Early neuromuscular electrical stimulation reduces the loss of muscle mass in critically ill patients - A within subject randomized controlled trial

PURPOSE

To investigate the effect of Neuromuscular Electrical Stimulation (NMES) on muscle thickness, strength and morphological and molecular markers of the quadriceps.

MATERIALS AND METHODS

Adult critically ill patients with an expected prolonged stay received unilateral quadriceps NMES sessions for 7 consecutive days. Before and after the intervention period, quadriceps thickness was measured with ultrasound. After the intervention period, strength was assessed in cooperative patients and muscle biopsies were taken. Multivariable regression was performed to identify factors affecting muscle thickness loss.

RESULTS

Muscle thickness decreased less in the stimulated leg (-6 ± 16% versus -12 ± 15%, p = 0.014, n = 47). Strength was comparable. Opioid administration, minimal muscle contraction and more muscle thickness loss in the non-stimulated muscle were independently associated with better muscle thickness preservation. Stimulated muscles showed a shift towards larger myofibers and higher MyHC-I gene expression. NMES did not affect gene expression of other myofibrillary proteins, MuRF-1 or atrogin-1. Signs of myofiber necrosis and inflammation were comparable for both muscles.

CONCLUSIONS

NMES attenuated the loss of muscle mass, but not of strength, in critically ill patients. Preservation of muscle mass was more likely in patients receiving opioids, patients with a minimal muscle contraction during NMES and patients more prone to lose muscle mass.

TRIAL REGISTRATION

clinicaltrials.govNCT02133300.

Early mobilization in clinical practice: the reliability and feasibility of the 'Start To Move' Protocol

PURPOSE

The properties of a local Intensive Care Unit early mobilization protocol ('Start To Move As Soon As Possible') in critically ill patients, consisting of an objective diagnostic assessment linked to six treatment levels were evaluated. This study aimed to investigate whether the protocol can be reliably applied by different health-care providers (reliability), to examine the associations between prescribed and delivered treatments (feasibility) and to explore safety and patient satisfaction with the protocol.

METHODS

Cross-sectional observational study evaluating the reliability of the protocol between physiotherapist was evaluated with Cohen's kappa, percentage of agreement, and intraclass correlation coefficients in 61 patients. Feasibility was analyzed as agreement between prescribed and delivered treatments with Spearman's rank correlation coefficients in 60 patients. A satisfaction survey was used to evaluate patient satisfaction with the protocol.

RESULTS

Excellent agreement was observed between physiotherapists for diagnostic level assignment (Kappa = 0.92), while the majority of the treatment proposals per level showed moderate to substantial agreement between the physiotherapists (Kappa range: 0.40-0.89). Three hundred and thirteen treatments were prescribed. Perfect agreement was observed between prescribed and delivered treatments in level 0 (Spearman's rho 1.00) and excellent associations for levels 1-5 (0.941, 0.995, 0.951, 0.998, and 0.999), respectively. Unwanted safety events rate was 3%. Most patients (92%) were very satisfied with physiotherapy.

CONCLUSION

Excellent inter-rater agreement for diagnostic level assignment and moderate to substantial agreement for proposed treatments support the reliability of the protocol. Perfect to excellent associations between prescribed and delivered treatments supports its feasibility. Complications were rare, and most patients were very positive regarding the care provided by physiotherapists during their stay in the ICU.

Upper limb impairments and their impact on activity measures in children with unilateral cerebral palsy

BACKGROUND

Insights in upper limb impairments and their relationship with activity measures in children with unilateral cerebral palsy (CP) are important to optimize treatment interventions.

AIMS

(1) To investigate upper limb impairments and activity limitations in children with unilateral CP; (2) to compare these according to the Manual Ability Classification System (MACS), timing of lesion (congenital/acquired) and age; (3) to determine the impact of impairments on activity measures.

METHODS

Eighty-one children with unilateral CP aged 5-15 years (mean 9 years 11 months; congenital N=69, acquired N=12) were recruited. Body function measurements included passive range of motion (PROM), muscle tone, strength and sensibility. At activity level, the Melbourne Assessment, Assisting Hand Assessment (AHA) and Abilhand-Kids were assessed.

RESULTS

Most PROM limitations were found for elbow extension and supination. Increased tone and weakness were most prominent in distal muscles. Stereognosis and two-point discrimination were mostly affected. Children with a lower MACS level or acquired lesion had significantly more impairments and activity limitations. In children with congenital lesions, best predictors for unimanual capacity (Melbourne Assessment) were wrist strength, stereognosis and proprioception, and for bimanual performance (AHA) wrist strength and grip strength, explaining 76% of the variance. For the Abilhand-Kids, wrist strength and stereognosis predicted 46% of the variance.

CONCLUSIONS

Classification according to MACS and timing of lesion is important to differentiate within the wide range of impairments and activity limitations. In children with congenital lesions, unimanual capacity and bimanual performance are highly determined by distal strength, supporting the additional use of impairment-based interventions.