechanically ventilated adult ICU patients.

Methods

We searched randomized controlled trials (RCTs) published in Medline, Embase, and CENTRAL databases (from inception to November 2022). According to the difference in timing and type, the intervention group was defined as a systematic EM group, and comparator groups were divided into the late mobilization group and the standard EM group. The primary outcome was mortality. The secondary outcomes were ICU length of stay, duration of mechanical ventilation (MV), and adverse events. EM had no impact on 180-day mortality and hospital mortality between intervention groups and comparator groups (RR 1.09, 95% CI 0.89-1.33, p = 0.39). Systemic EM reduced the ICU length of stay (LOS) (MD -2.18, 95% CI -4.22--0.13, p = 0.04) and the duration of MV (MD -2.27, 95% CI -3.99--0.56, p = 0.009), but it may increase the incidence of adverse events in patients compared with the standard EM group (RR 1.99, 95% CI 1.25-3.16, p = 0.004).

Conclusion

Systematic EM has no significant effect on short- or long-term mortality in mechanically ventilated adult ICU patients, but systematic EM could reduce the ICU LOS and duration of MV.

Critical Care Management of Acute-on-Chronic Liver Failure: Certainties and Unknowns

Intensive care unit (ICU) admission is frequently required in patients with decompensated cirrhosis for organ support. This entity, known as acute-on-chronic liver failure (ACLF), is associated with high short-term mortality. ICU management of ACLF is complex, as these patients are prone to develop new organ failures and infectious or bleeding complications. Poor nutritional status, lack of effective liver support systems, and shortage of liver donors are also factors that contribute to increase their mortality. ICU therapy parallels that applied in the general ICU population in some complications but has differential characteristics in others. This review describes the current knowledge on critical care management of patients with ACLF including organ support, prognostic assessment, early liver transplantation, and futility rules. Certainties and knowledge gaps in this area are also discussed.