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Tankisi H, Bostock H, Tan SV, Howells J, Ng K, Z'Graggen WJ. Muscle excitability testing. Clin Neurophysiol 2024; 164:1-18. [PMID: 38805900 DOI: 10.1016/j.clinph.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 05/30/2024]
Abstract
Conventional electrophysiological methods, i.e. nerve conduction studies and electromyography are suitable methods for the diagnosis of neuromuscular disorders, however, they provide limited information about muscle fibre membrane properties and underlying disease mechanisms. Muscle excitability testing is a technique that provides in vivo information about muscle fibre membrane properties such as membrane potential and ion channel function. Since the 1960s, various methodologies have been suggested to examine muscle membrane properties but technical difficulties have limited its use. In 2009, an automated, fast and simple application, the so-called multi-fibre muscle velocity recovery cycles (MVRC) has accelerated the use of muscle excitability testing. Later, frequency ramp and repetitive stimulation protocols have been developed. Though this method has been used mainly in research for revealing disease mechanisms across a broad range of neuromuscular disorders, it may have additional diagnostic uses; value has been shown particularly in muscle channelopathies. This review will provide a description of the state-of-the art of methodological and clinical studies for muscle excitability testing.
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Affiliation(s)
- H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - H Bostock
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, Queen Square, WC1N 3BG London, United Kingdom
| | - S V Tan
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, Queen Square, WC1N 3BG London, United Kingdom; Department of Neurology and Neurophysiology, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - J Howells
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - K Ng
- Department of Neurology and Neurophysiology, Royal North Shore Hospital, St Leonards, NSW, Australia; University of Sydney, Camperdown, NSW, Australia
| | - W J Z'Graggen
- Departments Neurology and Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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2
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Kouyoumdjian JA, Graca CR. Muscle fiber conduction velocity in situ revisited: A new approach to an ancient technique. Front Neurol 2023; 14:1118510. [PMID: 36908604 PMCID: PMC9996126 DOI: 10.3389/fneur.2023.1118510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/18/2023] [Indexed: 02/25/2023] Open
Abstract
The aim of this study was to measure the muscle fiber conduction velocity (MFCV) in situ in the tibialis anterior muscle in healthy subjects. A total of 36 subjects matched for age and sex were studied. The MFCV was measured with a concentric needle by intramuscular monopolar needle electrical activation at a distance of 50 mm. The mean consecutive difference (MCD) of <5 μs was obtained after a median of 62 muscle fiber action potentials (MFAPs), confirming a direct muscle fiber activation. The measuring latency was at the median point of ascending depolarizing line of the MFAP. The calculated MFCV from 784 MFAPs was 4.10 ± 0.66 m/s, 3.99 ± 0.57 for female subjects (95%, 2.85 to 5.13), and 4.20 ± 0.73 for male subjects (95%, 2.74 to 5.67). The MFCV was 5.22% faster in male subjects. The calculated fast-to-slow MFCV ratio (F/S ratio) was 1.47 for female subjects (95%, 1.27 to 2.54) and 1.67 for male subjects (95%, 1.31 to 3.74). Aging significantly increased the F/S ratio. As the MFCVs mainly depend on the muscle diameter, their assessment is a quick and helpful tool for estimating it. Its variability by the F/S ratio is also a powerful tool in the follow-up of some neuromuscular disorders.
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Affiliation(s)
- João Aris Kouyoumdjian
- Neuromuscular Investigation Laboratory, Department of Neurological Sciences, Psychiatry and Medical Psychology, State Medical School (FAMERP), São José do Rio Preto, São Paulo, Brazil
| | - Carla Renata Graca
- Neuromuscular Investigation Laboratory, Department of Neurological Sciences, Psychiatry and Medical Psychology, State Medical School (FAMERP), São José do Rio Preto, São Paulo, Brazil
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3
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Younger DS. Critical illness-associated weakness and related motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:707-777. [PMID: 37562893 DOI: 10.1016/b978-0-323-98818-6.00031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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4
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Multimodal assessment of intensive care unit-acquired weakness in severe stroke patients. Acta Neurol Belg 2022; 122:1313-1321. [PMID: 35790678 DOI: 10.1007/s13760-022-02009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/16/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Intensive care unit-acquired weakness (ICUAW) defines generalized muscle weakness seen in critically ill patients in the absence of other causative factors. Herein, we aimed to evaluate ICUAW in stroke patients by electrodiagnostic testing, histopathology, and assessment of respiratory complex activities (RCA), to define the frequency of ICUAW in this patient group, and to reach new parameters for early prediction and diagnosis. METHODS We prospectively recruited twenty-four severe acute stroke patients during a sixteen-month period. In addition to serial nerve conduction studies (NCS), we performed muscle biopsy and RCA analysis on the non-paretic side when ICUAW developed. Patients undergoing orthopedic surgery without metabolic and neuromuscular diseases constituted the control group for RCA. Survival and longitudinal data were analyzed by joint modeling to determine the relationship between electrophysiological parameters and ICUAW diagnosis. RESULTS Eight patients (33%) developed ICUAW, and six of them within the first two weeks. Extensor digitorum brevis, abductor digiti minimi (ADM), rectus femoris and vastus medialis (VM) compound muscle action potential (CMAP) amplitudes showed a significant decrease in the ICUAW group. VM CMAP amplitude (BIC = 358.1574) and ADM CMAP duration (BIC = 361.1028) were the best-correlated parameters with ICUAW diagnosis. The most informative electrophysiological findings during the entire study were obtained within the first 11 days. Muscle biopsies revealed varying degrees of type 2 fiber atrophy. Complex I (p = 0.003) and IV (p = 0.018) activities decreased in patients with ICUAW compared to controls. CONCLUSION VM CMAP amplitude and ADM CMAP duration correlate well with ICUAW diagnosis, and may aid in the early diagnosis.
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Rodriguez B, Larsson L, Z’Graggen WJ. Critical Illness Myopathy: Diagnostic Approach and Resulting Therapeutic Implications. Curr Treat Options Neurol 2022; 24:173-182. [PMID: 35370393 PMCID: PMC8958813 DOI: 10.1007/s11940-022-00714-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of review
Critical illness myopathy (CIM) is a common neuro-muscular complication of intensive care treatment associated with increased morbidity and mortality. The current guidelines for diagnosis include clinical and electrophysiological criteria as well as a muscle biopsy, and allow diagnosis only at an advanced stage of the disease. To date, there is no treatment for CIM available, apart from symptomatic and rehabilitative interventions. In this review, we discuss different diagnostic approaches and describe new treatment possibilities for CIM.
Recent findings
Of the diagnostic approaches evaluated, a new electrophysiological technique for measuring muscle excitability has the greatest potential to allow earlier diagnosis of CIM than the current guidelines do and thereby may facilitate the conduction of future pathophysiological and therapeutic studies. Although clinical trials are still lacking, in animal models, BGP-15, vamorolone, and ruxolitinib have been shown to have anti-inflammatory effects, to reduce muscle wasting and to improve muscle function and survival.
Summary
In recent years, promising methods for early and confirmatory diagnosis of CIM have been developed, but still need validation. Experimental studies on novel pharmacological interventions show promising results in terms of preventive CIM treatments, but future clinical studies will be needed to study the effectiveness and safety of these drugs.
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Affiliation(s)
- Belén Rodriguez
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Lars Larsson
- Section of Clinical Neurophysiology, Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Viron Molecular Medicine Institute, Boston, MA 02108 USA
| | - Werner J. Z’Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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6
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Soares MN, Eggelbusch M, Naddaf E, Gerrits KHL, van der Schaaf M, van den Borst B, Wiersinga WJ, van Vugt M, Weijs PJM, Murray AJ, Wüst RCI. Skeletal muscle alterations in patients with acute Covid-19 and post-acute sequelae of Covid-19. J Cachexia Sarcopenia Muscle 2022; 13:11-22. [PMID: 34997689 PMCID: PMC8818659 DOI: 10.1002/jcsm.12896] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/11/2021] [Accepted: 11/22/2021] [Indexed: 12/14/2022] Open
Abstract
Skeletal muscle-related symptoms are common in both acute coronavirus disease (Covid)-19 and post-acute sequelae of Covid-19 (PASC). In this narrative review, we discuss cellular and molecular pathways that are affected and consider these in regard to skeletal muscle involvement in other conditions, such as acute respiratory distress syndrome, critical illness myopathy, and post-viral fatigue syndrome. Patients with severe Covid-19 and PASC suffer from skeletal muscle weakness and exercise intolerance. Histological sections present muscle fibre atrophy, metabolic alterations, and immune cell infiltration. Contributing factors to weakness and fatigue in patients with severe Covid-19 include systemic inflammation, disuse, hypoxaemia, and malnutrition. These factors also contribute to post-intensive care unit (ICU) syndrome and ICU-acquired weakness and likely explain a substantial part of Covid-19-acquired weakness. The skeletal muscle weakness and exercise intolerance associated with PASC are more obscure. Direct severe acute respiratory syndrome coronavirus (SARS-CoV)-2 viral infiltration into skeletal muscle or an aberrant immune system likely contribute. Similarities between skeletal muscle alterations in PASC and chronic fatigue syndrome deserve further study. Both SARS-CoV-2-specific factors and generic consequences of acute disease likely underlie the observed skeletal muscle alterations in both acute Covid-19 and PASC.
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Affiliation(s)
- Madu N Soares
- Laboratory for Myology, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Moritz Eggelbusch
- Laboratory for Myology, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Nutrition and Dietetics, Amsterdam UMC, Location VUmc, Amsterdam Movement Sciences, Amsterdam, The Netherlands.,Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Karin H L Gerrits
- Laboratory for Myology, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Merem Medical Rehabilitation, Hilversum, The Netherlands
| | - Marike van der Schaaf
- Department of Rehabilitation, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.,Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Bram van den Borst
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michele van Vugt
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter J M Weijs
- Department of Nutrition and Dietetics, Amsterdam UMC, Location VUmc, Amsterdam Movement Sciences, Amsterdam, The Netherlands.,Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Andrew J Murray
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Rob C I Wüst
- Laboratory for Myology, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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7
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Hochstrasser A, Rodriguez B, Söll N, Bostock H, Z'Graggen WJ. Effect of intermittent high-frequency stimulation on muscle velocity recovery cycle recordings. J Neurophysiol 2021; 126:736-742. [PMID: 34288792 DOI: 10.1152/jn.00213.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The technique of multifiber muscle velocity recovery cycle recordings was developed as a diagnostic tool to assess muscle membrane potential changes and ion channel function in vivo. This study was undertaken to assess the impact of intermittent high-frequency stimulation on muscle velocity recovery cycle components and to study whether the changes can be modified by endurance training. We recorded muscle velocity recovery cycles with 1 and 2 conditioning stimuli in the left tibialis anterior muscle in 15 healthy subjects during intermittent 37-Hz stimulation and analyzed its effects on the different phases of supernormality. Recordings were conducted before and after 2-wk endurance training. Training effect was assessed by measuring the difference in endurance time, peak force, and limb circumference. Muscle velocity recovery cycle recordings during intermittent high-frequency stimulation were successfully recorded in 12 subjects. Supernormality for interstimulus intervals shorter than 15 ms (early supernormality) was maximally reduced at the beginning of repetitive stimulation and recovered during stimulation. Supernormality for interstimulus intervals between 50 and 150 ms (late supernormality) showed a delayed decrease and stayed significantly reduced after high-frequency stimulation. Training had no significant effect on any of the measured parameters, but we found that training induced changes in peak force correlated positively with baseline changes of early supernormality. Our results support the hypothesis that early supernormality represents membrane potential, which depolarizes in the beginning of high-frequency stimulation. Late supernormality probably reflects transverse tubular function and shows progressive changes during high-frequency stimulation with delayed normalization.NEW & NOTEWORTHY A conditioning impulse in human muscle fibers induces a prolonged phase of increased velocity (also called supernormality) with two phases related to an early and late afterpotential. We investigated the effects of intermittent 37-Hz stimulation on muscle fiber supernormality and found that the early and late phases of supernormality changed differently, and that the late phase may reflect the ionic interactions responsible for the counter-regulation of muscle fatigue.
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Affiliation(s)
- Annie Hochstrasser
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Belén Rodriguez
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Hugh Bostock
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Werner J Z'Graggen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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8
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Tankisi A, Pedersen TH, Bostock H, Z'Graggen WJ, Larsen LH, Meldgaard M, Elkmann T, Tankisi H. Early detection of evolving critical illness myopathy with muscle velocity recovery cycles. Clin Neurophysiol 2021; 132:1347-1357. [PMID: 33676846 DOI: 10.1016/j.clinph.2021.01.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/29/2020] [Accepted: 01/19/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the sensitivity of muscle velocity recovery cycles (MVRCs) for detecting altered membrane properties in critically ill patients, and to compare this to conventional nerve conduction studies (NCS) and quantitative electromyography (qEMG). METHODS Twenty-four patients with intensive care unit acquired weakness (ICUAW) and 34 healthy subjects were prospectively recruited. In addition to NCS (median, ulnar, peroneal, tibial and sural nerves) and qEMG (biceps brachii, vastus medialis and anterior tibial muscles), MVRCs with frequency ramp were recorded from anterior tibial muscle. RESULTS MVRC and frequency ramp parameters showed abnormal muscle fiber membrane properties with up to 100% sensitivity and specificity. qEMG showed myopathy in 15 patients (63%) while polyneuropathy was seen in 3 (13%). Decreased compound muscle action potential (CMAP) amplitude (up to 58%) and absent F-waves (up to 75%) were frequent, but long duration CMAPs were only seen in one patient with severe myopathy. CONCLUSIONS Altered muscle fiber membrane properties can be detected in patients with ICUAW not yet fulfilling diagnostic criteria for critical illness myopathy (CIM). MVRCs may therefore serve as a tool for early detection of evolving CIM. SIGNIFICANCE CIM is often under-recognized by intensivists, and large-scale longitudinal studies are needed to determine its incidence and pathogenesis.
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Affiliation(s)
- A Tankisi
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - T H Pedersen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - H Bostock
- Institute of Neurology, University College London, Queen Square House, London, United Kingdom
| | - W J Z'Graggen
- Departments of Neurology and Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - L H Larsen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - M Meldgaard
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - T Elkmann
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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9
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Uncini A, Foresti C, Frigeni B, Storti B, Servalli MC, Gazzina S, Cosentino G, Bianchi F, Del Carro U, Alfonsi E, Piccinelli SC, De Maria G, Padovani A, Filosto M, Ippoliti L. Electrophysiological features of acute inflammatory demyelinating polyneuropathy associated with SARS-CoV-2 infection. Neurophysiol Clin 2021; 51:183-191. [PMID: 33685769 PMCID: PMC7891083 DOI: 10.1016/j.neucli.2021.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/12/2021] [Accepted: 02/12/2021] [Indexed: 01/05/2023] Open
Abstract
Objective To assess whether patients with acute inflammatory demyelinating polyneuropathy (AIDP) associated with SARS-CoV-2 show characteristic electrophysiological features. Methods Clinical and electrophysiological findings of 24 patients with SARS-CoV-2 infection and AIDP (S-AIDP) and of 48 control AIDP (C-AIDP) without SARS-CoV-2 infection were compared. Results S-AIDP patients more frequently developed respiratory failure (83.3% vs. 25%, P = 0.000) and required intensive care unit (ICU) hospitalization (58.3% vs. 31.3%, P = 0.000). In C-AIDP, distal motor latencies (DMLs) were more frequently prolonged (70.9% vs. 26.2%, P = 0.000) whereas in S-AIDP distal compound muscle action potential (dCMAP) durations were more frequently increased (49.5% vs. 32.4%, P = 0.002) and F waves were more often absent (45.6% vs. 31.8%, P = 0.011). Presence of nerves with increased dCMAP duration and normal or slightly prolonged DML was elevenfold higher in S-AIDP (31.1% vs. 2.8%, P = 0.000);11 S-AIDP patients showed this pattern in 2 nerves. Conclusion Increased dCMAP duration, thought to be a marker of acquired demyelination, can also be oserved in critical illness myopathy. In S-AIDP patients, an increased dCMAP duration dissociated from prolonged DML, suggests additional muscle fiber conduction slowing, possibly due to a COVID-19-related hyperinflammatory state. Absent F waves, at least in some S-AIDP patients, may reflect α-motor neuron hypoexcitability because of immobilization during the ICU stay. These features should be considered in the electrodiagnosis of SARS-CoV-2 patients with weakness, to avoid misdiagnosis.
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Affiliation(s)
- Antonino Uncini
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy.
| | - Camillo Foresti
- Neuropathophysiology, "Papa Giovanni XXIII" Hospital, Bergamo, Italy
| | - Barbara Frigeni
- Neuropathophysiology, "Papa Giovanni XXIII" Hospital, Bergamo, Italy
| | - Benedetta Storti
- Neuropathophysiology, "Papa Giovanni XXIII" Hospital, Bergamo, Italy
| | | | | | - Giuseppe Cosentino
- Department of Brain and Behavioral Sciences, University of Pavia and IRCCS Mondino Foundation, Pavia, Italy
| | - Francesca Bianchi
- Neurology and Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milano, Italy
| | - Ubaldo Del Carro
- Neurology and Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milano, Italy
| | | | - Stefano Cotti Piccinelli
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | | | - Alessandro Padovani
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Massimiliano Filosto
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Luigi Ippoliti
- Statistics Unit, Department of Economics, University "G. d'Annunzio", Pescara, Italy
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10
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Versace V, Sebastianelli L, Ferrazzoli D, Saltuari L, Kofler M, Löscher W, Uncini A. Case Report: Myopathy in Critically Ill COVID-19 Patients: A Consequence of Hyperinflammation? Front Neurol 2021; 12:625144. [PMID: 33584530 PMCID: PMC7878532 DOI: 10.3389/fneur.2021.625144] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/13/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: COVID-19-associated muscular complications may comprise myalgia, weakness, wasting, and rhabdomyolysis. Skeletal muscle damage in COVID-19 may be due to direct infection by the virus SARS-CoV-2 through interaction with the ACE2 receptor, systemic hyper-inflammatory state with cytokine release and homeostatic perturbation, an autoimmune process, or myotoxic drugs. Disclosing the cause of weakness in an individual patient is therefore difficult. Case Description: We report two patients, who survived typical COVID-19 pneumonia requiring intensive care treatment and who developed early on myalgia and severe proximal weakness in all four limbs. Laboratory exams revealed elevated serum creatine kinase and markedly increased C-reactive protein and interleukin 6, concurring with a systemic inflammatory response. On admission in neurorehabilitation (4 and 7 weeks after COVID-19 onset, respectively), the patients presented with proximal flaccid tetraparesis and limb-girdle muscle atrophy. Motor nerve conduction studies showed decreased amplitude and prolonged duration of compound muscle action potentials (CMAPs) with normal distal motor latencies and normal conduction velocities in median and ulnar nerves. Needle electromyography in proximal muscles revealed spontaneous activity in one and myopathic changes in both patients. Discussion: Clinical, laboratory, and electrodiagnostic findings in these patients were unequivocally consistent with myopathy. Interestingly, increased distal CMAP duration has been described in patients with critical illness myopathy (CIM) and reflects slow muscle fiber conduction velocity due to membrane hypo-excitability, possibly induced by inflammatory cytokines. By analogy with CIM, the pathogenesis of COVID-19-related myopathy might also depend on hyperinflammation and metabolic pathways that may affect muscles in a pathophysiological continuum from hypo-excitability to necrosis.
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Affiliation(s)
- Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno, Italy
| | - Luca Sebastianelli
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno, Italy
| | - Davide Ferrazzoli
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno, Italy
| | - Leopold Saltuari
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Vipiteno, Italy
| | - Markus Kofler
- Department of Neurology, Hochzirl Hospital, Zirl, Austria
| | - Wolfgang Löscher
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Antonino Uncini
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
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11
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Abstract
Critical illness myopathy (CIM) is a primary myopathy associated with increased mortality and morbidity, which frequently develops in severely ill patients. Several risk factors have been suggested for the development of critical illness myopathy. However, neither the exact etiology nor the underlying mechanisms are known in detail. Although for definite diagnosis muscle biopsy is needed, electrophysiological tests are crucial for the diagnosis of probable critical illness myopathy and differential diagnosis. In this review, conventional electrophysiological tests such as nerve conduction studies, needle electromyography, direct muscle stimulation, and repetitive stimulation for diagnosis of critical illness myopathy are summarized. Moreover, studies using the novel method of recording muscle velocity recovery cycles are addressed.
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12
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McClafferty B, Umer I, Fye G, Kepko D, Kalayanamitra R, Shahid Z, Ramgobin D, Cai A, Groff A, Bhandari A, Aggarwal CS, Patel R, Bhatt D, Polimera H, Sahu N, Vunnam R, Golamari R, Kumar A, Jain R. Approach to critical illness myopathy and polyneuropathy in the older SARS-CoV-2 patients. J Clin Neurosci 2020; 79:241-245. [PMID: 33070904 PMCID: PMC7380205 DOI: 10.1016/j.jocn.2020.07.058] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/08/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
One of the major concerns of the health care community and the public surrounding the SARS-CoV-2 pandemic is the availability and use of ventilators. Unprecedented surges of patients presented to intensive care units across the country, with older adults making up a large proportion of the patient population. This paper illustrates contemporary approaches to critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy (CIPNM) in older patients, including incidence, risk factors, mechanisms for pathology, diagnosis, contemporary treatment approaches, and outcomes. We hope that the following analysis may help educate clinicians and ultimately decrease the duration of the mechanical ventilation required by these patients, resulting in improved clinical outcomes and an increase in ventilator availability for other patients in need.
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Affiliation(s)
| | - Ibrahim Umer
- Lake Erie College of Osteopathic Medicine, United States
| | - Gary Fye
- Lake Erie College of Osteopathic Medicine, United States
| | - Douglas Kepko
- Lake Erie College of Osteopathic Medicine, United States
| | | | - Zainab Shahid
- Lake Erie College of Osteopathic Medicine, United States
| | | | - Alice Cai
- Penn State College of Medicine, United States
| | | | - Abani Bhandari
- Department of Internal Medicine, KISTMC, Tribhuvan University, Nepal, India
| | | | - Ravi Patel
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Dhirisha Bhatt
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Hyma Polimera
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Nitasa Sahu
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Ramarao Vunnam
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Reshma Golamari
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Ashutosh Kumar
- Department of Pediatrics and Neurology, Penn State Milton S. Hershey Medical Center, United States
| | - Rohit Jain
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
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13
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Reliability of surface electromyography in estimating muscle fiber conduction velocity: A systematic review. J Electromyogr Kinesiol 2019; 48:53-68. [DOI: 10.1016/j.jelekin.2019.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 05/28/2019] [Accepted: 06/12/2019] [Indexed: 11/22/2022] Open
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14
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Formenti P, Umbrello M, Coppola S, Froio S, Chiumello D. Clinical review: peripheral muscular ultrasound in the ICU. Ann Intensive Care 2019; 9:57. [PMID: 31101987 PMCID: PMC6525229 DOI: 10.1186/s13613-019-0531-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/10/2019] [Indexed: 12/14/2022] Open
Abstract
Muscular weakness developing from critical illness neuropathy, myopathy and muscle atrophy has been characterized as intensive care unit-acquired weakness (ICUAW). This entity occurs commonly during and after critical care stay. Various causal factors for functional incapacity have been proposed. Among these, individual patient characteristics (such as age, comorbidities and nutritional status), acting in association with sustained bed rest and pharmacological interventions (included the metabolic support approach), seem influential in reducing muscular mass. Long-term outcomes in heterogeneous ICUAW populations include transient disability in 30% of patients and persistent disabilities that may occur even in patients with nearly complete functional recovery. Currently available tools for the assessment of skeletal muscle mass are imprecise and difficult to perform in the ICU setting. A valid alternative to these imaging modalities is muscular ultrasonography, which allows visualization and classification of muscle characteristics by cross-sectional area, muscle layer thickness, echointensity by grayscale and the pennation angle). The aim of this narrative review is to describe the current literature addressing muscular ultrasound for the detection of muscle weakness and its potential impact on treatment and prognosis of critically ill patients when combined with biomarkers of muscle catabolism/anabolism and bioenergetic state. In addition, we suggest a practical flowchart for establishing an early diagnosis.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy. .,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy.
| | - Michele Umbrello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| | - Sara Froio
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| | - Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
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15
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A unifying hypothesis for delirium and hospital-acquired weakness as synaptic dysfunctions. Med Hypotheses 2019; 124:105-109. [DOI: 10.1016/j.mehy.2019.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/20/2018] [Accepted: 02/03/2019] [Indexed: 12/23/2022]
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16
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What is in the Myopathy Literature? J Clin Neuromuscul Dis 2018; 19:217-223. [PMID: 29794577 DOI: 10.1097/cnd.0000000000000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This update covers the results of a randomized, placebo-controlled study that provides evidence that lamotrigine is effective in treating nondystrophic myotonias. Next, an overview of adverse effects of immune checkpoint inhibitors is provided, and the association of autoimmune myopathy and these monoclonal antibody therapies is discussed in light of recent reports. Last, the utility of electrodiagnostic testing in patients with intensive care unit weakness is addressed with emphasis on the high sensitivity and specificity of prolonged compound muscle action potential amplitudes in diagnosing critical illness myopathy.
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Yamada T, Himori K, Tatebayashi D, Yamada R, Ashida Y, Imai T, Akatsuka M, Masuda Y, Kanzaki K, Watanabe D, Wada M, Westerblad H, Lanner JT. Electrical Stimulation Prevents Preferential Skeletal Muscle Myosin Loss in Steroid-Denervation Rats. Front Physiol 2018; 9:1111. [PMID: 30147660 PMCID: PMC6097132 DOI: 10.3389/fphys.2018.01111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/24/2018] [Indexed: 12/16/2022] Open
Abstract
Severe muscle weakness concomitant with preferential depletion of myosin has been observed in several pathological conditions. Here, we used the steroid-denervation (S-D) rat model, which shows dramatic decrease in myosin content and force production, to test whether electrical stimulation (ES) treatment can prevent these deleterious changes. S-D was induced by cutting the sciatic nerve and subsequent daily injection of dexamethasone for 7 days. For ES treatment, plantarflexor muscles were electrically stimulated to produce four sets of five isometric contractions each day. Plantarflexor in situ isometric torque, muscle weight, skinned muscle fiber force, and protein and mRNA expression were measured after the intervention period. ES treatment partly prevented the S-D-induced decreases in plantarflexor in situ isometric torque and muscle weight. ES treatment fully prevented S-D-induced decreases in skinned fiber force and ratio of myosin heavy chain (MyHC) to actin, as well as increases in the reactive oxygen/nitrogen species-generating enzymes NADPH oxidase (NOX) 2 and 4, phosphorylation of p38 MAPK, mRNA expression of the muscle-specific ubiquitin ligases muscle ring finger-1 (MuRF-1) and atrogin-1, and autolyzed active calpain-1. Thus, ES treatment is an effective way to prevent muscle impairments associated with loss of myosin.
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Affiliation(s)
- Takashi Yamada
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Koichi Himori
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Daisuke Tatebayashi
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Ryotaro Yamada
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Yuki Ashida
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Tomihiro Imai
- Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan
| | - Masayuki Akatsuka
- Department of Intensive Care Medicine, Sapporo Medical University, Sapporo, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University, Sapporo, Japan
| | - Keita Kanzaki
- Faculty of Health Science and Technology, Kawasaki University of Medical Welfare, Kurashiki, Japan
| | - Daiki Watanabe
- School of Life Sciences, La Trobe University, Melbourne, VIC, Australia
| | - Masanobu Wada
- Graduate School of Integrated Arts and Sciences, Hiroshima University, Higashihiroshima, Japan
| | - Håkan Westerblad
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Johanna T Lanner
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Abstract
Intensive care unit-acquired weakness (ICUAW) is a substantial contributor to long-term disability in survivors of critical illness. Critical illness polyneuropathy, critical illness myopathy, and muscle atrophy from disuse contribute in various proportions to ICUAW. ICUAW is a clinical diagnosis supported by electrophysiology and newer diagnostic tests, such as muscle ultrasound. Risk factor reduction, including the aggressive treatment of sepsis and early mobilization, improves outcome. Although some patients with ICUAW experience a full recovery, for others improvement is slow and incomplete and quality of life is adversely affected. This article examines aspects of ICUAW and identifies potential areas of further study.
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Affiliation(s)
- Christopher L Kramer
- Department of Neurology, University of Chicago, 5841 South Maryland Avenue, MC 2050, Chicago, IL 60637, USA.
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19
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Boërio D, Corrêa TD, Jakob SM, Ackermann KA, Bostock H, Z'Graggen WJ. Muscle membrane properties in A pig sepsis model: Effect of norepinephrine. Muscle Nerve 2017; 57:808-813. [PMID: 29130505 DOI: 10.1002/mus.26013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2017] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Sepsis-induced myopathy and critical illness myopathy are common causes of muscle weakness in intensive care patients. This study investigated the effect of different mean arterial blood pressure (MAP) levels on muscle membrane properties following experimental sepsis. METHODS Sepsis was induced with fecal peritonitis in 12 of 18 anesthetized and mechanically ventilated pigs. Seven were treated with a high (75-85 mmHg) and 5 were treated with a low (≥60 mmHg) MAP target for resuscitation. In septic animals, resuscitation was started 12 h after peritonitis induction, and muscle velocity recovery cycles were recorded 30 h later. RESULTS Muscles in the sepsis/high MAP group showed an increased relative refractory period and reduced early supernormality compared with the remaining septic animals and the control group, indicating membrane depolarization and/or sodium channel inactivation. The membrane abnormalities correlated positively with norepinephrine dose. DISCUSSION Norepinephrine may contribute to sepsis-induced abnormalities in muscle by impairing microcirculation. Muscle Nerve 57: 808-813, 2018.
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Affiliation(s)
- Delphine Boërio
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thiago D Corrêa
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Karin A Ackermann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hugh Bostock
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, United Kingdom
| | - Werner J Z'Graggen
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
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20
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Parissis D, Syntila SA, Ioannidis P. Corticosteroids in neurological disorders: The dark side. J Clin Neurosci 2017. [DOI: 10.1016/j.jocn.2017.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Senger D, Erbguth F. [Critical illness myopathy and polyneuropathy]. Med Klin Intensivmed Notfmed 2017; 112:589-596. [PMID: 28875277 PMCID: PMC7095927 DOI: 10.1007/s00063-017-0339-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/08/2017] [Indexed: 12/23/2022]
Abstract
Bei durchschnittlich 50–80 % der intensivmedizinisch behandelten Patienten kommt es zu einer Beeinträchtigung der neuromuskulären Funktionen durch Schädigungen der Nerven und der Muskulatur, was zu den Bezeichnungen Critical-illness-Polyneuropathie und -Myopathie geführt hat. Beide Komponenten treten bei 30–50 % der Betroffenen kombiniert auf, beim Rest überwiegt die isolierte Myopathie, während die isolierte Neuropathie selten vorkommt. Mittlerweile wird der deskriptive Begriff der „intensive care unit-acquired weakness“ (ICUAW) bevorzugt. Bedeutendster Risikofaktor für die Entwicklung einer ICUAW sind Sepsis, Multiorgandysfunktion und ein „acute respiratory distress syndrome“ (ARDS). Bei mindestens einem Drittel der Patienten bestehen am Ende des Intensivstationsaufenthalts noch bleibende Störungen wie Lähmungen, Sensibilitätsstörungen und Gleichgewichtsprobleme. Bei etwa 10 % persistieren diese beinbetonten und stark alltagsrelevanten Störungen über das erste Jahr nach ICU-Therapie hinaus. Die reine Myopathie führt selten zu Residuen, während die neuropathische Komponente für die Langzeitbeeinträchtigungen verantwortlich ist.
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Affiliation(s)
- D Senger
- Universitätsklinik für Neurologie der Paracelsus Medizinischen Privatuniversität, Klinikum Nürnberg, Breslauer Str. 201, 90471, Nürnberg, Deutschland
| | - F Erbguth
- Universitätsklinik für Neurologie der Paracelsus Medizinischen Privatuniversität, Klinikum Nürnberg, Breslauer Str. 201, 90471, Nürnberg, Deutschland.
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22
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Kramer CL, Boon AJ, Harper CM, Goodman BP. Compound muscle action potential duration in critical illness neuromyopathy. Muscle Nerve 2017. [PMID: 28646510 DOI: 10.1002/mus.25732] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION We sought to determine the specificity of compound muscle action potential (CMAP) durations and amplitudes in a large critical illness neuromyopathy (CINM) cohort relative to controls with other neuromuscular conditions. METHODS Fifty-eight patients with CINM who had been seen over a 17-year period were retrospectively studied. Electrodiagnostic findings of the CINM cohort were compared with patients with axonal peripheral neuropathy and myopathy due to other causes. RESULTS Mean CMAP durations were prolonged, and mean CMAP amplitudes were severely reduced both proximally and distally in all nerves studied in the CINM cohort relative to the control groups. The specificity of prolonged CMAP durations for CINM approached 100% if they were encountered in more than 1 nerve. DISCUSSION Prolonged, low-amplitude CMAPs occur more frequently and with greater severity in CINM patients than in neuromuscular controls with myopathy and axonal neuropathy and are highly specific for the diagnosis of CINM. Muscle Nerve 57: 395-400, 2018.
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23
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Crone C. Tetraparetic critically ill patients show electrophysiological signs of myopathy. Muscle Nerve 2017; 56:433-440. [PMID: 27997678 DOI: 10.1002/mus.25525] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 12/12/2016] [Accepted: 12/14/2016] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Critically ill patients often develop tetraparesis. It has been debated whether this is caused by neuropathy, myopathy, or both. The aim was to determine the incidence of myopathy and neuropathy in weak patients in the intensive care unit by performing several electrophysiological examinations, including quantitative electromyography (qEMG). METHODS Forty-nine patients referred for electrophysiological examination because of suspected critical illness-related weakness underwent qEMG, nerve conduction studies, and direct muscle stimulation. RESULTS The qEMG showed signs of myopathy in 33 of 35 patients. Direct muscle stimulation was consistent with myopathy in 31 of 34 patients. Amplitudes of compound muscle action potentials were decreased in all patients. Four patients also had signs of sensory neuropathy, which could not be explained by preexisting medical conditions. CONCLUSIONS When combined, the results are compatible with muscle dysfunction in all patients. This will help to direct future studies of the pathophysiology of this serious condition. Muscle Nerve 56: 433-440, 2017.
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Affiliation(s)
- Clarissa Crone
- Department of Clinical Neurophysiology 3063, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
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24
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Abstract
Critical illness myopathy (CIM) and neuropathy are underdiagnosed conditions within the intensive care setting and contribute to prolonged mechanical ventilation and ventilator wean failure and ultimately lead to significant morbidity and mortality. These conditions are often further subdivided into CIM, critical illness polyneuropathy (CIP), or the combination-critical illness polyneuromyopathy (CIPNM). In this review, we discuss the epidemiology and pathophysiology of CIM, CIP, and CIPNM, along with diagnostic considerations such as detailed clinical examination, electrophysiological studies, and histopathological review of muscle biopsy specimens. We also review current available treatments and prognosis. Increased awareness and early recognition of CIM, CIP, and CIPNM in the intensive care unit setting may lead to earlier treatments and rehabilitation, improving patient outcomes.
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Affiliation(s)
- Starane Shepherd
- Department of Neurology, Brigham and Women’s Hospital & Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ayush Batra
- Department of Neurology, Brigham and Women’s Hospital & Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David P. Lerner
- Department of Neurology, Brigham and Women’s Hospital & Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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25
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Son YR, Kim NH, Kim DG, Park KS. Is thyrotoxic periodic paralysis a disease caused by muscle membrane dysfunction? Muscle Nerve 2016; 56:780-786. [PMID: 28006864 DOI: 10.1002/mus.25532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 12/12/2016] [Accepted: 12/16/2016] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Thyrotoxic periodic paralysis (TPP) is characterized by recurrent episodes of reversible paralysis with hyperthyroidism. It is clinically similar to hypokalemic periodic paralysis (HOPP), which features significant ion-channel dysfunction and reduced muscle fiber conduction velocity (MFCV). However, the muscle membrane function in TPP is not known. METHODS For 13 patients with TPP and 15 age-matched controls, clinical assessment and serial neurophysiological testing, including nerve conduction, prolonged exercise (PE) testing, and MFCV. were performed. RESULTS MFCV values were elevated up to 1 year from the paralytic attack in TPP patients. In the group with a positive PE test, MFCV values were higher. There was no significant relationship between MFCV values and either hypokalemia or hyperthyroidism. CONCLUSIONS Although clinical manifestations in TPP are similar to those observed in HOPP, TPP appears to feature an alternate pathogenic mechanism. Specifically, MFCV values increased rather than decreased. Further studies are needed to support these findings. Muscle Nerve, 2016 Muscle Nerve 56: 780-786, 2017.
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Affiliation(s)
- Yoo-Ri Son
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Geonggi-Do, Seoul, Republic of Korea
| | - Nam-Hee Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Republic of Korea
| | - Dong-Gun Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Geonggi-Do, Seoul, Republic of Korea
| | - Kyung-Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Geonggi-Do, Seoul, Republic of Korea
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Llano-Diez M, Cheng AJ, Jonsson W, Ivarsson N, Westerblad H, Sun V, Cacciani N, Larsson L, Bruton J. Impaired Ca(2+) release contributes to muscle weakness in a rat model of critical illness myopathy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:254. [PMID: 27510990 PMCID: PMC5050561 DOI: 10.1186/s13054-016-1417-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/20/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Critical illness myopathy is an acquired skeletal muscle disorder with severe myosin loss and muscle weakness frequently seen in intensive care unit (ICU) patients. It is unknown if impaired excitation-contraction coupling contributes to the muscle weakness. METHODS We used a unique ICU model where rats were deeply sedated, post-synaptically pharmacologically paralyzed, mechanically ventilated and closely monitored for up to ten days. Single intact fibers from the flexor digitorum brevis muscle were isolated and used to measure force and free myoplasmic [Ca(2+)] ([Ca(2+)]i) during tetanic contractions. RESULTS Fibers from ICU rats had 80 % lower tetanic [Ca(2+)]i and produced only 15 % of the force seen in fibers from sham-operated (SHAM) rats. In the presence of 5 mM caffeine, tetanic [Ca(2+)]i was similar in fibers from ICU and SHAM rats but force was 50 % lower in fibers from ICU rats than SHAM rats. Confocal imaging showed disrupted tetanic [Ca(2+)]i transients in fibers from ICU rats compared to SHAM rats. Western blots showed similar levels of Na(+) channel and dihydropyridine receptor (DHPR) protein expression, whereas ryanodine receptor (RyR) and sarco-endoplasmic reticulum Ca(2+) ATPase 1 (SERCA1) expression was markedly lower in muscle of ICU rats than in SHAM rats. Immunohistochemical analysis showed that distribution of Na(+) channel and DHPR protein on the sarcolemma was disrupted in fibers from ICU rats compared with SHAM rats. CONCLUSIONS These results suggest that impaired SR Ca(2+) release contributes to the muscle weakness seen in patients in ICU.
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Affiliation(s)
- Monica Llano-Diez
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden
| | - Arthur J Cheng
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden
| | - William Jonsson
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden
| | - Niklas Ivarsson
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden
| | - Håkan Westerblad
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden
| | - Vic Sun
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden
| | - Nicola Cacciani
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden
| | - Lars Larsson
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden
| | - Joseph Bruton
- Department of Physiology & Pharmacology, Karolinska Institutet, von Eulers väg, 8, 2 floor, Stockholm, 171 77, Sweden.
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27
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Marrero HG, Stålberg EV. Optimizing testing methods and collection of reference data for differentiating critical illness polyneuropathy from critical illness MYOPATHIES. Muscle Nerve 2016; 53:555-63. [PMID: 26311145 DOI: 10.1002/mus.24886] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 07/20/2015] [Accepted: 08/24/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In severe acute quadriplegic myopathy in intensive care unit (ICU) patients, muscle fibers are electrically inexcitable; in critical illness polyneuropathy, the excitability remains normal. Conventional electrodiagnostic methods do not provide the means to adequately differentiate between them. In this study we aimed to further optimize the methodology for the study of critically ill ICU patients and to create a reference database in healthy controls. METHODS Different electrophysiologic protocols were tested to find sufficiently robust and reproducible techniques for clinical diagnostic applications. RESULTS Many parameters show large test-retest variability within the same healthy subject. Reference values have been collected and described as a basis for studies of weakness in critical illness. CONCLUSIONS Using the ratio of neCMAP/dmCMAP (response from nerve and direct muscle stimulation), refractory period, and stimulus-response curves may optimize the electrodiagnostic differentiation of patients with critical illness myopathy from those with critical illness polyneuropathy.
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Affiliation(s)
- Humberto Gonzalez Marrero
- Section of Clinical Neurophysiology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erik V Stålberg
- Department of Clinical Neurophysiology, Section of Neuroscience, Uppsala University, Uppsala, Sweden
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28
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Wieske L, Verhamme C, Witteveen E, Bouwes A, Dettling-Ihnenfeldt DS, van der Schaaf M, Schultz MJ, van Schaik IN, Horn J. Feasibility and diagnostic accuracy of early electrophysiological recordings for ICU-acquired weakness: an observational cohort study. Neurocrit Care 2016; 22:385-94. [PMID: 25403763 DOI: 10.1007/s12028-014-0066-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND An early diagnosis of ICU-acquired weakness (ICU-AW) is difficult because disorders of consciousness frequently preclude muscle strength assessment. In this study, we investigated feasibility and accuracy of electrophysiological recordings to diagnose ICU-AW early in non-awake critically ill patients. METHODS Newly admitted patients, mechanically ventilated ≥2 days and unreactive to verbal stimuli, were included in this study. Electrophysiological recordings comprised nerve conduction studies (NCS) of three nerves and, if coagulation was normal, myography in three muscles. Upon awakening, strength was assessed (ICU-AW: average Medical Research Council score <4), blinded for electrophysiological recordings. Feasibility was expressed as the percentage of recordings that were both possible and had sufficient technical quality. Diagnostic accuracy of feasible (i.e., feasibility >75 %) recordings was analyzed based on cut-off values from healthy controls and from critically ill patients with and without ICU-AW. RESULTS Thirty-five patients were included (17 with ICU-AW). Recordings were obtained on day 4 (IQR: 3-6). Feasibility was acceptable for ulnar and peroneal nerve recordings, and low for sural recordings and myography. Diagnostic accuracy based on cut-off values from healthy controls was low. When using cut-off values from critically ill patients with and without ICU-AW, the peroneal compound muscle action potential amplitude and ulnar sensory nerve action potential amplitude had good diagnostic accuracy. CONCLUSION Nerve conduction studies of the ulnar and peroneal nerve are feasible in critically ill patients. The diagnostic accuracy is low using cut-off values from healthy controls. Cut-off values validated specifically for discrimination between critically ill patients with and without ICU-AW may improve diagnostic accuracy.
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Affiliation(s)
- Luuk Wieske
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, room C3-311, PO box 22700, 1105 AZ, Amsterdam, The Netherlands,
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Li N, Liu Z, Wang G, Wang S. Downregulation of the sodium channel Nav1.6 by potential transcriptomic deregulation may explain sensory deficits in critical illness neuropathy. Life Sci 2015; 143:231-6. [PMID: 26562765 DOI: 10.1016/j.lfs.2015.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 10/08/2015] [Accepted: 11/07/2015] [Indexed: 11/24/2022]
Abstract
AIMS Sepsis patients and other patients in the critical care settings are at very high risk of mortality due to the primary illness. However, a fraction of patients, even after showing initial clinical improvement, deteriorates relentlessly at later stages. Increasingly, it is being identified that this is mostly due to dysfunction of the neurological system. MAIN METHODS We obtained peripheral nerve biopsies from the sural nerve from ICU patients. Nav1.6 expression was significantly diminished. The expression of cellular membrane anchoring protein for Nav1.6, ankyrin, remained unaffected, suggesting that genomic repression may be responsible for the diminished expression of the sodium channels. We examined the expression of two regulatory transcription factors: (a) a positive regulator YY1 that binds to the promoter region of sodium channels and (b) an upstream negative neuronal regulator REST. KEY FINDINGS REST expression was significantly elevated, while YY1 expression was diminished. Finally, we also observed that the cholinergic synthetic enzyme acyltransferase was also significantly diminished in sensory nerve lysates. Finally, circulating antibodies was detected in the peripheral blood against all the major sodium channels Nav1.6, 1.8 and 1.9, which contribute to the development and propagation of action potentials. SIGNIFICANCE This may potentially explain why its dysfunction affects neurological functions across all systems of the body during critical illness. The underlying mechanism of why the expression of the REST transcriptional factor is affected in critical illnesses remains our future goals of investigation.
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Affiliation(s)
- Nan Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Jilin 130021, China
| | - Zhongmin Liu
- Department of Intensive Care Unit, The First Hospital of Jilin University, Jilin 130021, China
| | - Guang Wang
- Department of Intensive Care Unit, The First Hospital of Jilin University, Jilin 130021, China
| | - Shiji Wang
- Department of Intensive Care Unit, The First Hospital of Jilin University, Jilin 130021, China.
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Friedrich O, Reid MB, Van den Berghe G, Vanhorebeek I, Hermans G, Rich MM, Larsson L. The Sick and the Weak: Neuropathies/Myopathies in the Critically Ill. Physiol Rev 2015; 95:1025-109. [PMID: 26133937 PMCID: PMC4491544 DOI: 10.1152/physrev.00028.2014] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Critical illness polyneuropathies (CIP) and myopathies (CIM) are common complications of critical illness. Several weakness syndromes are summarized under the term intensive care unit-acquired weakness (ICUAW). We propose a classification of different ICUAW forms (CIM, CIP, sepsis-induced, steroid-denervation myopathy) and pathophysiological mechanisms from clinical and animal model data. Triggers include sepsis, mechanical ventilation, muscle unloading, steroid treatment, or denervation. Some ICUAW forms require stringent diagnostic features; CIM is marked by membrane hypoexcitability, severe atrophy, preferential myosin loss, ultrastructural alterations, and inadequate autophagy activation while myopathies in pure sepsis do not reproduce marked myosin loss. Reduced membrane excitability results from depolarization and ion channel dysfunction. Mitochondrial dysfunction contributes to energy-dependent processes. Ubiquitin proteasome and calpain activation trigger muscle proteolysis and atrophy while protein synthesis is impaired. Myosin loss is more pronounced than actin loss in CIM. Protein quality control is altered by inadequate autophagy. Ca(2+) dysregulation is present through altered Ca(2+) homeostasis. We highlight clinical hallmarks, trigger factors, and potential mechanisms from human studies and animal models that allow separation of risk factors that may trigger distinct mechanisms contributing to weakness. During critical illness, altered inflammatory (cytokines) and metabolic pathways deteriorate muscle function. ICUAW prevention/treatment is limited, e.g., tight glycemic control, delaying nutrition, and early mobilization. Future challenges include identification of primary/secondary events during the time course of critical illness, the interplay between membrane excitability, bioenergetic failure and differential proteolysis, and finding new therapeutic targets by help of tailored animal models.
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Affiliation(s)
- O Friedrich
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - M B Reid
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - G Van den Berghe
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - I Vanhorebeek
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - G Hermans
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - M M Rich
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - L Larsson
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
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Duez L, Qerama E, Jensen TS, Fuglsang-Frederiksen A. Modulation of the muscle and nerve compound muscle action potential by evoked pain. Scand J Pain 2015; 6:55-60. [PMID: 29911580 DOI: 10.1016/j.sjpain.2014.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 05/20/2014] [Indexed: 10/25/2022]
Abstract
Background and aims To our knowledge there are no studies that have examined the effects of the experimental pain on muscle fibre excitability as measured by the amplitudes of the potentials evoked by direct muscle stimulation (DMS) in a muscle at rest. We hypothesized that evoked pain can modulate the muscle compound action potential (CMAP) obtained by DMS possibly due to changes in muscle fibre excitability. Methods Pain was evoked by intramuscular infusion of hypertonic saline in 50 men. Ten control subjects were infused with isotonic saline. The infusions were given distal to the motor end plate region of the dominant brachial biceps muscle (BBM) in a double-blind manner. The nerve CMAP was obtained by stimulating the musculocutaneous nerve and recording from the BBM using surface-electrodes. Muscle CMAPs were obtained by direct muscle stimulation with subdermal electrodes placed subcutaneously in the distal third of the muscle. A stimuli-response curve of the amplitudes from muscle CMAP was obtained by stimulating from 10 to 90 mA. Results There was a decrease of the nerve CMAP amplitudes after infusion of isotonic saline (from 13.78mV to 12.16 mV), p-value 0.0007 and of hypertonic saline (from 13.35 mV to 10.85 mV), p-value 0.0000. The percent decrease from before to after infusion was larger in the hypertonic saline group (19.37%) compared to the isotonic saline group (12.18%), p-value 0.025. There was a decrease of the amplitudes of the muscle CMAP after infusion of both isotonic (at 90 mA from 13.84mV to 10.32 mV, p value 0.001) and of hypertonic saline (at 90 mA from 14.01 mV to 8.19 mV, p value 0.000). The percent decrease was larger in the hypertonic saline group compared to the isotonic saline group for all the stimulations intensities. At 90 mA we saw a 42% decrease in the hypertonic saline group and 24.5% in the isotonic saline group, p value 0.005. There were no changes in conduction velocity. Conclusion We found a larger amplitude decrease of the muscle and nerve potentials following hypertonic saline infusion compared with that of isotonic saline. We suggest that this deferential outcome of hypertonic saline on muscle CMAP may be linked to the nociceptive effect on muscle fibre membrane excitability. Implications The study supplies with some evidence of the peripheral effect of muscle pain. However, further trials with other nociceptive substances such as capsaicin should be performed.
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Affiliation(s)
- L Duez
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark.,Department of Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - E Qerama
- Department of Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - T S Jensen
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
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Walsh CJ, Batt J, Herridge MS, Dos Santos CC. Muscle wasting and early mobilization in acute respiratory distress syndrome. Clin Chest Med 2014; 35:811-26. [PMID: 25453427 DOI: 10.1016/j.ccm.2014.08.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Survivors of acute respiratory distress syndrome often sustain muscle wasting and functional impairment related to intensive care unit (ICU)-acquired weakness (ICUAW) and this disability may persist for years after ICU discharge. Early diagnosis in cooperative patients by physical examination is recommended to identify patients at risk for weaning failure and to minimize prolongation of risk factors for ICUAW. When possible, early rehabilitation in critically ill patients improves functional outcomes, likely by reducing disuse atrophy. Interventions designed to correct the functional impairment are lacking and further research to delineate the molecular pathways that give rise to ICUAW are needed.
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Affiliation(s)
- Christopher J Walsh
- Department of Medicine, Institute of Medical Sciences, Keenan Centre for Biomedical Science, Li Ka Shing Knowledge institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Jane Batt
- Department of Medicine, Institute of Medical Sciences, Keenan Centre for Biomedical Science, Li Ka Shing Knowledge institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care, University of Toronto, Toronto General Hospital, NCSB 11C-1180, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Claudia C Dos Santos
- Department of Medicine, Institute of Medical Sciences, Keenan Centre for Biomedical Science, Li Ka Shing Knowledge institute, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
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Zhou C, Wu L, Ni F, Ji W, Wu J, Zhang H. Critical illness polyneuropathy and myopathy: a systematic review. Neural Regen Res 2014; 9:101-10. [PMID: 25206749 PMCID: PMC4146320 DOI: 10.4103/1673-5374.125337] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2013] [Indexed: 12/31/2022] Open
Abstract
Critical illness polyneuropathy and critical illness myopathy are frequent complications of severe illness that involve sensorimotor axons and skeletal muscles, respectively. Clinically, they manifest as limb and respiratory muscle weakness. Critical illness polyneuropathy/myopathy in isolation or combination increases intensive care unit morbidity via the inability or difficulty in weaning these patients off mechanical ventilation. Many patients continue to suffer from decreased exercise capacity and compromised quality of life for months to years after the acute event. Substantial progress has been made lately in the understanding of the pathophysiology of critical illness polyneuropathy and myopathy. Clinical and ancillary test results should be carefully interpreted to differentiate critical illness polyneuropathy/myopathy from similar weaknesses in this patient population. The present review is aimed at providing the latest knowledge concerning the pathophysiology of critical illness polyneuropathy/myopathy along with relevant clinical, diagnostic, differentiating, and treatment information for this debilitating neurological disease.
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Affiliation(s)
- Chunkui Zhou
- Department of Neurology, the First Bethune Hospital, Jilin University, Changchun 130021, Jilin Province, China ; Department of Neurology, the Second Part, the First Bethune Hospital, Jilin University, Changchun 130021, Jilin Province, China
| | - Limin Wu
- Department of Neurology, the First Bethune Hospital, Jilin University, Changchun 130021, Jilin Province, China ; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Charlestown 02129, MA, USA
| | - Fengming Ni
- Department of Radiotherapy, Oncology Center, the First Bethune Hospital, Jilin University, Changchun 130021, Jilin Province, China
| | - Wei Ji
- Department of Vascular Surgery, People's Hospital of Jilin Province, Changchun 130000, Jilin Province, China
| | - Jiang Wu
- Department of Neurology, the First Bethune Hospital, Jilin University, Changchun 130021, Jilin Province, China
| | - Hongliang Zhang
- Department of Neurology, the First Bethune Hospital, Jilin University, Changchun 130021, Jilin Province, China
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Koch S, Wollersheim T, Bierbrauer J, Haas K, Mörgeli R, Deja M, Spies CD, Spuler S, Krebs M, Weber-Carstens S. Long-term recovery In critical illness myopathy is complete, contrary to polyneuropathy. Muscle Nerve 2014; 50:431-6. [PMID: 24415656 DOI: 10.1002/mus.24175] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 12/10/2013] [Accepted: 01/08/2014] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Muscle weakness in critically ill patients after discharge varies. It is not known whether the electrophysiological distinction between critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) during the early part of a patient's stay in the intensive care unit (ICU) predicts long-term prognosis. METHODS This was a prospective cohort study of mechanically ventilated ICU patients undergoing conventional nerve conduction studies and direct muscle stimulation in addition to neurological examination during their ICU stay and 1 year after ICU discharge. RESULTS Twenty-six patients (7 ICU controls, 8 CIM patients, and 11 CIM/CIP patients) were evaluated 1 year after discharge from the ICU. Eighty-eight percent (n = 7) of CIM patients recovered within 1 year compared with 55% (n = 6) of CIM/CIP patients. Thirty-six percent (n = 4) of CIM/CIP patients still needed assistance during their daily routine (P = 0.005). CONCLUSIONS Early electrophysiological testing predicts long-term outcome in ICU survivors. CIM has a significantly better prognosis than CIM/CIP.
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Affiliation(s)
- Susanne Koch
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Segers J, Hermans G, Bruyninckx F, Meyfroidt G, Langer D, Gosselink R. Feasibility of neuromuscular electrical stimulation in critically ill patients. J Crit Care 2014; 29:1082-8. [PMID: 25108833 DOI: 10.1016/j.jcrc.2014.06.024] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/19/2014] [Accepted: 06/25/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Critically ill patients often develop intensive care unit-acquired weakness. Reduction in muscle mass and muscle strength occurs early after admission to the intensive care unit (ICU). Although early active muscle training could attenuate this intensive care unit-acquired weakness, in the early phase of critical illness, a large proportion of patients are unable to participate in any active mobilization. Neuromuscular electrical stimulation (NMES) could be an alternative strategy for muscle training. The aim of this study was to investigate the safety and feasibility of NMES in critically ill patients. DESIGN This is an observational study. SETTING The setting is in the medical and surgical ICUs of a tertiary referral university hospital. PATIENTS Fifty patients with a prognosticated prolonged stay of at least 6 days were included on day 3 to 5 of their ICU stay. Patients with preexisting neuromuscular disorders and patients with musculoskeletal conditions limiting quadriceps contraction were excluded. INTERVENTION Twenty-five minutes of simultaneous bilateral NMES of the quadriceps femoris muscle. This intervention was performed 5 days per week (Monday-Friday). Effective muscle stimulation was defined as a palpable and visible contraction (partial or full muscle bulk). MEASUREMENTS The following parameters, potentially affecting contraction upon NMES, were assessed: functional status before admission to the ICU (Barthel index), type and severity of illness (Acute Physiology And Chronic Health Evaluation II score and sepsis), treatments possibly influencing the muscle contraction (corticosteroids, vasopressors, inotropes, aminoglycosides, and neuromuscular blocking agents), level of consciousness (Glasgow Coma Scale, score on 5 standardized questions evaluating awakening, and sedation agitation scale), characteristics of stimulation (intensity of the NMES, number of sessions per patient, and edema), and neuromuscular electrophysiologic characteristics. Changes in heart rate, blood pressure, oxygen saturation, respiratory rate, and skin reactions were registered to assess the safety of the technique. RESULTS In 50% of the patients, an adequate quadriceps contraction was obtained in at least 75% of the NMES sessions. Univariate analysis showed that lower limb edema (P<.001), sepsis (P=.008), admission to the medical ICU (P=.041), and treatment with vasopressors (P=.011) were associated with impaired quadriceps contraction. A backward multivariate analysis identified presence of sepsis, lower limb edema, and use of vasopressors as independent predictors of impaired quadriceps contraction (R2=59.5%). Patients responded better to NMES in the beginning of their ICU stay in comparison with after 1 week of ICU stay. There was no change in any of the safety end points with NMES. CONCLUSIONS Critically ill patients having sepsis, edema, or receiving vasopressors were less likely to respond to NMES with an adequate quadriceps contraction. Neuromuscular electrical stimulation is a safe intervention to be administered in the ICU.
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Affiliation(s)
- Johan Segers
- KU Leuven-University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
| | - Greet Hermans
- Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Department of General Internal Medicine, UZ Leuven, Leuven, Belgium
| | - Frans Bruyninckx
- KU Leuven/UZ Leuven, Department of Physical Medicine and Rehabilitation, Leuven, Belgium
| | - Geert Meyfroidt
- KU Leuven/UZ Leuven, Department of Intensive Care Medicine, Leuven, Belgium
| | - Daniel Langer
- KU Leuven-University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
| | - Rik Gosselink
- KU Leuven-University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium.
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Functional electrical stimulation with cycling in the critically ill: a pilot case-matched control study. J Crit Care 2014; 29:695.e1-7. [PMID: 24768534 DOI: 10.1016/j.jcrc.2014.03.017] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 02/05/2014] [Accepted: 03/11/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose was to determine (a) safety and feasibility of functional electrical stimulation (FES)-cycling and (b) compare FES-cycling to case-matched controls in terms of functional recovery and delirium outcomes. MATERIALS AND METHODS Sixteen adult intensive care unit patients with sepsis ventilated for more than 48 hours and in the intensive care unit for at least 4 days were included. Eight subjects underwent FES-cycling in addition to usual care and were compared to 8 case-matched control individuals. Primary outcomes were safety and feasibility of FES-cycling. Secondary outcomes were Physical Function in Intensive Care Test scored on awakening, time to reach functional milestones, and incidence and duration of delirium. RESULTS One minor adverse event was recorded. Sixty-nine out of total possible 95 FES sessions (73%) were completed. A visible or palpable contraction was present 80% of the time. There was an improvement in Physical Function in Intensive Care Test score of 3.9/10 points in the intervention cohort with faster recovery of functional milestones. There was also a shorter duration of delirium in the intervention cohort. CONCLUSIONS The delivery of FES-cycling is both safe and feasible. The preliminary findings suggest that FES-cycling may improve function and reduce delirium. Further research is required to confirm the findings of this study and evaluate the efficacy of FES-cycling.
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Koesters A, Engisch KL, Rich MM. Decreased cardiac excitability secondary to reduction of sodium current may be a significant contributor to reduced contractility in a rat model of sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R54. [PMID: 24669759 PMCID: PMC4057164 DOI: 10.1186/cc13800] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 03/03/2014] [Indexed: 01/07/2023]
Abstract
Introduction Multisystem organ failure remains a poorly understood complication of sepsis. During sepsis, reduced excitability contributes to organ failure of skeletal muscle, nerves and the spinal cord. The goal of this study was to determine whether reduced excitability might also contribute to cardiac failure during sepsis. Methods Wistar rats were made septic by cecal ligation and puncture. One day later, action potentials were recorded from beating left ventricular papillary muscle ex vivo by impaling myocytes with sharp microelectrodes. Results In cardiac papillary muscle from septic rats, action potential amplitude and rate of rise were reduced, while threshold was elevated. These changes in action potential properties suggest sepsis selectively reduces sodium current. To determine the effects of selective reduction in sodium current, we applied tetrodotoxin to papillary muscle from healthy rats and found reduction in action potential amplitude and rate of rise, as well as elevation of threshold. The changes were similar to those triggered by sepsis. Blocking calcium current using nifedipine did not mimic action potential changes induced by sepsis. Contractility of healthy papillary muscle was reduced to 40% of normal following partial block of sodium current by tetrodotoxin, close to the low contractility of septic papillary muscle, which was 30% of normal. Conclusions Our data suggest cardiac excitability is reduced during sepsis in rats. The reduction in excitability appears to be primarily due to reduction of sodium current. The reduction in sodium current may be sufficient to explain most of the reduction in cardiac contractility during sepsis.
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Argov Z, Latronico N. Neuromuscular complications in intensive care patients. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1673-85. [PMID: 24365440 DOI: 10.1016/b978-0-7020-4088-7.00108-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Increased survival of critically ill patients has focused the attention on secondary complications of intensive care unit (ICU) stay, mainly ICU-acquired weakness (ICUAW). ICUAW is relatively common with significant impact on recovery. Prolonging mechanical ventilation and overall hospitalization time, increased mortality, and persistent disability are the main problems associated with ICUAW. The chapter deals mainly with the differential diagnosis of neuromuscular generalized weakness that develops in the ICU, but focal ICUAW is reviewed too. The approach to the diagnosis and the yield of various techniques (mainly electrophysiological and histological) is discussed. Possible therapeutic interventions of this condition that modify the course of this deleterious situation and lead to better rehabilitation are discussed. The current postulated mechanisms associated with ICUAW (mainly the more frequent critical illness neuropathy and myopathy) are reviewed.
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Affiliation(s)
- Zohar Argov
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Nicola Latronico
- Department of Anesthesia Intensive Care and Postoperative Care, Division of Neuroanaesthesia and Neurocritical Care, University of Brescia, Spedali Civili, Brescia, Italy
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Gueret G, Guillouet M, Vermeersch V, Guillard E, Talarmin H, Nguyen BV, Rannou F, Giroux-Metges MA, Pennec JP, Ozier Y. [ICU acquired neuromyopathy]. ACTA ACUST UNITED AC 2013; 32:580-91. [PMID: 23958176 DOI: 10.1016/j.annfar.2013.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 05/08/2013] [Indexed: 12/19/2022]
Abstract
ICU acquired neuromyopathy (IANM) is the most frequent neurological pathology observed in ICU. Nerve and muscle defects are merged with neuromuscular junction abnormalities. Its physiopathology is complex. The aim is probably the redistribution of nutriments and metabolism towards defense against sepsis. The main risk factors are sepsis, its severity and its duration of evolution. IANM is usually diagnosed in view of difficulties in weaning from mechanical ventilation, but electrophysiology may allow an earlier diagnosis. There is no curative therapy, but early treatment of sepsis, glycemic control as well as early physiotherapy may decrease its incidence. The outcomes of IANM are an increase in morbi-mortality and possibly long-lasting neuromuscular abnormalities as far as tetraplegia.
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Affiliation(s)
- G Gueret
- Pôle anesthésie réanimations soins intensifs blocs opératoires urgences (ARSIBOU), CHRU de Brest, boulevard Tanguy-Prigent, 29200 Brest, France; Laboratoire de physiologie, faculté de médecine et des sciences de la santé, EA 1274 (mouvement, sport santé), université de Bretagne-Occidentale, 22, avenue Camille-Desmoulins, 29200 Brest, France; Université européenne de Bretagne, 5, boulevard Laennec, 35000 Rennes, France.
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Guillard E, Gueret G, Guillouet M, Vermeersch V, Rannou F, Giroux-Metges MA, Pennec JP. Alteration of muscle membrane excitability in sepsis: Possible involvement of ciliary nervous trophic factor (CNTF). Cytokine 2013; 63:52-57. [DOI: 10.1016/j.cyto.2013.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 02/01/2013] [Accepted: 04/15/2013] [Indexed: 10/26/2022]
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42
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Lacomis D. Electrophysiology of neuromuscular disorders in critical illness. Muscle Nerve 2013; 47:452-63. [PMID: 23386582 DOI: 10.1002/mus.23615] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2012] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Neuromuscular disorders, predominantly critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) occur in approximately one-third of patients in intensive care units. The aim of this study was to review the important role of electrophysiology in this setting. RESULTS In CIM, sarcolemmal inexcitability causes low amplitude compound muscle action potentials (CMAPs) that may have prolonged durations. Needle electrode examination usually reveals early recruitment of short duration motor unit potentials, often with fibrillation potentials. In CIP, the findings are usually those of a generalized axonal sensorimotor polyneuropathy. Direct muscle stimulation aids in differentiating CIP and CIM and in identifying mixed disorders along with other electrodiagnostic and histopathologic studies. Identifying evolving reductions in fibular CMAP amplitudes in intensive care unit (ICU) patients predicts development of neuromuscular weakness. CONCLUSIONS Knowledge of the various neuromuscular disorders in critically ill patients, their risk factors, and associated electrodiagnostic findings can lead to development of a rational approach to diagnosis of the cause of neuromuscular weakness in ICU patients.
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Affiliation(s)
- David Lacomis
- Department of Neurology, University of Pittsburgh School of Medicine, 200 Lothrop Street, F878, Pittsburgh, Pennsylvania 15213, USA.
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43
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Crone C, Krarup C. Neurophysiological approach to disorders of peripheral nerve. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:81-114. [PMID: 23931776 DOI: 10.1016/b978-0-444-52902-2.00006-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Disorders of the peripheral nerve system (PNS) are heterogeneous and may involve motor fibers, sensory fibers, small myelinated and unmyelinated fibers and autonomic nerve fibers, with variable anatomical distribution (single nerves, several different nerves, symmetrical affection of all nerves, plexus, or root lesions). Furthermore pathological processes may result in either demyelination, axonal degeneration or both. In order to reach an exact diagnosis of any neuropathy electrophysiological studies are crucial to obtain information about these variables. Conventional electrophysiological methods including nerve conduction studies and electromyography used in the study of patients suspected of having a neuropathy and the significance of the findings are discussed in detail and more novel and experimental methods are mentioned. Diagnostic considerations are based on a flow chart classifying neuropathies into eight categories based on mode of onset, distribution, and electrophysiological findings, and the electrophysiological characteristics in each type of neuropathy are discussed.
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Affiliation(s)
- Clarissa Crone
- Department of Clinical Neurophysiology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
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44
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Abstract
Patients admitted to the intensive care unit (ICU) can develop a condition referred to as "ICU-acquired weakness." This condition is characterized by profound weakness that is greater than might be expected to result from prolonged bed rest. Intensive care unit-acquired weakness often is accompanied by dysfunction of multiple organ systems. Individuals with ICU-acquired weakness typically have significant activity limitations, often requiring physical assistance for even the most basic activities associated with bed mobility. Many of these individuals have activity limitations months to years after hospitalization. The purpose of this article is to review evidence that guides physical rehabilitation of people with ICU-acquired weakness. Included are diagnostic criteria, medical management, and prognostic indicators, as well as criteria for beginning physical rehabilitation, with an emphasis on patient safety. Data are presented indicating that rehabilitation can be implemented with very few adverse effects. Evidence is provided for appropriate measurement approaches and for physical intervention strategies. Finally, some of the key issues are summarized that should be investigated to determine the best intervention guidelines for individuals with ICU-acquired weakness.
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BoËRio D, Z'graggen WJ, Tan SV, Guetg A, Ackermann K, Bostock H. Muscle velocity recovery cycles: Effects of repetitive stimulation on two muscles. Muscle Nerve 2012; 46:102-11. [DOI: 10.1002/mus.23267] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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46
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Techniques and applications of EMG: measuring motor units from structure to function. J Neurol 2012; 259:585-94. [DOI: 10.1007/s00415-011-6350-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 11/30/2011] [Indexed: 12/14/2022]
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47
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Physical function, disability and rehabilitation in the elderly critically ill. RÉFÉRENCES EN RÉANIMATION. COLLECTION DE LA SRLF 2012. [DOI: 10.1007/978-2-8178-0287-9_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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48
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Matsuda N, Kobayashi S, Tanji Y, Hasegawa A, Tase C, Ugawa Y. Widespread muscle involvement in critical illness myopathy revealed by MRI. Muscle Nerve 2011; 44:842-4. [PMID: 22006705 DOI: 10.1002/mus.22218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol 2011; 10:931-41. [PMID: 21939902 DOI: 10.1016/s1474-4422(11)70178-8] [Citation(s) in RCA: 388] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Critical illness polyneuropathy (CIP) and myopathy (CIM) are complications of critical illness that present with muscle weakness and failure to wean from the ventilator. In addition to prolonging mechanical ventilation and hospitalisation, CIP and CIM increase hospital mortality in patients who are critically ill and cause chronic disability in survivors of critical illness. Structural changes associated with CIP and CIM include axonal nerve degeneration, muscle myosin loss, and muscle necrosis. Functional changes can cause electrical inexcitability of nerves and muscles with reversible muscle weakness. Microvascular changes and cytopathic hypoxia might disrupt energy supply and use. An acquired sodium channelopathy causing reduced muscle membrane and nerve excitability is a possible unifying mechanism underlying CIP and CIM. The diagnosis of CIP, CIM, or combined CIP and CIM relies on clinical, electrophysiological, and muscle biopsy investigations. Control of hyperglycaemia might reduce the severity of these complications of critical illness, and early rehabilitation in the intensive care unit might improve the functional recovery and independence of patients.
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