Doa El-Ansary

Ultrasonography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function

PURPOSE This study aimed to (1) document patterns of quadriceps muscle wasting in the first 10 days of admission and (2) determine the relationship between muscle ultrasonography and volitional measures. MATERIALS AND METHODS Twenty-two adults ventilated for more than 48 hours were included. Sequential quadriceps ultrasound images were obtained over the first 10 days and at awakening and intensive care unit (ICU) discharge. Muscle strength and function were assessed at awakening and ICU discharge. RESULTS A total of 416 images were analyzed. There was a 30% reduction in vastus intermedius (VI) thickness, rectus femoris (RF) thickness, and cross-sectional area within 10 days of admission. Muscle echogenicity scores increased for both RF and VI muscles by +12.7% and +25.5%, respectively (suggesting deterioration in muscle quality). There was a strong association between function and VI thickness (r = 0.82) and echogenicity (r = -0.77). There was a moderate association between function and RF cross-sectional area (r = 0.71). CONCLUSIONS Muscle wasting occurs rapidly in the ICU setting. Ultrasonography is a useful surrogate measure for identifying future impairment. Vastus intermedius may be an important muscle to monitor in the future because it demonstrated the greatest change in muscle quality and had the strongest relationship to volitional measures.

Electrical muscle stimulation in the intensive care setting: a systematic review.

Context:The role of electrical muscle stimulation in intensive care has not previously been systematically reviewed. Objectives:To identify, evaluate, and synthesize the evidence examining the effectiveness and the safety of electrical muscle stimulation in the intensive care, and the optimal intervention variables. Data Sources:A systematic review of articles using eight electronic databases (Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica Database, Expanded Academic ASAP, MEDLINE, Physiotherapy Evidence Database, PubMed, and Scopus) personal files were searched, and cross-referencing was undertaken. Eligibility Criteria:Quantitative studies published in English, assessing electrical muscle stimulation in intensive care, were included. Data Extraction and Data Synthesis:One reviewer extracted data using a standardized form, which were cross-checked by a second reviewer. Quality appraisal was undertaken by two independent reviewers using the Physiotherapy Evidence Database and Newcastle–Ottawa scales, and the National Health and Medical Research Council Hierarchy of Evidence Scale. Preferred Reporting Items for Systematic Reviews guidelines were followed. Results:Nine studies on six individual patient groups of 136 participants were included. Eight were randomized controlled trials, with four studies reporting on the same cohort of participants. Electrical muscle stimulation appears to preserve muscle mass and strength in long-stay participants and in those with less acuity. No such benefits were observed when commenced prior to 7 days or in patients with high acuity. One adverse event was reported. Optimal training variables and safety of the intervention require further investigation. Conclusions:Electrical muscle stimulation is a promising intervention; however, there is conflicting evidence for its effectiveness when administered acutely. Outcomes measured are heterogeneous with small sample sizes.

Assessment of impairment and activity limitations in the critically ill: a systematic review of measurement instruments and their clinimetric properties

PurposeTo identify measures used to evaluate the broad constructs of functional impairment and limitations in the critically ill across the continuum of recovery, and to evaluate, synthesise and compare the clinimetric properties of the measures identified.MethodsA systematic review of articles was carried out using the databases Medline (1950–2014), CINAHL (1982–2014), EMBASE (1980–2014), Cochrane Library (2014) and Scopus (1960–2014). Additional studies were identified by searching personal files. Eligibility criteria for selection: Search 1: studies which assessed muscle mass, strength or function using objective non-laboratory measures; Search 2: studies which evaluated a clinimetric property (reliability, measurement error, validity or responsiveness) for one of the measures identified in search one. Two independent reviewers assessed articles for inclusion and assessed risk of bias using the consensus-based standards for selection of health status measurement instruments checklist.ResultsThirty-three measures were identified; however, only 20 had established clinimetric properties. Ultrasonography, dynamometry, physical function in intensive care test scored and the Chelsea critical care physical assessment tool performed the strongest for the measurement of impairment of body systems (muscle mass and strength) and activity limitations (physical function), respectively.ConclusionsThere is considerable variability in the type of measures utilized to measure physical impairments and limitations in survivors of critical illness. Future work should identify a core set of standardized measures, which can be utilized across the continuum of critical illness recovery embedded within the International Classification of Functioning framework. This will enable improved comparisons between future studies, which in turn will assist in identifying the most effective treatment strategies to ameliorate the devastating longer-term outcomes of a critical illness.

Functional electrical stimulation with cycling in the critically ill: A pilot case-matched control study

PURPOSE The purpose was to determine (a) safety and feasibility of functional electrical stimulation (FES)-cycling and (b) compare FES-cycling to case-matched controls in terms of functional recovery and delirium outcomes. MATERIALS AND METHODS Sixteen adult intensive care unit patients with sepsis ventilated for more than 48 hours and in the intensive care unit for at least 4 days were included. Eight subjects underwent FES-cycling in addition to usual care and were compared to 8 case-matched control individuals. Primary outcomes were safety and feasibility of FES-cycling. Secondary outcomes were Physical Function in Intensive Care Test scored on awakening, time to reach functional milestones, and incidence and duration of delirium. RESULTS One minor adverse event was recorded. Sixty-nine out of total possible 95 FES sessions (73%) were completed. A visible or palpable contraction was present 80% of the time. There was an improvement in Physical Function in Intensive Care Test score of 3.9/10 points in the intervention cohort with faster recovery of functional milestones. There was also a shorter duration of delirium in the intervention cohort. CONCLUSIONS The delivery of FES-cycling is both safe and feasible. The preliminary findings suggest that FES-cycling may improve function and reduce delirium. Further research is required to confirm the findings of this study and evaluate the efficacy of FES-cycling.

Early rehabilitation in critical care (eRiCC): functional electrical stimulation with cycling protocol for a randomised controlled trial

Introduction Intensive care-acquired weakness is a common problem, leads to significant impairment in physical functioning and muscle strength, and is prevalent in individuals with sepsis. Early rehabilitation has been shown to be safe and feasible; however, commencement is often delayed due to a patients inability to co-operate. An intervention that begins early in an intensive care unit (ICU) admission without the need for patient volition may be beneficial in attenuating muscle wasting. The eRiCC (early rehabilitation in critical care) trial will investigate the effectiveness of functional electrical stimulation-assisted cycling and cycling alone, compared to standard care, in individuals with sepsis. Methods and analysis This is a single centre randomised controlled trial. Participants (n=80) aged ≥18 years, with a diagnosis of sepsis or severe sepsis, who are expected to be mechanically ventilated for ≥48 h and remain in the intensive care ≥4 days will be randomised within 72 h of admission to (1) standard care or (2) intervention where participants will receive functional electrical muscle stimulation-assisted supine cycling on one leg while the other leg undergoes cycling alone. Primary outcome measures include: muscle mass (quadriceps ultrasonography; bioelectrical impedance spectroscopy); muscle strength (Medical Research Council Scale; hand-held dynamometry) and physical function (Physical Function in Intensive Care Test; Functional Status Score in intensive care; 6 min walk test). Blinded outcome assessors will assess measures at baseline, weekly, at ICU discharge and acute hospital discharge. Secondary measures will be evaluated in a nested subgroup (n=20) and will consist of biochemical/histological analyses of collected muscle, urine and blood samples at baseline and at ICU discharge. Ethics and dissemination Ethics approval has been obtained from the relevant institution, and results will be published to inform clinical practice in the care of patients with sepsis to optimise rehabilitation and physical function outcomes. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12612000528853.

Relationship between pain and upper limb movement in patients with chronic sternal instability following cardiac surgery

Physiotherapists routinely prescribe upper limb exercises for patients who have undergone a median sternotomy during cardiac surgery. It is not currently known whether upper limb exercises should be unilateral or bilateral and conducted with or without additional loading to minimise pain and further sternal separation in patients with sternal instability. Eight patients who had chronic sternal instability after cardiac surgery were included in this study. During a selected regimen of upper limb exercises, the amount of sternal separation at different vertical points on the sternum was measured by ultrasound. The amount of sternal separation was not related to type of upper limb activity, but both unilateral and unilateral loaded positions were found to be significantly associated with sternal pain (p = 0.009). In this group of patients with chronic sternal instability, bilateral upper limb movements were significantly less associated with sternal pain than unilateral movements.

Sternal instability following coronary artery bypass grafting

Several cases of sternal instability have been noted in patients following coronary artery bypass graft surgery attending our cardiac rehabilitation programme. The purpose of this prospective study was to identify factors associated with sternal instability following sternotomy involving saphenous vein grafts (SVG) and unilateral or bilateral internal mammary artery (IMA) grafts. A rating scale for quantifying sternal instability was developed and used by the physiotherapists to assess all patients. Inter-therapist and intra-therapist reliabilities for the scale were calculated and these were 0.97 and 0.98 (ICC) respectively. Twenty-four patients who underwent coronary artery bypass grafting with a sternotomy incision presented with the complication of sternal instability 6-8 weeks following surgery. They represented 16.3% of the 147 patients presenting for cardiac rehabilitation who had undergone surgery interstate over an 18-month period. Sternal symptoms reported were pain, crepitus, and/or clicking at rest or on trunk and upper limb motion. Risk factors to wound healing such as obesity, diabetes, bilateral IMA grafting, osteoporosis, repeat operations, and prolonged post-operative mechanical ventilation were noted. A significantly higher proportion of patients with bilateral IMA grafting (31.5%) as opposed to unilateral IMA grafting (14.3%) had sternal instability (P <. 05). Quantifying the degree of sternal instability may play a role in identifying management options, patient progression and the point of intervention.

Control of Separation in Sternal Instability by Supportive Devices: A Comparison of an Adjustable Fastening Brace, Compression Garment, and Sports Tape

OBJECTIVE To evaluate the effectiveness of 3 supportive devices in controlling sternal separation. DESIGN A cross-sectional, randomized intervention study. SETTING Participants were from the general community who were referred to the study by their cardiac surgeon or cardiologist. PARTICIPANTS Fifteen patients (12 men, 3 women) between 49 and 80 years of age with sternal instability after a median sternotomy. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Support from sports tape, a compression garment, and an adjustable fastening brace was assessed by an ultrasound-based measure of sternal separation contingent on movement and by self-report measures of comfort, pain, feeling of support, ease of upper-limb movement, and ease of breathing. RESULTS For both sternal separation and self-report data, some support was better than no support, and a supportive device worn on the body was better than sports tape. Wearing an adjustable fastening brace was better than a compression garment and, compared with no support, closed the sternal gap by 20% or 2.7 mm (95% confidence interval, 1.5-3.9 mm). The effects of wearing the different supportive devices on visual analog scale ratings of comfort, pain, support, ease of breathing, and movement mirrored the results obtained for sternal separation, thus providing agreement between self-report and objective measures. CONCLUSIONS Supportive devices may be useful in the management of patients with sternal instability because wearing one resulted in a reduction of both sternal separation and pain report after movement. The largest effect was obtained from wearing an adjustable fastening brace.

Replacing stressful challenges with positive coping strategies: a resilience program for clinical placement learning

Clinical education is foundational to health professional training. However, it is also a time of increased stress for students. A student’s perception of stressors and their capacity to effectively manage them is a legitimate concern for educators, because anxiety and decreased coping strategies can interfere with effective learning, clinical performance and capacity to care for patients. Resilience is emerging as a valuable construct to underpin positive coping strategies for learning and professional practice. We report the development and evaluation of a psycho-education resilience program designed to build practical skills-based resilience capacities in health science (physiotherapy) students. Six final year undergraduate physiotherapy students attended four action research sessions led by a clinical health psychologist. Resilience strategies drawn from cognitive behavioural therapy, and positive and performance psychology were introduced. Students identified personal learning stressors and their beliefs and responses. They chose specific resilience-based strategies to address them, and then reported their impact on learning performance and experiences. Thematic analysis of the audio-recorded and transcribed action research sessions, and students’ de identified notes was conducted. Students’ initial descriptions of stressors as ‘problems’ outside their control resulting in poor thinking and communication, low confidence and frustration, changed to a focus on how they managed and recognized learning challenges as normal or at least expected elements of the clinical learning environment. The research suggests that replacing stressful challenges with positive coping strategies offers a potentially powerful tool to build self-efficacy and cognitive control as well as greater self-awareness as a learner and future health practitioner.

Musculoskeletal and neurological complications following coronary artery bypass graft surgery: A comparison between saphenous vein and internal mammary artery grafting

The internal (thoracic) mammary artery (IMA) is currently the vessel of choice for coronary artery bypass grafting (CABG), due to its long term patency. The purpose of this study was to compare the incidence and nature of musculoskeletal and neurological complications following saphenous vein grafting (SVG) and internal mammary artery grafting (IMAG). Ninety-seven patients were screened by a physiotherapist for musculoskeletal and neurological complications three to six weeks following cardiac surgery. The incidence of new musculoskeletal and neurological complications was significantly higher in patients following IMAG (78.5 per cent) than SVG (45 per cent) (p < 0.001, chi2(1) = 17.04). A significant association between musculoskeletal complications affecting the anterior chest and harvesting of the IMA was also demonstrated.