Joint contracture following prolonged stay in the intensive care unit

The effects of using heel protectors on the prevention of heel pressure injuries and plantar flexion contractures

BACKGROUND

Immobilization in the intensive care unit can lead to pressure injuries and plantar flexion contractures.

AIM

This study was conducted to evaluate the effectiveness of heel protectors applied for the prevention of heel pressure injuries and plantar flexion contractures in intensive care units.

METHODS

This study was conducted as a randomized controlled trial in two adult intensive care units of a teaching and research hospital. The study sample consisted of 84 patients admitted to intensive care units between January 2022 and December 2022. Patients who had been in the intensive care unit for at least 5 days, scored 16 or less on the Braden Pressure Ulcer Risk Assessment Scale and scored 4 or more on the Ramsey Sedation Scale, were included in the study. Heel protector boots were applied to the heels of the patients in the intervention group, while standard positioning with a pillow and ROM exercises were continued in the control group. A sociodemographic data form, the Ramsey Sedation Scale and the Braden Pressure Ulcer Risk Assessment Scale were used to collect data. While pressure injuries were evaluated with the International NPUAP-EPUAP Pressure Ulcer Classification System, goniometric measurements were made to evaluate joint ROM.

RESULTS

In the intervention group, heel pressure injuries did not develop during the study, whereas five patients in the control group developed heel pressure injuries. The risk of pressure injury development that was seen in the control group was 1.7 times higher compared with the risk for the intervention group (log 95% CI: 0.91-2.59). There were significant differences between the right foot (99%; F = 99.229; p = .000) and left foot (99%; F = 100.519; p = .000) in range of motion measurement values of the patients in the intervention group according to the measurement times. According to the results of the multiple comparison test (Bonferroni) performed to determine the range of motion measurement periods showing significant differences, it was observed that each measurement for both feet yielded lower results than the previous measurement (seven measurements from day 1 to day 13).

CONCLUSION

The use of heel protector boots was found to be effective in preventing the development of heel pressure injuries and plantar flexion contractures in intensive care unit patients.

RELEVANCE FOR CLINICAL PRACTICE

This study provides evidence that intensive care nurses can use heel protector boots to prevent the development of heel pressure injuries and plantar flexion contractures.

Physical and Cognitive Impairment in Acute Respiratory Failure

Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.

Passive Movements Do not Appear to Prevent or Reduce Joint Stiffness in Medium to Long-Stay ICU Patients: A Randomized, Controlled, Within-Participant Trial

OBJECTIVES

ICU patients have an increased risk of joint stiffness because of their critical illness and reduced mobility. There is a paucity of evidence evaluating the efficacy of passive movements (PMs). We investigated whether PMs prevent or reduce joint stiffness in ICU patients.

DESIGN

A randomized, controlled, within-participant, assessor-blinded study.

SETTING

A 48-bed tertiary care adult ICU.

PATIENTS

Intubated patients who were expected to be invasively mechanically ventilated for greater than 48 hours with an ICU length of stay greater than or equal to 5 days, and unable to voluntarily move their limbs through full range of motion (ROM).

INTERVENTIONS

The ankle and elbow on one side of each participant's body received PMs (10 min each joint, morning and afternoon, 5 d/wk). The other side acted as the control. The PMs intervention continued for as long as clinically indicated to a maximum of 4 weeks.

MEASUREMENTS

The primary outcome was ankle dorsiflexion ROM at cessation of PMs. Plantarflexion, elbow flexion and extension ROM, and participant-reported joint pain and stiffness (verbal analog scale [VAS]) were also measured. Outcomes were recorded at baseline and cessation of PMs. For participants whose PMs intervention ceased early due to recovery, additional post-early-cessation of PMs review measurements were undertaken as near as possible to 4 weeks.

MAIN RESULTS

We analyzed data from 25 participants with a median (interquartile range) ICU stay of 15.6 days (11.3-25.4). The mean (95% CI) between-side difference for dorsiflexion ROM (with knee extension) at cessation of PMs was 0.4 degrees (-4.4 to 5.2; p = 0.882), favoring the intervention side, indicating there was not a clinically meaningful effect of 5 degrees. No statistically significant differences were found between the intervention and control sides for any ROM or VAS data.

CONCLUSIONS

PMs, as provided to this sample of medium to long-stay ICU patients, did not prevent or reduce joint stiffness.

Stretching, Bracing, and Devices for the Treatment of Osteoarthritis-Associated Joint Contractures in Nonoperated Joints: A Systematic Review and Meta-Analysis

CONTEXT

Many patients with osteoarthritis (OA) develop range of motion (ROM) restrictions in their affected joints (contractures), associated with worse outcomes and rising healthcare costs. Effective treatment guidance for lost ROM in OA-affected joints is lacking.

OBJECTIVE

A systematic review and meta-analysis evaluating the effectiveness of stretching and/or bracing protocols on native (nonoperated) joint ROM in the setting of radiographically diagnosed OA.

DATA SOURCES

Seven databases, English-language.

STUDY SELECTION

Studies including participants with radiographically diagnosed OA in any native joint evaluating the effect of stretching or bracing on ROM.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Two reviewers independently screened articles for inclusion and assessed risk of bias in included trials. Primary outcomes were ROM, pain, and adverse events (AEs).

RESULTS

We identified 6284 articles. A total of 9 randomized controlled trials, all evaluating the knee, met eligibility criteria. For stretching, 3 pooled studies reported total ROM, which improved by mean difference (MD) of 9.3° (95% CI 5.0°,13.5°) versus controls. Two pooled studies showed improved knee flexion ROM (MD 10.8° [7.3°,14.2°]) versus controls. Five studies were pooled for knee extension with mean improvement 9.1° [3.4°,14.8°] versus controls. Seven pooled studies showed reduced pain (standardized MD 1.9 [1.2,2.6]). One study reported improved knee extension of 3.7° [2.9°,4.5°] with use of a device. No studies used orthoses. One study reported on AEs, with none noted. Performance bias was present in all included studies, and only 3 studies clearly reported blinding of outcome assessors. Strength of evidence for primary outcomes was considered moderate.

CONCLUSION

There was moderate-quality evidence that stretching is an effective strategy for improving knee total, flexion and extension ROM, and pain. Our findings suggest that stretching to regain joint ROM in OA is not futile and that stretching appears to be an appropriate conservative intervention to improve patient outcomes as part of a comprehensive knee OA treatment plan before arthroplasty.

[Aftercare of ICU patients: A task for pneumology?]

As the number of patients treated in intensive care medicine increases, so does the number of those who suffer from the long-term consequences of critical illness and the consequences of a stay in an intensive care unit. For this group of patients with a post-intensive care syndrome (PICS), there are currently no specialized outpatient care structures that follow the hospital stay and possible follow-up treatment. A number of studies are researching the effectiveness of intensive care outpatient clinics nationally and internationally.After presenting the PICS and the associated complex need for care, this review article presents various model projects for outpatient follow-up care of critically ill patients. We discuss whether the field of pneumology is particularly suitable for the study of therapy control of complex clinical pictures since it has vast experience in the treatment of intensive care patients and the outpatient care of chronically ill patients.

Sex-based differences and relationship with the restricted knee flexion angle due to aging: a comparative study

BACKGROUND

The relationship between inferior patellar mobility (IPM) and knee flexion angle has yet to be elucidated. This study aimed to develop quantitative IPM measurement methods and clarify the relationship between IPM and knee flexion angle in community-dwelling older females.

METHODS

This was a cross-sectional study. Overall, 128 healthy older women (age 65-79 years) were recruited from the community to evaluate the relationship between IPM and knee flexion angle. This study was performed between May 2015 and December 2017. The reference value of and sex differences in IPM were evaluated in 205 healthy young adults aged between 19 and 21 years. IPM was compared between healthy older and young women and was objectively measured using our specially designed patellofemoral arthrometer (PFA). Patellar mobility was calculated by normalization to body height. IPM reliability was assessed before all measurements.

RESULTS

Intraclass correlation coefficients for intratester and intertester reliabilities varied from 0.87 to 0.99. The normal range based on two standard deviations of inferior patellar displacement/body height was 5.9-13.5% (young men), 5.1-14.3% (young women), and 1.2-8.8% (older women). IPM was significantly lower in older than young women (P < 0.001). There was a significant positive correlation (r = 0.72 and P < 0.01) between IPM and knee flexion angle in healthy older women unable to flex the knee joint fully.

CONCLUSIONS

Our PFA has good intratester and intertester reliability. The results suggest that IPM decreases with aging in women. IPM and knee flexion angle are correlated among older women unable to flex the knee joint fully.

CLINICAL TRIAL REGISTRATION

Not applicable.

Early passive orthostatic training prevents diaphragm atrophy and dysfunction in intensive care unit patients on mechanical ventilation: A retrospective case‒control study

BACKGROUND

Intensive care unit (ICU) patients on mechanical ventilation (MV), who are always bedridden, easily develop diaphragm atrophy and dysfunction. However, few studies have assessed diaphragmatic thickness and functional changes after early passive orthostatic training.

OBJECTIVES

This is the first study to investigate the efficacy of early passive orthostatic training in preventing diaphragm atrophy and dysfunction in ICU patients on MV.

METHODS

In this randomized retrospective case‒control study, 81 ICU patients on MV for 8 days or longer were enrolled. Forty-four patients received early passive orthostatic training initiated within 72 h of MV initiation (training group), and 37 patients did not receive training (no-training group). The protocol was performed for seven days, once a day for 30 min. The primary outcomes were diaphragmatic thickness and diaphragm contractile fraction (TFdi). The ventilatory parameters were secondary outcomes.

RESULTS

This study included 81 (45 male) ICU patients on MV [(mean ± SD) age = (60.63 ± 7.88) years]. The training group had a larger diaphragmatic thickness at end-expiration (Tdi_,ee) and a smaller magnitude of decrease in Tdi_,ee and TFdi (p = 0.001, 0.029, and <0.001, respectively) than the no-training group after 7 days of training. The mean arterial pressure, fraction of inspired oxygen, and white blood cell levels were decreased in the training group compared with the no-training group (p = 0.003, 0.001, and 0.026, respectively), but lactic acid levels decreased slightly in the training group with no significant difference (p = 0.708).

CONCLUSIONS

Early passive orthostatic training is suitable to ameliorate diaphragm atrophy and dysfunction in ICU patients on MV.

Effectiveness of physical rehabilitation interventions in critically ill patients-A protocol for an overview of systematic reviews

INTRODUCTION

Adult and pediatric patients admitted to intensive care units (ICUs) requiring invasive ventilatory support, sedation, and muscle blockade may present neuromusculoskeletal deterioration. Different physical rehabilitation interventions have been studied to evaluate their effectiveness in improving critically ill patients' outcomes. Given that many published systematic reviews (SRs) aims to determine the effectiveness of different types of physical rehabilitation interventions, it is necessary to group them systematically and assess the methodological quality of SRs to help clinicians make better evidence-based decisions. This overview of SRs (OoSRs) aims to map the existing evidence and to determine the effectiveness of physical rehabilitation interventions to improve neuromusculoskeletal function and other clinical outcomes in adult and pediatric critically ill patients.

METHODS

An OoSRs of randomized and non-randomized clinical trials involving critically ill adult and pediatric patients receiving physical rehabilitation intervention will be conducted. A sensitive search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Cochrane Library, Epistemonikos, and other search resources will be conducted. Two independent reviewers will conduct study selection, data extraction, and methodological quality assessment. Discrepancies will be resolved by consensus or a third reviewer. The degree of overlap of studies will be calculated using the corrected covered area. The methodological quality of the SRs will be measured using the AMSTAR-2 tool. The GRADE framework will report the certainty of evidence by selecting the "best" SR for each physical rehabilitation intervention and outcome.

DISCUSSION

The findings of this overview are expected to determine the effectiveness and safety of physical rehabilitation interventions to improve neuromusculoskeletal function in adult and pediatric critically ill patients based on a wide selection of the best available evidence and to determine the knowledge gaps in this topic by mapping and assessing the methodological quality of published SRs.

REGISTRATION NUMBER

CRD42023389672.

Mechanical properties within and beyond the physiological length of the semitendinosus muscle of knee-immobilized rats

BACKGROUND

The effects of immobilization on passive muscle mechanical properties are inconsistent between studies. Here, we investigated the mechanical properties of immobilized muscle by obtaining length-force curves within and beyond the physiological muscle-tendon length in a knee-contractured rat model.

METHODS

Unilateral rat knee joints were immobilized using an external fixator for up to 21 days. Length-passive force relationships in the immobilized and contralateral semitendinosus muscles were determined by tensile testing.

FINDINGS

The semitendinosus muscle-tendon length at end physiologic length in vivo was approximately at 5% strain of the slack length. Dynamic, elastic, and viscous force (three aspects of muscle mechanical properties) evoked by instantaneous constant stretch were higher than contralateral side within the physiological muscle-tendon length limit (strains of 5% or 5%-7.5% slack length). When beyond muscle-tendon length corresponding to the maximum knee extension (strains of 7.5% or 10%-20% slack length), there was no difference between the two sides. Dynamic and elastic stiffness were also larger, as estimated by tangent angles of length-force curves, at strains of 5% slack length, and matched contralateral levels at strains of 7.5% slack length on day 21. There were no differences in semitendinosus muscle-tendon lengths overtime. Despite significantly reductions in knee extension range of motion, collagen content only showed slight changes and correlation was hardly detected between collagen and mechanical properties on day 21.

INTERPRETATION

Viscoelasticity in immobilized semitendinosus muscle increased within the physiological muscle-tendon length. Collagen content may have little effect on passive force and stiffness.

Survivorship After Critical Illness and Post-Intensive Care Syndrome

Improvements in critical care medicine have led to a marked increase in survivors of the intensive care unit (ICU). These survivors encounter many difficulties following ICU discharge. The term post -intensive care syndrome (PICS) provides a framework for identifying the most common symptoms which fall into three domains: cognitive, physical, and mental health. There are numerous risk factors for the development of PICS including premorbid conditions and specific elements of ICU hospitalizations. Management is complex and should take an individualized approach with interdisciplinary care. Future research should focus on prevention, identification, and treatment of this unique population.

Factors associated with joint contractures in adults: a systematic review with narrative synthesis

PURPOSE

The primary objective of the review was to collate the available evidence on factors associated with joint contractures in adults.

METHODS

A systematic literature search was conducted on MEDLINE, CINAHL, AMED, and EMBASE. Studies that involved participants aged ≥18 and assessed joint contracture as a primary or secondary outcome were included. Two independent reviewers screened studies against the eligibility criteria, performed data extraction, and assessed the quality of evidence. A narrative synthesis by domain and sub-domain was undertaken. The protocol was registered on PROSPERO: CRD42019145079.

RESULTS

Forty-seven studies were included in the review. Identified factors were broadly classified into three major domains: sociodemographic factors, physical factors, and proxies for bed confinement. Sociodemographic factors were not associated with joint contractures. Functional ability, pain, muscle weakness, physical mobility, and bed confinement provided the most consistent evidence of association with joint contractures. The evidence regarding the relationship between spasticity and joint contractures remains unclear. Other factors might be important, but there was insufficient evidence to make inferences.

CONCLUSIONS

The review identified and collated evidence on factors associated with joint contractures, which can be utilised to develop effective prevention and management strategies. Implications for rehabilitationClinical interventions based on the timely identification of risks related to joint contractures in vulnerable adults have the potential to prevent or ameliorate their development or progression.Quality and consistency of care for vulnerable adults would be enhanced by developing effective joint contracture prevention and rehabilitation strategies based on the evidence presented in this review.As many vulnerable adults are located in the community or non-acute care settings, strategies should target these loci of care.Structured risk assessments that can support non-physiotherapy staff working in these loci of care to identify risks related to joint contractures would provide an important resource for risk management.

Effects of Different Static Progressive Stretching Durations on Range of Motion, Myofibroblasts, and Collagen in a Posttraumatic Knee Contracture Rat Model

OBJECTIVE

The purpose of this study was to investigate the effects of different durations of static progressive stretching (SPS) on posttraumatic knee contracture in rats, including range of motion (ROM), gait analysis, myofibroblast proliferation, and collagen regulation.

METHODS

The posttraumatic knee contracture model was established, and male Wistar rats were randomly divided into the 20-minute SPS treatment, 30-minute SPS treatment (S30), 40-minute SPS treatment, untreated, immobilization, and control groups. At Week 1, 2, and 4 of treatment intervention, joint ROM and gait were measured and compared. Knee joint samples stained with hematoxylin and eosin and Masson trichrome were used to observe alterations in pathological structures. Collagen density and cell numbers in the posterior joint capsule were used to assess joint capsule fibrosis and inflammation. Immunohistochemistry was used to detect type I collagen and α-smooth muscle actin expression.

RESULTS

The S30 group improved the most; ROM, stance, mean intensity, print area, and stride length were 115 (SD = 5) degrees, 0.423 (SD = 0.074) seconds, 156.020 (SD = 7.952), 2.116 (SD = 0.078) cm2, and 11.758 (SD = 0.548) cm, respectively. The numbers of myofibroblasts, fibroblasts, and inflammatory cells decreased, and collagen proliferation was significantly suppressed in the S30 group compared with the other groups.

CONCLUSION

S30 significantly improved posttraumatic knee contracture in rats, with reduced type I collagen and α-smooth muscle actin expression, decreased the numbers of myofibroblasts and inflammatory cells, suppressed fibrotic and inflammatory changes in the joint capsule, and increased joint mobility. This study provided basic evidence for an optimal standard-of-care treatment approach for posttraumatic knee joint contracture in rats, which may have significance for humans.

Outcomes of critically ill COVID-19 survivors and caregivers: a case study-centred narrative review

PURPOSE

Critical illness is a transformative experience for both patients and their family members. For COVID-19 patients admitted to the intensive care unit (ICU), survival may be the start of a long road to recovery. Our knowledge of the post-ICU long-term sequelae of acute respiratory distress syndrome (ARDS) and severe acute respiratory syndrome (SARS) may inform our understanding and management of the long-term effects of COVID-19.

SOURCE

We identified international and Canadian epidemiologic data on ICU admissions for COVID-19, COVID-19 pathophysiology, emerging ICU practice patterns, early reports of long-term outcomes, and federal support programs for survivors and their families. Centred around an illustrating case study, we applied relevant literature from ARDS and SARS to contextualize knowledge within emerging COVID-19 research and extrapolate findings to future long-term outcomes.

PRINCIPAL FINDINGS

COVID-19 is a multisystem disease with unknown long-term morbidity and mortality. Its pathophysiology is distinct and unique from ARDS, SARS, and critical illness. Nevertheless, based on initial reports of critical care management for COVID-19 and the varied injurious supportive practices employed in the ICU, patients and families are at risk for post-intensive care syndrome. The distinct incremental risk of COVID-19 multiple organ dysfunction is unknown. The risk of mood disorders in family members may be further exacerbated by imposed isolation and stigma.

CONCLUSION

Emerging literature on COVID-19 outcomes suggests some similarities with those of ARDS/SARS and prolonged mechanical ventilation. The pathophysiology of COVID-19 is presented here in the context of early outcome data and to inform an agenda for longitudinal research for patients and families.

Low-frequency electrical stimulation alleviates immobilization-evoked disuse muscle atrophy by repressing autophagy in skeletal muscle of rabbits

BACKGROUND

The study aimed to investigate the effect of low-frequency electrical stimulation (LFES) on disuse muscle atrophy and its mechanism in a rabbit model of knee extension contracture.

METHODS

This study involved two experiments. In the time-point experiment, 24 rabbits were randomly divided into 4 groups: Control 1 (Ctrl1 group), immobilization for 2 weeks (I-2 group), immobilization for 4 weeks (I-4 group), and immobilization for 6 weeks (I-6 group). In the intervention experiment, 24 rabbits were randomly divided into 4 groups: Control 2 (Ctrl2 group), electrical stimulation (ESG group), natural recovery (NRG group), and electrical stimulation treatment (ESTG group). All intervention effects were assessed by evaluating the knee joint range of motion (ROM), cross-sectional area (CSA) of the rectus femoris muscle, and expression of autophagy-related proteins.

RESULTS

The time-point experiment showed that immobilization reduced the knee ROM, reduced the rectus femoris muscle CSA, and activated autophagy in skeletal muscle. The levels of five autophagy-related proteins [mammalian target of rapamycin (mTOR), phosphorylated mTOR (p-mTOR), autophagy-related protein 7 (Atg7), p62, and microtubule-associated protein light chain 3B-II (LC3B-II)] were significantly elevated in the skeletal muscle of the I-4 group. The intervention experiment further showed that LFES significantly improved the immobilization-induced reductions in ROM and CSA. Additionally, LFES resulted in a significant decrease in the protein expression of mTOR, p-mTOR, Atg7, p62, and LC3B-II in the rectus femoris muscle.

CONCLUSIONS

LFES alleviates immobilization-evoked disuse muscle atrophy possibly by inhibiting autophagy in the skeletal muscle of rabbits.

Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes

Background

Neuromuscular weakness may manifest subsequent to critical illness in intensive care unit (ICU) patients. This weakness termed as “ICU-acquired weakness” (ICUAW) has a significant bearing on the length of mechanical ventilation, duration of ICU stays, long-term disability, and survival rate. Early identification of ICUAW helps in planning appropriate strategies, as well as in predicting the prognosis and long-term outcomes of these patients.

Aims and objectives

To identify the incidence of new-onset neuromuscular weakness developing among patients admitted in the ICU (ICUAW) and study its clinical course and impact on the duration of ICU stay.

Methods

This prospective observational study evaluated patients admitted to the ICU over a period of 1 year and 3 months (November 1, 2015, to January 31, 2017). All patients fulfilling the inclusion and exclusion criteria were evaluated with the Medical Research Council (MRC) score for muscle strength. Patients with an average score <4 were diagnosed with ICUAW. Included patients were examined on alternate days to study the clinical progression of the weakness till ICU discharge or death of the patient. The duration of ICU stay was noted.

Results and conclusion

The study revealed a significant association of ICUAW with age, Acute Physiology And Chronic Health Evaluation (APACHE II) Score, duration of mechanical ventilation, and ICU mortality. The incidence of the weakness was found to be 7.83% among the patients who survived and 50% among those patients who did not survive critical illness.

How to cite this article

Baby S, George C, Osahan NM. Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes. Indian J Crit Care Med 2021;25(9):1006–1012.

Effect of Intubation Timing on the Outcome of Patients With Severe Respiratory Distress Secondary to COVID-19 Pneumonia

Background

The optimal timing of intubation for critically ill patients with severe respiratory illness remains controversial among healthcare providers. The coronavirus disease 2019 (COVID-19) pandemic has raised even more questions about when to implement this life-saving therapy. While one group of providers prefers early intubation for patients with respiratory distress because these patients may deteriorate rapidly without it, other providers believe that intubation should be delayed or avoided because of its associated risks including worse outcomes.

Research question

Our objective was to assess whether the timing of intubation in patients with severe COVID-19 pneumonia was associated with differences in mortality or other outcomes.

Study design and methods

This was a single-center retrospective observational cohort study. We analyzed outcomes of patients who were intubated secondary to COVID-19 pneumonia between March 13, 2020, and December 12, 2020, at Henry Ford Hospital in Detroit, Michigan. Patients were categorized into two groups: early intubated (intubated within 24 hours of the onset of severe respiratory distress) and late intubated (intubated after 24 hours of the onset of severe respiratory distress). Demographics, comorbidities, respiratory rate oxygenation (ROX) index, sequential organ failure assessment (SOFA) score, and treatment received were compared between groups. The primary outcome was mortality. Secondary outcomes were ventilation time, intensive care unit stay, hospital length of stay, and discharge disposition. Post hoc and Kaplan-Meier survival analyses were performed.

Results

A total of 110 patients were included: 55 early intubated and 55 late intubated. We did not observe a significant difference in overall mortality between the early intubated (43%) and the late intubated groups (53%) (p = 0.34). There was no statistically significant difference in patients' baseline characteristics including SOFA scores (the early intubation group had a mean score of 7.5 compared to 6.7 in the late intubation group). Based on the ROX index, the early intubation group had significantly more patients with a reduced risk of intubation (45%) than the late group (27%) (p = 0.029). The early intubation group was treated with a high-flow nasal cannula at a significantly lower rate (47%) than the late intubation group (83%) (p < 0.001). Significant differences in patient baseline characteristics, treatment received, and other outcomes were not observed. Post hoc analysis adjusting for SOFA score between 0 and 9 revealed significantly higher mortality in the late intubation group (49%) than in the early intubation group (26%) (p = 0.03). Patients in the 0 to 9 SOFA group who were intubated later had 2.7 times the odds of dying during hospital admission compared to patients who were intubated early (CI, 1.09-6.67).

Interpretation

The timing of intubation for patients with severe COVID-19 pneumonia was not significantly associated with overall mortality or other patient outcomes. However, within the subgroup of patients with SOFA scores of 9 or lower at the time of intubation, patients intubated after 24 hours of the onset of respiratory distress had a higher risk of death than those who were intubated within 24 hours of respiratory distress. Thus, patients with COVID-19 pneumonia who are not at a high level of organ dysfunction may benefit from early mechanical ventilation.

Clinical assessment of upper limb hypertonia in central neurological diseases

The clinical assessment of a hypertonic upper limb in central neurological diseases should be analytical, systematic (shoulder, elbow, extrinsic and intrinsic hand) and focused on the patient or caregiver's wishes and on the expected objectives (esthetic, hygienic, functional). Nerve blocks can help to separate mixed contractures, show the existence of antagonist muscles or find a starter muscle in dystonia patterns. The etiology (especially the evolving nature of the disease), general health condition (especially in older adults), associated deficits (cerebellar, sensory and cognitive; hemineglect) are considered together to arrive at a contract with patients and/or caregivers.

A national survey in United Arab Emirates on practice of passive range of motion by physiotherapists in intensive care unit

BACKGROUND

Patients admitted to intensive care units (ICU) are at an increased risk of developing immobility related complications. Physiotherapists are challenged to employ preventive and rehabilitative strategies to combat these effects. Passive limb range of motion (PROM) exercises- a part of early mobilization-aid in maintaining joint range of motion and functional muscle strength and forms a part of treatment for patients in ICU. However, there is a lack of evidence on practice of PROM exercises on patients admitted to ICU in the United Arab Emirates (UAE). This study aimed at exploring practices regarding the same in UAE.

METHODS

This survey, conducted from January 2021 to February 2021 in College of Physiotherapy, Sharjah University studied practice of physiotherapists in the intensive care units. Physiotherapists currently working in ICU completed an online questionnaire composed of forty-two questions about physiotherapy service provision, assessment and intervention in the intensive care units.

RESULTS

33 physiotherapists completed the survey. 66.6% of respondents routinely assessed PROM for all the patients in ICU referred for physiotherapy. 84.8% of them assessed all the joints. More than half of the respondents (57.8%) reported that they administered PROM regularly to all the patients. According to 63.6% respondents, maintaining joint range of motion was the main reason for performing PROM. Responses pertaining to sets and repetitions of PROM were variable ranging from 1-6 sets and from 3 to 30 repetitions. Personal experience, resources/financial consideration and research findings were found to have influence on the practice.

CONCLUSIONS

PROM was found to be one of the frequently used mobilization techniques administered by physiotherapists in the intensive care units and was mostly performed after assessment. Maintaining joint range of motion was the main aim for performing PROM. Variability was found in the sets and repetitions of PROM administered. Various factors influenced the practice of PROM.

Grip Strength Correlates with Mental Health and Quality of Life after Critical Care: A Retrospective Study in a Post-Intensive Care Syndrome Clinic

Post-intensive care syndrome (PICS) is characterized by several prolonged symptoms after critical care, including physical and cognitive dysfunctions as well as mental illness. In clinical practice, the long-term follow-up of PICS is initiated after patients have been discharged from the intensive care unit, and one of the approaches used is a PICS clinic. Although physical dysfunction and mental illness often present in combination, they have not yet been examined in detail in PICS patients. Grip strength is a useful physical examination for PICS, and is reported to be associated with mental status in the elderly. We herein investigated the relationship between grip strength and the mental status using data from our PICS clinic. We primarily aimed to analyze the correlation between grip strength and the Hospital Anxiety and Depression Scale (HADS) score. We also analyzed the association between grip strength and the EuroQol 5 Dimension (EQ5D) score as quality of life (QOL). Subjects comprised 133 patients who visited the PICS clinic at one month after hospital discharge between August 2019 and December 2020. Total HADS scores were 7 (4, 13) and 10 (6, 16) (p = 0.029) and EQ5D scores were 0.96 (0.84, 1) and 0.77 (0.62, 0.89) (p ≤ 0.0001) in the no walking disability group and walking disability group, respectively. Grip strength negatively correlated with HADS and EQ5D scores. Correlation coefficients were r = -0.25 (p = 0.011) and r = -0.47 (p < 0.0001) for HADS and EQ5D scores, respectively. Grip strength was a useful evaluation that also reflected the mental status and QOL.

“Nanomaterials of curcumin-hyaluronic acid”: their various methods of formulations, clinical and therapeutic applications, present gap, and future directions

Background

Nanomaterials of curcumin with hyaluronic acid have gained a lot of attention for potential therapeutic applications of curcumin and hyaluronic acid with or without other additional drugs. Overall studies of curcumin and hyaluronic acid show that nanomaterials of curcumin with hyaluronic acid accelerate the efficacy of curcumin in the treatment of various disorders like arthritis, cancer, hepatic fibrosis, neural disorders, wound healing, and skin regeneration, it is largely due to the combined effect of hyaluronic acid and curcumin. However, due to limited clinical trials and experiments on humans and animals, there is a substantial gap in research for the safety and efficacy of nanomaterials of curcumin-hyaluronic acid in the treatment of curcumin and hyaluronic acid targeted diseases and disorders.

Main body of the abstract

In this current review, we have first described various reported synthetic nanomaterials of curcumin-hyaluronic acid, then in the next section, we have described various fields, disorders, and diseases where these are being applied and in the final section of this review, we discussed the research gap, and future research directions needed to propose the fabricated nanocurcumin-hyaluronic acid biomaterials.

Short conclusion

There are substantial gaps in research for the safety and efficacy of nanomaterials of curcumin with hyaluronic acid due to limited available data of clinical trials and experiments of nanocurcumin-hyaluronic acid biomaterials on humans and animals. So, it entirely requires serious and committed efforts through the well-organized system of practical and clinical trials which provide results, data, and detections that lead to the formulation of the best drug from curcumin with hyaluronic acid for the treatment of curcumin and hyaluronic acid targeted diseases and disorders.

Factors Associated with Development of New Joint Contractures in Long-Term Care Residents

OBJECTIVE

Limb contractures are associated with poor outcomes and quality of life in long-term care (LTC) residents. This study examined the rate of developing new joint contracture in the LTC residents and associated risk factors to formulate effective interventions in this critical but understudied area.

DESIGN

This is an observational study with data obtained from the Hong Kong Longitudinal Study on LTC Residents between 2005 and 2016.

SETTING AND PARTICIPANTS

Trained assessors (nurses, social workers, and therapists) used the Minimum Data Set Resident Assessment Instrument (MDS-RAI 2.0) to collect the data of the residents from 9 residential LTC facilities.

MEASURES

Limb contractures were defined as a functional limitation in the range of motion involving the upper or lower limbs. Primary outcomes included annual prevalence of joint contractures and factors that were associated with the development of new joint contractures.

RESULTS

We analyzed the data for 1914 older residents (674 males, mean age 83.4 years). During the first 5 years since admission, the annual prevalence of upper limb contractures increased from 29.8% to 36.5%, and lower limb contractures increased from 41.5% to 57.4%. Overall, the increment of the prevalence rate of joint contractures per year ranged from 0.7% to 3.2% for the upper limbs and 0.3% to 6.0% per year for the lower limbs. Impaired mobility, presence of neurologic diseases, and older age were the leading independent risk factors for the development of new joint contractures.

CONCLUSIONS AND IMPLICATIONS

Joint contractures are highly prevalent among residents admitted to the LTC facilities, and many residents develop new contractures during the first 5 years of their admission. Immobility appears to be the main modifiable risk factor. Further studies are needed to identify potential strategies to prevent new contractures in this vulnerable group.

[Post-intensive care syndrome]

Post-intensive care syndrome is an entity defined in 2010 and covering any sequelae following an extended hospitalization in intensive care unit. It comprises psychological, cognitive and physical disorders (neuromyopathy, respiratory dysfunction, joint stiffness, among others). These sequelae have important consequences on autonomy and quality of life of these patients, as well as on their healthcare consumption and on mortality. Psychological sequelae can also be seen in hospitalized patients' relatives. Screening and management of these disorders is more and more frequent but no method has formally proven effective. The number of patients surviving an intensive care unit hospitalization is increasing, and management of post-intensive care syndrome is a major issue. It seems important that the internist be aware of this syndrome, given his pivotal role in global management of patients and frequent implication into care after the intensive care unit.

Neglected reactive arthritis complicated by bilateral hip and temporomandibular joints ankylosis after a suspected tetanus infection: a case report

Background

Reactive arthritis had been reported to occur after various vaccinations, including the tetanus toxoid vaccine; here, we report a case of ankylosing arthropathy suggested to be a complication of missed neglected reactive arthritis after tetanus infection.

Case presentation

A healthy 20-year-old woman presented with subtrochanteric right femoral fracture; imaging studies showed bilateral ankylosed hip, kyphoscoliosis, bilateral fused temporomandibular joints, and normal sacroiliac joints bilaterally. Laboratory investigations for a rheumatic or autoimmune disease were all within normal ranges. Detailed history revealed admission of the patient to an ICU unit (1 year before the trauma) for a month as she was diagnosed as having tetanus infection, after which she was unable to walk or feed herself. At the final follow-up, the patient started walking with a moderate limb after having a series of surgeries including femoral fracture fixation, temporomandibular joint excision arthroplasty, and bilateral total hip arthroplasty.

Conclusion

Unusual complications after tetanus infection can occur in the form of joint ankylosis, which could be presented after prolonged immobilization possibly due to improper management of reactive arthritis.

Flexion contracture is a risk factor for knee osteoarthritis incidence, progression and earlier arthroplasty: Data from the Osteoarthritis Initiative

BACKGROUND

Knee joint osteoarthritis (OA) is often accompanied by flexion contracture (FC), but the impact of FC on important outcomes across the spectrum of OA, such as the incidence, progression and need for total knee arthroplasty (TKA), is not well established.

OBJECTIVE

We evaluated whether the presence and/or severity of knee FC were risk factors for worse OA clinical outcomes, radiographic incidence and progression as well as time to TKA.

METHODS

We evaluated longitudinal 9-year data from the Osteoarthritis Initiative (OAI) database for 3 sub-cohorts: at-risk of knee OA (n=3284), radiographically established knee OA (n=1390), and low-risk controls (n=122). We classified knee FC as none, mild, moderate or severe based on knee extension at enrolment. Knee OA outcomes were extracted from the database.

RESULTS

FC was present in 32.4% of knees. Participants with FC had increased knee OA incidence with joint space narrowing in the definition (corrected odds ratio 1.31 [95% confidence interval (CI) 1.04-1.64]). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for pain, stiffness and function were worse with than without FC at nearly all times (p<0.001). Effect estimates were significant for all 3 WOMAC sub-scales comparing FC to no FC (pain: 0.15 [95% CI 0.02-0.28], stiffness: 0.11 [0.05-0.18], function: 0.49 [0.05-0.93]). Individuals with knee FC had higher Kellgren and Lawrence grade (effect size 0.31 [95% CI 0.25-0.37]) and were more likely to undergo TKA (corrected odds ratio 1.37 [95% CI 1.10-1.71]) than those without FC. All outcomes were worse with increasing FC severity.

CONCLUSION

The presence of knee FC at enrolment was a risk factor for radiographic OA incidence including joint space narrowing, worse clinical outcomes, radiographic progression and the need for early TKA. Treatment of knee FC may represent an option across the OA spectrum. Further research is needed to evaluate the pathophysiology, joint structure alterations and longitudinal impact of treating FC in individuals with knee OA.

Embryonic movement stimulates joint formation and development: Implications in arthrogryposis multiplex congenita

Arthrogryposis multiplex congenita (AMC) is a heterogeneous syndrome where multiple joints have reduced range of motion due to contracture formation prior to birth. A common cause of AMC is reduced embryonic movement in utero. This reduction in embryonic movement can perturb molecular mechanisms and signaling pathways involved in the formation of joints during development. The absence of mechanical stimuli can impair joint cavitation, resulting in joint fusion, and ultimately eliminate function. In turn, mechanical stimuli are critical for proper joint formation during development and for mitigating AMC. Studies in experimental animal models have provided a greater understanding on the molecular pathophysiology of congenital contracture formation as a consequence of embryonic immobilization. Elucidation of how the mechanical signaling environment is transduced to initiate a biological response will be necessary to gain a deeper understanding of how mechanical stimuli are intertwined in the molecular regulation of joint development.

COVID-19: Patient Characteristics in the First Phase of Postintensive Care Rehabilitation

Objective

To describe clinical characteristics of patients after intensive care unit (ICU) treatment for coronavirus disease 2019 (COVID-19) who were admitted for inpatient rehabilitation.

Design

A cross-sectional design.

Setting

Inpatient rehabilitation care in the Netherlands.

Participants

All post-ICU patients with COVID-19 admitted to the rehabilitation center between April 2 and May 13, 2020, were invited to participate in the study. Included were patients older than 18 years needing inpatient rehabilitation after ICU treatment for COVID-19 (N=60; mean age, 59.9y; 75% male).

Interventions

Not applicable.

Main Outcome Measures

The following information was collected in the first week of inpatient rehabilitation care: (1) demographics; (2) ICU stay parameters; (3) medical, physical, and functional characteristics; and (4) self-reported symptoms.

Results

The most important findings for rehabilitation were the following: in the first week after discharge to the rehabilitation center, 38.3% of all patients experienced exercise-induced oxygen desaturation, in 72.7% muscle weakness was present in all major muscle groups, and 21.7% had a reduced mobility in 1 or both shoulders. Furthermore 40% had dysphagia, and 39.2% reported symptoms of anxiety.

Conclusion

Post-ICU patients with COVID-19 display physical and anxiety symptoms as reported in other post-ICU patient groups. However, this study showed some remarkable clinical characteristics of post-ICU patients with COVID-19. Rehabilitation programs need to anticipate on this. Long-term follow-up studies are necessary.

Physical rehabilitation in Intensive Care Unit in acute respiratory distress syndrome patients with COVID-19

BACKGROUND

The risk of muscle weakness is high in the survivors of acute respiratory distress syndrome with COVID-19 following discharge from intensive care unit.

AIM

To evaluate the effects of early rehabilitation program in intensive care unit in patients with acute respiratory distress syndrome secondary to COVID-19.

DESIGN

The design of the study is observational.

SETTING

The setting of the study is inpatient.

POPULATION

Thirty-five patients with acute respiratory distress syndrome secondary to COVID-19 were enrolled.

METHODS

This study was performed in an intensive care unit of a university hospital. Early rehabilitation program consisting of passive or active range of motion exercises and neuromuscular electrical stimulation in addition to standard intensive care (N.=18) compared to standard intensive care (N.=17). Primary outcome was hand grip strength following discharge.

RESULTS

Rehab group had higher prevalence of chronic pulmonary diseases and neurologic diseases. There was no difference in hand grip or manual muscle strength following discharge between rehab and non-rehab groups. No adverse event was noted.

CONCLUSIONS

The results did not support the beneficial effects of early rehabilitation in intensive care unit on improving muscle strength. More patients with pulmonary and neurologic diseases in rehab group might impede the impact of rehabilitation on outcomes. On the other hand, these comorbidities underline the role and need of rehabilitation. It is safe both for the patients and the health care workers when necessary precautions are taken.

CLINICAL REHABILITATION IMPACT

This study guide how to rehabilitate patients with acute respiratory distress syndrome with COVID-19 during intensive care unit in a safe way.

COMPARISON OF METHODS FOR EVALUATING UPPER LIMB STRENGTH BY HAND-HELD DYNAMOMETRY

ABSTRACT Introduction The upper limbs are segments of the human body responsible for primary activities of daily life, and the muscles are essential structures for performing these activities. There have been few studies on intra- and inter-examiner reliability of the hand-held dynamometer (HHD) in healthy subjects, and none have been published that compare dynamometric evaluation methods in the main muscles in this segment. Objective Evaluate intra-examiner and inter-examiner assessment reliability of the hand-held dynamometry of upper limb muscles in healthy individuals, as well as comparing the assessment reliability between fixed and non-fixed methods. Methods Healthy subjects aged over 18 years were recruited for the study. The isometric contraction for ten muscle groups of the dominant upper limb was tested. For the fixed method, we used a system of suction cups, connected to the HHD by an inelastic belt. For the non-fixed method, the examiner supported the device by hand. The isometric contraction was sustained for three seconds. Each measurement was repeated three times, considering the highest value obtained. The reliability was calculated using the intraclass correlation coefficient (ICC). The dispersion between measurements was expressed by a Bland-Altman plot. Results The sample consisted of 25 volunteers, all right-handed. The intra-examiner ICC was 0.89-0.99 for the non-fixed method, and 0.43 to 0.85 for the fixed method. Inter-examiner reliability showed equivalent behavior. This study showed that evaluation of upper limb muscle strength using an isometric dynamometer has excellent intra-examiner and inter-examiner reliability. The supine position was chosen due to the need to propose a feasible protocol for clinical practice that could be replicated for the majority of publics and in different environments. The non-fixed method showed better reliability overall, demonstrating the feasibility of this tool without the need for adaptations, additional devices, or increased operating costs for this evaluation. Conclusion Comparison between the fixed and non-fixed HHD methods demonstrated superiority of the non-fixed method in terms of reliability. Level of evidence II; Investigation of a diagnostic exam - Development of diagnostic criteria with consecutive patients.

Bone replaces unloaded articular cartilage during knee immobilization. A longitudinal study in the rat

BACKGROUND

Joint immobility results in deleterious changes such as capsule shortening, bone loss and articular cartilage damage. Immobilization of rat knees in flexion for 32 weeks resulted in the distinctive feature of well-established replacement of articular cartilage by bone. Determining the time of onset of bone replacement is critical for the prevention of this likely irreversible complication of joint immobilization.

OBJECTIVES

To determine the onset and progression of bone replacement in the anterior tibial articular cartilage following knee immobilization in flexion.

METHODS

One hundred forty-nine adult male Sprague-Dawley rats were used. The experimental groups had one knee immobilized at 135°of flexion for durations of 2, 4, 8, 16 or 32 weeks and were compared to age-matched controls. The knees were evaluated histologically for the presence and cross-sectional area of bone within the articular cartilage of the tibia. Distance between the anterior aspect of the tibia and intact articular cartilage and cross-sectional bone area of the tibial epiphysis were also measured.

RESULT

Bone replacement in the articular cartilage was observed in 14%, 75%, 95%, 100% and 100% of knees after 2, 4, 8, 16 and 32 weeks of immobilization, respectively. No bone replacement was seen in the control knees. The mean area of bone replacement increased from 0.004 ± 0.007 mm² after 2 weeks to 0.041 ± 0.036 mm²; 0.085 ± 0.077 mm²; 0.092 ± 0.056 mm² and 0.107 ± 0.051 mm² after 4, 8, 16 and 32 weeks of immobilization, respectively, (p < 0.001) largely restricted to the anterior tibial articular cartilage. Mean distance to intact articular cartilage increased from 0.89 ± 0.69 mm at 2 weeks to 1.10 ± 0.35 mm; 1.65 ± 0.77 mm; 1.48 ± 0.63 mm; and 1.78 ± 0.58 mm after 4, 8, 16 and 32 weeks of immobilization, respectively (p = 0.001). Epiphyseal bone cross-sectional area was significantly reduced following 4, 8, and 16 weeks of immobilization compare to controls (all 3 p < 0.05).

CONCLUSION

Knee immobilization in flexion resulted in bone replacement in the anterior tibial articular cartilage that began after 2 weeks and was prevalent after 4 weeks of immobilization. The bone replacement progressed in an anterior-to-posterior direction and stopped at the area of contact between tibia and femur. These findings stress the importance of mobility to maintain joint health.

Long-term outcomes from critical care

With the improved survival of critical care patients, a cohort of chronically critically ill patients has emerged. These patients have a higher 5-year morbidity and mortality and greater utilization of healthcare resources. This well-documented deterioration in physical, cognitive and/or psychological health in critical care survivors is known as post intensive care syndrome (PICS) which has personal and socioeconomic implications not only for the patient, but also for their families, care givers and society. Greater awareness of the impact of critical illness on quality of life has led to the emergence of research focused on overall patient outcomes rather than crude survival. National guidelines state personal rehabilitation programmes involving a multidisciplinary team should be commenced within 4 days of admission and continued after discharge to the ward. Once discharged home specialist ICU follow-up clinics are key in identifying any long-term complications of critical care admission and should focus on all aspects of the PICS. COVID-19 has highlighted PICS on a national level with patients experiencing multiple long-term complications of critical illness, some as yet unknown.

Demographic and Burn Injury-Specific Variables Associated with Limited Joint Mobility at Discharge in a Multicenter Study

Burn scar contractures. Existing research on contractures is limited by incomplete analysis of potential contributing variables and differing protocols. This study expands the exploration of contributing variables to include surgery and rehabilitation treatment-related factors. Additionally, this study quantifies direct patient therapy time and patient exposure to rehabilitation prevention therapies. Data from subjects enrolled in the prospective Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) were analyzed to determine variables related to a limited range of motion (limROM) in seven joints and 18 motions (forearm supination) at discharge. Chi-squared and Student’s t-test were used accordingly. Multivariate analysis was performed at the patient and joint motion level to control for confounders. Of the 300-member study group, 259 (86.3%) patients had limROM at discharge. Variables independently related to the development of moderate-to-severe limROM on the patient level were larger TBSA, having skin grafted and prolonged bed rest. Variables independently related to moderate–severe limROM on the joint motion level were the percentage of cutaneous functional unit (CFU) burned (P = .044), increase in the length of stay, weight gain, poor compliance with rehabilitation therapy and lower extremity joint burns. Rates of limROM are increased in patients who had larger burns, required surgery, had a greater percentage of the associated CFU burned, and had lower extremity burns. Attention to adequate pain control to ensure rehabilitation tolerance and early ambulation may also decrease limROM at discharge and quicker return to pre-burn activities and employment.

Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit

Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.

Joint flexibility problems and the impact of its operationalisation

BACKGROUND

Dissatisfaction is being voiced with the generally used way joint flexibility problems are defined (operationalised), i.e. as a range of motion (ROM) one or more degrees lower than normative ROM of healthy subjects. Other, specifically more function-related operationalisations have been proposed. The current study evaluated the effect of applying different operationalisations of joint flexibility problems on its prevalence.

METHOD

ROM data of 95 joints affected by burns of 23 children were used, and data on 18 functional activities (Burn Outcome Questionnaire (BOQ)). Five methods were used to operationalise joint flexibility problems: (1) ROM below normative ROM, (2) ROM below normative ROM minus 1SD, (3) ROM below normative ROM minus 2SD, (4) ROM below functional ROM, and (5) a score of 2 or more on the Likert Scale (BOQ).

RESULTS

Prevalence of joint flexibility problems on a group level ranged from 13 to 100% depending on the operationalisation used. Per joint and movement direction, prevalence ranged from 40% to 100% (Method 1) and 0% to 80% (Methods 2-4). 18% of the children received '2' on the Likert Scale (Method 5).

CONCLUSION

The operationalisation of joint flexibility problems substantially influences prevalence, both on group and joint level. Changing to a function-related operationalisation seems valuable; however, international consensus is required regarding its adoption.

TRIAL REGISTRATION

The study is registered in the National Academic Research and Collaborations Information System of the Netherlands (OND1348800).

Hyaluronic acid-curcumin conjugate suppresses the fibrotic functions of myofibroblasts from contractive joint by the PTGER2 demethylation

Joint contracture is a fibrotic complication induced by joint immobilization and trauma, which is characterized as excessive myofibroblast proliferation in joint capsule. The treatments of joint contracture are unsatisfied and patients are suffered from joint dysfunction. Our previous study has shown that curcumin can inhibit myofibroblast proliferation in vitro, but the major challenge is the low aqueous solubility and biological activity of curcumin. In this study, hyaluronic acid-curcumin (HA-Cur) conjugate was synthesized to suppress myofibroblasts in joint contracture. Cells were isolated from the joint capsules of joint contracture patients and induced to active myofibroblasts by transforming growth factor-β (TGF-β). The anti-fibrotic function and mechanisms of HA-Cur were investigated by immunohistochemistry, reverse transcription-quantitative polymerase chain reaction (PCR), methylation-specific PCR, western blot, transwell migration assay and proliferation assay. Results showed that 30 μM HA-Cur significantly attenuated the fibrotic functions of myofibroblast in joint contracture in vitro by regulating the methylation of prostaglandin E receptor 2 (PTGER2) and inhibiting TGF-β signaling. This may provide a mechanism for the treatment of joint contracture, and provide a molecular target PTGER2 for therapy during the pathogenesis of joint contracture.

Shoulder Impairment Following Critical Illness: A Prospective Cohort Study

Supplemental Digital Content is available in the text.

Objectives:

Identify the prevalence of shoulder impairment in ICU survivors within 6 months of discharge from ICU. Evaluate the impact of shoulder impairment on upper limb functional status in patients treated on an ICU. Identify risk factors for the development of shoulder impairment.

Design:

Prospective cohort study.

Setting:

A tertiary care medical-surgical-trauma ICU at a U.K. hospital over 18 months, with a further 6-month follow-up after hospital discharge.

Subjects:

Adult patients with an ICU length of stay of greater than 72 hours with no preexisting or new neurologic or traumatic upper limb injury.

Interventions:

None.

Measurements and Main Results:

Patients underwent targeted shoulder assessments (pain, range of movement, Constant-Murley Score, shortened version of the disabilities of the arm, shoulder, and hand [DASH] score [QuickDASH] score) at hospital discharge, 3 and 6 months after hospital discharge. Assessments were undertaken on 96 patients, with 62 patients attending follow-up at 3 months and 61 patients at 6 months. Multivariate regression analysis was used to investigate risk factors for shoulder impairment. ICU-related shoulder impairment was present in 67% of patients at 6 months following discharge from hospital. Upper limb dysfunction occurred in 46%, with 16% having severe dysfunction (equivalent to shoulder dislocation). We were unable to identify specific risk factors for shoulder impairment.

Conclusions:

Shoulder impairment is a highly prevalent potential source of disability in ICU survivors. This persists at 6 months after discharge with a significant impact on upper limb function. More research is needed into potential mechanisms underlying shoulder impairment and potential targeted interventions to reduce the prevalence.

The effect of adding TENS to stretch on improvement of ankle range of motion in inactive patients in intensive care units: a pilot trial

Background

Patients hospitalized in intensive care units (ICUs) are susceptible to joint contracture and diminished range of motion. This is due to immobility as well as other underlying factors such as brain damage. Joint contracture causes functional disorders thereby diminishing the quality of life of patients following the intensive care period. Recent studies have introduced transcutaneous electrical nerve stimulation (TENS) as a new method for preventing and treating joint contracture. This study was performed to determine the effect of adding TENS to stretch on the range of ankle motion in patients hospitalized in ICUs.

Methods

Thirty-six patients admitted to the ICU ward of the hospital who were not able to move their legs voluntarily were assigned randomly into experimental (n = 18) and control (n = 18) groups. The intervention group received TENS along with manual stretch in the ankle three times a week for 2 weeks. The control group only received stretch in the ankle for the same time. The extent of dorsiflexion and plantar flexion of the ankle was measured using a standard goniometer. Both groups were evaluated before and one and 2 weeks after the intervention. The obtained data were analyzed by SPSS 21 through analysis of covariance and repeated measures ANOVA tests.

Results

In both groups, the increase in the ankle range of motion parameters was significant over time (means ranged over 44–48 for plantar flexion and means ranged over 5–11 for dorsiflexion, P < 0.001 for all of time points). The increase in ankle plantar and dorsiflexion in experimental group was significantly more than control group (mean between-group differences ranged over 1.35–3.57 within 95% CI of 1.04 to 4.01, P < 0.001).

Conclusion

Adding TENS to stretch may provide more improvement in ankle dorsiflexion and plantar flexion.

Trial registration

Trial registration: This study was registered in the Iranian Clinical Trial Center with the code IRCT2017010814333N64, registered 20 January 2017.

Effectiveness of stretching and bracing for the treatment of osteoarthritis-associated joint contractures prior to joint replacement: a systematic review protocol

INTRODUCTION

Many patients with osteoarthritis (OA) develop restrictions in passive range of motion (ROM) of their affected joints (called contractures), leading to increased pain and reduced function. Effective treatment to reverse OA-associated contractures is lacking. Our aim is to evaluate the effectiveness of stretching and bracing on native (non-operated) joint contractures in people with radiographically diagnosed OA.

METHODS AND ANALYSIS

We will search the following databases without time restriction: Cochrane Library (CENTRAL, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database), MEDLINE, Embase, CINAHL, SCI-EXPANDED (ISI Web of Knowledge) and PEDro. Other sources will include WHO International Clinical Trials Registry Platform, reference lists of included studies, relevant systematic reviews and textbooks. We will include randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies, cohort studies and case-control studies that include participants ≥18 years of age with radiographic evidence of OA. Participants with inflammatory arthropathies or those that have undergone joint arthroplasty will be excluded. Interventions will include therapist-administered or patient-administered stretching, use of an orthosis (static or dynamic), use of serial casting and/or adjunctive modalities. Outcomes will include joint ROM (active and passive), pain (rest and/or activity related), stiffness, activity limitations, participation restrictions, quality of life and adverse events. Studies will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study inclusion, data extraction and quality assessment will be performed independently by two reviewers. Risk of bias will be assessed using appropriate tools for each study design. Data synthesis will be performed using Cochrane Review Manager software. If sufficient data are available, meta-analysis will be conducted. We will summarise the quality of evidence using Grading of Recommendations Assessment, and the effect size of interventions for RCT and non-RCT studies.

ETHICS AND DISSEMINATION

Ethics approval not required because individual patient data are not included. Findings will be disseminated in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019127244.

Chronic pain in critical care survivors: a narrative review

Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.

Chronic Pain and Chronic Opioid Use After Intensive Care Discharge - Is It Time to Change Practice?

Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33-73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.

Effects of early, combined endurance and resistance training in mechanically ventilated, critically ill patients: A randomised controlled trial

INTRODUCTION

Neuromuscular weakness resulting in severe functional impairment is common in critical care survivors. This study aimed to evaluate effects of an early progressive rehabilitation intervention in mechanically ventilated adults at risk.

METHODS

This was a parallel, two-arm, assessor-blinded, randomised controlled trial with 6-months follow-up that was conducted in a mixed ICU of an academic centre in Switzerland. Previously independent, mechanically ventilated, critically ill adults with expected critical care stay ≥72 hours (n = 115) were randomised to a control group receiving standard physiotherapy including early mobilisation or to an experimental group with early endurance and resistance training combined with mobilisation. Primary endpoints were functional capacity (6-Minute Walk Distance) and functional independence (Functional Independence Measure) at hospital discharge. Secondary endpoints including muscle strength were assessed at critical care discharge. Safety was monitored closely by standard monitoring and predefined adverse events.

RESULTS

Physiotherapy started within 48 hours of critical care admission while 97% of participants were still ventilated and 68% on inotropes. Compared to the control group (n = 57), the experimental group (n = 58) received significantly more physiotherapy (sessions: 407 vs 377, p<0.001; time/session: 25min vs 18min, p<0.001) and had less days with sedation (p<0.001). Adverse events were rare (0.6%) and without consequences. There were no significant between-group differences in 6-Minute Walk Distance (experimental 123m (IQR 25-280) vs control 100m (IQR 0-300); p = 0.542) or functional independence (98 (IQR 66-119) vs 98 (IQR 18-115); p = 0.308). Likewise, no differences were found for the secondary outcomes, except a trend towards improved mental health in the experimental group after 6 months (84 (IQR 68-88) vs 70 (IQR 64-76); p = 0.023).

CONCLUSIONS

Early endurance and resistance training in mechanically ventilated, intensive care patients does not improve functional capacity or independence at hospital discharge compared to early standard physiotherapy but may improve mental health 6-months after critical care discharge.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00004347, registered on 10 September 2012.

Effect of Transcutaneous Electrical Neuromuscular Stimulation on Myopathy in Intensive Care Patients

BACKGROUND

Critical illness polyneuropathy or myopathy is a severe disorder that may adversely affect patients in the intensive care unit, resulting in reduced mobilization, decline in muscle mass, and prolonged recovery periods.

OBJECTIVE

To examine whether the application of trans-cutaneous electrical neuromuscular stimulation (TENMS) reduces the incidence or severity of myopathy related to critical illness in intensive care unit patients.

METHODS

A total of 80 patients aged 18 years or older with an intensive care unit stay of 96 hours or more and receipt of mechanical ventilation for 96 hours or more were initially enrolled in a prospective, open-label randomized controlled trial in a university hospital. Patients received either conventional physical therapy alone (control group) or conventional physical therapy plus TENMS (TENMS group) for 10 days. Myopathy was assessed histologically (by needle biopsy of the quadriceps muscles) on the 4th and 14th days of the intensive care unit stay.

RESULTS

Of the 68 patients who completed the study, 27 (40%) had myopathy on the 14th day: 11 patients in the TENMS group (9 mild, 1 moderate, and 1 severe) and 16 patients in the control group (13 mild, 2 moderate, and 1 severe). Patients who progressed from mild to moderate or severe myopathy between the 4th and 14th days had significantly lower body mass index (P = .001) and longer time periods with inadequate nutrition (P = .049) compared with the other patients. Mean (SD) Rankin scale scores at 6 months were 3.2 (1.8) and 3.8 (2.1) in the TENMS and control groups, respectively (P = .09).

CONCLUSION

TENMS had no significant impact on myopathy in the critically ill patients in this study.

The Incidence of Physiatry-Relevant Complications in Trauma Patients Admitted to an Urban Canadian Trauma Center

The objective of this study was to describe the incidence of complications in trauma patients that could be prevented, diagnosed, or managed by a consulting acute care physiatrist. Demographic and complication data were extracted by chart review of adult trauma patients admitted to a Canadian academic trauma center. Subjects were included if they had a diagnosis of traumatic brain injury, spinal cord injury, or multiple injuries resulting in an Injury Severity Score greater than 15. Means and standard deviations were calculated for continuous variables and frequencies for categorical data. Secondary analyses involved using Spearman's ρ and χ analysis to examine relationships between the development of complications and various patient factors. A total of 286 individuals were included. The overall incidence of a physical medicine & rehabilitation-relevant complication was 32.9%. The complications with the highest incidence were pneumonia (15.5%), delirium (14.1%), and urinary tract infection (13.4%). Secondary analyses demonstrated associations between the development of complications with older age, the presence of comorbidities, having both a traumatic brain injury and spinal cord injury, and length of stay. This study demonstrated that trauma patients may experience multiple complications that are of relevance to the consulting physiatrist.

Rating scales for shoulder and elbow range of motion impairment: Call for a functional approach

Background

To evaluate the effect of (new) treatments or analyse prevalence and risk factors of contractures, rating scales are used based on joint range of motion. However, cut-off points for levels of severity vary between scales, and it seems unclear how cut-off points relate to function. The purpose of this study was to compare severity ratings of different rating scales for the shoulder and elbow and relate these with functional range of motion.

Methods

Often used contracture severity rating scales in orthopedics, physiotherapy, and burns were included. Functional range of motion angles for the shoulder and elbow were derived from a recent synthesis published by our group. Shoulder flexion and elbow flexion range of motion data of patients three months after a burn injury were rated with each of the scales to illustrate the effects of differences in classifications. Secondly, the shoulder and elbow flexion range of motion angles were related to the required angles to perform over 50 different activities of daily living tasks.

Results

Eighteen rating scales were included (shoulder: 6, elbow: 12). Large differences in the number of severity levels and the cut-off points between scales were determined. Rating the measured range of motions with the different scales showed substantial inconsistency in the number of joints without impairment (shoulder: 14–36%, elbow: 26–100%) or with severe impairment (shoulder: < 10%–29%, elbow 0%–17%). Cut-off points of most scales were not related to actual function in daily living.

Conclusion

There is an urgent need for rating scales that express the severity of contractures in terms of loss of functionality. This study proposes a direction for a solution.

Changing the Perceptions of a Culture of Safety for the Patient and the Caregiver: Integrating Improvement Initiatives to Create Sustainable Change

Evidence indicates that chances for a successful patient mobility program, prevention of pressure injury and falls, and safe patient handling are enhanced when an organization possesses an appropriate culture for safety. Frequently, these improvement initiatives are managed within silos often creating a solution for one and a problem for the others. A model of prevention integrating early patient mobility, preventing pressure injuries and falls while ensuring caregiver safety, is introduced. The journey begins by understanding why early mobility and safe patient handling are critical to improving overall patient outcomes. Measuring current culture and understanding the gaps in practice as well as strategies for overcoming some of the major challenges for success in each of these areas will result in sustainable change.