Muscle atrophy in intensive care unit patients

Effect of Early Multiprofessional Mobilization on Quality Indicators of Intensive Care in a Less Economically Developed Country: An Action on "Rehabilitation 2030" in Brazil

OBJECTIVE

To investigate the effects of implementing early multiprofessional mobilization on quality indicators of intensive care in Brazil.

DESIGN

This is a retrospective cohort study.

SETTING

A Brazilian educational and research-intensive care unit (ICU).

PARTICIPANTS

A total of 1047 patients were hospitalized from May 2016 to April 2018.

INTERVENTIONS

Implementation of early multiprofessional mobilization using the MobilizAÇÃO Program (MAP).

MAIN OUTCOME MEASURES

Clinical, ventilation and safety quality indicators, and physical function before (preprogram period) and after (postprogram period) the MAP.

RESULTS

There was a reduction in sedation time (4 vs 1d), hospital stay (21 vs 14d) and ICU stay (14 vs 7d), mechanical ventilation (8 vs 4d), hospital death rate (46% vs 26%) (P<.001), and ICU readmission (21% vs 16%; P=.030) from pre to post MAP. Successful weaning (42% vs 55%) and discharge rate (50% vs 71%) (P<.001) increased after MAP. No differences were found to safety quality indicators between periods. After MAP, complex physical functions assessed using the Manchester Mobility Score (MMS) were more frequent. The in-bed intervention was a predictor for readmission (P=.009; R²=0.689) and death (P=.035; R²=0.217), while walking was a predictor for successful weaning (P=.030; R²=0.907) and discharge (P=.033; R²=0.373). The postprogram period was associated with the MMS at ICU discharge (P<.001; R²=0.40).

CONCLUSIONS

Early mobilization implementation through changes in low mobility culture and multiprofessional actions improved quality indicators, including clinical, ventilation, and physical functional quality, without compromising patient safety in the ICU.

Dysphagia as a Manifestation of Endocrine and Metabolic Disorders

Dysphagia is a common manifestation of endocrine and metabolic diseases. Swallowing is a complex neuromuscular process, with an interplay of sensory and motor function, that has voluntary and involuntary control. Disruptions in any of these processes can cause significant dysphagia. Endocrine disorders and metabolic derangements are systemic conditions that affect multiple organ systems. They contribute to the development of neuropathies, myopathies, and motility disorders that lead to swallowing difficulty. Malnutrition and critical illness can lead to deconditioning and atrophy which can cause dysphagia, which in turn can lead to further malnutrition and deconditioning.

Predictors of Functional Impairment in Severe COVID-19 Patients Two Months After Discharge

Background

The Post-COVID-19 Functional Status (PCFS) scale is a validated tool used to measure the functional status of patients discharged from the hospital.

Objectives

To describe the functional limitations of hospitalized COVID-19 patients at the time of discharge and two months afterward, and to identify risk factors associated with functional impairment.

Design

Retrospective study.

Methods

A total of 540 patients were included in this monocentric study. The functional status assessment using the PCFS scale and ventilatory needs were recorded at discharge and two months later. Univariate and multivariate analyses were performed in order to identify the risk factors of a high PCFS score.

Results

Two months after discharge, the PCFS grade was 0 in 60,6% of the survivors, 1 in 24.5%, 2 in 6.9%, 3 in 2.8%, and 4 in 5.3%. The identified risk factors of a high PCFS scale were: age, arterial hypertension, diabetes mellitus, immunosuppression, cardiovascular disease, high need for oxygen and high News2 score at admission, a high percentage of ground glass at chest CT scan performed at admission or during follow-up, elevated leukocytes, neutrophils, LDH, D-dimers, procalcitonin, and serum creatinine levels. During the hospital stay, treatment with steroids, tocilizumab, longer duration of hospitalization, ICU admission and prolonged stay, and the occurrence of thromboembolic or hemorrhagic events were also significantly associated with a higher PCFS. Multivariate analysis identified that only age and a high News2 score at admission were independent risk factors of a low PCFS score.

Conclusion

Multiple risk factors for a higher PCFS score were identified, but only age and a high News2 score at admission were found to be independent risk factors.

Biological sex divergence in transcriptomic profiles during the onset of hindlimb unloading-induced atrophy

Disuse-induced muscle atrophy is a common clinical problem observed mainly in older adults, intensive care units patients, or astronauts. Previous studies presented biological sex divergence in progression of disuse-induced atrophy along with differential changes in molecular mechanisms possibly underlying muscle atrophy. The aim of this study was to perform transcriptomic profiling of male and female mice during the onset and progression of unloading disuse-induced atrophy. Male and female mice underwent hindlimb unloading (HU) for 24, 48, 72, and 168 h (n = 8/group). Muscles were weighed for each cohort and gastrocnemius was used for RNA-sequencing analysis. Females exhibited muscle loss as early as 24 h of HU, whereas males after 168 h of HU. In males, pathways related to proteasome degradation were upregulated throughout 168 h of HU, whereas in females these pathways were upregulated up to 72 h of HU. Lcn2, a gene contributing to regulation of myogenesis, was upregulated by 6.46- to 19.86-fold across all time points in females only. A reverse expression of Fosb, a gene related to muscle degeneration, was observed between males (4.27-fold up) and females (4.57-fold down) at 24-h HU. Mitochondrial pathways related to tricarboxylic acid (TCA) cycle were highly downregulated at 168 h of HU in males, whereas in females this downregulation was less pronounced. Collagen-related pathways were consistently downregulated throughout 168 h of HU only in females, suggesting a potential biological sex-specific protective mechanism against disuse-induced fibrosis. In conclusion, females may have protection against HU-induced skeletal muscle mitochondrial degeneration and fibrosis through transcriptional mechanisms, although they may be more vulnerable to HU-induced muscle wasting compared with males.NEW & NOTEWORTHY Herein, we have assessed the transcriptomic response across biological sexes during the onset and progression of unloading disuse-induced atrophy in mice. We have demonstrated an inverse expression of Fosb between males and females, as well as differentially timed patterns of expressing atrophy-related pathways between sexes that are concomitant to the accelerated atrophy in females. We also identified in females signs of mechanisms to combat disuse-induced mitochondrial degeneration and fibrosis.

Soleus muscle contains a higher concentration of lipid metabolites than extensor digitorum longus in rats with lipopolysaccharide-induced acute muscle atrophy

BACKGROUND & AIMS

Muscle atrophy is one of the most important and frequent problems for critically ill patients. The purpose of this study was to evaluate the effect of lipid mediators on acute muscle atrophy. Skeletal muscle fiber-specific analysis of lipid mediators in endotoxemic rats was therefore performed.

METHODS

Male Wistar rats were intraperitoneally injected with lipopolysaccharide (LPS). Slow-twitch soleus muscle and fast-twitch extensor digitorum longus (EDL) muscle were harvested 0, 6, and 24 h after LPS injection. Lipid mediators were profiled using liquid chromatography-tandem mass spectrometry, and free fatty acid (FFA) concentrations were measured using gas chromatography-mass spectrometry. Muscles were weighed and their cross-sectional areas were evaluated. Expression levels of mRNAs encoding inflammatory cytokines, autophagy-related transcription factors, and members of the ubiquitin-proteasome system were measured using real-time PCR.

RESULTS

Before LPS injection, the concentrations of all FFAs, including arachidonic acid, eicosapentaenoic acid, and docosahexaenoic acid, and all measured lipid mediators were higher in soleus muscle than in EDL muscle, especially those of pro-inflammatory prostaglandin E2 (PGE2) and leukotriene B4. LPS injection, increased PGE2 and D2 and decreased FFAs in soleus muscle but did not change in EDL muscle. The concentrations of specialized pro-resolving mediators E-series hydroxy-eicosapentaenoic acid and D-series hydroxy-docosahexaenoic acid were higher in soleus muscle. Muscle cross-sectional area decreased and the expression level of atrogin-1 was upregulated in EDL muscle, but both were unchanged in soleus muscle. After LPS injection, a discrepancy involving an increased PGE2 concentration and decreased muscle atrophy was identified in this acute muscle atrophy model of critical illness.

CONCLUSION

Concentrations of FFAs and lipid mediators were higher in soleus muscle than in EDL muscle, and LPS injection rapidly increased concentrations of pro-inflammatory lipid mediators. However, muscle atrophy with upregulation of autophagy-related transcription factors was observed in EDL muscle but not in soleus muscle.

Critical illness myopathy and trajectory of recovery in acute kidney injury requiring continuous renal replacement therapy: a prospective observational trial protocol

INTRODUCTION

Acute kidney injury requiring renal replacement therapy (AKI-RRT) is common in the intensive care unit (ICU) and is associated with significant morbidity and mortality. Continuous RRT (CRRT) non-selectively removes large amounts of amino acids from plasma, lowering serum amino acid concentrations and potentially depleting total-body amino acid stores. Therefore, the morbidity and mortality associated with AKI-RRT may be partly mediated through accelerated skeletal muscle atrophy and resulting muscle weakness. However, the impact of AKI-RRT on skeletal muscle mass and function during and following critical illness remains unknown. We hypothesise that patients with AKI-RRT have higher degrees of acute muscle loss than patients without AKI-RRT and that AKI-RRT survivors are less likely to recover muscle mass and function when compared with other ICU survivors.

METHODS AND ANALYSIS

This protocol describes a prospective, multicentre, observational trial assessing skeletal muscle size, quality and function in ICU patients with AKI-RRT. We will perform musculoskeletal ultrasound to longitudinally evaluate rectus femoris size and quality at baseline (within 48 hours of CRRT initiation), day 3, day 7 or at ICU discharge, at hospital discharge, and 1-3 months postdischarge. Additional skeletal muscle and physical function tests will be performed at hospital discharge and postdischarge follow-up. We will analyse the effect of AKI-RRT by comparing the findings in enrolled subjects to historical controls of critically ill patients without AKI-RRT using multivariable modelling.

ETHICS AND DISSEMINATION

We anticipate our study will reveal that AKI-RRT is associated with greater degrees of muscle loss and dysfunction along with impaired postdischarge recovery of physical function. These findings could impact the in-hospital and postdischarge treatment plan for these patients to include focused attention on muscle strength and function. We intend to disseminate findings to participants, healthcare professionals, the public and other relevant groups via conference presentation and publication without any publication restrictions.

TRIAL REGISTRATION NUMBER

NCT05287204.

Endoplasmic reticulum stress promotes sepsis-induced muscle atrophy via activation of STAT3 and Smad3

Endoplasmic reticulum (ER) stress is involved in skeletal muscle atrophy in various conditions, but the role of ER stress in sepsis-induced muscle atrophy is not well understood. In this study, we conducted experiments in wild-type (WT) mice and C/EBP homologous protein knockout (CHOP KO) mice to explore the role and mechanism of ER stress in sepsis-induced muscle atrophy. Cecal ligation and puncture (CLP) was used to establish a mouse model of sepsis. In WT mice, the body weight, muscle mass, and cross-sectional area of muscle fibers in CLP group both decreased significantly compared with sham group, which revealed that sepsis-induced dramatic muscle atrophy. Additionally, sepsis activated the ubiquitin-proteasome system (UPS), accompanied by the activation of ER stress. In vitro, inhibition of ER stress suppressed the activity of E3 ubiquitin ligases and alleviated the myotube atrophy. In vivo, CHOP KO also reduced the expression of E3 ubiquitin ligases and UPS-mediated protein degradation, and significantly attenuated sepsis-induced muscle atrophy. Deletion of CHOP also decreased the phosphorylation of signal transducer and activator of transcription 3 (STAT3) and Smad3, and inhibition of STAT3 and Smad3 partly reduced proteolysis caused by ER stress in vitro. These findings confirm that ER stress activates UPS-mediated proteolysis and promotes sepsis-induced muscle atrophy, which is partly achieved by activating STAT3 and Smad3.

Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study

BACKGROUND

Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.

OBJECTIVES

To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

METHODS

Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

RESULTS

The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.

CONCLUSIONS

The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

Astragaloside IV alleviates sepsis-induced muscle atrophy by inhibiting the TGF-β1/Smad signaling pathway

BACKGROUND

Muscle atrophy occurs in patients with sepsis and increases mortality and disability. Remission of muscle atrophy may improve the quality of life in patients with sepsis. Astragaloside IV (ASIV) has been shown to have excellent anti-inflammatory and anti-fibrotic effects and to reduce organ damage caused by sepsis. However, the effect of ASIV on sepsis-induced muscle atrophy has not been reported. Therefore, this study explored the pharmacological effects and mechanisms of ASIV in sepsis-induced muscle atrophy.

METHODS

Cecal ligation and puncture (CLP) was used to establish a mouse model of sepsis and lipopolysaccharide (LPS)-stimulated C2C12 myotubes. After administration of ASIV, the body weight, tibialis anterior (TA) and gastrocnemius muscle weight and fiber cross-sectional area of the mice were measured. The diameter of myotubes was observed by immunofluorescence staining. ELISA was used to assess inflammatory factors in plasma and cell culture supernatants. RT-PCR and Western blotting were used to detect the expression of MuRF1, Atrogin-1 and TGF-β1/Smad signaling pathway components in TA and C2C12 myotubes.

RESULTS

Our study found that ASIV reduced serum inflammatory factors and improved survival in septic mice. ASIV alleviated muscle mass reduction, myofiber cross-sectional area reduction, and C2C12 myotube atrophy by inhibiting the expression of the E3 ubiquitin ligases MuRF1 and atrogin-1. In addition, we observed that ASIV inhibited TGF-β1/Smad signaling. Inhibition of the TGF-β1/Smad signaling pathway partly blocked the anti-muscle atrophy effect of ASIV.

CONCLUSION

ASIV can alleviate sepsis-induced muscle atrophy, which may be related to the inhibition of the TGF-β1/Smad signaling pathway.

The time course of disuse muscle atrophy of the lower limb in health and disease

Short, intermittent episodes of disuse muscle atrophy (DMA) may have negative impact on age related muscle loss. There is evidence of variability in rate of DMA between muscles and over the duration of immobilization. As yet, this is poorly characterized. This review aims to establish and compare the time-course of DMA in immobilized human lower limb muscles in both healthy and critically ill individuals, exploring evidence for an acute phase of DMA and differential rates of atrophy between and muscle groups. MEDLINE, Embase, CINHAL and CENTRAL databases were searched from inception to April 2021 for any study of human lower limb immobilization reporting muscle volume, cross-sectional area (CSA), architecture or lean leg mass over multiple post-immobilization timepoints. Risk of bias was assessed using ROBINS-I. Where possible meta-analysis was performed using a DerSimonian and Laird random effects model with effect sizes reported as mean differences (MD) with 95% confidence intervals (95% CI) at various time-points and a narrative review when meta-analysis was not possible. Twenty-nine studies were included, 12 in healthy volunteers (total n = 140), 18 in patients on an Intensive Therapy Unit (ITU) (total n = 516) and 3 in patients with ankle fracture (total n = 39). The majority of included studies are at moderate risk of bias. Rate of quadriceps atrophy over the first 14 days was significantly greater in the ITU patients (MD -1.01 95% CI -1.32, -0.69), than healthy cohorts (MD -0.12 95% CI -0.49, 0.24) (P < 0.001). Rates of atrophy appeared to vary between muscle groups (greatest in triceps surae (-11.2% day 28), followed by quadriceps (-9.2% day 28), then hamstrings (-6.5% day 28), then foot dorsiflexors (-3.2% day 28)). Rates of atrophy appear to decrease over time in healthy quadriceps (-6.5% day 14 vs. -9.1% day 28) and triceps surae (-7.8% day 14 vs. -11.2% day 28), and ITU quadriceps (-13.2% day 7 vs. -28.2% day 14). There appears to be variability in the rate of DMA between muscle groups, and more rapid atrophy during the earliest period of immobilization, indicating different mechanisms being dominant at different timepoints. Rates of atrophy are greater amongst critically unwell patients. Overall evidence is limited, and existing data has wide variability in the measures reported. Further work is required to fully characterize the time course of DMA in both health and disease.

Muscle size, strength, and physical function in response to augmented calorie delivery: A TARGET sub-study

PURPOSE

Augmented calories may attenuate muscle loss experienced in critical illness. This exploratory sub-study assessed the effect of augmented calorie delivery on muscle mass, strength, and function.

MATERIALS AND METHODS

Patients in The Augmented versus Routine approach to Giving Energy Trial (TARGET) randomised to 1.5 kcal/ml or 1.0 kcal/ml enteral formulae at a single-centre were included. Ultrasound-derived muscle layer thickness (MLT) at quadriceps, forearm and mid-upper arm, and handgrip strength, were measured weekly from baseline to hospital discharge, and 3- and 6-months. Physical function was assessed at 3- and 6-months using the 'get up and go' and 6-min walk tests. Data are mean ± SD.

RESULTS

Eighty patients were recruited (1.5 kcal: n = 38, 58 ± 14y, 60%M, APACHE II 20 ± 7; 1.0 kcal: n = 42, 54 ± 18y, 66%M, APACHE II 22 ± 10). The 1.5 kcal/ml group received more calories with no difference in quadriceps MLT at any timepoint including ICU discharge (primary outcome) (2.90 ± 1.27 vs 2.39 ± 1.06 cm; P = 0.141). Relationships were similar for all MLT measures, handgrip strength, and 6-min walk test. Patients in the 1.5 kcal/ml group had improved 'get up and go' test at 3-months (6.66 ± 1.33 vs. 9.11 ± 2.94 s; P = 0.014).

CONCLUSION

Augmented calorie delivery may not attenuate muscle loss or recovery of strength or function 6-months post-ICU, but this requires exploration in a larger trial.

The Role of Circadian Clock Genes in Critical Illness: The Potential Role of Translational Clock Gene Therapies for Targeting Inflammation, Mitochondrial Function, and Muscle Mass in Intensive Care

The Earth's 24-h planetary rotation, with predictable light and heat cycles, has driven profound evolutionary adaptation, with prominent impacts on physiological mechanisms important for surviving critical illness. Pathways of interest include inflammation, mitochondrial function, energy metabolism, hypoxic signaling, apoptosis, and defenses against reactive oxygen species. Regulation of these by the cellular circadian clock (BMAL-1 and its network) has an important influence on pulmonary inflammation; ventilator-associated lung injury; septic shock; brain injury, including vasospasm; and overall mortality in both animals and humans. Whether it is cytokines, the inflammasome, or mitochondrial biogenesis, circadian medicine represents exciting opportunities for translational therapy in intensive care, which is currently lacking. Circadian medicine also represents a link to metabolic determinants of outcome, such as diabetes and cardiovascular disease. More than ever, we are appreciating the problem of circadian desynchrony in intensive care. This review explores the rationale and evidence for the importance of the circadian clock in surviving critical illness.

A randomized controlled clinical trial of the effects of range of motion exercises and massage on muscle strength in critically ill patients

BACKGROUND

Atrophy and muscle weakness is a common problem in critically ill patients admitted to the intensive care unit (ICU). Muscle weakness in severe cases can lead to tetraplegia, reduced or lost tendon reflexes, delayed weaning from mechanical ventilation, physical disability, and increased mortality. The aim of this study was to compare the effects of range of motion exercises (ROM) and massage on muscle strength of the patients admitted to ICUs.

METHODS

This study was a single-blinded randomized controlled trial conducted in ICUs of Afzalipour hospital in Kerman, southeastern Iran. Ninety conscious ICU patients were randomly divided into three groups (massage, ROM exercises and control). The researcher/co-researcher massaged or did ROM exercises on the patients' extremities once a day for seven consecutive days. Using a hand-held dynamometer, the co-researcher, rated the muscle strength before, on the fourth and seventh days of intervention at 8 p.m.

RESULTS

The mean muscles strength of the right arm in the ROM exercise and massage groups increased by 0.63 kg, and 0.29 kg, respectively after the intervention compared with before the intervention. The muscle strength of the right arm in the control group reduced by 0.55 kg. The mean muscles strength of the left arm in the ROM exercise and massage groups increased by 0.61 kg and 0.28 kg after the intervention, respectively while it reduced by 0.56 kg in the control group. The mean muscles strength of the right leg in the ROM exercise and massage groups increased by 0.53 kg and 0.27 kg after the intervention compared with before the intervention while it reduced by 0.70 kg in the control group. The mean muscles strength of the left leg in the ROM exercise and massage groups increased by 0.54 kg and 0.26 kg after the intervention compared with before the intervention while it reduced by 0.71 kg in the control group.

CONCLUSION

The results of the present study showed that ROM exercises and massage were effective interventions in increasing muscle strength of the critically ill patients admitted to intensive care units.

The effect of passive mobilization associated with blood flow restriction and combined with electrical stimulation on cardiorespiratory safety, neuromuscular adaptations, physical function, and quality of life in comatose patients in an ICU: a randomized controlled clinical trial

Background

Intensive care unit-acquired atrophy and weakness are associated with high mortality, a reduction in physical function, and quality of life. Passive mobilization (PM) and neuromuscular electrical stimulation were applied in comatose patients; however, evidence is inconclusive regarding atrophy and weakness prevention. Blood flow restriction (BFR) associated with PM (BFRp) or with electrical stimulation (BFRpE) was able to reduce atrophy and increase muscle mass in spinal cord-injured patients, respectively. Bulky venous return occurs after releasing BFR, which can cause unknown repercussions on the cardiovascular system. Hence, the aim of this study was to investigate the effect of BFRp and BFRpE on cardiovascular safety and applicability, neuromuscular adaptations, physical function, and quality of life in comatose patients in intensive care units (ICUs).

Methods

Thirty-nine patients will be assessed at baseline (T0–18 h of coma) and randomly assigned to the PM (control group), BFRp, or BFRpE groups. The training protocol will be applied in both legs alternately, twice a day with a 4-h interval until coma awake, death, or ICU discharge. Cardiovascular safety and applicability will be evaluated at the first training session (T1). At T0 and 12 h after the last session (T2), muscle thickness and quality will be assessed. Global muscle strength and physical function will be assessed 12 h after T2 and ICU and hospital discharge for those who wake up from coma. Six and 12 months after hospital discharge, physical function and quality of life will be re-assessed.

Discussion

In view of applicability, the data will be used to inform the design and sample size of a prospective trial to clarify the effect of BFRpE on preventing muscle atrophy and weakness and to exert the greatest beneficial effects on physical function and quality of life compared to BFRp in comatose patients in the ICU.

Trial registration

Universal Trial Number (UTN) Registry UTN U1111-1241-4344. Retrospectively registered on 2 October 2019. Brazilian Clinical Trials Registry (ReBec) RBR-2qpyxf. Retrospectively registered on 21 January 2020, http://ensaiosclinicos.gov.br/rg/RBR-2qpyxf/

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05916-z.

L-carnitine: Searching for New Therapeutic Strategy for Sepsis Management

In this review, we discussed the biological targets of carnitine, its effects on immune function, and how L-carnitine supplementation may help critically ill patients. L-carnitine is a potent antioxidant. L-carnitine depletion has been observed in prolonged intensive care unit (ICU) stays, while L-carnitine supplementation has beneficial effects in health promotion and regulation of immunity. It is essential for the uptake of fatty acids into mitochondria. By inhibiting the ubiquitin-proteasome system, down-regulation of apelin receptor in cardiac tissue, and reducing β-oxidation of fatty acid, carnitine may decrease vasopressor requirement in septic shock and improve clinical outcomes of this group of patients. We also have an overview of animal and clinical studies that have been recruited for evaluating the beneficial effects of L-carnitine in the management of sepsis/ septic shock. Additional clinical data are required to evaluate the optimal daily dose and duration of L-carnitine supplementation.

Early movement restriction deteriorates motor function and soleus muscle physiology

Children with low physical activity and interactions with environment experience atypical sensorimotor development and maturation leading to anatomical and functional disorganization of the sensorimotor circuitry and also to enduring altered motor function. Previous data have shown that postnatal movement restriction in rats results in locomotor disturbances, functional disorganization and hyperexcitability of the hind limb representations in the somatosensory and motor cortices, without apparent brain damage. Due to the reciprocal interplay between the nervous system and muscle, it is difficult to determine whether muscle alteration is the cause or the result of the altered sensorimotor behavior (Canu et al., 2019). In the present paper, our objectives were to evaluate the impact of early movement restriction leading to sensorimotor restriction (SMR) during development on the postural soleus muscle and on sensorimotor performance in rats, and to determine whether changes were reversed when typical activity was resumed. Rats were submitted to SMR by hind limb immobilization for 16 h / day from birth to postnatal day 28 (PND28). In situ isometric contractile properties of soleus muscle, fiber cross sectional area (CSA) and myosin heavy chain content (MHC) were studied at PND28 and PND60. In addition, the motor function was evaluated weekly from PND28 to PND60. At PND28, SMR rats presented a severe atrophy of soleus muscle, a decrease in CSA and a force loss. The muscle maturation appeared delayed, with persistence of neonatal forms of MHC. Changes in kinetic properties were moderate or absent. The Hoffmann reflex provided evidence for spinal hyperreflexia and signs of spasticity. Most changes were reversed at PND60, except muscle atrophy. Functional motor tests that require a good limb coordination, i.e. rotarod and locomotion, showed an enduring alteration related to SMR, even after one month of 'typical' activity. On the other hand, paw withdrawal test and grip test were poorly affected by SMR whereas spontaneous locomotor activity increased over time. Our results support the idea that proprioceptive feedback is at least as important as the amount of motor activity to promote a typical development of motor function. A better knowledge of the interplay between hypoactivity, muscle properties and central motor commands may offer therapeutic perspectives for children suffering from neurodevelopmental disorders.

Protein and Energy Intake Assessment and Their Association With In-Hospital Mortality in Critically Ill COVID-19 Patients: A Prospective Cohort Study

Background and Aim: It is partially known that nutritional intake could alleviate proteolysis and course of disease severity in patients with COVID-19; however, not enough data are available in this regard. The present study aimed to assess protein and energy intake and their association with in-hospital mortality in critically ill COVID-19 patients.

Methods: A total of 126 patients with COVID-19, who were critically ill, ≥5 days and a subset of 111 patients in ICU ≥10 days completed the present prospective observational cohort study.

Results: Protein and energy intakes on Day 5 of ICU admission in survivors were 46 and 58% of target values, respectively. These values in non-survivors were 42 and 50% of target values, respectively (p < 0.05). In the sample ≥10 days, protein and energy intakes in survivors reached 64 and 87% of target values, respectively, without statistically significant differences with non-survivors. In the sample ≥5 days, Cox proportional hazard regression was adjusted for GLIM, APACHE II, comorbidity, and age; the results indicated that the patients with protein and energy intake lower than 0.59 g/kg/day and 14 kcal/kg/day, had ~2-fold mortality hazard (protein: HR, 2.38; 95% CI, 1.40–4.03; P = 0.001 and energy: HR, 2.23; 95% CI, 1.27–3.92; P = 0.005).

Conclusion: Actual protein and energy intakes in critically ill patients with COVID-19 are in suboptimal levels compared with goal recommendations in these patients. Moreover, higher amounts of protein and energy intakes in the early acute phase were significantly associated with better survival and lower risk of in-hospital mortality.

Physiotherapy elastic band disinfection by UV-C irradiation in an intensive care unit

BACKGROUND

The transmission of healthcare-associated pathogens is mainly related to the massive flow of patients with infections in hospitals, presenting surfaces as potential transmission sources of these microorganisms. The physiotherapist who works in the intensive care area has become a specialist in daily routine in critical care with ventilatory support and post-surgical recovery. Furthermore, for this, the instruments are used in the patient's hands and body. Chemicals such as chlorine derivatives, triclosan, chlorhexidine and, 70 % alcohol are currently used to decontaminate surfaces. This study evaluated ultraviolet C (UV-C) irradiation efficiency in the physiotherapy object's disinfection in daily use in the Hospital Intensive Care Unit (ICU).

METHODS

the microbiological quantification carried out using the elastic band during physiotherapy in a cross-sectional study with 21 patients. The methodology compared the cleaning protocol (70 % alcohol) with a new irradiation method in elastic band in the ICU.

RESULTS

The results showed microbial reductions in the elastic band using both 70 % alcohol and UV-C irradiation (254 nm), with 60 s of illumination, totaling a light dose of 0.78 J/cm²; however, the UV-C irradiation showed better results.

CONCLUSION

This study showed that disinfection by UV-C irradiation could be introduced in an intensive care hospital environment for physiotherapeutic conduct.

The need for exercise sciences and an integrated response to COVID-19: A position statement from the international HL-PIVOT network

COVID-19 is one of the biggest health crises that the world has seen. Whilst measures to abate transmission and infection are ongoing, there continues to be growing numbers of patients requiring chronic support, which is already putting a strain on health care systems around the world and which may do so for years to come. A legacy of COVID-19 will be a long-term requirement to support patients with dedicated rehabilitation and support services. With many clinical settings characterized by a lack of funding and resources, the need to provide these additional services could overwhelm clinical capacity. This position statement from the Healthy Living for Pandemic Event Protection (HL-PIVOT) Network provides a collaborative blueprint focused on leading research and developing clinical guidelines, bringing together professionals with expertise in clinical services and the exercise sciences to develop the evidence base needed to improve outcomes for patients infected by COVID-19.

Nox2 signaling and muscle fiber remodeling are attenuated by losartan administration during skeletal muscle unloading

Reduced mechanical loading results in atrophy of skeletal muscle fibers. Increased reactive oxygen species (ROS) are causal in sarcolemmal dislocation of nNOS and FoxO3a activation. The Nox2 isoform of NADPH oxidase and mitochondria release ROS during disuse in skeletal muscle. Activation of the angiotensin II type 1 receptor (AT1R) can elicit Nox2 complex formation. The AT1R blocker losartan was used to test the hypothesis that AT1R activation drives Nox2 assembly, nNOS dislocation, FoxO3a activation, and thus alterations in morphology in the unloaded rat soleus. Male Fischer 344 rats were divided into four groups: ambulatory control (CON), ambulatory + losartan (40 mg kg^-1  day^-1 ) (CONL), 7 days of tail-traction hindlimb unloading (HU), and HU + losartan (HUL). Losartan attenuated unloading-induced loss of muscle fiber cross-sectional area (CSA) and fiber-type shift. Losartan mitigated unloading-induced elevation of ROS levels and upregulation of Nox2. Furthermore, AT1R blockade abrogated nNOS dislocation away from the sarcolemma and elevation of nuclear FoxO3a. We conclude that AT1R blockade attenuates disuse remodeling by inhibiting Nox2, thereby lessening nNOS dislocation and activation of FoxO3a.

A atuação do terapeuta ocupacional em Unidade de Terapia Intensiva: uma revisão sistemática

Resumo Introdução A participação do terapeuta ocupacional (TO) em Unidades de Terapia Intensiva (UTI) ainda é discreta no Brasil, talvez, por isso, haja pouca discussão das intervenções e inserção do profissional nessa área. Objetivo Sintetizar as atuações do TO para restabelecimento da função em pacientes adultos internados na UTI mais frequentemente descritas na literatura especializada. Método Revisão Sistemática baseada na recomendação PRISMA. A busca dos estudos foi realizada nas plataformas Cochrane, PubMed, OTSeek e PEDro, utilizando os termos de busca “Occupational Therapy”, no título ou resumo, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, em outras partes do texto. Foram incluídos textos em língua inglesa e publicados nos últimos 20 anos. Excluiu-se textos que abordavam UTI pediátrica/neonatal, doenças psiquiátricas e artigos de revisão. Dois pesquisadores independentes selecionaram os artigos e a concordância foi submetida à análise Kappa. O nível de evidência e a qualidade metodológica dos estudos incluídos foram avaliados pela Escala PEDro e pela Ferramenta de Colaboração Cochrane, respectivamente. Resultados As principais intervenções foram relativas ao treino de Atividades de Vida Diária (AVDs) e tarefas relacionadas às Atividades Instrumentais de Vida Diária (AIVDs). Essas atribuições privativas da profissão ocorreram isoladamente ou com fisioterapeutas. As sessões, excluídos os critérios de contraindicação, aconteceram precocemente (24-48h). Conclusão Os achados evidenciam intervenções de mobilização precoce, seguidas por práticas de treino de AVDs/ AIVDs. Ademais, é notado que a atuação do terapeuta ocupacional na UTI está em elaboração. Estudos sobre outros efeitos da internação prolongada na UTI devem ser conduzidos. Registro PROSPERO: CRD42020214615.

Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis

Background

Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US.

Methods

We present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses.

Results

In adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (− 3.05 days; 95% CI − 5.03, − 1.07; p = 0.003) and ICU length of stay (LOS) (− 1.89 days; 95% CI − 3.33, − 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (− 3.98 days; 95% CI − 6.90, − 1.06; p = 0.008) and ICU LOS (− 2.14 days; 95% CI − 3.89, − 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US.

Conclusion

These analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems.

Study registration

PROSPERO CRD42019129311.

Cost-Effectiveness of Parenteral Nutrition Containing ω-3 Fatty Acids in Hospitalized Adult Patients From 5 European Countries and the US

Background

ω‐3 Fatty acid (FA)–containing parenteral nutrition (PN) is associated with improvements in patient outcomes and with reductions in hospital length of stay (HLOS) vs standard PN regimens (containing non–ω‐3 FA lipid emulsions). We present a cost‐effectiveness analysis of ω‐3 FA–containing PN vs standard PN in 5 European countries (France, Germany, Italy, Spain, UK) and the US.

Methods

This pharmacoeconomic model was based on estimates of ω‐3 efficacy reported in a recent meta‐analysis and data from country‐specific sources. It utilized a probabilistic discrete event simulation model to compare ω‐3 FA–containing PN with standard PN in a population of critically ill and general ward patients. The influence of model parameters was evaluated using probabilistic and deterministic sensitivity analyses.

Results

Overall costs were reduced with ω‐3 FA–containing PN in all 6 countries compared with standard PN, ranging from €1741 (±€1284) in Italy to €5576 (±€4193) in the US. Expenses for infections and HLOS were lower in all countries for ω‐3 FA–containing PN vs standard PN, with the largest cost differences for both in the US (infection: €825 ± €4001; HLOS: €4879 ± €1208) and the smallest savings in the UK for infections and in Spain for HLOS (€63 ± €426 and €1636 ± €372, respectively).

Conclusion

This cost‐effectiveness analysis in 6 countries demonstrates that the superior clinical efficacy of ω‐3 FA–containing PN translates into significant decreases in mean treatment cost, rendering it an attractive cost‐saving alternative to standard PN across different healthcare systems.

Current Concepts in Rehabilitation Protocols to Optimize Patient Function Following Musculoskeletal Trauma

Musculoskeletal (MSK) trauma is a major cause of disability and pain worldwide. Despite surgical advances following MSK injuries, poor functional outcomes following surgery remain a major public health concern. Traditional methods of rehabilitation involving bed rest and immobilization led to muscle weakness, joint stiffness, and an inability to return to previous levels of activity. Recent research has provided evidence that early rehabilitation with a multidisciplinary team can prevent these negative outcomes and improve functional outcomes following MSK trauma. In order to continue to optimize recovery, standardized rehabilitation protocols and technological advances are required.

Validation by CT scan of quadriceps muscle thickness measurement by ultrasound in acute kidney injury

BACKGROUND

Accelerated muscle wasting still represents a major issue in critically ill patients. However, a key problem in the intensive care unit is the lack of adequate tools for bedside evaluation of muscle mass. Moreover, when acute kidney injury (AKI) coexists, fluid overload and/or rapid fluid shifts due to renal replacement therapies that frequently occur and may interfere with muscle mass assessment. The purpose of this study is to validate muscle ultrasound (US) by a gold standard (muscle CT scan) for the assessment of quadriceps muscle thickness in critically ill patients with AKI.

METHODS

Quadriceps rectus femoris thickness and quadriceps vastus intermedius thickness of critically ill patients with AKI were blindly assessed at the same leg sites by both US and computed tomography (CT) scan. Using bivariate mixed-model linear regression analysis, we estimated, average difference in thickness between measurement sites, agreement (differential and proportional bias) of US compared to CT, and precision of the two methods, and eventually performed Bland-Altman analysis for repeated measurements on pooled results.

RESULTS

We analyzed 233 couples of measurements (30 patients). Average muscle thickness ranged between 1.0 and 1.6, depending on the measurement site. When comparing US to CT, both the observed differential bias (between + 0.04 and + 0.26 cm depending on the muscle site) and the proportional bias (between 82 and 98% of the reference values, depending on the muscle site) were not statistically significant. However, precision analysis showed that US scan tended to be slightly less precise in comparison to CT. Bland-Altman analysis on pooled results showed that the 95% limits of agreement between the US and CT were narrow, ranging from - 0.34 to + 0.36 cm.

CONCLUSION

In critically ill patients with AKI, quadriceps muscle thickness assessment based on US is unbiased, although it occurs with a minor loss of precision compared to CT.

"NO LOAD" resistance training increases functional capacity and muscle size in hospitalized female patients: A pilot study

The aim of the present study was to compare the effects of resistance training performed with no external load (NLRT) versus resistance training performed with elastic bands (RTEB) on muscle hypertrophy and functional performance in hospitalized patients. Twenty hospitalized females (age, 59.05±3.2 years; height 163.6±2.5 cm; body mass 70.2±3.6 kgs) were randomly assigned to RTEB or NLRT. Both groups trained three times a week for five weeks. RTEB was performed with elastic bands, while NLRT involved maximum voluntary contractions with no external loads. Biceps brachii, triceps brachii and pectoralis muscle thickness (MT) were measured by ultrasound. Functional performance was measured by the 30s elbow flexion test. MT significantly increased in all muscles tested for both groups, with no differences between groups. Changes ranged from 14 to 38%. Functional performance significantly improved by 42.7% for NLRT and 52.1% for RTEB, with no difference between them. The present results suggest that NLRT might be an efficient, feasible and low-cost strategy to promote morphological and functional benefits in the upper limb of hospitalized patients.

ULK2 is essential for degradation of ubiquitinated protein aggregates and homeostasis in skeletal muscle

Basal protein turnover, which largely relies on the degradation of ubiquitinated substrates, is instrumental for maintenance of muscle mass and function. However, the regulation of ubiquitinated protein degradation in healthy, nonatrophying skeletal muscle is still evolving, and potential tissue-specific modulators remain unknown. Using an unbiased expression analysis of 34 putative autophagy genes across mouse tissues, we identified unc-51 like autophagy activating kinase (Ulk)2, a homolog of the yeast autophagy related protein 1, as particularly enriched in skeletal muscle. Subsequent experiments revealed accumulations of insoluble ubiquitinated protein aggregates associated with the adaptors sequestosome 1 (SQSTM1, also known as p62) and next to breast cancer type 1 susceptibility protein gene 1 protein (NBR1) in adult muscles with ULK2 deficiency. ULK2 deficiency also led to impaired muscle force and caused myofiber atrophy and degeneration. These features were not observed in muscles with deficiency of the ULK2 paralog, ULK1. Furthermore, short-term ULK2 deficiency did not impair autophagy initiation, autophagosome to lysosome fusion, or protease activities of the lysosome and proteasome. Altogether, our results indicate that skeletal muscle ULK2 has a unique role in basal selective protein degradation by stimulating the recognition and proteolytic sequestration of insoluble ubiquitinated protein aggregates associated with p62 and NBR1. These findings have potential implications for conditions of poor protein homeostasis in muscles as observed in several myopathies and aging.-Fuqua, J. D., Mere, C. P., Kronemberger, A., Blomme, J., Bae, D., Turner, K. D., Harris, M. P., Scudese, E., Edwards, M., Ebert, S. M., de Sousa, L. G. O., Bodine, S. C., Yang, L., Adams, C. M., Lira, V. A. ULK2 is essential for degradation of ubiquitinated protein aggregates and homeostasis in skeletal muscle.

Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit

Objectives:

To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit.

Methods:

Participants were patients with first or recurrent stroke (n=60, age=49.02±6.36 years, body mass index=32.95±5.67 kg/m²) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out.

Results:

There were significant improvements in muscle strength of upper and lower extremities´ muscles after treatment (p<0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p<0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p<0.01).

Conclusion:

This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.

Impact of Intravenous Lipid Emulsions Containing Fish Oil on Clinical Outcomes in Critically Ill Surgical Patients: A Literature Review

A fish oil (FO)-containing intravenous lipid emulsion (ILE; FO ILE) has been approved for use in the United States; however, similar formulations have been used throughout Europe and China in intensive care units since the 1990s. This literature review evaluates the evidence regarding the effectiveness of FO ILE on clinical outcomes in the critically ill surgical patient population. The review of available evidence demonstrates that ILEs containing FO lower triglyceride concentrations, inflammatory markers, and liver function enzymes, and improve morbidity and mortality outcomes in critically ill surgical patients.

Implications of low muscle mass across the continuum of care: a narrative review

Abnormalities in body composition can occur at any body weight. Low muscle mass is a predictor of poor morbidity and mortality and occurs in several populations. This narrative review provides an overview of the importance of low muscle mass on health outcomes for patients in inpatient, outpatient and long-term care clinical settings. A one-year glimpse at publications that showcases the rapidly growing research of body composition in clinical settings is included. Low muscle mass is associated with outcomes such as higher surgical and post-operative complications, longer length of hospital stay, lower physical function, poorer quality of life and shorter survival. As such, the potential clinical benefits of preventing and reversing this condition are likely to impact patient outcomes and resource utilization/health care costs. Clinically viable tools to measure body composition are needed for routine screening and intervention. Future research studies should elucidate the effectiveness of multimodal interventions to counteract low muscle mass for optimal patient outcomes across the healthcare continuum. Key messages Low muscle mass is associated with several negative outcomes across the healthcare continuum. Techniques to identify and counteract low muscle mass in clinical settings are needed.

Addition of blood flow restriction to passive mobilization reduces the rate of muscle wasting in elderly patients in the intensive care unit: a within-patient randomized trial

OBJECTIVE:

To evaluate the addition of blood flow restriction to passive mobilization in patients in the intensive care unit.

DESIGN:

The study was a within-patient randomized trial.

SETTING:

Two intensive care units in Belém, from September to October 2017.

SUBJECTS:

In total, 34 coma patients admitted to the intensive care unit sector, and 20 patients fulfilled the study requirements.

INTERVENTIONS:

All participants received the passive mobilization protocol for lower limbs, and blood flow restriction was added only for one side in a concurrent fashion. Intervention lasted the entire patient's hospitalization time.

MAIN OUTCOME MEASUREMENT:

Thigh muscle thickness and circumference.

RESULTS:

In total, 34 subjects were enrolled in the study: 11 were excluded for exclusion criteria, 3 for death, and 20 completed the intervention (17 men and 3 women; mean age: 66 ± 4.3 years). Despite both groups presented atrophy, the atrophy rate was lower in blood flow restriction limb in relation to the control limb (-2.1 vs. -2.8 mm, respectively, in muscle thickness; P = 0.001). In addition, the blood flow restriction limb also had a smaller reduction in the thigh circumference than the control limb (-2.5 vs. -3.6 cm, respectively; P = 0.001).

CONCLUSION:

The use of blood flow restriction did not present adverse effects and seems to be a valid strategy to reduce the magnitude of the rate of muscle wasting that occurs in intensive care unit patients.

A Multidisciplinary Approach to Equipment Use in Pediatric Patient Mobilization

Research has shown that patients who are mechanically ventilated or immobile for greater than 7 days are at increased risk for deconditioning and muscle atrophy. Immobility impacts length of stay as well as patients' ability to return to their prior level of function. As part of the safe patient-handling initiative created at Michigan Medicine, a special team of nurses and therapists was assembled to adapt an adult mobility framework for the pediatric population. The pediatric mobility model determines each patient's specific mobility "phase" based on detailed criteria. Clinical staff can then implement strategies aimed at preventing deconditioning and hospital-acquired weakness. At C.S. Mott Children's Hospital, a multidisciplinary team is available to support this pediatric mobility model. Specific equipment utilized during the different phases of mobility has been reviewed and discussed in this article.

Instituting a Standardized Mobility Aid in the Cardiovascular Intensive Care Unit

The complexity of ambulation increases when patients are challenged with acute illness in the cardiovascular intensive care unit (CVICU). The difficulties in this setting entailed limited ancillary assistance, proper equipment, and complex medical devices. It was imperative that mobility was made a priority in the CVICU despite multiple barriers. To improve mobility functionality, mobility aids were obtained. To evaluate the effectiveness of the mobility aids, data were collected, including staff surveys, time studies, and chart audits. The outcomes from implementing the mobility aids revealed a reduction in the number of staff required to ambulate medically complex patients from an average of 2.3 to 1.9 staff members and in medically noncomplex patients remained unchanged from 1.4 to 1.6 staff members. Preparation time for ambulation was reduced from 12.8 to 8.3 minutes on average for medically noncomplex patients and from 14 to 9.7 minutes for the medically complex patients. Ambulation sessions for medically noncomplex patients increased on average from 1.5 to 2.8 sessions per day and for medically complex patients decreased from 1.2 to 0.5 sessions per day. Overall, clinically significant improvements were noted with both preparation time for ambulation and the number of mobility sessions that support the use of a standardized mobility aid.

Shoulder and arm muscle activity during elastic band exercises performed in a hospital bed

OBJECTIVE

Muscle atrophy is a common side-effect of bed rest during hospitalization. However, resistance training may minimize or even prevent these complications. Therefore, we evaluated the efficiency of four upper-body elastic resistance exercises that could be performed while lying or sitting in a hospital bed.

METHODS

Twenty-two healthy subjects performed three repetitions of each exercise in a supine and seated position with a perceived intensity of 3 (low) and 8 (high) on the Borg CR10 Scale. Surface electromyography was collected from 12 shoulder and arm muscles (e.g. trapezius, deltoideus, and biceps brachii), and normalized to a maximal voluntary isometric contraction (nEMG).

RESULTS

During all exercises performed at high intensity, moderate (>40%) to high (>60%) levels of nEMG were found for the majority of the analysed muscles, e.g. deltoideus (from 37% to 69%, median 57.5%), trapezius (from 43% to 66%, median 51%), and infraspinatus (from 54% to 66%, median 59%), with the exception of pectoralis major (from 29% to 47%, median 39.5%) and latissimus dorsi (from 15% to 22%, median 18.5%). No significant differences were found between the supine and seated positions for any of the exercises.

CONCLUSION

This study showed that high levels of shoulder and arm muscle activity can be achieved while lying or sitting in a hospital bed using appropriate exercises with elastic bands. The data presented here can be used by physiotherapists as a guideline for selecting suitable and effective strengthening exercises during in-hospital rehabilitation to counteract bed-rest related muscle atrophy in the upper body.

Serum miRNAs miR-23a, 206, and 499 as Potential Biomarkers for Skeletal Muscle Atrophy

Muscle biopsy has long been expected to be replaced by noninvasive biomarkers with diagnostic value and prognostic applications for muscle atrophy. Growing evidence suggests that circulating microRNAs (miRNAs) could act as biomarkers for numerous pathophysiological statuses. In the present study, our results showed that the serum levels of six muscle-specific miRNAs (miR-1/23a/133/206/208b/499) were all elevated in unloading induced mice. The medium levels of these six muscle-specific miRNAs were all elevated in starvation induced atrophic C2C12 myotubes. Moreover, the serum levels of miR-23a/206/499 were induced in participants after 45 days of head-down bed rest (HDBR). The levels of miR-23a/206/499 were positively correlated with the ratio of soleus volume loss in HDBR participants, indicating that they might represent the process of muscle loss. In conclusion, our results demonstrated that circulating miRNAs could serve as useful biochemical and molecular indicators for muscle atrophy diagnosis and disease progression.

Effects that passive cycling exercise have on muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients: a randomized clinical trial

Objective

To evaluate the effects that passive cycling exercise, in combination with conventional physical therapy, have on peripheral muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients admitted to the ICU of a tertiary care university hospital.

Methods

This was a randomized clinical trial involving 38 patients (≥ 18 years of age) on mechanical ventilation who were randomly divided into two groups: control (n = 16), receiving conventional physical therapy; and intervention (n = 22), receiving conventional physical therapy and engaging in passive cycling exercise five days per week. The mean age of the patients was 46.42 ± 16.25 years, and 23 were male. The outcomes studied were peripheral muscle strength, as measured by the Medical Research Council scale, duration of mechanical ventilation, and length of hospital stay.

Results

There was a significant increase in peripheral muscle strength (baseline vs. final) in both groups (control: 40.81 ± 7.68 vs. 45.00 ± 6.89; and intervention: 38.73 ± 11.11 vs. 47.18 ± 8.75; p < 0.001 for both). However, the range of increase in strength was higher in the intervention group than in the control group (8.45 ± 5.20 vs. 4.18 ± 2.63; p = 0.005). There were no significant differences between the groups in terms of duration of mechanical ventilation or length of hospital stay.

Conclusions

The results suggest that the performance of continuous passive mobilization on a cyclical basis helps to recover peripheral muscle strength in ICU patients. (ClinicalTrials.gov Identifier: NCT01769846 [http://www.clinicaltrials.gov/]).

Using the Hephaistos orthotic device to study countermeasure effectiveness of neuromuscular electrical stimulation and dietary lupin protein supplementation, a randomised controlled trial

Purpose

The present study investigated whether neuromuscular electrical stimulation for 20 min twice a day with an electrode placed over the soleus muscle and nutritional supplementation with 19 g of protein rich lupin seeds can reduce the loss in volume and strength of the human calf musculature during long term unloading by wearing an orthotic unloading device.

Methods

Thirteen healthy male subjects (age of 26.4 ± 3.7 years) wore a Hephaistos orthosis one leg for 60 days during all habitual activities. The leg side was randomly chosen for every subject. Six subjects only wore the orthosis as control group, and 7 subjects additionally received the countermeasure consisting of neuromuscular electrical stimulation of the soleus and lateral gastrocnemius muscles and lupin protein supplementation. Twenty-eight days before and on the penultimate day of the intervention cross-sectional images of the calf muscles were taken by magnetic resonance imaging (controls n = 5), and maximum voluntary torque (controls n = 6) of foot plantar flexion was estimated under isometric (extended knee, 90° knee flexion) and isokinetic conditions (extended knee), respectively.

Results

After 58 days of wearing the orthosis the percentage loss of volume in the entire triceps surae muscle of the control subjects (-11.9 ± 4.4%, mean ± standard deviation) was reduced by the countermeasure (-3.5 ± 7.2%, p = 0.032). Wearing the orthosis generally reduced plantar flexion torques values, however, only when testing isometric contraction at 90° knee ankle the countermeasure effected a significantly lower percentage decrease of torque (-9.7 ± 7.2%, mean ± SD) in comparison with controls (-22.3 ± 11.2%, p = 0.032).

Conclusion

Unloading of calf musculature by an orthotic device resulted in the expected loss of muscle volume and maximum of plantar flexion torque. Neuromuscular electrical muscle stimulation and lupin protein supplementation could significantly reduce the process of atrophy.

Trial registration

ClinicalTrials.gov, identifier NCT02698878

Acute intermittent hypoxia in rats activates muscle proteolytic pathways through a gluccorticoid-dependent mechanism

Although it is well known that chronic hypoxia induces muscle wasting, the effects of intermittent hypoxia on skeletal muscle protein metabolism remain unclear. We hypothesized that acute intermittent hypoxia (AIH), a challenge that activates the hypothalamic-pituitary-adrenal axis, would alter muscle protein homeostasis through a glucocorticoid-dependent mechanism. Three-week-old rats were submitted to adrenalectomy (ADX) and exposed to 8 h of AIH (6% O₂ for 40 s at 9-min intervals). Animals were euthanized, and the soleus and extensor digitorum longus (EDL) muscles were harvested and incubated in vitro for measurements of protein turnover. AIH increased plasma levels of corticosterone and induced insulin resistance as estimated by the insulin tolerance test and lower rates of muscle glucose oxidation and the HOMA index. In both soleus and EDL muscles, rates of overall proteolysis increased after AIH. This rise was accompanied by an increased proteolytic activities of the ubiquitin(Ub)-proteasome system (UPS) and lysosomal and Ca²⁺-dependent pathways. Furthermore, AIH increased Ub-protein conjugates and gene expression of atrogin-1 and MuRF-1, two key Ub-protein ligases involved in muscle atrophy. In parallel, AIH increased the mRNA expression of the autophagy-related genes LC3b and GABARAPl1. In vitro rates of protein synthesis in skeletal muscles did not differ between AIH and control rats. ADX completely blocked the insulin resistance in hypoxic rats and the AIH-induced activation of proteolytic pathways and atrogene expression in both soleus and EDL muscles. These results demonstrate that AIH induces insulin resistance in association with activation of the UPS, the autophagic-lysosomal process, and Ca²⁺-dependent proteolysis through a glucocorticoid-dependent mechanism.NEW & NOTEWORTHY Since hypoxia is a condition in which the body is deprived of adequate oxygen supply and muscle wasting is induced, the present work provides evidence linking hypoxia to proteolysis through a glucocorticoid-dependent mechanism. We show that the activation of proteolytic pathways, atrophy-related genes, and insulin resistance in rats exposed to acute intermittent hypoxia was abolished by surgical removal of adrenal gland. This finding will be helpful for understanding of the muscle wasting in hypoxemic conditions.

Effects of Early Bedside Cycle Exercise on Intracranial Pressure and Systemic Hemodynamics in Critically Ill Patients in a Neurointensive Care Unit

BACKGROUND

Physiotherapy is an important part of treatment after severe brain injuries and stroke, but its effect on intracranial and systemic hemodynamics is minimally investigated. Therefore, the aim of this study was to assess the effects of an early bedside cycle exercise on intracranial and systemic hemodynamics in critically ill patients when admitted to a neurointensive care unit (NICU).

METHODS

Twenty critically ill patients suffering from brain injuries or stroke were included in this study performed in the NICU at Sahlgrenska University Hospital. One early implemented exercise session was performed using a bedside cycle ergometer for 20 min. Intracranial and hemodynamic variables were measured two times before, three times during, and two times after the bedside cycling exercise. Analyzed variables were intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial blood pressure (MAP), heart rate (HR), peripheral oxygen saturation (SpO2), cardiac output (CO), stroke volume (SV), and stroke volume variation (SVV). The cycling intervention was conducted within 7 ± 5 days after admission to the NICU.

RESULTS

Cycle exercise increased MAP (p = 0.029) and SV (p = 0.003) significantly. After exercise CO, SV, MAP, and CPP decreased significantly, while no changes in HR, SVV, SpO2, or ICP were noted when compared to values obtained during exercise. There were no differences in data obtained before versus after exercise.

CONCLUSION

Early implemented exercise with a bedside cycle ergometer, for patients with severe brain injuries or stroke when admitted to a NICU, is considered to be a clinically safe procedure.

Regenerative and Rehabilitative Medicine: A Necessary Synergy for Functional Recovery from Volumetric Muscle Loss Injury

Volumetric muscle loss (VML) is a complex and heterogeneous problem due to significant traumatic or surgical loss of skeletal muscle tissue. The consequences of VML are substantial functional deficits in joint range of motion and skeletal muscle strength, resulting in life-long dysfunction and disability. Traditional physical medicine and rehabilitation paradigms do not address the magnitude of force loss due to VML and related musculoskeletal comorbidities. Recent advancements in regenerative medicine have set forth encouraging and emerging therapeutic options for VML injuries. There is significant potential that combined rehabilitative and regenerative therapies can restore limb and muscle function following VML injury in a synergistic manner. This review presents the current state of the VML field, spanning clinical and preclinical literature, with particular focus on rehabilitation and regenerative medicine in addition to their synergy. Moving forward, multidisciplinary collaboration between clinical and research fields is encouraged in order to continue to improve the treatment of VML injuries and specifically address the encompassing physiology, pathology, and specific needs of this patient population. This is a work of the US Government and is not subject to copyright protection in the USA. Foreign copyrights may apply. Published by S. Karger AG, Basel.

Determination of functional prognosis in hospitalized patients following an intensive care admission

AIM

To investigate the factors associated with the functional progress of hospitalized patients following an intensive care admission.

METHODS

Retrospective study including data from a cohort of 198 hospitalized patients following an intensive care admission and not requiring mechanical ventilation in a single tertiary referral hospital. A generalized linear model was used to identify the main effects of clinical and demographic variables on the outcomes of functionality (KATZ Index of Independence in Activities of Daily Living) and muscle strength (MRC Scale). The covariates identified as independent predictors were analysed using the receiver operating characteristic curves. The analysis differentiated the periods in the intensive care unit (ICU), in the Ward (WARD) and the total time of hospital stay (TOT).

RESULTS

Considering the functional outcome (ΔKATZ), the variables that significantly contributed to the model (P < 0.05) were the KATZ and MRC on admission, age, sepsis (no), and total length of stay (TLS). Regarding the muscle strength outcome model (ΔMRC), the predictors were MRC on admission, Simplified Acute Physiology Score III, previous stroke, TLS, and sex (female). The variable age (AUC = 0.664) discriminated the ΔKATZ_ICU. The variables age (AUC = 0.712), KATZ in ICU (AUC = 0.590) and on ward admission (AUC = 0.746), and MRC on ward admission (AUC = 0.721) were discriminative for ΔKATZ_WARD. For ΔKATZ_TOT the variables KATZ on ICU admission (AUC = 0.621) and TLS (AUC = 0.617) were discriminative. For ΔMRC_ICU the variables SAPSIII (AUC = 0.661) and MRC on ICU admission (AUC = 0.653) were discriminative. MRC on ICU (AUC = 0.681) and ward admission (AUC = 0.553) were discriminative for ΔMRC_WARD. TLS (AUC = 0.649) and MRC on ward admission (AUC = 0.696) discriminative for the ΔMRC_TOT.

CONCLUSION

Specific functional, clinical and demographical variables at ICU admission are associated with the functional prognosis during the hospitalization period.