Joint contractures in the intensive care unit: quality of life and function 3.3 years after hospital discharge

Effects of Acupotomy on Immobilization-Induced Gastrocnemius Contracture and Fibrosis in Rats via Wnt/β-Catenin Signaling

OBJECTIVE

To determine whether acupotomy ameliorates immobilization-induced muscle contracture and fibrosis via Wnt/β-catenin signaling pathway.

METHODS

Thirty Wistar rats were randomly divided into 5 groups (n=6) by a random number table, including control, immobilization, passive stretching, acupotomy, and acupotomy 3 weeks (3-w) groups. The rat model of gastrocnemius contracture was established by immobilizing the right hind limb in plantar flexion for 4 weeks. Rats in the passive stretching group received passive stretching at gastrocnemius, a daily series of 10 repetitions for 30 s each at 30-s intervals for 10 consecutive days. Rats in the acupotomy and acupotomy 3-w groups received acupotomy once and combined with passive stretching at gastrocnemius a daily series of 10 repetitions for 30 s each at 30-s intervals for 10 consecutive days. Additionally, rats in the acupotomy 3-w group were allowed to walk freely for 3 weeks after 10-day therapy. After treatment, range of motion (ROM), gait analysis [i.e., paw area, stance/swing and maximum ratio of paw area to paw area duration (Max dA/dT)], gastrocnemius wet weight and the ratio of muscle wet weight to body weight (MWW/BW) were tested. Gastrocnemius morphometric and muscle fiber cross-sectional area (CSA) were assessed by hematoxylin-eosin staining. Fibrosis-related mRNA expressions (i.e., Wnt 1, β-catenin, axin-2, α-smooth muscle actin, fibronectin, and types I and III collagen) were measured using real-time quantitative polymerase chain reactions. Wnt 1, β-catenin and fibronectin concentrations were measured by enzyme-linked immunosorbent assay. Types I and III collagen in the perimysium and endomysium were analyzed using immunofluorescence.

RESULTS

Compared with the control group, ROM, gait function, muscle weight, MWW/BW and CSA were significantly decreased in the immobilization group (all P<0.01), while protein levels of types I and III collagen, Wnt 1, β-catenin, fibronectin and mRNA levels of fibrosis-related genes were obviously increased (all P<0.01). Treatment with passive stretching or acupotomy restored ROM and gait function and increased muscle wet weight, MWW/BW and CSA (all P<0.05), while protein expression levels of Wnt 1, β-catenin, fibronectin, types I and III collagen and mRNA levels of fibrosis-related genes were remarkably declined compared with the immobilization group (all P<0.05). Compared with passive stretching group, ROM, gait function, MWW was remarkably restored (all P<0.05), and mRNA levels of fibrosis-related genes as well as protein expression levels of Wnt 1, β-catenin, fibronectin, types I and III collagen in the acupotomy group were obviously decreased (all P<0.05). Compared with the acupotomy group, ROM, paw area, Max dA/dT, and MWW were restored (all P<0.05), and mRNA levels of fibrosis-related genes along with protein levels of Wnt 1, β-catenin, fibronectin, types I and III collagen in the acupotomy 3-w group were decreased (P<0.05).

CONCLUSION

Improvements in motor function, muscle contractures, and muscle fibrosis induced by acupotomy correlates with the inhibition of Wnt/β-catenin signaling pathway.

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.

Upper limb function of individuals hospitalized in intensive care: A 6-month cohort study

BACKGROUND

Impaired physical function is a common complication in intensive care unit (ICU) patients. However, specific upper limb (UL) function is still poorly studied in this population.

OBJECTIVE

To evaluate UL function at discharge and after a 6-month follow-up of individuals hospitalized in the ICU.

METHODS

This was a longitudinal prospective 6-month multicentre cohort study with forty-six individuals hospitalized in the ICU undergoing mechanical ventilation for ≥ 48 h (ICU Group) and forty-six healthy individuals matched by sex, age, and socioeconomic status (control Group). The primary outcomes were measurements of UL disability using the Jebsen-Taylor Hand Function Test (JTT) and the Nine Hole Peg Test (NHPT). Secondary outcomes were physical function (Barthel index), muscle strength (Medical Research Council scale and hand grip strength), and quality of life (EuroQol-5 Dimension). All measurements were assessed after ICU discharge and at a 6-month follow-up.

RESULTS

The JTT performance time in the ICU group after discharge was worse than that in the control group [121 s (86-165) vs. 54 s (49-61), median (IQR), p<0,001] and was reduced after 6 months [62 s (54-81), p<0,01]. The NHPT performance time at discharge in the ICU group was worse than that in the controls [39 s (33-59) vs. 21 s (20-23), p<0,001] and was reduced after 6 months of follow-up [24 s (21-27), p<0,01]. Physical function, muscle strength and quality of life were reduced after ICU discharge.

CONCLUSION

Individuals hospitalized in the ICU presented with reduced UL function at discharge and at the 6-month follow-up.

A holistic approach for severe flexion contracture of bilateral hip, knee, and ankle joints in a neglected patient with prolonged knee-chest positioning on extreme undernourishment: a case report and review of the literature

Background

Flexion contracture in the lower extremity is a common finding in the patient with neuromusculoskeletal disorders. However, severe cases due to prolonged immobilization in knee–chest position are rarely established and remain underreported. This condition is associated with high morbidity and reduced quality of life, especially when it comes to neglected cases with missed injury and late presentation for adequate primary care and rehabilitative program. It remains a difficult challenge to treat, with no established treatment protocol. In addition, other factors related to psychological and socioeconomic conditions may interfere and aggravate the health state of such patients.

Case presentation

A 19-year-old Javanese man presented with flexion contracture of bilateral hip, knee, and ankle joints due to prolonged immobilization in knee–chest position for almost 2 years following a traffic accident and falling in the bathroom. The condition had persisted for the last 3 years due to irrecoverable condition and lack of awareness. In addition, the patient also presented with paraplegia at level L2–S1, dermatitis neglecta, multiple pressure ulcers, community-acquired pneumonia, and severe malnutrition. Prolonged and sustained passive stretching with serial plastering were performed in the patient. By the time of discharge, patient was able to move and ambulate using wheelchair. Progressive improvement of range of motion and good sitting balance were observed by 3-month follow-up.

Conclusion

A combination of surgery and rehabilitative care is required in the setting of severe flexion contracture. Passive prolonged stretching showed a better outcome and efficacy in the management of flexion contracture, whether the patient undergoes surgery or not. However, evaluation of residual muscle strength, changes in bone density and characteristic, and the patient’s general and comorbid conditions must always be considered when determining the best treatment of choice for each patient to achieve good outcome and result. A holistic approach with comprehensive assessment is important when treating such patients.

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.

Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review

Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.

Preventive effect and possible mechanisms of ultrashort wave diathermy on myogenic contracture in a rabbit model

The purpose of this study was to determine the preventive effect of ultrashort wave diathermy on immobilization-induced myogenic contracture and to explore its underlying mechanisms. Forty-two rabbits were randomly assigned into control (Group C), immobilization (Group I, which was further divided into one week, Group I-1; two weeks, Group I-2; and four weeks, Group I-4, subgroups by the length of immobilization) and ultrashort wave prevention (Group U, which was further divided into one week, Group U-1; two weeks, Group U-2; and four weeks, Group U-4, by time of treatment) groups. Intervention effects were assessed by evaluating rectus femoris cross-sectional area (CSA), knee range of motion, and the protein levels for myogenic differentiation (MyoD) and muscle atrophy F-box (MAFbx-1) in the rectus femoris. Compared with those of Group C, in Groups I and U, total contracture, myogenic contracture, MyoD and MAFbx-1 levels were significantly elevated, and CSA was significantly smaller (p < 0.05). Compared with those of Group I at each time point, MyoD levels were significantly elevated, MAFbx-1 levels were significantly lower, CSA was significantly larger, and myogenic contracture was significantly alleviated in Group U (p < 0.05). In the early stages of contracture, ultrashort wave diathermy reduces muscle atrophy and delays the process of myogenic contracture during joint immobilization; the mechanism of this may be explained as increased expression of MyoD triggered by suppression of the MAFbx-1-mediated ubiquitin-proteasome pathway.

Modular reorganization of gait in chronic but not in artificial knee joint constraint

It is currently unknown if modular reorganization does occur if not the central nervous system, but the musculoskeletal system is affected. The aims of this study were to investigate 1) the effects of an artificial knee joint constraint on the modular organization of gait in healthy subjects; and 2) the differences in modular organization between healthy subjects with an artificial knee joint constraint and people with a similar but chronic knee joint constraint. Eleven healthy subjects and eight people with a chronic knee joint constraint walked overground at 1 m/s. The healthy subjects also walked with a constraint limiting knee joint movement to 20°. The total variance accounted (tVAF) for one to four synergies and modular organization were assessed using surface electromyography from 11 leg muscles. The distribution of number of synergies were not significantly different between groups. The tVAF and the motor modules were not significantly affected by the artificial knee constraint. A higher tVAF for one and two synergies, as well as merging of motor modules were observed in the chronic knee constraint group. We conclude that in the short-term a knee constraint does not affect the modular organization of gait, but in the long-term a knee constraint results in modular reorganization. These results indicate that merging of motor modules may also occur when changes in the mechanics of the musculoskeletal system is the primary cause of the motor impairment.NEW & NOTEWORTHY It is currently unknown if modular reorganization does occur if not the central nervous system, but the musculoskeletal system is affected. This study showed that in the short-term a knee constraint does not affect the modular organization of gait, but in the long-term a knee constraint results in modular reorganization. These results indicate that modular reorganization may also occur when changes in the mechanics of the musculoskeletal system is the primary cause of the motor impairment.

Psychometric validation of the Chinese version of the PaArticular Scales among elderly residents in long-term care facilities with joint contractures

Background

Joint contractures, which affect activity, participation, and quality of life, are common complications of neurological conditions among elderly residents in long-term care facilities. This study examined the reliability and validity of the Chinese version of the PaArticular Scales in a population with joint contractures.

Methods

A cross-sectional study design was used. The sample included elderly residents older than 64 years with joint contractures in an important joint who had lived at one of 12 long-term care facilities in Taiwan for more than 6 months (N = 243). The Chinese version of the PaArticular Scales for joint contractures was generated from the English version through five stages: translation, review, back-translation, review by a panel of specialists, and a pretest. Test-retest reliability, internal consistency reliability, construct validity, and criterion validity were evaluated, and the results were compared with those for the World Health Organization Quality of Life scale and the World Health Organization Disability Assessment Schedule.

Results

The Chinese version of the PaArticular Scales had excellent reliability, with a Cronbach α coefficient of 0.975 (mean score, 28.98; standard deviation, 17.34). An exploratory factor analysis showed three factors and one factor with an eigenvalue > 1 that explained 75.176 and 62.83 % of the total variance in the Activity subscale and Participation subscale, respectively. The subscale-to-total scale correlation analysis showed Pearson correlation coefficients of 0.881 for the Activity subscale and 0.843 for the Participation subscale. Pearson’s product-moment correlation revealed that the correlation coefficient (r) between the Chinese version of the PaArticular Scales and the World Health Organization Disability Assessment Schedule was 0.770, whereas that for the World Health Organization Quality of Life scale was − 0.553; these values were interpreted as large coefficients.

Conclusions

The underlying theoretical model of the Chinese version of the PaArticular Scales functions well in Taiwan and has acceptable levels of reliability and validity. However, the Chinese version must be further tested for applicability and generalizability in future studies, preferably with a larger sample and in different clinical domains.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02297-5.

Réadaptation musculaire après infection à COVID-19

L’infection sévère à COVID 19 peut-être à l’origine d’atteintes respiratoires et neuromusculaires variées autant à la phase aiguë qu’à distance de l’infection initiale. Une prise en charge rééducative doit être proposée aux différentes phases de l’infection. Par manque de données probantes, cette prise en charge s’appuie sur les données publiées pour les infections respiratoires sévères comme le SARS et l’avis d’experts. Elle doit associer du renforcement musculaire, un reconditionnement à l’effort et une kinésithérapie respiratoire plus spécifique pour certains patients.

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.

Long-term health-related quality of life and burden of disease after intensive care: development of a patient-reported outcome measure

BACKGROUND

ICU survivorship includes a diverse burden of disease. Current questionnaires used for collecting information about health-related problems and their relation to quality of life lack detailed questions in several areas relevant to ICU survivors. Our aim was to construct a provisional questionnaire on health-related issues based on interviews with ICU survivors and to test if this questionnaire was able to show differences between ICU survivors and a control group.

METHODS

Thirty-two ICU survivors were identified at a post-ICU clinic and interviewed at least six months after ICU discharge. Using an established qualitative methodology from oncology, all dysfunctions and disabilities were extracted, rephrased as questions and compiled into a provisional questionnaire. In a second part, this questionnaire was tested on ICU survivors and controls. Inclusion criteria for the ICU survivors were ICU stay at least 72 h with ICU discharge six months to three years prior to the study. A non-ICU-treated control group was obtained from the Swedish Population Register, matched for age and sex. Eligible participants received an invitation letter and were contacted by phone. If willing to participate, they were sent the questionnaire. Descriptive statistics were applied.

RESULTS

Analysis of the interviews yielded 238 questions in 13 domains: cognition, fatigue, physical health, pain, psychological health, activities of daily living, sleep, appetite and alcohol, sexual health, sensory functions, gastrointestinal functions, urinary functions and work life. In the second part, 395 of 518 ICU survivors and 197 of 231 controls returned a completed questionnaire, the response rates being 76.2% and 85.3%, respectively. The two groups differed significantly in 13 of 22 comorbidities. ICU survivors differed in a majority of questions (p ≤ 0.05) distributed over all 13 domains compared with controls.

CONCLUSIONS

This study describes the development of a provisional questionnaire to identify health-related quality of life issues and long-term burden of disease after intensive care. The questionnaire was answered by 395 ICU survivors. The questionnaire could identify that they experience severe difficulties in a wide range of domains compared with a control group. Trial registry ClinicalTrials.gov Ref# NCT02767180.

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.

Influence of the initial level of consciousness on early, goal-directed mobilization: a post hoc analysis

PURPOSE

Early mobilization within 72 h of intensive care unit (ICU) admission improves functional status at hospital discharge. We aimed to assess the effectiveness of early, goal-directed mobilization in critically ill patients across a broad spectrum of initial consciousness levels.

METHODS

Post hoc analysis of the international, randomized, controlled, outcome-assessor blinded SOMS trial conducted 2011-2015. Randomization was stratified according to the immediate post-injury Glasgow Coma Scale (GCS) (≤ 8 or > 8). Patients received either SOMS-guided mobility treatment with a facilitator or standard care. We used general linear models to test the hypothesis that immediate post-randomization GCS modulates the intervention effects on functional independence at hospital discharge.

RESULTS

Two hundred patients were included in the intention-to-treat analysis. The significant effect of early, goal-directed mobilization was consistent across levels of GCS without evidence of effect modification, for the primary outcome functional independence at hospital discharge (p = 0.53 for interaction), as well as average achieved mobility level during ICU stay (mean achieved SOMS level) and functional status at hospital discharge measured with the functional independence measure. In patients with low GCS, delay to first mobilization therapy was longer (0.7 ± 0.2 days vs. 0.2 ± 0.1 days, p = 0.008), but early, goal-directed mobilization compared with standard care significantly increased functional independence at hospital discharge in this subgroup of patients with immediate post-randomization GCS ≤ 8 (OR 3.67; 95% CI 1.02-13.14; p = 0.046).

CONCLUSION

This post hoc analysis of a randomized controlled trial suggests that early, goal-directed mobilization in patients with an impaired initial conscious state (GCS ≤ 8) is not harmful but effective.

Overview of Intensive Care Unit-Related Physical and Functional Impairments and Rehabilitation-Related Devices

Rehabilitation after critical illness requires a multidisciplinary effort. Nutrition support of critically ill patients aims to correct the imbalance between protein synthesis and protein degradation to maximize strengthening and muscle mass, whereas physical and occupational therapists focus on optimizing strength and mobility through functional activity to help intensive care (ICU) patients return to their precritical illness level of function and improve quality of life. Early mobility has become the new standard of care for ICU patients. Therapists utilize various devices and technologies to increase the feasibility of early mobility and enhance the rehabilitation process to ensure that patients reach their rehabilitation goals. Tools such as electrical stimulation, cycle ergometers, dynamic tilt tables, and resistive bands aid in strengthening. Therapists use safe patient-handling equipment and ambulation aids to address gait impairments. Adaptive toileting, dressing, bathing, and feeding tools facilitate greater independence with activities of daily living. Augmentative and alternative communication devices promote well-being and communication of basic needs. Splints prevent joint contracture and maintain functional range of motion. Overall, many rehabilitation devices are safe and feasible for use in an ICU setting and serve to maximize strength and functional independence. The purpose of this narrative review is to discuss the benefits and limitations of available rehabilitation devices in the context of critical illness rehabilitation goals.

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.

Intra-articular collagenase injection increases range of motion in a rat knee flexion contracture model

Objectives

A knee joint contracture, a loss in passive range of motion (ROM), can be caused by prolonged immobility. In a rat knee immobilization flexion contracture model, the posterior capsule was shown to contribute to an irreversible limitation in ROM, and collagen pathways were identified as differentially expressed over the development of a contracture. Collagenases purified from Clostridium histolyticum are currently prescribed to treat Dupuytren’s and Peyronie’s contractures due to their ability to degrade collagen. The potential application of collagenases to target collagen in the posterior capsule was tested in this model.

Materials and methods

Rats had one hind leg immobilized, developing a knee flexion contracture. After 4 weeks, the immobilization device was removed, and the rats received one 50 µL intra-articular injection of 0.6 mg/mL purified collagenase. Control rats were injected with only the buffer. After 2 weeks of spontaneous remobilization following the injections, ROM was measured with a rat knee arthrometer, and histological sections were immunostained with antibodies against rat collagen types I and III.

Results/conclusion

Compared with buffer-injected control knees, collagenase-treated knees showed increased ROM in extension by 8.0°±3.8° (p-value <0.05). Immunohistochemical analysis revealed an increase in collagen type III staining (p<0.01) in the posterior capsule of collagenase-treated knees indicating an effect on the extracellular matrix due to the collagenase. Collagen I staining was unchanged (p>0.05). The current study provides experimental evidence for the pharmacological treatment of knee flexion contractures with intra-articular collagenase injection, improving the knee ROM.

Stretch for the treatment and prevention of contractures

BACKGROUND

Contractures are a common complication of neurological and non-neurological conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective. This review is an update of the original 2010 version of this review.

OBJECTIVES

The aim of this review was to determine the effects of stretch on contractures in people with, or at risk of developing, contractures.The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions, spasticity and adverse events.

SEARCH METHODS

In November 2015 we searched CENTRAL, DARE, HTA; MEDLINE; Embase; CINAHL; SCI-EXPANDED; PEDro and trials registries.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed risk of bias. The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions and adverse events. We evaluated outcomes in the short term (up to one week after the last stretch) and in the long term (more than one week). We expressed effects as mean differences (MD) or standardised mean differences (SMD) with 95% confidence intervals (CI). We conducted meta-analyses with a random-effects model. We assessed the quality of the body of evidence for the main outcomes using GRADE.

MAIN RESULTS

Forty-nine studies with 2135 participants met the inclusion criteria. No study performed stretch for more than seven months. Just over half the studies (51%) were at low risk of selection bias; all studies were at risk of detection bias for self reported outcomes such as pain and at risk of performance bias due to difficulty of blinding the intervention. However, most studies were at low risk of detection bias for objective outcomes including range of motion, and the majority of studies were free from attrition and selective reporting biases. The effect of these biases were unlikely to be important, given that there was little benefit with treatment. There was high-quality evidence that stretch did not have clinically important short-term effects on joint mobility in people with neurological conditions (MD 2°; 95% CI 0° to 3°; 26 studies with 699 participants) or non-neurological conditions (SMD 0.2, 95% CI 0 to 0.3, 19 studies with 925 participants).In people with neurological conditions, it was uncertain whether stretch had clinically important short-term effects on pain (SMD 0.2; 95% CI -0.1 to 0.5; 5 studies with 174 participants) or activity limitations (SMD 0.2; 95% CI -0.1 to 0.5; 8 studies with 247 participants). No trials examined the short-term effects of stretch on quality of life or participation restrictions in people with neurological conditions. Five studies involving 145 participants reported eight adverse events including skin breakdown, bruising, blisters and pain but it was not possible to statistically analyse these data.In people with non-neurological conditions, there was high-quality evidence that stretch did not have clinically important short-term effects on pain (SMD -0.2, 95% CI -0.4 to 0.1; 7 studies with 422 participants) and moderate-quality evidence that stretch did not have clinically important short-term effects on quality of life (SMD 0.3, 95% CI -0.1 to 0.7; 2 studies with 97 participants). The short-term effect of stretch on activity limitations (SMD 0.1; 95% CI -0.2 to 0.3; 5 studies with 356 participants) and participation restrictions were uncertain (SMD -0.2; 95% CI -0.6 to 0.1; 2 studies with 192 participants). Nine studies involving 635 participants reported 41 adverse events including numbness, pain, Raynauds' phenomenon, venous thrombosis, need for manipulation under anaesthesia, wound infections, haematoma, flexion deficits and swelling but it was not possible to statistically analyse these data.

AUTHORS' CONCLUSIONS

There was high-quality evidence that stretch did not have clinically important effects on joint mobility in people with or without neurological conditions if performed for less than seven months. Sensitivity analyses indicate results were robust in studies at risk of selection and detection biases in comparison to studies at low risk of bias. Sub-group analyses also suggest the effect of stretch is consistent in people with different types of neurological or non-neurological conditions. The effects of stretch performed for periods longer than seven months have not been investigated. There was moderate- and high-quality evidence that stretch did not have clinically important short-term effects on quality of life or pain in people with non-neurological conditions, respectively. The short-term effects of stretch on quality of life and pain in people with neurological conditions, and the short-term effects of stretch on activity limitations and participation restrictions for people with and without neurological conditions are uncertain.

Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments

Joint contractures, defined as the limitation in the passive range of motion of a mobile joint, can be classified as noninflammatory diseases of the musculoskeletal system. The pathophysiology is not well understood; limited information is available on causal factors, progression, the pathophysiology involved, and prediction of response to treatment. The clinical heterogeneity of joint contractures combined with the heterogeneous contribution of joint connective tissues to joint mobility presents challenges to the study of joint contractures. Furthermore, contractures are often a symptom of a wide variety of heterogeneous disorders that are in many cases multifactorial. Extended immobility has been identified as a causal factor and evidence is provided from both experimental and epidemiology studies. Of interest is the involvement of the joint capsule in the pathophysiology of joint contractures and lack of response to remobilization. While molecular pathways involved in the development of joint contractures are being investigated, current treatments focus on physiotherapy, which is ineffective on irreversible contractures. Future treatments may include early diagnosis and prevention.