Electrical muscle stimulation in the intensive care setting: a systematic review

Functional Magnetic Neuromuscular Stimulation vs. Routine Physiotherapy in the Critically Ill for Prevention of ICU Acquired Muscle Loss: A Randomised Controlled Trial

Background and Objectives: Muscle loss is a known complication of ICU admission. The aim of the study was to investigate the effect of neuromuscular functional magnetic stimulation (FMS) on quadriceps muscle thickness in critically ill patients. Materials and Methods: Among ICU patients one quadriceps was randomized to FMS (Tesla Stym, Iskra Medical, Ljubljana, Slovenia) stimulation and the other to control care. Quadriceps thickness was measured by ultrasound (US) in transversal and longitudinal planes at enrolment, Days 3-5, and Days 9-12. The trial stopped early following an interim analysis comparing muscle thickness differences between groups using repeated measures ANOVA. Results: Of 18 patients randomized, 2 died before completing the trial. The final analysis reported included 16 patients (female 38%, age 68 ± 10 years, SOFA 10.8 ± 2.7). Three mild skin thermal injuries were noted initially, which were later avoided with proper positioning of FMS probe. Primary outcome comparison showed that quadriceps thickness in transversal and longitudinal planes decreased in the non-stimulated legs and, but it did not change in FMS legs (-4.1 mm (95%CI: -9.4 to -0.6) vs. -0.7 mm (95%CI: -4.1 to -0.7) (p = 0.03) and -4.4 mm (95%CI: -8.9 to -1.1) vs. -1.5 mm (95%CI: -2.6 to -2.2) (p = 0.02), respectively) (ANOVA difference between groups p = 0.036 and 0.01, respectively). Conclusions: In the critically ill, neuromuscular FMS is feasible and safe with precautions applied to avoid possible skin thermal injury. FMS decreases the loss of quadriceps muscle thickness.

Direct electrical stimulation impacts on neuromuscular junction morphology on both stimulated and unstimulated contralateral soleus

BACKGROUND

There is increasing evidence of crosstalk between organs. The neuromuscular junction (NMJ) is a peripheral chemical synapse whose function and morphology are sensitive to acetylcholine (ACh) release and muscle depolarization. In an attempt to improve our understanding of NMJ plasticity and muscle crosstalk, the effects of unilateral direct electrical stimulation of a hindlimb muscle on the NMJ were investigated in rats exposed long-term post-synaptic neuromuscular blockade.

METHODS

Sprague Dawley rats were subjected to post-synaptic blockade of neuromuscular transmission by systemic administration of α-cobrotoxin and mechanically ventilated for up to 8 days and compared with untreated sham operated controls and animals exposed to unilateral chronic electrical stimulation 12 h/day for 5 or 8 days.

RESULTS

NMJs produced axonal and glial sprouts (growth of processes that extend beyond the confines of the synapse defined by high-density aggregates of acetylcholine receptors [AChRs]) in response to post-synaptic neuromuscular blockade, but less than reported after peripheral denervation or pre-synaptic blockade. Direct electrical soleus muscle stimulation reduced the terminal Schwann cell (tSC) and axonal sprouting in both stimulated and non-stimulated contralateral soleus. Eight days chronic stimulation reduced (P < 0.001) the number of tSC sprouts on stimulated and non-stimulated soleus from 6.7 ± 0.5 and 6.9 ± 0.5 sprouts per NMJ, respectively, compared with 10.3 ± 0.9 tSC per NMJ (P < 0.001) in non-stimulated soleus from rats immobilized for 8 days. A similar reduction of axonal sprouts (P < 0.001) was observed in stimulated and non-stimulated contralateral soleus in response to chronic electrical stimulation. RNAseq-based gene expression analyses confirmed a restoring effect on both stimulated and unstimulated contralateral muscle. The cross-over effect was paralleled by increased cytokine/chemokine levels in stimulated and contralateral unstimulated muscle as well as in plasma.

CONCLUSIONS

Motor axon terminals and terminal Schwann cells at NMJs of rats subjected to post-synaptic neuromuscular blockade exhibited sprouting responses. These axonal and glial responses were likely dampened by a muscle-derived myokines released in an activity-dependent manner with both local and systemic effects.

Effects of electrical muscle stimulation on core muscle activation and physical performance in non-athletic adults: A randomized controlled trial

BACKGROUND

Electrical muscle stimulation (EMS) activates muscles through electrical currents, resulting in involuntary muscle contractions. This study aimed to evaluate the immediate clinical effects of superimposing EMS on strength training compared with conventional exercise in healthy non-athletic adults.

METHODS

This study was a randomised, controlled, parallel-group trial conducted at a single centre. Forty-one healthy young volunteers were recruited and randomised into two groups: strengthening with superimposed EMS (S+E) and strengthening (S) groups. All participants underwent the 30 minutes of strength training program, three times a week for 8 weeks, consisting of core muscle exercises. Additionally, the S+E group received EMS during training, which stimulated the bilateral abdominal, gluteus, and hip adductor muscles. As the primary outcome measure, we evaluated the changes in muscle thickness, including the abdominal, gluteal, and hip adductor muscles, using ultrasound. Muscle thickness was measured in both resting and contracted states. For secondary outcomes, physical performance (Functional Movement System score, McGill's core stability test, and hip muscle power) and body composition analysis were evaluated. All assessments were performed at the beginning and end of the intervention.

RESULTS

39 participants (S+E group = 20, S group = 19) completed the study. The clinical characteristics and baseline functional status of each group did not differ significantly between the groups. After completion of the training, the S+E group showed more efficient contraction in most of the evaluated muscles. The resting muscle thickness did not differ significantly between the groups; however, the contracted muscle thickness in the S+E group was higher than that in the S group (p < 0.05). Physical performance and body composition were not significantly different between the two groups. No intervention-related complications were reported during the study.

CONCLUSION

EMS seems to be a safe and reasonable modality for improving physical fitness in healthy individuals.

Attenuating Muscle Mass Loss in Critical Illness: the Role of Nutrition and Exercise

PURPOSE OF REVIEW

Impaired recovery following an intensive care unit (ICU) admission is thought related to muscle wasting. Nutrition and physical activity are considered potential avenues to attenuate muscle wasting. The aim of this review was to present evidence for these interventions in attenuating muscle loss or improving strength and function.

RECENT FINDINGS

Randomised controlled trials on the impact of nutrition or physical activity interventions in critically ill adult patients on muscle mass, strength or function are presented. No nutrition intervention has shown an effect on strength or function, and the effect on muscle mass is conflicting. RCTs on the effect of physical activity demonstrate conflicting results; yet, there is a signal for improved strength and function with higher levels of physical activity, particularly when commenced early. Further research is needed to elucidate the impact of nutrition and physical activity on muscle mass, strength and function, particularly in combination.

Electrical stimulated GLUT4 signalling attenuates critical illness-associated muscle wasting

BACKGROUND

Critical illness myopathy (CIM) is a debilitating condition characterized by the preferential loss of the motor protein myosin. CIM is a by-product of critical care, attributed to impaired recovery, long-term complications, and mortality. CIM pathophysiology is complex, heterogeneous and remains incompletely understood; however, loss of mechanical stimuli contributes to critical illness-associated muscle atrophy and weakness. Passive mechanical loading and electrical stimulation (ES) therapies augment muscle mass and function. While having beneficial outcomes, the mechanistic underpinning of these therapies is less known. Therefore, here we aimed to assess the mechanism by which chronic supramaximal ES ameliorates CIM in a unique experimental rat model of critical care.

METHODS

Rats were subjected to 8 days of critical care conditions entailing deep sedation, controlled mechanical ventilation, and immobilization with and without direct soleus ES. Muscle size and function were assessed at the single cell level. RNAseq and western blotting were employed to understand the mechanisms driving ES muscle outcomes in CIM.

RESULTS

Following 8 days of controlled mechanical ventilation and immobilization, soleus muscle mass, myosin : actin ratio, and single muscle fibre maximum force normalized to cross-sectional area (CSA; specific force) were reduced by 40-50% (P < 0.0001). ES significantly reduced the loss of soleus muscle fibre CSA and myosin : actin ratio by approximately 30% (P < 0.05) yet failed to effect specific force. RNAseq pathway analysis revealed downregulation of insulin signalling in the soleus muscle following critical care, and GLUT4 trafficking was reduced by 55% leading to an 85% reduction of muscle glycogen content (P < 0.01). ES promoted phosphofructokinase and insulin signalling pathways to control levels (P < 0.05), consistent with the maintenance of GLUT4 translocation and glycogen levels. AMPK, but not AKT, signalling pathway was stimulated following ES, where the downstream target TBC1D4 increased 3 logFC (P = 0.029) and AMPK-specific P-TBC1D4 levels were increased approximately two-fold (P = 0.06). Reduction of muscle protein degradation rather than increased synthesis promoted soleus CSA, as ES reduced E3 ubiquitin proteins, Atrogin-1 (P = 0.006) and MuRF1 (P = 0.08) by approximately 50%, downstream of AMPK-FoxO3.

CONCLUSIONS

ES maintained GLUT4 translocation through increased AMPK-TBC1D4 signalling leading to improved muscle glucose homeostasis. Soleus CSA and myosin content was promoted through reduced protein degradation via AMPK-FoxO3 E3 ligases, Atrogin-1 and MuRF1. These results demonstrate chronic supramaximal ES reduces critical care associated muscle wasting, preserved glucose signalling, and reduced muscle protein degradation in CIM.

Modalities of Exercise Training in Patients with Extracorporeal Membrane Oxygenation Support

The aim of this qualitative systematic review is to summarize and analyze the different modalities of exercise training and its potential effects in patients on extracorporeal membrane oxygenation (ECMO) support. ECMO is an outbreaking, life-saving technology of the last decades which is being used as a gold standard treatment in patients with severe cardiac, respiratory or combined cardiorespiratory failure. Critically ill patients on ECMO very often present intensive care unit-acquired weakness (ICU-AW); thus, leading to decreased exercise capacity and increased mortality rates. Early mobilization and physical therapy have been proven to be safe and feasible in critically ill patients on ECMO, either as a bridge to lung/heart transplantation or as a bridge to recovery. Rehabilitation has beneficial effects from the early stages in the ICU, resulting in the prevention of ICU-AW, and a decrease in episodes of delirium, the duration of mechanical ventilation, ICU and hospital length of stay, and mortality rates. It also improves functional ability, exercise capacity, and quality of life. Rehabilitation requires a very careful, multi-disciplinary approach from a highly specialized team from different specialties. Initial risk assessment and screening, with appropriate physical therapy planning and exercise monitoring in patients receiving ECMO therapy are crucial factors for achieving treatment goals. However, more randomized controlled trials are required in order to establish more appropriate individualized exercise training protocols.

A Comparison of Vibrotactile Feedback and Electrical Muscle Stimulation (EMS) for Motor Response During Active Hand Movement

Wearable haptic technologies have garnered recent widespread attention due to increased accessibility, functionality, and affordability. These systems typically provide haptic feedback to augment the human ability to interact with their environment. This study compares two haptic feedback modalities, vibrotactile and EMS, against visual feedback to elicit a motor response during active hand movement. Forty-five participants, divided into three groups, performed a task to touch their face and received one of three possible sensory feedback cues, namely visual, vibrotactile, and electrical muscle stimulation (EMS), to interrupt their movement and avoid touching their face. Two quantitative performance measures are used in the comparison, the response time (time elapsed from stimulation to motor response) and the error rate (percentage that the user fails to avoid touching their face). Results showed that vibrotactile and EMS feedback yielded significantly faster response time than visual feedback, while no significant differences between vibrotactile and EMS were observed. Furthermore, the error rate was significantly lower for EMS compared to visual feedback, whereas no significant differences were observed between vibrotactile and visual feedback. In conclusion, it seems that EMS feedback is preferable for applications where errors are not tolerable (critical medical applications), whereas vibrotactile is superior for non-critical applications due to its low cost and higher usability (more pleasant compared to EMS).

The effectiveness of functional electrical stimulation of the legs in patients with heart failure: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the effectiveness of functional electrical stimulation of the legs in patients with heart failure.

METHODS

Data were obtained from PubMed, Cochrane Library, and Embase databases until August 12, 2021. We included randomized controlled trials that evaluated the effects of functional electrical stimulation applied to the legs of patients with heart failure, namely changes in cardiopulmonary function, muscle strength, and quality of life.

RESULTS

In total, 14 randomized controlled trials (consisting of 518 patients) were included in our article. Pooled estimates demonstrated that functional electrical stimulation significantly improved peak oxygen consumption (peak VO₂; standardized mean difference = 0.33, 95% confidence interval = 0.07-0.59, eight randomized controlled trials, n = 321), 6-min walking distance (mean difference = 48.03 m, 95% confidence interval = 28.50-67.57 m, 10 randomized controlled trials, n = 380), and Minnesota Living with Heart Failure Questionnaire quality of life score (mean difference =  - 8.23, 95% confidence interval =  - 12.64 to - 3.83, nine randomized controlled trials, n = 383). Muscle strength of lower extremities was not significantly improved in the functional electrical stimulation group compared with that in the control group (standardized mean difference = 0.26, 95% confidence interval =  - 0.18 to 0.71, five randomized controlled trials, n = 218). Furthermore, the subgroup analysis revealed that functional electrical stimulation significantly improved peak VO₂, 6-min walking distance, and Minnesota Living with Heart Failure Questionnaire quality of life score in the heart failure with reduced ejection fraction and heart failure with preserved ejection fraction subgroups.

CONCLUSION

Functional electrical stimulation can effectively improve the cardiopulmonary function and quality of life in patients with heart failure. However, functional electrical stimulation did not significantly improve muscle strength in the legs.

Rehabilitation to enable recovery from COVID-19: a rapid systematic review

OBJECTIVES

To establish the evidence for rehabilitation interventions tested in populations of patients admitted to ICU and critical care with severe respiratory illness, and consider whether the evidence is generalizable to patients with COVID-19.

METHODS

The authors undertook a rapid systematic review. Medline (via OvidSP), CINAHL Complete (via EBSCOhost), Cochrane Library, Cochrane Database of Systematic Reviews and CENTRAL (via Wiley), Epistemonikos (via Epistemonikos.org), PEDro (via pedro.org.au) and OTseeker (via otseeker.com) searched to 7 May 2020. The authors included systematic reviews, RCTs and qualitative studies involving adults with respiratory illness requiring intensive care who received rehabilitation to enhance or restore resulting physical impairments or function. Data were extracted by one author and checked by a second. TIDier was used to guide intervention descriptions. Study quality was assessed using Critical Skills Appraisal Programme (CASP) tools.

RESULTS

Six thousand nine hundred and three titles and abstracts were screened; 24 systematic reviews, 11 RCTs and eight qualitative studies were included. Progressive exercise programmes, early mobilisation and multicomponent interventions delivered in ICU can improve functional independence. Nutritional supplementation in addition to rehabilitation in post-ICU hospital settings may improve performance of activities of daily living. The evidence for rehabilitation after discharge from hospital following an ICU admission is inconclusive. Those receiving rehabilitation valued it, engendering hope and confidence.

CONCLUSIONS

Exercise, early mobilisation and multicomponent programmes may improve recovery following ICU admission for severe respiratory illness that could be generalizable to those with COVID-19. Rehabilitation interventions can bring hope and confidence to individuals but there is a need for an individualised approach and the use of behaviour change strategies. Further research is needed in post-ICU settings and with those who have COVID-19. Registration: Open Science Framework https://osf.io/prc2y.

Effect of Electrical Muscle Stimulation on Upper and Lower Limb Muscles in Critically Ill Patients: A Two-Center Randomized Controlled Trial

OBJECTIVES

Electrical muscle stimulation is widely used to enhance lower limb mobilization. Although upper limb muscle atrophy is common in critically ill patients, electrical muscle stimulation application for the upper limbs has been rarely reported. The purpose of this study was to investigate whether electrical muscle stimulation prevents upper and lower limb muscle atrophy and improves physical function.

DESIGN

Randomized controlled trial.

SETTING

Two-center, mixed medical/surgical ICU.

PATIENTS

Adult patients who were expected to be mechanically ventilated for greater than 48 hours and stay in the ICU for greater than 5 days.

INTERVENTIONS

Forty-two patients were randomly assigned to the electrical muscle stimulation (n = 17) or control group (n = 19).

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were change in muscle thickness and cross-sectional area of the biceps brachii and rectus femoris from day 1 to 5. Secondary outcomes included occurrence of ICU-acquired weakness, ICU mobility scale, length of hospitalization, and amino acid levels. The change in biceps brachii muscle thickness was -1.9% versus -11.2% in the electrical muscle stimulation and control (p = 0.007) groups, and the change in cross-sectional area was -2.7% versus -10.0% (p = 0.03). The change in rectus femoris muscle thickness was -0.9% versus -14.7% (p = 0.003) and cross-sectional area was -1.7% versus -10.4% (p = 0.04). No significant difference was found in ICU-acquired weakness (13% vs 40%; p = 0.20) and ICU mobility scale (3 vs 2; p = 0.42) between the groups. The length of hospitalization was shorter in the electrical muscle stimulation group (23 d [19-34 d] vs 40 d [26-64 d]) (p = 0.04). On day 3, the change in the branched-chain amino acid level was lower in the electrical muscle stimulation group (40.5% vs 71.5%; p = 0.04).

CONCLUSIONS

In critically ill patients, electrical muscle stimulation prevented upper and lower limb muscle atrophy and attenuated proteolysis and decreased the length of hospitalization.

Blood Flow Restriction Combined with Electrical Stimulation Attenuates Thigh Muscle Disuse Atrophy

PURPOSE

This study aimed to investigate the effects of blood flow restriction (BFR) combined with electrical muscle stimulation (EMS) on skeletal muscle mass and strength during a period of limb disuse.

METHODS

Thirty healthy participants (22 ± 3 yr; 23 ± 3 kg·m-2) were randomly assigned to control (CON; n = 10), BFR alone (BFR; n = 10), or BFR combined with EMS (BFR + EMS; n = 10). All participants completed unloading of a single leg for 14 d, with no treatment (CON), or while treated with either BFR or BFR + EMS (twice daily, 5 d·wk-1). BFR treatment involved arterial three cycles of 5-min occlusion using suprasystolic pressure, each separated by 5 min of reperfusion. EMS (6 s on, 15 s off; 200 μs; 60 Hz; 15% maximal voluntary contraction [MVC]) was applied continuously throughout the three BFR cycles. Quadriceps muscle mass (whole-thigh lean mass via dual-energy x-ray absorptiometry and vastus lateralis [VL] muscle thickness via ultrasound) and strength (via knee extension MVC) were assessed before and after the 14-d unloading period.

RESULTS

After limb unloading, whole-thigh lean mass decreased in the control group (-4% ± 1%, P < 0.001) and BFR group (-3% ± 2%, P = 0.001), but not in the BFR + EMS group (-0.3% ± 3%, P = 0.8). VL muscle thickness decreased in the control group (-4% ± 4%, P = 0.005) and was trending toward a decrease in the BFR group (-8% ± 11%, P = 0.07) and increase in the BFR + EMS group (+5% ± 10%, P = 0.07). Knee extension MVC decreased over time (P < 0.005) in the control group (-18% ± 15%), BFR group (-10% ± 13%), and BFR + EMS group (-18% ± 15%), with no difference between groups (P > 0.5).

CONCLUSION

Unlike BFR performed in isolation, BFR + EMS represents an effective interventional strategy to attenuate the loss of muscle mass during limb disuse, but it does not demonstrate preservation of strength.

Influence of sarcopenia focused on critically ill patients

A systemic review was performed to evaluate the epidemiological, pathophysiological, and clinical features of sarcopenia, the relationship of sarcopenia with critical illness and its impact on mortality, and diagnostic methods and treatment modalities. Generally, in the presence of critical illness, sarcopenia is not included in the treatment approach strategies. An intensivist should be aware that sarcopenia may be present in critically ill patients. Although the main modalities against sarcopenia are early mobilization and nutritional support, they can only prevent its development and may have positive effects on prognosis rather than treating the existing sarcopenia.

Current Physical Therapy Practice in the Intensive Care Unit in Saudi Arabia: A Multicentre Cross-Sectional Survey

BACKGROUND

Early mobilisation of patients in the intensive care unit (ICU) is associated with positive health benefits. Research literature lacks insight into the current status of ICU physical therapy (PT) practice in the Kingdom of Saudi Arabia.

AIM

To determine the current standard of ICU PT practice, attitude, and barriers.

METHODS

A questionnaire was e-mailed to physiotherapists (PTs) working in the hospital. The questions pertained to experience, qualification, barriers, and most frequently encountered case scenarios in the ICU.

RESULTS

The response rate was 28.1% (124/442). Frequent cases referred to the PTs were traumatic paraplegia (n = 111, 89%) and stroke (n = 102, 82.3%) as compared to congestive heart failure (n = 20, 16.1%) and pulmonary infections (n = 7, 5.6%). The preferred treatment of choice among PTs was chest physiotherapy (n = 102, 82.2%) and positioning (n = 73, 58.8%), whereas functional electrical stimulation (n = 12, 9.6%) was least preferred irrespective of the condition. Perceived barriers in the ICU PT management were of low confidence in managing cases (n = 89, 71.7%) followed by inadequate training (n = 53, 42.7%), and the least quoted barrier was a communication gap between the critical care team members (n = 8, 6.4%).

CONCLUSION

PTs reported significant variation in the choice of treatment for different clinical cases inside ICU. The main barriers in the ICU setting were low confidence and inadequate training.

Precision implementation of early ambulation in elderly patients undergoing off-pump coronary artery bypass graft surgery: a randomized-controlled clinical trial

Background

Although early ambulation (EA) is associated with improved outcomes in post-operative patients, implementation of EA in elderly patients is still a challenge. In this study, we aimed to design and assess a precision early ambulation program for cardiac rehabilitation.

Methods

We conducted a single-center, randomized and controlled clinical trial in elderly patients aged over 60 years after off-pump coronary artery bypass graft (OPCABG) surgery. Patients were randomly assigned to a precision early ambulation (PEA) group or a routine ambulation (Control) group. Age-predicted maximal heart rate (APMHR) and maximal oxygen uptake (VO_2max) were used as a reference to formulate and monitor the PEA regimen. The primary end-point was the postoperative length of stay in hospital (PLOS). The secondary end-points included 90-day mortality, incidence of early discharge, laboratory tests, length of ICU stay, the incidence of multiple organ complications and post-traumatic stress disorder (PTSD). Ambulation outcomes were also recorded.

Results

In total, 178 patients were enrolled (n = 89 per group). In the intent-to-treat analysis, PLOS in the PEA group was shorter than that in the Control group (9.04 ± 3.08 versus 10.09 ± 3.32 days, respectively. Mean difference 1.045 days; 95% confidence interval [CI] 0.098–1.992; P = 0.031 in the unadjusted model; mean difference 0.957 days; CI 0.007–1.907; P = 0.048 in adjusted model). The incidence of early discharge differed significantly between the PEA and control groups (41[46.1%] versus 24[27.0%] patients, respectively. Odds ratio [OR] 0.432; CI 0.231–0.809; P = 0.009 in unadjusted model; OR 0.466; CI 0.244–0.889, P = 0.02 in adjusted model). The time of first bowel movement, partial pressure O₂ and post-traumatic stress disorder score in the PEA group were better than those in the Control group. Participants walked much longer distances on day 3 in the PEA group than those in the Control group (76.12 ± 29.02 versus 56.80 ± 24.40 m, respectively, P < 0.001).

Conclusion

APMHR and VO_2max are valuable for implementation of PEA according to an established security threshold. PEA after OPCAPG surgery is safe and reliable for elderly patients, not only reducing the hospital stay, but also improving their physiological and psychological symptoms.

Trial registration

This study is a component of a protocol retrospectively registered: Application of ERAS in cardiovascular surgery. Trial registration number: ChiCTR1800018167. Date of registration: 3rd September, 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx

Early Mobilization Interventions in the Intensive Care Unit: Ongoing and Unpublished Randomized Trials

Background

Critical care societies recommend early mobilization (EM) as standard practice in the intensive care unit (ICU) setting. However, there is limited randomized controlled trial (RCT) evidence supporting EM's effectiveness. Our objective was to identify ongoing or completed RCTs assessing EM's effectiveness in the ICU.

Method

We searched ClinicalTrials.gov and the Australian New Zealand Clinical Trials Registry for ongoing or completed but not published RCTs in an ICU setting with objective outcome measures.

Results

There were 14 RCTs included in the analysis. All studies were in the general or mixed ICU setting (N=14). Half of the studies (N=7) were small RCTs (<100 projected participants) and half (N=7) were medium-sized RCTs (100–999 participants). Inclusion criteria included mechanical ventilation use or expected use (N=13) and prehospital functional status (N=7). Primary EM interventions were standard physiotherapist-based activities (N=4), cycling (N=9), and electrical muscle stimulation (N=1). Only one study involved nurse-led EM. The most common assessment tool was the 6-minute walk test (N=6). Primary outcome measures were physiological (N=3), clinical (N=3), patient-centered (N=7), and healthcare resource use (N=1). Most studies (N=8) involved post-ICU follow-up measures up to 1-year posthospitalization. There were no studies targeting older adults or people with acute cardiac disease.

Conclusion

Identified studies will further the evidence base for EM's effectiveness. There is a need for studies looking at specific patient populations that may benefit from EM, such as older adults and cardiac patients, as well as for novel EM delivery strategies, such as nurse-led EM.

The effect of early mobilization in critically ill patients: A meta-analysis

BACKGROUND

The aim of this meta-analysis was to assess if early mobilization and rehabilitation in the intensive care unit (ICU) could reduce ICU-acquired weakness (ICU-AW), improve functional recovery, improve muscle strength, shorten the length of ICU and hospital stays, and reduce the mortality rate.

METHODS

A comprehensive literature search in PubMed, Embase, Web of Science, SinoMed (Chinese BioMedical Literature Service System, China), and National Knowledge Infrastructure, China (CNKI) was performed. Results were expressed as a risk ratio (RR) with 95% confidence intervals (95% CIs) or weight mean difference (WMD) with 95% CIs. Pooled estimates were calculated using a fixed-effects or random-effects model according to the heterogeneity among studies.

RESULTS

Fifteen randomized controlled trials involving a total of 1941 patients were included in this meta-analysis. Pooled estimates suggested that early mobilization significantly reduced the incidence of ICU-AW (RR = 0.49, 95% CI: 0.26, 0.91; P = .025), shortened the length of ICU (WMD = -1.82 days, 95% CI: -2.88, -0.76; P = .001) and hospital (WMD = -3.90 days, 95% CI: -5.94, -1.85; P < .001) stays, and improved the Medical Research Council score (WMD = 4.47, 95% CI: 1.43, 7.52; P = .004) and Barthel Index score at hospital discharge (WMD = 21.44, 95% CI: 10.97, 31.91; P < .001). Moreover, early mobilization also decreased complications such as deep vein thrombosis (RR = 0.16, 95% CI: 0.04, 0.59; P = .006), ventilator-associated pneumonia (RR = 0.26, 95% CI: 0.11, 0.63; P = .003), and pressure sores (RR = 0.14, 95% CI: 0.04, 0.44; P = .001). However, early mobilization did not reduce the ICU mortality rate (RR = 1.31, 95% CI: 0.97, 1.76; P = .074), improve the handgrip strength (WMD = 4.03 kg, 95% CI: -0.68, 8.74; P = .094), and shorten the duration of mechanical ventilation (WMD = 0.20 days, 95% CI: -0.10, 0.50; P = .194).

CONCLUSION

This study indicated that early mobilization was effective in preventing the occurrence of ICU-AW, shortening the length of ICU and hospital stay, and improving the functional mobility. However, it had no effect on the ICU mortality rate and ventilator-free days.

RELEVANCE TO CLINICAL PRACTICE

ICU-AW is a common neuromuscular complication of critical illness, and it is predictive of adverse outcomes. Early mobilization of critically ill patients is a candidate intervention to reduce the incidence and severity of ICU-AW. Some clinical studies have demonstrated this, whereas others found opposite results. The aim of our study is to assess if early mobilization and rehabilitation in the ICU could reduce the ICU-AW, improve functional recovery, improve muscle strength, shorten length of ICU and hospital stay, and reduce the mortality rate.

Effects of neuromuscular electrical stimulation in critically ill patients: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

We performed a systematic review and meta-analysis to examine the effect of neuromuscular electrical stimulation (NES) on prevention of critical care myopathy and its effect on various clinical outcomes in the intensive care unit (ICU).

REVIEW METHODS USED

This study involved systematic review and meta-analysis of randomised controlled trials (RCTs) comparing NES (applied to different muscle groups combined with usual care) and usual care (passive and active exercises along with early mobilisation and rehabilitation). Included studies enrolled adult patients managed in the ICU for medical or surgical diseases who were or were not mechanically ventilated. The primary outcome was global muscle strength measured by the Medical Research Council grading system. Secondary outcomes included ICU mortality, duration of mechanical ventilation (MV), and ICU length of stay. Risk ratio for dichotomous data and mean difference (MD) for continuous data with their corresponding 95% confidence interval (CI) were calculated.

DATA SOURCE

A search in major electronic databases, including PubMed, Cochrane Library, and Embase, from inception to November 2018 was carried out.

RESULTS

Six RCTs were included, representing 718 patients. The mean age 60 ± 15.3 years, and 60.6% were male. There was no significant difference between NES and usual care on global muscle strength measured by Medical Research Council grading system (MD: 0.45; 95% CI: -2.89 to 3.80; p = 0.79), ICU mortality (risk ratio: 1.30; 95% CI: 0.95-1.78; p = 0.10), duration of MV (days) (MD: -2.07; 95% CI: -5.06 to 0.92; p = 0.18), or ICU length of stay (days) (MD: -3.06; 95% CI: -9.79 to 3.68; p = 0.37) in comparison with the usual therapy alone in critically ill patients.

CONCLUSION

NES combined with usual care was not associated with significant differences in global muscle strength, ICU mortality, duration of MV, or ICU length of stay in comparison with usual care alone in critically ill patients. Further RCTs are needed to determine patients with maximum benefit and to examine NES safety and efficacy.

Interventions for the management and prevention of sarcopenia in the critically ill: A systematic review

PURPOSE

In the critically ill, sarcopenia is associated with a variety of adverse outcomes however there is no consensus regarding its management. This study aimed to systematically review the evidence for interventions for the management and prevention of sarcopenia in critically ill patients.

MATERIALS AND METHODS

Bibliographic databases were searched according to pre-specified criteria (PROSPERO-CRD42018086271). Randomised controlled trials (RCTs) investigating interventions to preserve muscle mass and/or function in critically ill patients were included. Two independent authors selected the articles and assessed bias using the Cochrane Risk of Bias Tool.

RESULTS

Twenty-two eligible RCTs were identified comprising 2792 patients. Three main groups of interventions were implemented in these trials: neuromuscular electrical stimulation (NMES), exercise-based and nutritional. Both the interventions and outcomes measured varied significantly between studies. NMES was most frequently studied as an intervention to preserve muscle mass whilst exercise-based treatments were evaluated as interventions to preserve muscle function. There was significant variation in the efficacy of the interventions on sarcopenia markers and secondary outcomes.

CONCLUSIONS

NMES and exercise-based interventions may preserve muscle mass and function in patients with critical illness. There is a lack of consistency seen in the effects of these interventions. Further, large, high quality RCTs are required.

Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review

Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.

ICEAGE (Incidence of Complications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery

Background

Postoperative complications and delayed physical recovery are significant problems following emergency abdominal surgery. Physiotherapy aims to aid recovery and prevent complications in the acute phase after surgery and is commonplace in most first-world hospitals. Despite ubiquitous service provision, no well-designed, adequately powered, parallel-group, randomised controlled trial has investigated the effect of physiotherapy on the incidence of respiratory complications, paralytic ileus, rate of physical recovery, ongoing need for formal sub-acute rehabilitation, hospital length of stay, health-related quality of life, and mortality following emergency abdominal surgery. We hypothesise that an enhanced physiotherapy care package of additional education, breathing exercises, and early rehabilitation prevents postoperative complications and improves physical recovery following emergency abdominal surgery compared to standard care alone.

Methods

The Incidence of Complications following Emergency Abdominal surgery: Get Exercising (ICEAGE) trial is a pragmatic, investigator-initiated, multicentre, patient- and assessor-blinded, parallel-group, active-placebo controlled randomised trial, powered for superiority. ICEAGE will compare standard care physiotherapy to an enhanced physiotherapy care package in 288 participants admitted for emergency abdominal surgery at three Australian hospitals. Participants will be randomised using concealed allocation to receive either standard care physiotherapy (education, single session of coached breathing exercises, and daily early ambulation for 15 min) or an enhanced physiotherapy care package (education, twice daily coached breathing exercises for a minimum 2 days, and 30 min of daily supervised early rehabilitation for minimum five postoperative days). The primary outcome is a respiratory complication within the first 14 postoperative hospital days assessed daily with standardised diagnostic criteria. Secondary outcomes include referral for sub-acute rehabilitation services, discharge destination, paralytic ileus, hospital length of stay and costs, intensive care unit utilisation, 90-day patient-reported complications and health-related quality of life and physical capacity, and mortality at 30 days and at 1 year following surgery.

Discussion

The morbidity, mortality, and fiscal burdens following emergency abdominal surgery are some of the worst within surgery. Physiotherapy may be an effective, low-cost, minimal harm intervention to improve outcomes and reduce hospital utilisation following this surgery type. ICEAGE will test the benefits of this commonly provided intervention within a methodologically robust, multicentre, double-blinded, active-placebo controlled randomised trial.

Trial registration

ACTRN 12615000318583. Registered 8 April 2015

Electronic supplementary material

The online version of this article (10.1186/s13017-018-0189-y) contains supplementary material, which is available to authorized users.

Comparison of exercise intensity during four early rehabilitation techniques in sedated and ventilated patients in ICU: a randomised cross-over trial

BACKGROUND

In the ICU, out-of-bed rehabilitation is often delayed and in-bed exercises are generally low-intensity. Since the majority of rehabilitation is carried out in bed, it is essential to carry out the exercises that have the highest intensity. The aim of this study was to compare the physiological effects of four common types of bed exercise in intubated, sedated patients confined to bed in the ICU, in order to determine which was the most intensive.

METHODS

A randomised, single-blind, placebo-controlled crossover trial was carried out to evaluate the effects of four bed exercises (passive range of movements (PROM), passive cycle-ergometry, quadriceps electrical stimulation and functional electrical stimulation (FES) cycling) on cardiac output. Each exercise was carried out for ten minutes in ventilated, sedated patients. Cardiac output was recorded using cardiac Doppler ultrasound. The secondary aims were to evaluate right heart function and pulmonary and systemic artery pressures during the exercises, and the microcirculation of the vastus lateralis muscle.

RESULTS

The results were analysed in 19 patients. FES cycling was the only exercise that increased cardiac output, with a mean increase of 1 L/min (15%). There was a concomitant increase in muscle oxygen uptake, suggesting that muscle work occurred. FES cycling thus constitutes an effective early rehabilitation intervention. No muscle or systemic effects were induced by the passive techniques.

CONCLUSION

Most bed exercises were low-intensity and induced low levels of muscle work. FES cycling was the only exercise that increased cardiac output and produced sufficient intensity of muscle work. Longer-term studies of the effect of FES cycling on functional outcomes should be carried out.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02920684 . Registered on 30 September 2016. Prospectively registered.

Neuromuscular Electrical Stimulation for Treatment of Muscle Impairment: Critical Review and Recommendations for Clinical Practice

Purpose: In response to requests from physiotherapists for guidance on optimal stimulation of muscle using neuromuscular electrical stimulation (NMES), a review, synthesis, and extraction of key data from the literature was undertaken by six Canadian physical therapy (PT) educators, clinicians, and researchers in the field of electrophysical agents. The objective was to identify commonly treated conditions for which there was a substantial body of literature from which to draw conclusions regarding the effectiveness of NMES. Included studies had to apply NMES with visible and tetanic muscle contractions. Method: Four electronic databases (CINAHL, Embase, PUBMED, and SCOPUS) were searched for relevant literature published between database inceptions until May 2015. Additional articles were identified from bibliographies of the systematic reviews and from personal collections. Results: The extracted data were synthesized using a consensus process among the authors to provide recommendations for optimal stimulation parameters and application techniques to address muscle impairments associated with the following conditions: stroke (upper or lower extremity; both acute and chronic), anterior cruciate ligament reconstruction, patellofemoral pain syndrome, knee osteoarthritis, and total knee arthroplasty as well as critical illness and advanced disease states. Summaries of key details from each study incorporated into the review were also developed. The final sections of the article outline the recommended terminology for describing practice using electrical currents and provide tips for safe and effective clinical practice using NMES. Conclusion: This article provides physiotherapists with a resource to enable evidence-informed, effective use of NMES for PT practice.

Neuromuscular electrophysiological disorders and muscle atrophy in mechanically-ventilated traumatic brain injury patients: New insights from a prospective observational study

PURPOSE

It is unclear whether the muscular changes in mechanically-ventilated traumatic brain injury patients (TBI) are only associated with disuse or additionally to neuromuscular electrophysiological disorders (NED). The correlation between muscle atrophy and NED may affect functional outcomes and rehabilitation programs significantly.

MATERIAL AND METHODS

An observational study was performed to investigate the presence of NED and muscle atrophy in TBI patients undergoing mechanical ventilation. NED was diagnosed by the stimulus electrodiagnosis test when chronaxie was ≥1000μs. The muscle structure (thickness and echogenicity) was assessed by B-mode ultrasound. Tibialis anterior (TA), rectus femoris (RF), and biceps brachialis (BB) muscles were analyzed. Patients were followed from the first day of admission in the intensive care unit (ICU) to the fourteenth day.

RESULTS

Twenty-two patients were analyzed. An increase of 48% in NED from day 1 to day 14 was detected in TA (p=0.004). All muscles presented a significant decrease in thickness (~18%, p<0.05), but echogenicity increased only in TA (19%), p<0.01 and RF (23%), p<0.01.

CONCLUSIONS

Mechanically-ventilated patients with TBI developed NED in addition to changes in muscle structure during their stay in the ICU.

Disease-Induced Skeletal Muscle Atrophy and Fatigue

Numerous health problems, including acute critical illness, cancer, diseases associated with chronic inflammation, and neurological disorders, often result in skeletal muscle weakness and fatigue. Disease-related muscle atrophy and fatigue is an important clinical problem because acquired skeletal muscle weakness can increase the duration of hospitalization, result in exercise limitation, and contribute to a poor quality of life. Importantly, skeletal muscle atrophy is also associated with increased morbidity and mortality of patients. Therefore, improving our understanding of the mechanism(s) responsible for skeletal muscle weakness and fatigue in patients is a required first step to develop clinical protocols to prevent these skeletal muscle problems. This review will highlight the consequences and potential mechanisms responsible for skeletal muscle atrophy and fatigue in patients experiencing acute critical illness, cancer, chronic inflammatory diseases, and neurological disorders.

Protein Kinetics and Metabolic Effects Related to Disease States in the Intensive Care Unit

Evaluating protein kinetics in the critically ill population remains a very difficult task. Heterogeneity in the intensive care unit (ICU) population and wide spectrum of disease processes creates complexity in assessing protein kinetics. Traditionally, protein has been delivered in the context of total energy. Focus on energy delivery has recently come into question, as the importance of supplemental protein in patient outcomes has been shown in several recent trials. The ICU patient is prone to catabolism, immobilization, and impaired immunity, which is a perfect storm for massive loss of lean body tissue with a unidirectional flow of amino acids from muscle to immune tissue for immunoglobulin production, as well as liver for gluconeogenesis and acute phase protein synthesis. The understanding of protein metabolism in the ICU has been recently expanded with the discovery of how the mammalian target of rapamycin complex 1 is regulated. The concept of "anabolic resistance" and identifying the quantity of protein required to overcome this resistance is gaining support among critical care nutrition circles. It appears that a minimum of at least 1.2 g/kg/d with levels up to 2.0 g/kg/d of protein or amino acids appears safe for delivery in the ICU setting and may yield a better clinical outcome.

Physiotherapy management of intensive care unit-acquired weakness

[Hodgson CL, Tipping CJ (2016) Physiotherapy management of intensive care unit-acquired weakness.Journal of Physiotherapy63: 4-10].

Intensive care unit-acquired weakness

When critically ill, a severe weakness of the limbs and respiratory muscles often develops with a prolonged stay in the intensive care unit (ICU), a condition vaguely termed intensive care unit-acquired weakness (ICUAW). Many of these patients have serious nerve and muscle injury. This syndrome is most often seen in surviving critically ill patients with sepsis or extensive inflammatory response which results in increased duration of mechanical ventilation and hospital length of stay. Patients with ICUAW often do not fully recover and the disability will seriously impact on their quality of life. In this chapter we discuss the current knowledge on the pathophysiology and risk factors of ICUAW. Tools to diagnose ICUAW, how to separate ICUAW from other disorders, and which possible treatment strategies can be employed are also described. ICUAW is finally receiving the attention it deserves and the expectation is that it can be better understood and prevented.

Exercise rehabilitation following intensive care unit discharge for recovery from critical illness: executive summary of a Cochrane Collaboration systematic review

Skeletal muscle wasting and weakness are major complications of critical illness and underlie the profound physical and functional impairments experienced by survivors after discharge from the intensive care unit (ICU). Exercise-based rehabilitation has been shown to be beneficial when delivered during ICU admission. This review aimed to determine the effectiveness of exercise rehabilitation initiated after ICU discharge on primary outcomes of functional exercise capacity and health-related quality of life. We sought randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials comparing an exercise intervention commenced after ICU discharge vs. any other intervention or a control or 'usual care' programme in adult survivors of critical illness. Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature databases were searched up to February 2015. Dual, independent screening of results, data extraction, and quality appraisal were performed. We included six trials involving 483 patients. Overall quality of evidence for both outcomes was very low. All studies evaluated functional exercise capacity, with three reporting positive effects in favour of the intervention. Only two studies evaluated health-related quality of life and neither reported differences between intervention and control groups. Meta-analyses of data were precluded due to variation in study design, types of interventions, and selection and reporting of outcome measurements. We were unable to determine an overall effect on functional exercise capacity or health-related quality of life of interventions initiated after ICU discharge for survivors of critical illness. Findings from ongoing studies are awaited. Future studies need to address methodological aspects of study design and conduct to enhance rigour, quality, and synthesis.

Sarcopenia in critically ill patients

Sarcopenia occurring as a primary consequence of aging and secondary due to certain medical problems including chronic disease, malnutrition and inactivity is a progressive generalized loss of skeletal muscle mass, strength and function. The prevalence of sarcopenia increases with aging (approximately 5-13 % in the sixth and seventh decades). However, data showing the prevalence and clinical outcomes of sarcopenia in intensive care units (ICUs) are limited. A similar condition to sarcopenia in the ICU, called ICU-acquired weakness (ICU-AW), has been reported more frequently. Here, we aim to examine the importance of sarcopenia, especially ICU-AW, in ICU patients via related articles in Medline.

Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews

BACKGROUND

Physical rehabilitation interventions aim to ameliorate the effects of critical illness-associated muscle dysfunction in survivors. We conducted an overview of systematic reviews (SR) evaluating the effect of these interventions across the continuum of recovery.

METHODS

Six electronic databases (Cochrane Library, CENTRAL, DARE, Medline, Embase, and Cinahl) were searched. Two review authors independently screened articles for eligibility and conducted data extraction and quality appraisal. Reporting quality was assessed and the Grading of Recommendations Assessment, Development and Evaluation approach applied to summarise overall quality of evidence.

RESULTS

Five eligible SR were included in this overview, of which three included meta-analyses. Reporting quality of the reviews was judged as medium to high. Two reviews reported moderate-to-high quality evidence of the beneficial effects of physical therapy commencing during intensive care unit (ICU) admission in improving critical illness polyneuropathy/myopathy, quality of life, mortality and healthcare utilisation. These interventions included early mobilisation, cycle ergometry and electrical muscle stimulation. Two reviews reported very low to low quality evidence of the beneficial effects of electrical muscle stimulation delivered in the ICU for improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy. One review reported that due to a lack of good quality randomised controlled trials and inconsistency in measuring outcomes, there was insufficient evidence to support beneficial effects from physical rehabilitation delivered post-ICU discharge.

CONCLUSIONS

Patients derive short-term benefits from physical rehabilitation delivered during ICU admission. Further robust trials of electrical muscle stimulation in the ICU and rehabilitation delivered following ICU discharge are needed to determine the long-term impact on patient care. This overview provides recommendations for design of future interventional trials and SR.

TRIAL REGISTRATION NUMBER

CRD42015001068.

Safety and feasibility of a neuromuscular electrical stimulation chronaxie-based protocol in critical ill patients: A prospective observational study

PURPOSE

The aim of this study was to evaluate the safety and feasibility of a neuromuscular electrical stimulation (NMES) protocol based on neuromuscular excitability and applied in numerous muscle groups of critical ill patients.

MATERIALS AND METHODS

We performed a prospective observational study using an NMES applied daily and bilaterally into 5 muscle groups in lower limbs for 3 consecutive days. The characteristics of NMES were 90 contractions per muscle, pulse width equal to chronaxie, and a pulse frequency of 100 Hz. We assessed safety with central venous oxygen saturation, serum lactate, and creatine phosphokinase measurements. To evaluate feasibility, we recorded the time spent for the entire NMES protocol and the number of NMES sessions completed.

RESULTS

Eleven male patients finished the study. There were no significant changes observed in creatine phosphokinase from baseline up to 96 hours: 470(±270) IU/L and 455(±240) IU/L (P>.99). Central venous oxygen saturation and serum lactate had the same pattern with no significant variations (P=.23 and P=.8, respectively). The time spent during the whole procedure and the number of complete NMES sessions performed were 107±24 minutes and 84 sessions (85%), respectively.

CONCLUSIONS

We demonstrated that NMES chronaxie-based protocol is safe and feasible.

Early Mobilization and Rehabilitation of Patients Who Are Critically Ill

Neuromuscular disorders are increasingly recognized as a cause of both short- and long-term physical morbidity in survivors of critical illness. This recognition has given rise to research aimed at better understanding the risk factors and mechanisms associated with neuromuscular dysfunction and physical impairment associated with critical illness, as well as possible interventions to prevent or treat these issues. Among potential risk factors, bed rest is an important modifiable risk factor. Early mobilization and rehabilitation of patients who are critically ill may help prevent or mitigate the sequelae of bed rest and improve patient outcomes. Research studies and quality improvement projects have demonstrated that early mobilization and rehabilitation are safe and feasible in patients who are critically ill, with potential benefits including improved physical functioning and decreased duration of mechanical ventilation, intensive care, and hospital stay. Despite these findings, early mobilization and rehabilitation are still uncommon in routine clinical practice, with many perceived barriers. This review summarizes potential risk factors for neuromuscular dysfunction and physical impairment associated with critical illness, highlights the potential role of early mobilization and rehabilitation in improving patient outcomes, and discusses some of the commonly perceived barriers to early mobilization and strategies for overcoming them.

Efficacy of neuromuscular electrical stimulation in patients with COPD followed in intensive care unit

INTRODUCTION

Serious problems on muscle strength and functional status can be seen in bedridden-patients with chronic obstructive pulmonary diseases (COPD) receiving mechanical ventilation. We aimed to investigate the impact of active extremity mobilization and neuromuscular electrical stimulation (NMES) on weaning processes, discharge from hospital and inflammatory mediators in COPD patients receiving mechanical ventilation.

METHODS

Thirty conscious COPD patients (F/M:15/15) hospitalized in the intensive care unit (ICU) with diagnosis of respiratory failure were enrolled to this study. Patients were randomized into three groups, including 10 patients for each. Active extremity-exercise training and NMES were applied to Group-1, only NMES was applied to Group-2 and active extremity exercise training was applied to Group-3. Muscle strengths, mobilization duration and weaning situation were evaluated. Serum cytokine levels were evaluated.

RESULTS

Lower extremity muscle-strength was significantly improved in Group-1 (from 3.00 to 5.00, P = 0.014) and 2 (from 4.00 to 5.00, P = 0.046). Upper extremity muscle strength was also significantly improved in all three groups (from 4.00 to 5.00 for all groups, P = 0.038, P = 0.046 and P = 0.034, respectively). Duration of mobilization and discharge from the ICU were similar among groups. There was a significant decrease in serum interleukin (IL)-6 level in Group-1 and in serum IL-8 level in Group-1 and Group-2 after rehabilitation.

CONCLUSION

This study indicates that pulmonary rehabilitation can prevent loss of muscle strength in ICU. Nevertheless, we consider that further studies with larger populations are needed to examine the impact of NMES and/or active and passive muscle training in bedridden ICU patients who are mechanically ventilated.

Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations

OBJECTIVE

To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units.

METHODS

We used the EBRO method, as recommended by the 'Dutch Evidence Based Guideline Development Platform' to develop an 'evidence statement for physiotherapy in the intensive care unit'. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts.

RESULTS

Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment.

CONCLUSIONS

These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.

Physical rehabilitation interventions for adult patients with critical illness across the continuum of recovery: an overview of systematic reviews protocol

BACKGROUND

Patients admitted to the intensive care unit with critical illness often experience significant physical impairments, which typically persist for many years following resolution of the original illness. Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit, following discharge to the ward and beyond hospital discharge. Multiple systematic reviews have been published appraising the expanding evidence investigating these physical rehabilitation interventions, although there appears to be variability in review methodology and quality. We aim to conduct an overview of existing systematic reviews of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery.

METHODS/DESIGN

This protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will search the Cochrane Systematic Review Database, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, MEDLINE, Excerpta Medica Database and Cumulative Index to Nursing and Allied Health Literature databases. We will include systematic reviews of randomised controlled trials of adult patients, admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery. Data extraction will include systematic review aims and rationale, study types, populations, interventions, comparators, outcomes and quality appraisal method. Primary outcomes of interest will focus on findings reflecting recovery of physical function. Quality of reporting and methodological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Reviews tool.

DISCUSSION

We anticipate the findings from this novel overview of systematic reviews will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015001068.

A Novel Noninvasive Method for Measuring Fatigability of the Quadriceps Muscle in Noncooperating Healthy Subjects

Background. Critical illness is associated with muscle weakness leading to long-term functional limitations. Objectives. To assess the reliability of a novel method for evaluating fatigability of the quadriceps muscle in noncooperating healthy subjects. Methods. On two occasions, separated by seven days, nonvoluntary isometric contractions (twitch and tetanic) of the quadriceps femoris muscle evoked by transcutaneous electrical muscle stimulation were recorded in twelve healthy adults. For tetanic contractions, the Fatigue Index (ratio of peak torque values) and the slope of the regression line of peak torque values were primary outcome measures. For twitch contractions, maximum peak torque and rise time were calculated. Relative (intraclass correlation, ICC_3.1) and absolute (standard error of measurement, SEM) reliability were assessed and minimum detectable change was calculated using a 95% confidence interval (MDC_95%). Results. The Fatigue Index (ICC_3.1, 0.84; MDC_95%, 0.12) and the slope of the regression line (ICC_3.1, 0.99; MDC_95%, 0.03) showed substantial relative and absolute reliability during the first 15 and 30 contractions, respectively. Conclusion. This method for assessing fatigability of the quadriceps muscle produces reliable results in healthy subjects and may provide valuable data on quantitative changes in muscle working capacity and treatment effects in patients who are incapable of producing voluntary muscle contractions.

A conceptual framework: the early and late phases of skeletal muscle dysfunction in the acute respiratory distress syndrome

Patients with acute respiratory distress syndrome (ARDS) often develop severe diaphragmatic and limb skeletal muscle dysfunction. Impaired muscle function in ARDS is associated with increased mortality, increased duration of mechanical ventilation, and functional disability in survivors. In this review, we propose that muscle dysfunction in ARDS can be categorized into an early and a late phase. These early and late phases are based on the timing in relationship to lung injury and the underlying mechanisms. The early phase occurs temporally with the onset of lung injury, is driven by inflammation and disuse, and is marked predominantly by muscle atrophy from increased protein degradation. The ubiquitin-proteasome, autophagy, and calpain-caspase pathways have all been implicated in early-phase muscle dysfunction. Late-phase muscle weakness persists in many patients despite resolution of lung injury and cessation of ongoing acute inflammation-driven muscle atrophy. The clinical characteristics and mechanisms underlying late-phase muscle dysfunction do not involve the massive protein degradation and atrophy of the early phase and may reflect a failure of the musculoskeletal system to regain homeostatic balance. Owing to these underlying mechanistic differences, therapeutic interventions for treating muscle dysfunction in ARDS may differ during the early and late phases. Here, we review clinical and translational investigations of muscle dysfunction in ARDS, placing them in the conceptual framework of the early and late phases. We hypothesize that this conceptual model will aid in the design of future mechanistic and clinical investigations of the skeletal muscle system in ARDS and other critical illnesses.

Effect of Early Rehabilitation during Intensive Care Unit Stay on Functional Status: Systematic Review and Meta-Analysis

Background and Aim

Critically ill survivors may have functional impairments even five years after hospital discharge. To date there are four systematic reviews suggesting a beneficial impact for mobilisation in mechanically ventilated and intensive care unit (ICU) patients, however there is limited information about the influence of timing, frequency and duration of sessions. Earlier mobilisation during ICU stay may lead to greater benefits. This study aims to determine the effect of early rehabilitation for functional status in ICU/high-dependency unit (HDU) patients.

Design

Systematic review and meta-analysis. MEDLINE, EMBASE, CINALH, PEDro, Cochrane Library, AMED, ISI web of science, Scielo, LILACS and several clinical trial registries were searched for randomised and non-randomised clinical trials of rehabilitation compared to usual care in adult patients admitted to an ICU/HDU. Results were screened by two independent reviewers. Primary outcome was functional status. Secondary outcomes were walking ability, muscle strength, quality of life, and healthcare utilisation. Data extraction and methodological quality assessment using the PEDro scale was performed by primary reviewer and checked by two other reviewers. The authors of relevant studies were contacted to obtain missing data.

Results

5733 records were screened. Seven articles were included in the narrative synthesis and six in the meta-analysis. Early rehabilitation had no significant effect on functional status, muscle strength, quality of life, or healthcare utilisation. However, early rehabilitation led to significantly more patients walking without assistance at hospital discharge (risk ratio 1.42; 95% CI 1.17-1.72). There was a non-significant effect favouring intervention for walking distance and incidence of ICU-acquired weakness.

Conclusions

Early rehabilitation during ICU stay was not associated with improvements in functional status, muscle strength, quality of life or healthcare utilisation outcomes, although it seems to improve walking ability compared to usual care. Results from ongoing studies may provide more data on the potential benefits of early rehabilitation in critically ill patients.

Interobserver Reliability of Quantitative Muscle Sonographic Analysis in the Critically Ill Population

OBJECTIVES

There is growing interest in the use of quantitative high-resolution neuromuscular sonography to evaluate skeletal muscles in patients with critical illness. There is currently considerable methodological variability in the measurement technique of quantitative muscle analysis. The reliability of muscle parameters using different measurement techniques and assessor expertise levels has not been examined in patients with critical illness. The primary objective of this study was to determine the interobserver reliability of quantitative sonographic measurement analyses (thickness and echogenicity) between assessors of different expertise levels and using different techniques for selecting the region of interest.

METHODS

We conducted a cross-sectional observational study in neurocritical care and mixed surgical-medical intensive care units from 2 tertiary referral hospitals.

RESULTS

Twenty diaphragm and 20 quadriceps images were evaluated. Images were obtained by using standardized imaging acquisition techniques. Quantitative sonographic measurements included muscle thickness and echogenicity analysis (either by the trace or square technique). All images were analyzed twice independently by 4 assessors of differing expertise levels. Excellent interobserver reliability was obtained for all measurement techniques regardless of expertise level (intraclass correlation coefficient, >0.75 for all comparisons). There was less variability between assessors for echogenicity values when the square technique was used for the quadriceps muscle and the trace technique for the diaphragm.

CONCLUSIONS

Excellent interobserver reliability exists regardless of expertise level for quantitative analysis of muscle parameters on sonography in the critically ill population. On the basis of these findings, it is recommended that echogenicity analysis be performed using the square technique for the quadriceps and the trace technique for the diaphragm.

Exercise rehabilitation following intensive care unit discharge for recovery from critical illness

BACKGROUND

Skeletal muscle wasting and weakness are significant complications of critical illness, associated with degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and can markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients after critical illness. Exercise-based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However, its effectiveness when initiated after ICU discharge has yet to be established.

OBJECTIVES

To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, for functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated longer than 24 hours.

SEARCH METHODS

We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid SP MEDLINE, Ovid SP EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host to 15 May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015 and will deal with the three studies of interest when we update the review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs and controlled clinical trials (CCTs) that compared an exercise intervention initiated after ICU discharge versus any other intervention or a control or 'usual care' programme in adult (≥ 18 years) survivors of critical illness.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by the Cochrane Collaboration.

MAIN RESULTS

We included six trials (483 adult ICU participants). Exercise-based interventions were delivered on the ward in two studies; both on the ward and in the community in one study; and in the community in three studies. The duration of the intervention varied according to length of hospital stay following ICU discharge (up to a fixed duration of 12 weeks).Risk of bias was variable for all domains across all trials. High risk of bias was evident in all studies for performance bias, although blinding of participants and personnel in therapeutic rehabilitation trials can be pragmatically challenging. For other domains, at least half of the studies were at low risk of bias. One study was at high risk of selection bias, attrition bias and other sources of bias. Risk of bias was unclear for the remaining studies across domains. We decided not to undertake a meta-analysis because of variation in study design, types of interventions and outcome measurements. We present a narrative description of individual studies for each outcome.All six studies assessed functional exercise capacity, although we noted wide variability in the nature of interventions, outcome measures and associated metrics and data reporting. Overall quality of the evidence was very low. Individually, three studies reported positive results in favour of the intervention. One study found a small short-term benefit in anaerobic threshold (mean difference (MD) 1.8 mL O2/kg/min, 95% confidence interval (CI) 0.4 to 3.2; P value = 0.02). In a second study, both incremental (MD 4.7, 95% CI 1.69 to 7.75 watts; P value = 0.003) and endurance (MD 4.12, 95% CI 0.68 to 7.56 minutes; P value = 0.021) exercise testing results were improved with intervention. Finally self reported physical function increased significantly following use of a rehabilitation manual (P value = 0.006). Remaining studies found no effect of the intervention.Similar variability was evident with regard to findings for the primary outcome of health-related quality of life. Only two studies evaluated this outcome. Individually, neither study reported differences between intervention and control groups for health-related quality of life due to the intervention. Overall quality of the evidence was very low.Four studies reported rates of withdrawal, which ranged from 0% to 26.5% in control groups, and from 8.2% to 27.6% in intervention groups. The quality of evidence for the effect of the intervention on withdrawal was low. Very low-quality evidence showed rates of adherence with the intervention. Mortality ranging from 0% to 18.8% was reported by all studies. The quality of evidence for the effect of the intervention on mortality was low. Loss to follow-up, as reported in all studies, ranged from 0% to 14% in control groups, and from 0% to 12.5% in intervention groups, with low quality of evidence. Only one non-mortality adverse event was reported across all participants in all studies (a minor musculoskeletal injury), and the quality of the evidence was low.

AUTHORS' CONCLUSIONS

At this time, we are unable to determine an overall effect on functional exercise capacity, or on health-related quality of life, of an exercise-based intervention initiated after ICU discharge for survivors of critical illness. Meta-analysis of findings was not appropriate because the number of studies and the quantity of data were insufficient. Individual study findings were inconsistent. Some studies reported a beneficial effect of the intervention on functional exercise capacity, and others did not. No effect on health-related quality of life was reported. Methodological rigour was lacking across several domains, influencing the quality of the evidence. Wide variability was noted in the characteristics of interventions, outcome measures and associated metrics and data reporting.If further trials are identified, we may be able to determine the effects of exercise-based intervention following ICU discharge on functional exercise capacity and health-related quality of life among survivors of critical illness.

Ultrasound for the assessment of peripheral skeletal muscle architecture in critical illness: a systematic review

OBJECTIVES

To critically evaluate and summarize identified evidence for the use of ultrasound to measure peripheral skeletal muscle architecture during critical illness.

DATA SOURCES

Seven electronic databases (Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Physiotherapy Evidence Database, Scopus, Excerpta Medica Database, and Web of Science [including Science Citations and Conference Proceedings]) and personal libraries were searched for relevant articles. Cross-referencing further identified references.

STUDY SELECTION

Quantitative study designs excluding abstracts, published in English, including adult critically ill patients in the ICU, evaluating peripheral skeletal muscle architecture during critical illness with ultrasound were included. Studies using ultrasonographic muscle data as outcome measures in interventional trials were excluded.

DATA EXTRACTION

Performed by one reviewer using a standardized data extraction form and cross-checked by a second reviewer. Quality appraisal was undertaken by two independent reviewers-studies were classified, graded, and appraised according to standardized algorithms and checklists. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to.

DATA SYNTHESIS

Seven studies with independent patient cohorts totaling 300 participants were included. One study adopted a case-control design, and the remainder were case series. Ultrasound data demonstrated deficits in a variety of peripheral skeletal muscle architecture variables across a range of muscle groups associated with critical illness. Ultrasound offered more accurate data compared to limb circumference measurement and has excellent reported reliability, but underestimated data acquired via more invasive muscle biopsy.

CONCLUSION

Ultrasound provides clinical utility for assessing the trajectory of change in peripheral skeletal muscle architecture during critical illness, supplementing more detailed characterization, albeit rarely used, from muscle biopsy analysis. Adoption of standardized operating protocols for measurement will facilitate future meta-analysis of data.

Early physical rehabilitation in intensive care patients with sepsis syndromes: a pilot randomised controlled trial

RATIONALE

Survivors of sepsis syndromes have poor outcomes for physical and cognitive function. No investigations of early physical rehabilitation in the intensive care unit have specifically targeted patients with sepsis syndromes.

OBJECTIVE

To determine whether early physical rehabilitation improves physical function and associated outcomes in patients with sepsis syndromes.

METHODS

Fifty critically ill adults admitted to a general intensive care unit with sepsis syndromes were recruited into a prospective double-blinded randomised controlled trial investigating early physical rehabilitation.

MEASUREMENTS

Primary outcomes of physical function (acute care index of function) and self-reported health-related quality of life were recorded at ICU discharge and 6 months post-hospital discharge, respectively. Secondary measures included inflammatory biomarkers; Interleukin-6, Interleukin-10 and tumour necrosis factor-α, blood lactate, fat-free muscle mass, exercise capacity, muscle strength and anxiety.

MAIN RESULTS

A significant increase in patient self-reported physical function (81.8 ± 22.2 vs. 60.0 ± 29.4), p = 0.04) and physical role (61.4 ± 43.8 vs. 17.1 ± 34.4, p = 0.005) for the SF-36 at 6 months was found in the exercise group. Physical function scores were not significantly different between groups. Muscle strength scores were (51.9 ± 10.5 vs. 47.3 ± 13.6, p = 0.24) with the standard care mean Medical Research Council Muscle Score (MRC) <48/60. The mean change of Interleukin-10 increased and was significantly higher in the exercise group (1.8 pg/ml, 180 % vs. 0.9 pg/ml, 90 %, p = 0.04). There was no significant difference between groups for lactate, Interleukin-6, tumour necrosis factor-α, muscle strength, exercise capacity, fat-free mass or hospital anxiety.

CONCLUSION

Implementation of early physical rehabilitation can improve self-reported physical function and induce systemic anti-inflammatory effects.

Myopathic characteristics in septic mechanically ventilated patients

PURPOSE OF REVIEW

Survivors of a critical illness may experience poor physical function and quality of life as a result of reduced skeletal muscle mass and strength during their acute illness. Patients diagnosed with sepsis are particularly at risk, and mechanical ventilation may result in diaphragm dysfunction. Interest in the interaction of these conditions is both growing and important to understand for individualized patient care.

RECENT FINDINGS

This review describes developments in the presentation of both diaphragm and limb myopathy in critical illness, as measured from muscle biopsy and at the bedside with various imaging and strength-testing modalities. The influence of unloading of the diaphragm with mechanical ventilation and peripheral muscles with immobilization in septic patients has been recently questioned. Systemic inflammation appears to primarily accelerate and accentuate dysfunction, which may be remedied by early mobilization and augmented with developing muscle and/or nerve stimulation techniques.

SUMMARY

Many acute muscle changes in septic patients are likely to stem from pre-existing impairments, which should provide context for clinical evaluations of strength. During illness, sarcolemmal injury promotes a cascade of intra-cellular abnormalities. As unique characteristics of ICU-acquired weakness and differential effects on muscle groups are understood, early diagnosis and management should be facilitated.