Singapore multidisciplinary consensus recommendations on muscle health in older adults: assessment and multimodal targeted intervention across the continuum of care.

BACKGROUND: The rapidly aging societies worldwide and in Singapore present a unique challenge, requiring an integrated multidisciplinary approach to address high-value targets such as muscle health. We propose pragmatic evidence-based multidisciplinary consensus recommendations for the assessment and multi-modal management of muscle health in older adults (≥65 years) across the continuum of care. METHODS: The recommendations are derived from an in-depth review of published literature by a multidisciplinary working group with clinical experience in the care of the older population in both acute and community settings. RESULTS: The panel recommends screening for muscle impairment using the SARC-F questionnaire, followed by assessment for low muscle strength (handgrip strength or 5-times chair stand test ≥10 s as a surrogate for lower limb strength) to diagnose possible/probable sarcopenia. For uncomplicated cases, lifestyle modifications in exercise and diet can be initiated in the community setting without further assessment. Where indicated, individuals diagnosed with possible/probable sarcopenia should undergo further assessment. Diagnosis of sarcopenia should be based on low muscle strength and low muscle mass (bioimpedance analysis, dual-energy X-ray absorptiometry or calf circumference as a surrogate). The severity of sarcopenia should be determined by assessment of physical performance (gait speed or 5-times chair stand test ≥12 s as a surrogate for gait speed). To treat sarcopenia, we recommend a combination of progressive resistance-based exercise training and optimization of nutritional intake (energy, protein and functional ingredients). High quality protein in sufficient quantity, to overcome anabolic resistance in older adults, and distributed throughout the day to enable maximum muscle protein synthesis, is essential. The addition of resistance-based exercise training is synergistic in improving the sensitivity of muscle protein synthesis response to the provision of amino acids and reducing anabolic resistance. An expected dose-response relationship between the intensity of resistance-based training, lean mass and muscle strength is described. CONCLUSIONS: Reviewed and endorsed by the Society of Rehabilitation Medicine Singapore and the Singapore Nutrition and Dietetics Association, these multidisciplinary consensus recommendations can provide guidance in the formulation of comprehensive and pragmatic management plans to improve muscle health in older adults in Singapore and Asia.

Evaluating Physical Functioning in Survivors of Critical Illness: Development of a New Continuum Measure for Acute Care.

OBJECTIVES: Evaluation of physical functioning is central to patient recovery from critical illness-it may enable the ability to determine recovery trajectories, evaluate rehabilitation efficacy, and predict individuals at highest risk of ongoing disability. The Physical Function in ICU Test-scored is one of four recommended physical functioning tools for use within the ICU; however, its utility outside the ICU is poorly understood. The De Morton Mobility Index is a common geriatric mobility tool, which has had limited evaluation in the ICU population. For the field to be able to track physical functioning recovery, we need a measurement tool that can be used in the ICU and post-ICU setting to accurately measure physical recovery. Therefore, this study sought to: 1) examine the clinimetric properties of two measures (Physical Function in ICU Test-scored and De Morton Mobility Index) and 2) transform these measures into a single measure for use across the acute care continuum. DESIGN: Clinimetric analysis. SETTING: Multicenter study across four hospitals in three countries (Australia, Singapore, and Brazil). PATIENTS: One hundred fifty-one ICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Physical function tests (Physical Function in ICU Test-scored and De Morton Mobility Index) were assessed at ICU awakening, ICU, and hospital discharge. A significant floor effect was observed for the De Morton Mobility Index at awakening (23%) and minimal ceiling effects across all time points (5-12%). Minimal floor effects were observed for the Physical Function in ICU Test-scored across all time points (1-7%) and a significant ceiling effect for Physical Function in ICU Test-scored at hospital discharge (27%). Both measures had strong concurrent validity, responsiveness, and were predictive of home discharge. A new measure was developed using Rasch analytical principles, which involves 10 items (scored out of 19) with minimal floor/ceiling effects. CONCLUSIONS: Limitations exist for Physical Function in ICU Test-scored and De Morton Mobility Index when used in isolation. A new single measure was developed for use across the acute care continuum.

Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this systematic review was to review the evidence base for exercise in critically ill patients. DATA SOURCES AND STUDY SELECTION: Using keywords critical care and physical therapy and related synonyms, randomized controlled trials, meta-analyses, and systematic reviews were identified through electronic database searches and citation tracking. Clinical trials with outcomes of mortality, length of hospital and ICU stay, physical function and quality of life, muscle strength, and ventilator-free days were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers abstracted data and assessed quality independently. Effect sizes and 95% confidence intervals were calculated. From 3,126 screened abstracts, 10 randomized controlled trials and five reviews were found. The mean Physiotherapy Evidence Database score was 5.4. Overall there was a significant positive effect favoring physical therapy for the critically ill to improve the quality of life (g = 0.40, 95% confidence interval 0.08, 0.71), physical function (g = 0.46, 95% confidence interval 0.13, 0.78), peripheral muscle strength (g = 0.27, 95% confidence interval 0.02, 0.52), and respiratory muscle strength (g = 0.51, 95% confidence interval 0.12, 0.89). Length of hospital (g = -0.34, 95% confidence interval -0.53, -0.15) and ICU stay (g = -0.34, 95% confidence interval -0.51, -0.18) significantly decreased and ventilator-free days increased (g = 0.38, 95% confidence interval 0.16, 0.59) following physical therapy in the ICU. There was no effect on mortality. CONCLUSION: Physical therapy in the ICU appears to confer significant benefit in improving quality of life, physical function, peripheral and respiratory muscle strength, increasing ventilator-free days, and decreasing hospital and ICU stay. However, further controlled trials of better quality and larger sample sizes are required to verify the strength of these tentative associations.

Artificial intelligence in physical rehabilitation: A systematic review.

BACKGROUND: Physical disabilities become more common with advancing age. Rehabilitation restores function, maintaining independence for longer. However, the poor availability and accessibility of rehabilitation limits its clinical impact. Artificial Intelligence (AI) guided interventions have improved many domains of healthcare, but whether rehabilitation can benefit from AI remains unclear. METHODS: We conducted a systematic review of AI-supported physical rehabilitation technology tested in the clinical setting to understand: 1) availability of AI-supported physical rehabilitation technology; 2) its clinical effect; 3) and the barriers and facilitators to implementation. We searched in MEDLINE, EMBASE, CINAHL, Science Citation Index (Web of Science), CIRRIE (now NARIC), and OpenGrey. RESULTS: We identified 9054 articles and included 28 projects. AI solutions spanned five categories: App-based systems, robotic devices that replace function, robotic devices that restore function, gaming systems and wearables. We identified five randomised controlled trials (RCTs), which evaluated outcomes relating to physical function, activity, pain, and health-related quality of life. The clinical effects were inconsistent. Implementation barriers included technology literacy, reliability, and user fatigue. Enablers included greater access to rehabilitation programmes, remote monitoring of progress, reduction in manpower requirements and lower cost. CONCLUSION: Application of AI in physical rehabilitation is a growing field, but clinical effects have yet to be studied rigorously. Developers must strive to conduct robust clinical evaluations in the real-world setting and appraise post implementation experiences.

Essential elements of weight loss apps for a multi-ethnic population with high BMI: a qualitative study with practical recommendations.

Smartphone weight loss apps are constantly being developed but the essential elements needed by a multi-ethnic population with overweight and obesity remains unclear. Purpose: To explore the perceptions of an Asian multi-ethnic population with overweight and obesity on the essential elements of weight loss apps. Twenty two participants were purposively sampled from a specialist weight management clinic in Singapore from 13 April to 30 April 2021. Recorded interviews were conducted using face-to-face and videoconferencing modalities. Data saturation was reached at the 18th participant. Data analysis was performed using inductive content analysis with constant comparison between and within transcripts. Findings: Three themes and eight subthemes on the essential app components emerged-(a) comprehensive and flexible calorie counters; (b) holistic, gradual and individualized behavior change recommendations tailored for people with overweight and obesity, and (c) just-in-time reminders of future consequences. There was a need to incorporate flexible options for food logging; break down general recommendations into small steps towards sustainable changes; tailor app contents for people with overweight and obesity; and evoke one's considerations of future consequences. Future weight loss apps should be designed to meet the needs of those with overweight and obesity, the very population that needs assistance with weight loss. Future apps could consider leveraging the capacity of artificial intelligence to provide personalized weight management in terms of sustaining self-regulation behaviors, optimizing goal-setting and providing personalized and timely recommendations for weight loss.

Weight loss smartphone apps are ubiquitous but the essential elements needed and preferred by people with overweight and obesity remains unclear. Therefore, we conducted a qualitative study to explore the perceptions and needs of this population in a weight loss app to prolong app engagement and enhance weight loss success. 22 participants were interviewed through face-to-face or videoconferencing sessions during the peak of the COVID-19 pandemic. Interview transcripts were analyzed within and between participants to develop codes, subthemes and themes that represent the participants' perceptions and needs in weight loss apps. Participants expressed the need for (a) comprehensive and flexible calorie counters; (b) holistic, gradual, and individualized behavior change recommendations tailored for people with overweight and obesity; and (c) just-in-time reminders of future consequences. Our findings showed a need to incorporate flexible options for food logging; break down general recommendations into small steps towards sustainable changes; tailor app contents for people with overweight and obesity; and evoke one's considerations of future consequences. Future apps could consider leveraging the capacity of artificial intelligence to provide personalized weight management in terms of sustaining self-regulation behaviors, optimizing goal-setting and providing personalized and timely recommendations for weight loss.

Nutrition support practices for critically ill patients with severe acute respiratory syndrome coronavirus-2: A multicentre observational study in Singapore.

INTRODUCTION: To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. METHODS: This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. RESULTS: Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25-35.99; 6.30, 95% CI 1.15-34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. CONCLUSION: The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease.

Early rehabilitation in sepsis: a prospective randomised controlled trial investigating functional and physiological outcomes The i-PERFORM Trial (Protocol Article).

BACKGROUND: Patients with sepsis syndromes in comparison to general intensive care patients can have worse outcomes for physical function, quality of life and survival. Early intensive care rehabilitation can improve the outcome in general Intensive Care Unit (ICU) patients, however no investigations have specifically looked at patients with sepsis syndromes. The 'i-PERFORM Trial' will investigate if early targeted rehabilitation is both safe and effective in patients with sepsis syndromes admitted to ICU. METHODS/DESIGN: A single-centred blinded randomized controlled trial will be conducted in Brisbane, Australia. Participants (n = 252) will include those ≥ 18 years, mechanically ventilated for ≥ 48 hours and diagnosed with a sepsis syndrome. Participants will be randomised to an intervention arm which will undergo an early targeted rehabilitation program according to the level of arousal, strength and cardiovascular stability and a control group which will receive normal care.The primary outcome measures will be physical function tests on discharge from ICU (The Acute Care Index of Function and The Physical Function ICU Test). Health-related quality of life will be measured using the Short Form-36 and the psychological component will be tested using The Hospital Anxiety and Depression Scale. Secondary measures will include inflammatory biomarkers; Interleukin-6, Interleukin-10 and Tumour Necrosis Factor-α, peripheral blood mitochondrial DNA content and lactate, fat free muscle mass, tissue oxygenation and microcirculatory flow. DISCUSSION: The 'i-PERFORM Trial' will determine whether early rehabilitation for patients with sepsis is effective at improving patient outcomes with functional and physiological parameters reflecting long and short-term effects of early exercise and the safety in its application in critical illness. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000808044.

Early Detection of Muscle Weakness and Functional Limitations in the Critically Ill: A Retrospective Evaluation of Bioimpedance Spectroscopy.

BACKGROUND: The potential for bioimpedance spectroscopy (BIS) to identify muscle weakness and functional limitations in critical illness is unknown; this study aimed to determine association of BIS with strength/function and differences between 3 intensive care units (ICUs). METHODS: A retrospective post hoc analysis of BIS, strength, and functional data from adults who required ≥48 hours of mechanical ventilation was conducted. Measures of body composition included the proportion (%) of total body water (TBW), fat mass (FM), and fat-free mass (FFM). The Medical Research Council sum score (MRC-ss) and Physical Function in ICU Test-Scored (PFIT-s) were used for strength and functional assessments. Nonparametric cross-sectional analyses were done at enrollment (≤48 hours of admission: site-A, site-C) and awakening from sedation (site-A, site-B). Raw impedance variables including 50-kHz phase angle (PA) and impedance ratio (IR) were available from site-A and site-B. RESULTS: Participants were 135 adults (site-A n=59, site-B n=33, site-C n=44), with a median (interquartile range) age of 59 (50-69) years. At enrollment, TBW%, FM%, and FFM% were similar between site-A and site-C (P>.05); pooled data were not associated with MRC-ss at awakening or MRC-ss/PFIT-s at ICU discharge. At awakening, there was less TBW%, less FFM%, and greater FM% at site-B vs site-A (P≤.001) but no associations with MRC-ss/PFIT-s when using pooled data. Trends with pooled data of a lower PA and higher IR being associated with awakening MRC-ss were confirmed within site-B (PA ρ=0.70, P≤.001; IR ρ=-0.79, P≤.001). CONCLUSION: Site-by-site data suggest that raw impedance variables might be useful for screening weakness and poor function.

Early physical rehabilitation in intensive care patients with sepsis syndromes: a pilot randomised controlled trial.

RATIONALE: Survivors of sepsis syndromes have poor outcomes for physical and cognitive function. No investigations of early physical rehabilitation in the intensive care unit have specifically targeted patients with sepsis syndromes. OBJECTIVE: To determine whether early physical rehabilitation improves physical function and associated outcomes in patients with sepsis syndromes. METHODS: Fifty critically ill adults admitted to a general intensive care unit with sepsis syndromes were recruited into a prospective double-blinded randomised controlled trial investigating early physical rehabilitation. MEASUREMENTS: Primary outcomes of physical function (acute care index of function) and self-reported health-related quality of life were recorded at ICU discharge and 6 months post-hospital discharge, respectively. Secondary measures included inflammatory biomarkers; Interleukin-6, Interleukin-10 and tumour necrosis factor-α, blood lactate, fat-free muscle mass, exercise capacity, muscle strength and anxiety. MAIN RESULTS: A significant increase in patient self-reported physical function (81.8 ± 22.2 vs. 60.0 ± 29.4), p = 0.04) and physical role (61.4 ± 43.8 vs. 17.1 ± 34.4, p = 0.005) for the SF-36 at 6 months was found in the exercise group. Physical function scores were not significantly different between groups. Muscle strength scores were (51.9 ± 10.5 vs. 47.3 ± 13.6, p = 0.24) with the standard care mean Medical Research Council Muscle Score (MRC) <48/60. The mean change of Interleukin-10 increased and was significantly higher in the exercise group (1.8 pg/ml, 180 % vs. 0.9 pg/ml, 90 %, p = 0.04). There was no significant difference between groups for lactate, Interleukin-6, tumour necrosis factor-α, muscle strength, exercise capacity, fat-free mass or hospital anxiety. CONCLUSION: Implementation of early physical rehabilitation can improve self-reported physical function and induce systemic anti-inflammatory effects.