Move to improve: the feasibility of using an early mobility protocol to increase ambulation in the intensive and intermediate care settings.

BACKGROUND: Prolonged bed rest in hospitalized patients leads to deconditioning, impaired mobility, and the potential for longer hospital stays. OBJECTIVE: The purpose of this study was to determine the effectiveness of a nurse-driven mobility protocol to increase the percentage of patients ambulating during the first 72 hours of their hospital stay. DESIGN: A quasi-experimental design was used before and after intervention in a 16-bed adult medical/surgical intensive care unit (ICU) and a 26-bed adult intermediate care unit (IMCU) at a large community hospital. METHOD: A multidisciplinary team developed and implemented a mobility order set with an embedded algorithm to guide nursing assessment of mobility potential. Based on the assessments, the protocol empowers the nurse to consult physical therapists or occupational therapists when appropriate. Daily ambulation status reports were reviewed each morning to determine each patient's activity level. Retrospective and prospective chart reviews were performed to evaluate the effectiveness of the protocol for patients 18 years of age and older who were hospitalized 72 hours or longer. RESULTS: In the 3 months prior to implementation of the Move to Improve project, 6.2% (12 of 193) of the ICU patients and 15.5% (54 of 349) of the IMCU patients ambulated during the first 72 hours of their hospitalization. During the 6 months following implementation, those rates rose to 20.2% (86 of 426) and 71.8% (257 of 358), respectively. LIMITATIONS: The study was carried out at only one center. CONCLUSION: The initial experience with a nurse-driven mobility protocol suggests that the rate of patient ambulation in an adult ICU and IMCU during the first 72 hours of a hospital stay can be increased.

Early effect of gene therapy on a direct muscle neurotization model.

Direct nerve-to-muscle neurotization has been the subject of both clinical and experimental studies. In this study, the authors report a new animal model to test the regenerative properties of a nerve (musculocutaneous) implanted in a muscle (biceps). They also report the early effects of the application at the implantation site of exogenously administered Brain Derived Nerve Factor (BDNF) and of endogenously produced BDNF, via the administration of an adenoviral construct with a tissue-specific promotor for muscle cells (AdRSV), and containing the BDNF gene. Evaluation included behavioral testing (grooming test), electrical stimulation, Western blot analysis of the distal implanted nerve to determine the presence of locally produced BDNF, and motor end-plate staining of the biceps muscle. At the early time point of 1 week following the musculocutaneous nerve to biceps muscle implantation, there was no increased production of recombinant BDNF at the distal implanted musculocutaneous nerve, as assessed by Western blot analysis. Therefore, there was no significant difference in the behavioral evaluation of the animals at 1 week; the Terzis grooming test showed no statistical difference among groups, but a trend toward better function for the BDNF and the high-dose AdRSV-BDNF groups, compared to the control groups. There was also no difference in the histologic appearance and number of the motor end-plates at the implantation site, compared to the controls. The electrical stimulation of the MC nerve did not produce statistically significant results among the experimental groups. In this direct nerve to muscle neurotization model, the application of AdRSV-BDNF at 3 x 10 (9) pfu/ul did not show enhanced production of BDNF at 1 week.

Muscle preservation by prolonged sensory protection.

The functional recovery of a muscle target following nerve repair is inversely related to the denervation time: i.e., the longer the muscle denervation, the poorer the functional outcome following nerve reconstruction. The trophic and protective effects of sensory innervation to a motor nerve, following prolonged denervation (greater than 6 months), have been studied. Following proximal transection of the musculocutaneous nerve (MC) close to its C6 origin in 10 adult male Sprague-Dawley rats, the severed nerve was coapted to supraclavicular purely sensory nerves originating from C3 and C4 (sensory protection [SP] group). In another 10 Sprague-Dawley rats, the transected MC nerve was not protected by coaptation to sensory nerves (control group). After prolonged denervation or "sensory protection" (6 months), the MC nerve was then coapted in both groups to the purely motor medial pectoral nerve. Behavioral testing (grooming test) was performed on a weekly basis during the reinnervation time, which lasted 4 weeks. Statistically significant differences (p<0.05) favoring the SP group, were found at the second week of the reinnervation period, but not at the end of the experiment. Evaluation also included intraoperative electrical stimulation of the MC nerve, biceps muscle dry weights, motor endplate counts, and nerve axon counts of the MC nerve. The biceps muscle dry weights were statistically higher in the SP group, along with a trend for a higher number of motor endplates. No statistically significant difference was found in the nerve axon counts of the MC nerve between the two groups. Statistically better intraoperative electrical stimulation results were also encountered in the sensory protection group. An interpretation of the results favors the hypothesis that sensory reinnervation of a motor target may provide the necessary trophic environment to minimize muscle atrophy, until a motor donor nerve becomes available.