Michael Quittan

MuSCLE WASTING IN INTENSIVE CARE PATIENTS: uLTRASouND oBSERVATIoN oF THE M. QuADRICEPS FEMoRIS MuSCLE LAYER

OBJECTIVE Patients in intensive care exhibit a high degree of loss of muscle mass. Appropriate instruments are needed to document muscle wasting in these patients. The aim of this pilot study was to describe muscle wasting in patients in the intensive care unit. DESIGN Two-fold study setting: prospective longitudinal and cross-sectional single-blind. PATIENTS A total of 118 patients in the intensive care unit (length of stay 1-98 days; male:female ratio 88:30; age 55 +/- 17 years) were included in a two-fold study setting. METHODS Muscle layer thickness of the M. quadriceps femoris was documented using ultrasound measurement at well-defined points. Seventeen pilot-patients were measured twice; at baseline and after 28 days. In another group of 101 patients, muscle layer thickness was determined once after a random length of stay. The results of both groups were compared and correlated. RESULTS In both groups, M. quadriceps femoris thickness showed a significant negative correlation with length of stay in the intensive care unit (p < 0.01). Furthermore, muscle wasting in intensive care patients could be described using a logarithmic function. CONCLUSION Loss of muscle mass shows a negative correlation with length of stay, and seems to be higher during the first 2-3 weeks of immobilization/intensive care unit stay. Ultrasound is a valid and practical measurement tool for documenting muscle mass (e.g. muscle layer thickness) as part of the daily routine at an intensive care unit.

Improvement of thigh muscles by neuromuscular electrical stimulation in patients with refractory heart failure: a single-blind, randomized, controlled trial.

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, randomized, controlled trial. Am J Phys Med Rehabil 2001;80:206–214. ObjectiveTo 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. DesignForty-two patients with a stable disease course were assigned randomly 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. ResultsPrimary 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. ConclusionsActivities 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.

Cross-cultural adaptation of the Roland-Morris questionnaire for German-speaking patients with low back pain.

STUDY DESIGN Cross-cultural adaptation and cross-sectional psychometric testing. OBJECTIVES To develop and validate a cross-cultural version of the Roland-Morris Questionnaire for use in German-speaking patients with low back pain. SUMMARY OF THE BACKGROUND DATA Clinical research related to the management of back pain would be facilitated enormously if a small number of patient-oriented questionnaires became widely used. If the transposition of a questionnaire from its original cultural context is done by simple translation, it is unlikely to be successful because of language and cultural differences. Therefore, a simple direct translation of a questionnaire from one language to another does not permit its use in clinical trials. METHODS The instrument was translated and back-translated, pretested, and reviewed by a committee. The German version of the Roland-Morris Questionnaire was tested in 125 patients with low back pain. The study was conducted at the spa resort at Senftenberg, Austria, which is visited by patients from all countries of German-speaking Europe. Reliability and concurrent construct validity were assessed with Pearsons correlation coefficient on the Roland-Morris Questionnaire scores compared with the scales of the Medical Outcome Study Short Form-36 questionnaire. RESULTS Pearsons correlation coefficient for test-retest reliability of the German version was r = 0.82 (P = 0.0001), and Cronbachs alpha was 0.81. The concurrent validity was r = 0.81 (Roland-Morris Questionnaire/pain rating; P = 0.0001), r = 0.48 (Roland-Morris Questionnaire/forward bending; P = 0.0001), and r = -0.47 (Roland-Morris Questionnaire/lateral bending; P = 0.0001). Correlation between the functional scales of the Medical Outcome Study Short Form-36 questionnaire and the Roland-Morris Questionnaire sum scores ranged from r = -0.29 (emotional limitations; P = 0.0011) to r = -0.71 (physical limitations; P = 0.0001). CONCLUSION Because the German version of the Roland-Morris Questionnaire seems to be reliable and valid for the assessment of the functional status in German-speaking patients with low back pain, the use of this translated instrument can be recommended in future clinical trials.

Muscle strength as a predictor of long‐term survival in severe congestive heart failure

The objective of the study was to test the relationship between isolated muscle strength and outcome, and its significance in the context of other exercise variables.

Effects of neuromuscular electrical stimulation on muscle layer thickness of knee extensor muscles in intensive care unit patients: a pilot study.

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 Randomized, controlled, double-blind, pilot trial. PATIENTS Thirty-three patients, male to female ratio 26:7, mean age 55 years (standard 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 randomized 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.

Aerobic capacity in adult dermatomyositis/polymyositis patients and healthy controls

OBJECTIVE Assessment of myositis patients has relied on symptoms, strength testing, and serum muscle enzyme activity. Recently, functional assessments and evaluation of strength by dynamometry and of disease activity by magnetic resonance imaging have also been added. Aerobic testing in selected patients has been considered useful. DESIGN Case-control study. SETTING University Hospital, Vienna, Austria. PATIENTS Twenty-two subjects (8 outpatients with chronic dermatomyositis and 3 outpatients with chronic polymyositis, and 11 healthy controls) participated, allowing the identification of 11 case-control pairs matched by age (+/-3 years) and gender (mean age, 48+/-14 yrs; ratio of women to men, 18/4). MAIN OUTCOME MEASURES Target parameters were peak oxygen uptake (peak VO2) to estimate aerobic exercise capacity and peak isometric torque for muscle strength. Creatine phosphokinase (CPK) was measured to assess elevation of muscle enzymes. RESULTS The mean peak VO2 in patients with dermatomyositis/polymyositis was 15.3 mL/min/kg (SD = 5.8) and in the healthy controls 28.7 mL/min/kg (SD = 7.8). Cardiorespiratory capacity expressed as peak VO2 was thus significantly reduced at 53% (p = .0001) of the control value. Muscle strength expressed as peak isometric torque was significantly lower (p = .01) in patients (mean 148+/-73 Nm) when compared to the control group (mean 261+/-99 Nm). In myositis patients peak VO2 and peak isometric torque correlate well with each other (r = .7631; p = .0001), but not at all with serum CPK levels (r = .056; p = .869). CONCLUSION Peak VO2 is significantly diminished in patients with dermatomyositis/polymyositis, compared with age- and sex-matched controls. Serum CPK did not significantly correlate with VO2. Aerobic exercise testing may be a useful assessment parameter in selected patients with dermatomyositis/ polymyositis.

EMG fatigue patterns accompanying isometric fatiguing knee-extensions are different in mono- and bi-articular muscles

OBJECTIVES AND METHODS Isometric, fatiguing knee-extensions at 30%, 50% and 70% maximum voluntary contraction (MVC) were performed by 18 healthy human subjects. Surface electromyographic (SEMG) activity was recorded from the mono-articular vastus medialis (VM) and vastus lateralis (VL) muscles, and the bi-articular rectus femoris muscle (RF). To make the bi-articular muscle work under (1) constant and (2) similar working conditions as the two mono-articulars do, the hip was fixed in a flexed position. The root mean square (RMS) SEMG recorded during fatigue was standardized to the respective values of MVC. The mean coefficients of regression of the RMS and median frequency (MF) changes were then analyzed by multivariate analysis of variance. RESULTS The load effect upon the muscle fatigue changes, as measured by increase in RMS EMG, differed between the bi-articular muscle and the two mono-articulars, in that the parameter dropped with maximum load for the bi-articular, whilst it remained stable or even increased for the mono-articulars. This might suggest that the mono- and bi-articular muscles have different roles in fatigue tasks where the bi-articulars function purely as mono-articulars. By contrast, such a clear dichotomy between the bi-articular RF and the two mono-articulars, VM and VL, was lacking for the fatigue parameter of MF. CONCLUSIONS As these findings were confined to the changes in RMS EMG, different neuronal coding mechanisms for the mono- and bi-articular muscles in the central nervous system may be inferred.

Regular physical exercise improves endothelial function in heart transplant recipients

Background: Impaired endothelial function is detectable in heart transplant (HTX) recipients and regarded as risk factor for coronary artery disease. We have studied whether endothelial function can be improved in HTX patients participating in a regular physical training program as demonstrated in patients with chronic heart failure, hypertension and coronary artery disease.

PHYSICAL PERFORMANCE AND HEALTH-RELATED QUALITY OF LIFE IN MEN ON A LIVER TRANSPLANTATION WAITING LIST

Twenty-six men on a liver transplant waiting list (12 had alcoholic cirrhosis, 8 suffered from posthepatitic cirrhosis, and 6 from cirrhosis of other etiologies) were eligible for this observation. Nineteen subjects underwent exercise testing to determine oxygen uptake at anaerobic threshold. In all patients dynamometry was performed to determine isokinetic muscle strength of knee extensor muscles, and handgrip. Quality of life was evaluated in all patients with the MOS SF-36 questionnaire. Child-Pugh A patients showed 54 +/- 8%, Child-Pugh B patients 36 +/- 2%, and Child-Pugh C patients 31 +/- 4% of VO2 max predicted at the anaerobic threshold (Kruskal-Wallis ANOVA, p < 0.05). Isokinetic muscle strength of the quadriceps femoris (left/right) was 149 +/- 20/134 +/- 14 Nm in Child-Pugh A, 108 +/- 16/114 +/- 19 Nm in Child-Pugh B, and 89 +/- 10/81 +/- 11 Nm in Child-Pugh C patients (Kruskal-Wallis ANOVA, p < 0.05). MOS-SF36 revealed a Child-Pugh class dependent reduced functional status (Kruskal-Wallis ANOVA, p < 0.05). No significant differences in target parameters were found when analysed according to the etiology of cirrhosis. Patients on the liver transplant waiting list do have a stage dependent reduction in physical health. These data are the basis for longitudinal studies measuring the effects of preoperative rehabilitation programs in these patients.

ICF Core Sets for chronic ischaemic heart disease

OBJECTIVE To report on the results of the consensus process integrating evidence from preliminary studies to develop the first version of a Comprehensive ICF Core Set, and a Brief ICF Core Set for chronic ischaemic heart disease. METHODS A formal decision-making and consensus process integrating evidence gathered from preliminary studies was followed. Preliminary studies included a Delphi exercise, a systematic review and an empirical data collection. After training in the ICF and based on these preliminary studies relevant ICF categories were identified in a formal consensus process by international experts from different backgrounds. RESULTS The preliminary studies identified a set of 253 ICF categories at the second, third and fourth ICF levels with 89 categories on body functions, 25 on body structures, 82 on activities and participation and 57 on environmental factors. Sixteen experts attended the consensus conference on CIHD (11 physicians with various sub-specializations and 3 physical therapists). Altogether 61 second-level categories were included in the Comprehensive ICF Core Set with 14 categories from the component body functions, one from body structures, 17 from activities and participation and 29 from environmental factors. The Brief ICF Core Set included a total of 36 second-level categories with 10 on body functions, one on body structures, 13 on activities and participation and 12 on environmental factors. CONCLUSION A formal consensus process integrating evidence and expert opinion based on the ICF framework and classification led to the definition of ICF Core Sets for CIHD. Both the Comprehensive ICF Core Set and the Brief ICF Core Set were defined.