title: Electrical muscle stimulation preserves the muscle mass of critically ill patients: a randomized study Skeletal muscle effects of electrostimulation after COPD exacerbation: a pilot study Electrical muscle stimulation prevents critical illness polyneuromyopathy: a randomized parallel intervention trial Electrical Muscle Stimulation: An Effective Form of Exercise and Early Mobilization to Preserve Muscle Strength in Critically Ill Patients Effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor muscles in intensive care unit patients: a pilot study. Effects of electrical muscle stimulation early in the quadriceps and tibialis anterior muscle of critically ill patients Peripheral Muscle Strength Training in Bed‐Bound Patients with COPD Receiving Mechanical Ventilation: Effect of Electrical Stimulation. Effects of Exercise Training on Pulmonary Mechanics and Functional Status in Patients With Prolonged Mechanical Ventilation PREVENTION OF DISUSE MUSCLE ATROPHY BY MEANS OF ELECTRICAL STIMULATION: MAINTENANCE OF PROTEIN SYNTHESIS Early intensive care unit mobility therapy in the treatment of acute respiratory failure* Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial Effect of transcutaneous electrical muscle stimulation on muscle volume in patients with septic shock* Improvement of Thigh Muscles by Neuromuscular Electrical Stimulation in Patients with Refractory Heart Failure: A Single-Blind, Randomized, Controlled Trial Paresis acquired in the intensive care unit: a prospective multicenter study. Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. Acute skeletal muscle wasting in critical illness. Acquired weakness, handgrip strength, and mortality in critically ill patients.
abstract: Introduction Critically ill patients are characterized by increased loss of muscle mass , partially attributed to sepsis and multiple organ failure , as well as immobilization . Recent studies have shown that electrical muscle stimulation ( EMS ) may be an alternative to active exercise in chronic obstructive pulmonary disease ( COPD ) and chronic heart failure ( CHF ) patients with myopathy . The aim of our study was to investigate the EMS effects on muscle mass preservation of critically ill patients with the use of ultrasonography ( US ) . Methods Forty-nine critically ill patients ( age : 59 ± 21 years ) with an APACHE II admission score ≥13 were r and omly assigned after stratification upon admission to receive daily EMS sessions of both lower extremities ( EMS-group ) or to the control group ( control group ) . Muscle mass was evaluated with US , by measuring the cross sectional diameter ( CSD ) of the vastus intermedius and the rectus femoris of the quadriceps muscle . Results Twenty-six patients were finally evaluated . Right rectus femoris and right vastus intermedius CSD decreased in both groups ( EMS group : from 1.42 ± 0.48 to 1.31 ± 0.45 cm , P = 0.001 control group : from 1.59 ± 0.53 to 1.37 ± 0.5 cm , P = 0.002 ; EMS group : from 0.91 ± 0.39 to 0.81 ± 0.38 cm , P = 0.001 control group : from 1.40 ± 0.64 to 1.11 ± 0.56 cm , P = 0.004 , respectively ) . However , the CSD of the right rectus femoris decreased significantly less in the EMS group ( -0.11 ± 0.06 cm , -8 ± 3.9 % ) as compared to the control group ( -0.21 ± 0.10 cm , -13.9 ± 6.4 % ; P < 0.05 ) and the CSD of the right vastus intermedius decreased significantly less in the EMS group ( -0.10 ± 0.05 cm , -12.5 ± 7.4 % ) as compared to the control group ( -0.29 ± 0.28 cm , -21.5 ± 15.3 % ; P < 0.05 ) . Conclusions EMS is well tolerated and seems to preserve the muscle mass of critically ill patients . The potential use of EMS as a preventive and rehabilitation tool in ICU patients with polyneuromyopathy needs to be further investigated . Trial Registration clinical trials.gov : Muscle dysfunction is a major problem in chronic obstructive pulmonary disease ( COPD ) , particularly after exacerbations . We thus asked whether neuromuscular electrostimulation ( NMES ) might be directly useful following an acute exacerbation and if such a therapy decreases muscular oxidative stress and /or alters muscle fibre distribution . A pilot r and omised controlled study of NMES lasting 6 weeks was carried out in 15 in- patients ( n=9 NMES ; n=6 sham ) following a COPD exacerbation . Stimulation was delivered to the quadriceps and hamstring muscles ( 35 Hz ) . Primary outcomes were quadriceps force and muscle oxidative stress . At the end of the study , quadriceps force improvement was statistically different between groups ( p=0.02 ) , with a significant increase only in the NMES group ( median ( interquartile range ) 10 ( 4.7–11.5 ) kg ; p=0.01 ) . Changes in the 6-min walking distance were statistically different between groups ( p=0.008 ) , with a significant increase in the NMES group ( 165 ( 125–203 ) m ; p=0.003 ) . NMES did not lead to higher muscle oxidative stress , as indicated by the decrease in total protein carbonylation ( p=0.02 ) and myosin heavy chain carbonylation ( p=0.01 ) levels . Finally , we observed a significant increase in type I fibre proportion in the NMES group . Our study shows that following COPD exacerbation , NMES is effective in counteracting muscle dysfunction and decreases muscle oxidative stress Introduction Critical illness polyneuromyopathy ( CIPNM ) is a common complication of critical illness presenting with muscle weakness and is associated with increased duration of mechanical ventilation and weaning period . No preventive tool and no specific treatment have been proposed so far for CIPNM . Electrical muscle stimulation ( EMS ) has been shown to be beneficial in patients with severe chronic heart failure and chronic obstructive pulmonary disease . Aim of our study was to assess the efficacy of EMS in preventing CIPNM in critically ill patients . Methods One hundred and forty consecutive critically ill patients with an APACHE II score ≥ 13 were r and omly assigned after stratification to the EMS group ( n = 68 ) ( age:61 ± 19 years ) ( APACHE II:18 ± 4 , SOFA:9 ± 3 ) or to the control group ( n = 72 ) ( age:58 ± 18 years ) ( APACHE II:18 ± 5 , SOFA:9 ± 3 ) . Patients of the EMS group received daily EMS sessions . CIPNM was diagnosed clinical ly with the medical research council ( MRC ) scale for muscle strength ( maximum score 60 , < 48/60 cut off for diagnosis ) by two unblinded independent investigators . Duration of weaning from mechanical ventilation and intensive care unit ( ICU ) stay were recorded . Results Fifty two patients could be finally evaluated with MRC ; 24 in the EMS group and 28 in the control group . CIPNM was diagnosed in 3 patients in the EMS group as compared to 11 patients in the control group ( OR = 0.22 ; CI : 0.05 to 0.92 , P = 0.04 ) . The MRC score was significantly higher in patients of the EMS group as compared to the control group [ 58 ( 33 to 60 ) vs. 52 ( 2 to 60 ) respectively , median ( range ) , P = 0.04 ) . The weaning period was statistically significantly shorter in patients of the EMS group vs. the control group [ 1 ( 0 to 10 ) days vs. 3 ( 0 to 44 ) days , respectively , median ( range ) , P = 0.003 ] . Conclusions This study suggests that daily EMS sessions prevent the development of CIPNM in critically ill patients and also result in shorter duration of weaning . Further studies should evaluate which patients benefit more from EMS and explore the EMS characteristics most appropriate for preventing CIPNM.Trial Registration Number Clinical Trials.gov Purpose . This is a secondary analysis of previously published data to investigate the effects of electrical muscle stimulation ( EMS ) on strength of various muscle groups in critically ill patients . Methods . One hundred forty-two consecutive patients , with APACHE II score ≥ 13 , were r and omly assigned to the EMS or the control group . EMS sessions were applied daily on vastus lateralis , vastus medialis , and peroneus longus of both lower extremities . Various muscle groups were evaluated with the Medical Research Council ( MRC ) scale for muscle strength . H and grip strength assessment was also employed . Results . Twenty four patients in the EMS group and 28 patients in the control group were finally evaluated .  EMS patients achieved higher MRC scores than controls ( P ≤ 0.05 ) in wrist flexion , hip flexion , knee extension , and ankle dorsiflexion . Collectively , the EMS group performed higher ( P < 0.01 ) in the legs and overall . H and grip strength correlated ( P ≤ 0.01 ) with the upper and lower extremities ' muscle strength and the overall MRC scores . Conclusions . EMS has beneficial effects on the strength of critically ill patients mainly affecting muscle groups stimulated , while it may also affect muscle groups not involved presenting itself as a potential effective means of muscle strength preservation and early mobilization in this patient population OBJECTIVE It is known that patients in the intensive care unit show an enormous loss of muscle mass . Neuromuscular electrical stimulation is effective in enhancing strength and endurance in immobilized patients . The aim of this study was to evaluate the effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor muscles in intensive care unit patients . DESIGN R and omized , controlled , double-blind , pilot trial . PATIENTS Thirty-three patients , male to female ratio 26:7 , mean age 55 years ( st and ard deviation 15 ) . METHODS After enrolment in the study , intensive care unit patients ( main diagnoses : polytrauma , cardiovascular diseases , transplantation , pneumonia , cancer ) were stratified ( based on the length of their stay in hospital ) into 2 groups : 17 acute patients ( < 7 days ) and 16 long-term patients ( > 14 days ) . Both groups were r and omized to a stimulation group or a sham-stimulation group . Neuromuscular electrical stimulation was applied to knee extensor muscles for a period of 4 weeks ( session time 30 - 60 minutes , 5 days/week ) . Ultrasound measurements were performed before and after the stimulation period to quantify muscle layer thickness of knee extensor muscles . RESULTS Only stimulated long-term patients ( + 4.9 % ) showed a significant ( p = 0.013 ) increase in muscle layer thickness compared with sham-stimulated patients ( -3.2 % ) . CONCLUSION Neuromuscular electrical stimulation appears to be a useful adjunct to revert muscle wasting in intensive care unit long-term patients ; however , larger studies with a larger sample size are needed to confirm these promising , but preliminary , results Abstract Background : Electrical muscle stimulation ( EMS ) is applied to critically ill patients in order to improve their muscle strength , thereby preventing hypotrophy and promoting functional recovery . Objective : To assess the effects of early EMS on the range of movement of the ankle joint , and on thigh and leg circumference in critically ill patients . Methods : This is a prospect i ve r and omized clinical trial comprising 11 patients undergoing mechanical ventilation . Before and after EMS the thigh and leg circumference in both lower limbs and the goniometry of the tibiotarsal joint were measured . The angle of 90 ° on the goniometer was taken as the st and ard neutral position ( NP ) , with the arm fixed on the lateral malleolus of the ankle joint . Other measurements , namely dorsiflexion and plantar flexion , referred to as mobile arm , were taken from the NP . These recordings were obtained following an active contraction of the patients ’ muscles . Results : Compared with the electrostimulated limb , a difference in dorsiflexion of the control limb was observed ( 96.2 ± 24.9 versus 119.9 ± 14.1 ° ; p = 0.01 ) . A girth of 10 cm of the leg was found in limb reduction when compared to the electrostimulated one ( 24.7 ± 3.1 versus 26.4 ± 4.0 cm ; p = 0.03 ) . Conclusions : EMS used at low current intensity and for a short duration failed to prevent muscle atrophy in critically ill patients . However , we did find a significant improvement in active dorsiflexion of the ankle joint suggesting that it could help to prevent against stance plantar flexion in these patients STUDY OBJECTIVE To compare the effects of active limb mobilization ( ALM ) with or without electrical stimulation ( ES ) on muscle strength , respiratory rate ( RR ) , heart rate , oxygen saturation , and time needed to transfer from bed to chair in two groups of patients with COPD . DESIGN R and omized , controlled study . SETTING Respiratory high-dependency care unit . PATIENTS Twenty-four bed-bound patients with chronic hypercapnic respiratory failure due to COPD who were receiving mechanical ventilation , with marked peripheral muscle hypotonia and atrophy . METHODS Patients were r and omly assigned either to ALM alone or to ALM plus ES ( ALM/ES ) . ES was applied using square-wave alternate , symmetric , and compensated impulses for 30 min bid . The duration of treatment was 28 days for all patients . RESULTS Muscle strength improved significantly in the overall group of patients ( from 1.75 + /- 0.73 to 3.44 + /- 0.65 , p < 0.05 ) . Comparing the change ( end minus beginning ) of the analyzed variables , ALM/ES significantly improved muscle strength ( 2.16 + /- 1.02 vs 1.25 + /- 0.75 , p = 0.02 ) and RR ( - 1.91 + /- 1.72 vs 0.41 + /- 1.88 , p = 0.004 ) , and decreased the number of days needed to transfer from bed to chair ( 10.75 + /- 2.41 days vs 14.33 + /- 2.53 days , p = 0.001 ) . CONCLUSION In bed-bound patients with COPD receiving mechanical ventilation , with marked peripheral muscle hypotonia and atrophy , application of ES in addition to classical ALM significantly improved muscle strength and decreased the number of days needed to transfer from bed to chair BACKGROUND : The functional status and outcomes in patients with prolonged mechanical ventilation ( PMV ) are often limited by poor endurance and pulmonary mechanics , which result from the primary diseases or prolonged time bedridden . We evaluate the impact of exercise training on pulmonary mechanics , physical functional status , and hospitalization outcomes in PMV patients . METHODS : Twenty-seven subjects with PMV in our respiratory care center ( RCC ) were divided r and omly into an exercise training group ( n = 12 ) and a control group ( n = 15 ) . The exercise program comprised 10 sessions of exercise training . The measurement of pulmonary mechanics and physical functional status ( Functional Independence Measurement and Barthel index ) were performed pre- study and post- study . The hospitalization outcomes included : days of mechanical ventilation , hospitalization days , and weaning and mortality rates during RCC stay . RESULTS : The training group had significant improvement in tidal volume ( 143.6 mL vs 192.5 mL , P = .02 ) and rapid shallow breathing index after training ( 162.2 vs 110.6 , P = .009 ) . No significant change was found in the control group except respiratory rate . Both groups had significant improvement in functional status during the study . However , the training group had greater changes in FIM score than the control group ( 44.6 vs 34.2 , P = .024 ) . The training group also had shorter RCC stay and higher weaning and survival rates than the control group , although no statistical difference was found . CONCLUSIONS : Subjects with PMV in our RCC demonstrated significant improvement in pulmonary mechanics and functional status after exercise training . The application of exercise training may be helpful for PMV patients to improve hospitalization outcomes The effect of percutaneous electrical stimulation in preventing immobilisation-induced muscle atrophy was determined from measurements of quadriceps mass , composition , and rate of protein synthesis in seven men who had a fracture of one tibia immobilised in a long-leg cast for 6 weeks . These features were compared with those of fourteen men with similar injuries who did not use an electrical stimulator .  In men who did not use the stimulator , quadriceps cross-sectional area ( CSA ) at midthigh , measured by ultrasonography , fell by a mean ( SD ) 17 (10)% and the rate of muscle protein synthesis was 23 (10)% lower on the immobilised than on the control side ( 0.037 [ 0.016 ] vs 0.048 [0.02]%/h ) . In contrast , in those who used the stimulator , quadriceps CSA ( 55.5 [ 7.3 ] ) cm2 control leg , 50.9 [ 9.0 ] cm2 immobilised leg ) and the rate of muscle protein synthesis ( 0.053 [ 0.009 ] % /h control leg , 0.059 [ 0.012 ] % /h immobilised leg ) were similar on the two sides . The results suggest that brief periods of low-voltage percutaneous electrical stimulation will reduce quadriceps atrophy secondary to knee immobilisation , and that the mechanism includes prevention of the fall in muscle protein synthesis that usually occurs on immobilisation Objective : Immobilization and subsequent weakness are consequences of critical illness . Despite the theoretical advantages of physical therapy to address this problem , it has not been shown that physical therapy initiated in the intensive care unit offers benefit . Design and Setting : Prospect i ve cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care .  Patients : Medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission : Protocol , n = 165 ; Usual Care , n = 165 . Interventions : An intensive care unit Mobility Team ( critical care nurse , nursing assistant , physical therapist ) initiated the protocol within 48 hrs of mechanical ventilation . Measurements and Main Results : The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge .  Baseline characteristics were similar between groups . Outcome data are reflective of survivors . More Protocol patients received at least one physical therapy session than did Usual Care ( 80 % vs. 47 % , p ≤ .001 ) . Protocol patients were out of bed earlier ( 5 vs. 11 days , p ≤ .001 ) , had therapy initiated more frequently in the intensive care unit ( 91 % vs. 13 % , p ≤ .001 ) , and had similar low complication rates compared with Usual Care . For Protocol patients , intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care ( p = .025 ) ; hospital length of stay for Protocol patients was 11.2 vs. 14.5 days for Usual Care ( p = .006 ) ( intensive care unit/hospital length of stay adjusted for body mass index , Acute Physiology and Chronic Health Evaluation II , vasopressor ) . There were no untoward events during an intensive care unit Mobility session and no cost difference ( survivors + nonsurvivors ) between the two arms , including Mobility Team costs . Conclusions : A Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible , safe , did not increase costs , and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care BACKGROUND Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely . Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)-ie , daily interruption of sedatives-with spontaneous breathing trials ( SBTs ) . METHODS In four tertiary-care hospitals , we r and omly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT  ( intervention group ; n=168 )  or with sedation per usual care plus a daily SBT ( control group ; n=168 ) . The primary endpoint was time breathing without assistance . Data were analysed by intention to treat . This study is registered with Clinical Trials.gov , number NCT00097630 . FINDINGS One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up . Seven patients in the control group discontinued their assigned protocol , and two of these patients were lost to follow-up . Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group ( 14.7 days vs 11.6 days ; mean difference 3.1 days , 95 % CI 0.7 to 5.6 ; p=0.02 ) and were discharged from intensive care ( median time in intensive care 9.1 days vs 12.9 days ; p=0.01 ) and the hospital earlier ( median time in the hospital 14.9 days vs 19.2 days ; p=0.04 ) . More patients in the intervention group self-extubated than in the control group ( 16 patients vs six patients ; 6.0 % difference , 95 % CI 0.6 % to 11.8 % ; p=0.03 ) , but the number of patients who required reintubation after self-extubation was similar ( five patients vs three patients ; 1.2 % difference , 95 % CI -5.2 % to 2.5 % ; p=0.47 ) , as were total reintubation rates ( 13.8%vs 12.5 % ; 1.3 % difference , 95 % CI -8.6 % to 6.1 % ; p=0.73 ) . At any instant during the year after enrolment , patients in the intervention group were less likely to die than were patients in the control group ( HR 0.68 , 95 % CI 0.50 to 0.92 ; p=0.01 ) . For every seven patients treated with the intervention , one life was saved ( number needed to treat was 7.4 , 95 % CI 4.2 to 35.5 ) . INTERPRETATION Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials ( ie , interruption of sedatives ) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current st and ard approaches and should become routine practice Objective : Intensive care unit admission is associated with muscle wasting and impaired physical function . We investigated the effect of early transcutaneous electrical muscle stimulation on quadriceps muscle volume in patients with septic shock . Design : R and omized interventional study using a single-legged exercise design with the contralateral leg serving as a paired control . Setting : A mixed 18-bed intensive care unit at a tertiary care university hospital . Patients : Eight adult male intensive care unit patients with septic shock included within 72 hrs of diagnosis . Interventions : After r and omization of the quadriceps muscles , transcutaneous electrical muscle stimulation was applied on the intervention side for 7 consecutive days and for 60 mins per day . All patients underwent computed tomographic scans of both thighs immediately before and after the 7-day treatment period . The quadriceps muscle was manually delineated on the computed tomography slices , and muscle volumes were calculated after three-dimensional reconstruction . Measurements and Main Results : Median age and Acute Physiology and Chronic Health Evaluation II score were 67 years ( interquartile range , 64–72 years ) and 25 ( interquartile range , 20–29 ) , respectively . During the 7-day study period , the volume of the quadriceps muscle on the control thigh decreased by 16 % ( 4–21 % , p = .03 ) corresponding to a rate of 2.3 % per day . The volume of the stimulated muscle decreased by 20 % ( 3–25 % , p = .04 ) corresponding to a rate of 2.9 % per day ( p = .12 for the difference in decrease ) . There was no difference in muscle volume between the stimulated and nonstimulated thigh at baseline ( p = .10 ) or at day 7 ( p = .12 ) . The charge delivered to the muscle tissue per training session ( 0.82 [ 0.66–1.18 ] coulomb ) correlated with the maximum sequential organ failure assessment score . Conclusions : We observed a marked decrease in quadriceps volume within the first week of intensive care for septic shock . This loss of muscle mass was unaffected by transcutaneous electrical muscle stimulation applied for 60 mins per day for 7 days Quittan M , Wiesinger GF , Sturm B , Puig S , Mayr W , Sochor A , Paternostro T , Resch KL , Pacher R , Fialka-Moser V : Improvement of thigh muscles by neuromuscular electrical stimulation in patients with refractory heart failure : a single-blind , r and omized , controlled trial . Am J Phys Med Rehabil 2001;80:206–214 . Objective To determine the impact of an 8-wk neuromuscular stimulation program of thigh muscles on strength and cross-sectional area in patients with refractory heart failure listed for transplantation . Design Forty-two patients with a stable disease course were assigned r and omly to a stimulation group ( SG ) or a control group ( CG ) . The stimulation protocol consisted of biphasic symmetric impulses with a frequency of 50 Hz and an on/off regime of 2/6 sec. Results Primary outcome measures were isometric and isokinetic thigh muscle strength and muscle cross-sectional area . Our results showed an increase of muscle strength by mean 22.7 for knee extensor and by 35.4 for knee flexor muscles . The CG remained unchanged or decreased by −8.4 in extensor strength . Cross-sectional area increased in the SG by 15.5 and in the CG by 1.7 . Conclusions Activities of daily living as well as quality of life increased in the SG but not in the CG . Subscales of the SF-36 increased significantly in the SG , especially concerning physical functioning by + 7.5 ( 1.3–30.0 ) , emotional role by + 33.3 ( 0–66.6 ) , and social functioning by + 18.8 ( 0–46.9 ) , all P < 0.05 . Neither a change nor a decrease was observed in the CG . Neuromuscular electrical stimulation of thigh muscles in patients with refractory heart failure is effective in increasing muscle strength and bulk and positively affects the perception of quality of life and activities of daily living CONTEXT Although electrophysiologic and histologic neuromuscular abnormalities are common in intensive care unit ( ICU ) patients , the clinical incidence of ICU-acquired neuromuscular disorders in patients recovering from severe illness remains unknown . OBJECTIVES To assess the clinical incidence , risk factors , and outcomes of ICU-acquired paresis ( ICUAP ) during recovery from critical illness in the ICU and to determine the electrophysiologic and histologic patterns in patients with ICUAP . DESIGN Prospect i ve cohort study conducted from March 1999 to June 2000 . SETTING Three medical and 2 surgical ICUs in 4 hospitals in France . PARTICIPANTS All consecutive ICU patients without preexisting neuromuscular disease who underwent mechanical ventilation for 7 or more days were screened daily for awakening . The first day a patient was considered awake was day 1 . Patients with severe muscle weakness on day 7 were considered to have ICUAP . MAIN OUTCOME MEASURES Incidence and duration of ICUAP , risk factors for ICUAP , and comparative duration of mechanical ventilation between ICUAP and control patients . RESULTS Among the 95 patients who achieved satisfactory awakening , the incidence of ICUAP was 25.3 % ( 95 % confidence interval [ CI ] , 16.9%-35.2 % ) . All ICUAP patients had a sensorimotor axonopathy , and all patients who underwent a muscle biopsy had specific muscle involvement not related to nerve involvement . The median duration of ICUAP after day 1 was 21 days . Mean ( SD ) duration of mechanical ventilation after day 1 was significantly longer in patients with ICUAP compared with those without ( 18.2 [ 36.3 ] vs 7.6 [ 19.2 ] days ; P = .03 ) . Independent predictors of ICUAP were female sex ( odds ratio [ OR ] , 4.66 ; 95 % CI , 1.19 - 18.30 ) , the number of days with dysfunction of 2 or more organs ( OR , 1.28 ; 95 % CI , 1.11 - 1.49 ) , duration of mechanical ventilation ( OR , 1.10 ; 95 % CI , 1.00 - 1.22 ) , and administration of corticosteroids  ( OR , 14.90 ; 95 % CI , 3.20 - 69.80 ) before day 1 . CONCLUSIONS Identified using simple bedside clinical criteria , ICUAP was frequent during recovery from critical illness and was associated with a prolonged duration of mechanical ventilation . Our findings suggest an important role of corticosteroids in the development of ICUAP PURPOSE The aim of this study was to describe the frequency , physiologic effects , safety , and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation . MATERIAL S AND METHODS Prospect i ve observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit ( ICU ) during a 13-week period was conducted . RESULTS Of the 32 patients who met the inclusion criteria , only 21 ( 66 % ) received physician orders for evaluation by rehabilitation services ( physical and /or occupational therapy ) . Fifty rehabilitation treatments were provided to 19 patients on a median of 12 % of medical ICU days per patient , with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment . Physiologic changes during rehabilitation therapy were minimal . Joint contractures were frequent in the lower extremities and did not improve during hospitalization . In 53 % and 79 % of initial ICU assessment s , muscle weakness was present in upper and lower extremities , respectively , with a decreased prevalence of 19 % and 43 % at hospital discharge , respectively . New impairments in physical function were common at hospital discharge . CONCLUSIONS This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength , range of motion , and functional outcomes at hospital discharge IMPORTANCE Survivors of critical illness demonstrate skeletal muscle wasting with associated functional impairment . OBJECTIVE To perform a comprehensive prospect i ve characterization of skeletal muscle wasting , defining the pathogenic roles of altered protein synthesis and breakdown . DESIGN , SETTING , AND PARTICIPANTS Sixty-three critically ill patients ( 59 % male ; mean age : 54.7 years [ 95 % CI , 50.0 - 59.6 years ] ) with an Acute Physiology and Chronic Health Evaluation II score of 23.5 ( 95 % CI , 21.9 - 25.2 ) were prospect ively recruited within 24 hours following intensive care unit ( ICU ) admission from August 2009 to April 2011 at a university teaching and a community hospital in Engl and . Patients were recruited if older than 18 years and were anticipated to be intubated for longer than 48 hours , to spend more than 7 days in critical care , and to survive ICU stay . MAIN OUTCOMES AND MEASURES Muscle loss was determined through serial ultrasound measurement of the rectus femoris cross-sectional area ( CSA ) on days 1 , 3 , 7 , and 10 . In a subset of patients , the fiber CSA area was quantified along with the ratio of protein to DNA on days 1 and 7 . Histopathological analysis was performed . In addition , muscle protein synthesis , breakdown rates , and respective signaling pathways were characterized . RESULTS There were significant reductions in the rectus femoris CSA observed at day 10 ( −17.7 % [ 95 % CI , −25.9 % to 8.1 % ] ; P < .001 ) . In the 28 patients assessed by all 3 measurement methods on days 1 and 7 , the rectus femoris CSA decreased by 10.3 % ( 95 % CI , 6.1 % to 14.5 % ) , the fiber CSA by 17.5 % ( 95 % CI , 5.8 % to 29.3 % ) , and the ratio of protein to DNA by 29.5 % ( 95 % CI , 13.4 % to 45.6 % ) . Decrease in the rectus femoris CSA was greater in patients who experienced multiorgan failure by day 7 ( −15.7 % ; 95 % CI , −27.7 % to 11.4 % ) compared with single organ failure ( −3.0 % ; 95 % CI , −5.3 % to 2.1 % ) ( P < .001 ) , even by day 3 ( −8.7 % [ 95 % CI , −59.3 % to 50.6 % ] vs −1.8 % [ 95 % CI , −12.3 % to 10.5 % ] , respectively ; P = .03 ) . Myofiber necrosis occurred in 20 of 37 patients ( 54.1 % ) . Protein synthesis measured by the muscle protein fractional synthetic rate was depressed in patients on day 1 ( 0.035%/hour ; 95 % CI , 0.023 % to 0.047%/hour ) compared with rates observed in fasted healthy controls ( 0.039%/hour ; 95 % CI , 0.029 % to 0.048%/hour ) ( P = .57 ) and increased by day 7 ( 0.076 % [ 95 % CI , 0.032%-0.120%/hour ] ; P = .03 ) to rates associated with fed controls ( 0.065%/hour [ 95 % CI , 0.049 % to 0.080%/hour ] ; P = .30 ) , independent of nutritional load . Leg protein breakdown remained elevated throughout the study ( 8.5 [ 95 % CI , 4.7 to 12.3 ] to 10.6 [ 95 % CI , 6.8 to 14.4 ] μmol of phenylalanine/min/ideal body weight × 100 ; P = .40 ) . The pattern of intracellular signaling supported increased breakdown ( n = 9 , r = −0.83 , P = .005 ) and decreased synthesis ( n = 9 , r = −0.69 , P = .04 ) . CONCLUSIONS AND RELEVANCE Among these critically ill patients  , muscle wasting occurred early and rapidly during the first week of critical illness and was more severe among those with multiorgan failure compared with single organ failure . These findings may provide insights into skeletal muscle wasting in critical illness RATIONALE ICU-acquired paresis ( ICUAP ) is common in survivors of critical illness . There is significant associated morbidity , including prolonged time on the ventilator and longer hospital stay . However , it is unclear whether ICUAP is independently associated with mortality , as sicker patients are more prone and existing studies have not adjusted for this . OBJECTIVES To test the hypothesis that ICUAP is independently associated with increased mortality . Secondarily , to determine if h and grip dynamometry is a concise measure of global strength and is independently associated with mortality . METHODS A prospect i ve multicenter cohort study was conducted in intensive care units ( ICU ) of five academic medical centers . Adults requiring at least 5 days of mechanical ventilation without evidence of preexisting neuromuscular disease were followed until awakening and were then examined for strength . MEASUREMENTS AND MAIN RESULTS We measured global strength and h and grip dynamometry . The primary outcome was in-hospital mortality and secondary outcomes were hospital and ICU-free days , ICU readmission , and recurrent respiratory failure .  Subjects with ICUAP ( average MRC score of < 4 ) had longer hospital stays and required mechanical ventilation longer . H and grip strength was lower in subjects with ICUAP and had good test performance for diagnosing ICUAP . After adjustment for severity of illness , ICUAP was independently associated with hospital mortality ( odds ratio [ OR ] , 7.8 ; 95 % confidence interval [ CI ] , 2.4 - 25.3 ; P = 0.001 ) . Separately , h and grip strength was independently associated with hospital mortality ( OR , 4.5 ; 95 % CI , 1.5 - 13.6 ; P = 0.007 ) . CONCLUSIONS ICUAP is independently associated with increased hospital mortality . H and grip strength is also independently associated with poor hospital outcome and may serve as a simple test to identify ICUAP . Clinical trial registered with www . clinical trials.gov ( NCT00106665 )
target: No outcomes evaluated the effect on participation restrictions .
  NMES , as an adjunct to current rehabilitation practice s in critically ill patients , may maintain muscle strength .
background: OBJECTIVE To review , in conformance with the Preferred Reporting Items for Systematic Review s and Meta-Analyses guidelines , the totality of evidence for the use of neuromuscular electrical stimulation ( NMES ) in the critical care setting , when compared with usual care , under all domains of the World Health Organisation , International Classification of Functioning , Disability and Health ( ICF ) framework .