Therapeutic Potential of Electromyostimulation (EMS) in Critically Ill Patients—A Systematic Review

Neuromuscular Electrical Stimulation Under Deep Sedation Reduces the Incidence of ICU-Acquired Weakness in Critically Ill Patients With COVID-19 With Acute Respiratory Distress Syndrome

BACKGROUND

The COVID-19 pandemic has led to an unprecedented increase in cases of acute respiratory distress syndrome (ARDS). In such cases, deep sedation using sedatives and muscle relaxants is commonly used to prevent patient self-inflicted lung injury during the early phase. However, such sedation limits the ability to perform early rehabilitation, leading to ICU-acquired muscle weakness (ICU-AW) and a worse prognosis.

SUBJECTS

This study aimed to clarify the preventive effect of neuromuscular electrical stimulation (NMES) during deep sedation on ICU-AW and physical function at discharge in critically ill patients with COVID-19 with ARDS.

METHODS

A retrospective, single-center study was conducted on patients admitted to the ICU or advanced critical care center with severe COVID-19 with ARDS between March 1, 2020, and March 31, 2022. Patients who were managed with the Richmond Agitation-Sedation Scale between -4 and -5 for at least three days were included. Patients in the NMES group received NMES within two days of deep sedation, whereas those in the non-NMES group did not. The primary endpoint was the incidence of ICU-AW at discharge from the ICU, and the secondary endpoints included physical activity levels, skeletal muscle mass index, time to active mobilization, and Barthel index (BI) at discharge. Statistical analyses included Pearson's chi-squared test, Fisher's exact test, and multiple logistic and linear regression analyses.

RESULTS

Of the 129 patients, 68 (54 males and 14 females) were included after applying the exclusion criteria, with 38 in the NMES group and 30 in the non-NMES group. The incidence of ICU-AW was significantly lower in the NMES group (28.95% vs. 56.67%, p = 0.0211). NMES implementation (OR: 0.20, p = 0.03), ventilator weaning (OR: 0.10, p = 0.01), and duration of deep sedation (OR: 0.81, p < 0.01) were significant predictors of ICU-AW. Higher ICU Mobility Scale scores and shorter time to active mobilization were associated with a higher BI at discharge.

CONCLUSIONS

Early rehabilitation using NMES during deep sedation may prevent ICU-AW in critically ill patients with COVID-19 with ARDS. NMES is associated with a reduced risk of ICU-AW and improved functional independence at discharge. This procedure can be safely performed in sedated patients and may help prevent ICU-AW, supporting early mobilization strategies in ARDS rehabilitation.

Optimal timing for early mobilization initiatives in intensive care unit patients: A systematic review and network meta-analysis

OBJECTIVES

Analyse the effect of varying start times for early exercise interventions on the prevention of intensive care unit-acquired weakness.

RESEARCH METHODOLOGY

We conducted a comprehensive search on PubMed, Cochrane Library, Web of Science, Embase, China Biology Medicine Disc, China National Knowledge Infrastructure, Wan Fang Database, and reference lists up to May 2023.

SETTING

We systematically searched the literature for all randomized controlled trials on the effect of early mobilization in patients with critical illness.

MAIN OUTCOME MEASURES

The primary outcome assessed was the incidence of intensive care unit-acquired weakness. The secondary outcomes included: the Medical Research Council Score, the Barthel Index, duration of mechanical ventilation, length of intensive care unit stay, total length of hospital stay, mortality and incidence of intensive care unit-related complications.

RESULTS

The results of meta-analysis showed that compared with routine care, less than 24 hours after admission (RR = 0.44, 95 %CI: 0.28-0.68), more than 24 hours (RR = 0.33, 95 %CI: 0.16-0.67), less than 72 hours after admission (RR = 0.33, 95 %CI: 0.20-0.52) may lead to a lower incidence of intensive care unit-acquired weakness. The results of under surface cumulative ranking showed that early mobilization within 72 hours may have the lowest incidence of intensive care unit-acquired weakness (SUCRA = 81.9 %).

CONCLUSIONS

The current empirical evidence from intensive care unit patients suggests that initiating mobilization protocols within 24-72 hours timeframe following admission to the intensive care unit could potentially be the most beneficial strategy to reduce the incidence of intensive care unit-acquired weakness and the related medical complications. Moreover, this strategy seems to significantly improve rehabilitation and treatment outcomes for these patients.

IMPLICATIONS FOR CLINICAL PRACTICE

According to this study, medical and nursing staff in the intensive care unit have the chance to identify the most suitable timing for the implementation of early rehabilitative measures for patients. This can potentially prevent intensive care unit-acquired weakness and enhance various clinical outcomes for patients.

Resistance training combined with β-hydroxy β-methylbutyrate for patients with critical illness: A four-arm, mixed-methods, feasibility randomised controlled trial

OBJECTIVES

This study aimed to assess the feasibility, safety, acceptability, and potential effectiveness of resistance training (RT) with or without β-Hydroxy β-Methylbutyrate (HMB) intervention program for ICU patients.

DESIGN

Open-label, parallel group, mixed method, randomized controlled trial.

SETTINGS

A tertiary general hospital in Fuzhou, China.

METHODS

Participants were randomly allocated to one of four groups. The RT group received supervised multilevel resistance training (RT) using elastic bands, administered by trained ICU nurses. The HMB group received an additional daily dose of 3.0 g HMB. The combination group underwent both interventions concurrently, while the control group received standard care. These interventions were implemented throughout the entire hospitalization period. Primary outcomes included feasibility indicators such as recruitment rate, enrollment rate, retention rate, and compliance rate. Secondary outcomes covered adverse events, acceptability (evaluated through questionnaires and qualitative interviews), and physical function. Quantitative analysis utilized a generalized estimation equation model, while qualitative analysis employed directed content analysis.

RESULTS

All feasibility indicators met predetermined criteria. Forty-eight patients were randomly assigned across four arms, achieving a 96% enrollment rate. Most patients adhered to the intervention until discharge, resulting in a 97.9% retention rate. Compliance rates for both RT and HMB interventions approached or exceeded 85%. No adverse events were reported. The intervention achieved 100% acceptability, with a prevailing expression of positive experiences and perception of appropriateness. The RT intervention shows potential improvement in physical function, while HMB does not.

CONCLUSIONS

Implementing nurse-led resistance training with elastic bands with or without HMB proved to be feasible and safe for ICU patients.

IMPLICATIONS FOR CLINICAL PRACTICE

A large-scale, multicenter clinical trials are imperative to definitively assess the impact of this intervention on functional outcomes in this population.

Characteristics of the Cerebrospinal Fluid in Septic Patients with Critical Illness Polyneuropathy - A Retrospective Cohort Study

Background

Critical illness polyneuropathy (CIP) is a complex disease commonly occurring in septic patients which indicates a worse prognosis. Herein, we investigated the characteristics of cerebrospinal fluid (CSF) in septic patients with CIP.

Methods

This retrospective study was conducted between Match 1, 2018, and July 1, 2022. Patients with sepsis who underwent a CSF examination and nerve electrophysiology were included. The levels of protein, glucose, lipopolysaccharide, white blood cell (WBC), interleukin (IL)-1, IL-6, IL-8, and tumor necrosis factor (TNF) α in CSF were measured. The fungi and bacteria in CSF were also assessed.

Results

Among the 175 septic patients, 116 (66.3%) patients were diagnosed with CIP. 28-day Mortality in CIP patients was higher than that in non-CIP patients (25.0% vs. 10.2%, P = 0.02) which was confirmed by survival analysis. The results of propensity score matching analysis (PSMA) indicated a significant difference in the level of protein, WBC, IL-1, IL-6, IL-8, and TNFα present in the CSF between CIP patients and non-CIP patients. The results of the receiver operating characteristic (ROC) analysis showed that IL-1, WBC, TNFα, and their combined indicator had a good diagnostic value with an AUC > 0.8.

Conclusion

The increase in the levels of WBC, IL-1, and TNFα in CSF might be an indicator of CIP in septic patients.

Case report of belt electrode-skeletal muscle electrical stimulation for acute heart failure with severe obesity: a novel therapeutic option for acute phase rehabilitation

Background

Belt electrode skeletal muscle electrical stimulation (B-SES) is an emerging therapy anticipated to yield more favorable outcomes than conventional neuromuscular electrical stimulation (NMES), owing to its larger stimulation area. However, information on its efficacy and safety in patients with heart failure remains limited.

Case presentation

A 43-year-old man with a body mass index of 41 kg/m2 was admitted to our hospital for acute heart failure due to dilated cardiomyopathy. The patient required prolonged catecholamine support owing to poor cardiac function, and heart transplantation was considered. We initiated a mobilization program, but the patient's mobility was highly limited due to severe obesity and symptomatic orthostatic hypotension. B-SES was introduced to accomplish weight loss and early ambulation. We applied an intensive monitoring program for safe use and modulated the intensity of B-SES according to physical function. During the B-SES program, the patient's body weight decreased from 89.6 kg to 78.6 kg. Sequential evaluations of body composition and skeletal muscle ultrasonography revealed improved muscle mass, quality, and physical function. Furthermore, we explored the workload of B-SES using expiratory gas analysis. No adverse events were observed during B-SES.

Discussion

We successfully used B-SES to improve muscle function and morbidity in the treatment of acute heart failure. B-SES could be an option for patients with heart failure who have limited mobility and obesity.

Effect of neuromuscular electrical stimulation in critically ill adults with mechanical ventilation: a systematic review and network meta-analysis

BACKGROUND

Neuromuscular electrical stimulation (NMES) is widely used as a rehabilitation methods to restore muscle mass and function in prolonged immobilization individuals. However, its effect in mechanically ventilated patients to improve clinical outcomes remains unclear.

METHODS

A comprehensive search was conducted using PubMed, Embase, Web of Science, PEDro, and the Cochrane Library from their inception until December 24th, 2023. The search targeted randomized controlled trials (RCTs) comparing NMES with physical therapy (PT) or usual ICU care (CG), for improving clinical outcomes in mechanically ventilated patients. We performed a network meta-analysis utilizing Stata version 14.0 and R 4.3.1.

RESULTS

We included 23 RCTs comprising 1312 mechanically ventilated adults. The treatments analyzed were NMES, PT, NMES combined with PT (NMES+PT), and CG. Network meta-analyses revealed that NMES or NMES+PT significantly improved extubation success rate compared to CG, with ORs of 1.85 (95% CI: 1.11, 3.08) and 5.89 (95% CI: 1.77, 19.65), respectively. Additionally, NMES exhibited a slight decrease in extubation success rate compared with NMES+PT, with OR of 0.31 (95% CI: 0.11, 0.93). Nevertheless, neither NMES nor NMES+PT showed any significant improvement in ICU length of stay (LOS), ventilation duration, or mortality when compared with PT or CG. NMES+PT emerged as the most effective strategy for all considered clinical outcomes according to the ranking probabilities. The evidence quality ranged from "low" to "very low" in this network meta-analysis.

CONCLUSIONS

NMES appears to be a straightforward and safe modality for critically ill, mechanically ventilated patients. When combined with PT, it significantly improved the extubation success rate against standard ICU care and NMES alone, and showed a better ranking over PT or NMES alone for clinical outcomes. Therefore, NMES combined with PT may be a superior rehabilitation strategy for this patient group.

The combined intervention of neuromuscular electrical stimulation and nutrition therapy: A scoping review

BACKGROUND & AIMS

Neuromuscular electrical stimulation (NMES) is a safe and appropriate complement to voluntary resistance training for muscle weakness. However, its feasibility and effectiveness in combination with nutritional therapy remains unclear. This scoping review aimed to summarize the evidence on combined interventions for individuals with or at risk of sarcopenia for guiding future relevant research.

METHODS

A systematic electronic search was conducted using the following databases and registry: MEDLINE, CINAHL, Web of Science, PEDro, and ClinicalTrials. gov. Two independent reviewers summarized the characteristics, effectiveness, and feasibility of the combined intervention and the risk of bias in the literature.

RESULTS

Nine RCTs and four non-RCTs involving 802 participants were eligible. A diverse group of participants were included: older adults with sarcopenic obesity, patients in intensive care, and patients with cancer. Evidence-based interventions combining NMES and nutritional therapy were tailored to each patient's underlying disease. Although most studies were of low to moderate quality, it can be suggested that combined interventions may be feasible and effective for increasing skeletal muscle mass.

CONCLUSION

This scoping review demonstrates the potential of combined interventions as a new sarcopenia treatment strategy and highlights the need to examine the effects in high-quality RCTs with larger sample sizes.

A single session of EMS training induces long-lasting changes in circulating muscle but not cardiovascular miRNA levels: a randomized crossover study

Electromyostimulation (EMS) is used to maintain or build skeletal muscle and to increase cardiopulmonary fitness. Only limited data on the molecular mechanisms induced by EMS are available and effects on circulating microRNAs (c-miRNAs) have not been reported. This study aimed to evaluate whether EMS induces long-term changes in muscle- and cardiovascular-specific c-miRNA levels. Twelve healthy participants (33.0 ± 12.0 yr, 7 women) performed a 20-min whole body EMS training and a time- and intensity-matched whole body circuit training (CT) in random order. Blood samples were drawn pre-/posttraining and at 1.5, 3, 24, 48, and 72 h to determine creatine kinase (CK) and miRNA-21-5p, -126-3p, -133a-3p, -146a-5p, -206-3p, -222-3p, and -499a-5p levels. Muscular exertion was determined using an isometric strength test, and muscle soreness/pain was assessed by questionnaire. EMS participants reported higher muscle soreness 48 and 72 h postexercise and mean CK levels after EMS increased compared with CT at 48 and 72 h (time × group P ≤ 0.01). The EMS session induced a significant elevation of myomiR-206 and -133a levels starting at 1.5 and 3 h after exercise. Both miRNAs remained elevated for 72 h with significant differences between 24 and 72 h (time × group P ≤ 0.0254). EMS did not induce changes in cardiovascular miRNAs and no elevation in any miRNA was detected following CT. Time-course analysis of muscle damage marker CK and c-miR-133a and -206 levels did not suggest a common scheme (P ≥ 0.277). We conclude that a single EMS session induces specific long-lasting changes of miR-206 and miR-133 involved in muscle proliferation and differentiation. A single EMS session does not affect primary cardiovascular miRNA-21-5p, -126-3p, -146a-5p, and -222-3p levels.NEW & NOTEWORTHY Our study describes the long-term effects of electromyostimulation (EMS) on circulating miRNA levels. The observed increase of functional myomiR-206 and -133a levels over 72 h suggests long-lasting effects on muscle proliferation and differentiation, whereas cardiovascular miRNAs appear unaffected. Our findings suggest that circulating miRNAs provide useful insight into muscle regeneration processes after EMS and may thus be used to optimize EMS training effects.

Safety and efficacy of electrical stimulation for lower-extremity muscle weakness in intensive care unit 2019 Novel Coronavirus patients: A phase I double-blinded randomized controlled trial

Background

Intensive care unit (ICU) prolonged immobilization may lead to lower-extremity muscle deconditioning among critically ill patients, particularly more accentuated in those with 2019 Novel Coronavirus (COVID-19) infection. Electrical stimulation (E-Stim) is known to improve musculoskeletal outcomes. This phase I double-blinded randomized controlled trial examined the safety and efficacy of lower-extremity E-Stim to prevent muscle deconditioning.

Methods

Critically ill COVID-19 patients admitted to the ICU were randomly assigned to control (CG) or intervention (IG) groups. Both groups received daily E-Stim (1 h) for up to 14 days on both gastrocnemius muscles (GNMs). The device was functional in the IG and non-functional in the CG. Primary outcomes included ankle strength (Ankle_s) measured by an ankle-dynamometer, and GNM endurance (GNM_e) in response to E-Stim assessed with surface electromyography (sEMG). Outcomes were measured at baseline, 3 and 9 days.

Results

Thirty-two (IG = 16, CG = 16) lower extremities in 16 patients were independently assessed. The mean time between ICU admission and E-Stim therapy delivery was 1.8 ± 1.9 days (p = 0.29). At 3 days, the IG showed an improvement compared to the CG with medium effect sizes for Ankle_s (p = 0.06, Cohen's d = 0.77) and GNM_e (p = 0.06, d = 0.69). At 9 days, the IG GNM_e was significantly higher than the CG (p = 0.04, d = 0.97) with a 6.3% improvement from baseline (p = 0.029). E-Stim did not alter vital signs (i.e., heart/respiratory rate, blood saturation of oxygen), showed no adverse events (i.e., pain, skin damage, discomfort), nor interfere with ICU standard of care procedures (i.e., mechanical ventilation, prone rotation).

Conclusion

This study supports the safety and efficacy of early E-Stim therapy to potentially prevent deterioration of lower-extremity muscle conditions in critically ill COVID-19 patients recently admitted to the ICU. If confirmed in a larger sample, E-Stim may be used as a practical adjunctive therapy.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT04685213].