Shoulder Impairment Following Critical Illness: A Prospective Cohort Study.

OBJECTIVES: Identify the prevalence of shoulder impairment in ICU survivors within 6 months of discharge from ICU. Evaluate the impact of shoulder impairment on upper limb functional status in patients treated on an ICU. Identify risk factors for the development of shoulder impairment. DESIGN: Prospective cohort study. SETTING: A tertiary care medical-surgical-trauma ICU at a U.K. hospital over 18 months, with a further 6-month follow-up after hospital discharge. SUBJECTS: Adult patients with an ICU length of stay of greater than 72 hours with no preexisting or new neurologic or traumatic upper limb injury. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients underwent targeted shoulder assessments (pain, range of movement, Constant-Murley Score, shortened version of the disabilities of the arm, shoulder, and hand [DASH] score [QuickDASH] score) at hospital discharge, 3 and 6 months after hospital discharge. Assessments were undertaken on 96 patients, with 62 patients attending follow-up at 3 months and 61 patients at 6 months. Multivariate regression analysis was used to investigate risk factors for shoulder impairment. ICU-related shoulder impairment was present in 67% of patients at 6 months following discharge from hospital. Upper limb dysfunction occurred in 46%, with 16% having severe dysfunction (equivalent to shoulder dislocation). We were unable to identify specific risk factors for shoulder impairment. CONCLUSIONS: Shoulder impairment is a highly prevalent potential source of disability in ICU survivors. This persists at 6 months after discharge with a significant impact on upper limb function. More research is needed into potential mechanisms underlying shoulder impairment and potential targeted interventions to reduce the prevalence.

The effectiveness of prehabilitation interventions on biopsychosocial and service outcomes pre and post upper gastrointestinal surgery: a systematic review.

PURPOSE: This review synthesised the evidence for the effect of prehabilitation interventions on biopsychosocial and service outcomes. MATERIALS AND METHODS: A systematic review was conducted. 10 databases were searched to December 2023. Prospective experimental studies exploring prehabilitation interventions in adults undergoing upper gastrointestinal surgery were included. Prehabilitation was any preoperative intervention to improve physical or psychological outcomes. Included studies required a comparator group or alternative preoperative intervention as well as baseline, presurgical and postoperative assessment points. Study quality was assessed using the Cochrane risk of bias tool (v.2). Data synthesis was narrative (SWiM guidance). RESULTS: 6028 studies were screened, with 25 studies included. Prehabilitation interventions were: inspiratory muscle training (five studies n = 450); exercise (nine studies n = 683); psychological (one study n = 400); and nutritional (ten studies n = 487). High quality studies showed preoperative improvements in impairments directly targeted by the interventions. Generally, these did not translate into functional or postoperative improvements, but multimodal interventions were more promising. CONCLUSION: Current evidence supports prehabilitation as safe to preserve or improve preoperative function. Heterogeneity in outcomes and variable study quality means definitive conclusions regarding interventions are not yet possible, limiting implementation. Agreement of clinical outcomes and cost effectiveness evaluation is required.

Prehabilitation interventions are safe and when combined optimally may preserve or improve preoperative function in patients undergoing upper gastrointestinal surgery.Multimodal interventions (including exercise, nutritional, and psychological components) showed promise which supports the delivery of prehabilitation by multidisciplinary teams.Development of a core outcome set and agreed time points for both preoperative and postoperative outcomes is needed for effective evidence synthesis.Focus on long term outcomes is necessary to determine cost effectiveness and commissioning of resources.

Mobilisation in the EveNing to prevent and TreAt deLirium (MENTAL): a mixed-methods, randomised controlled feasibility trial.

Background: Delirium is common in critically ill patients and associated with longer hospital stays, increased morbidity and higher healthcare costs. Non-pharmacological interventions have been advocated for delirium management, however there is little evidence evaluating feasibility and acceptability of physical interventions administered in the evening. The aim of this study was to conduct a feasibility trial of evening mobilisation to prevent and treat delirium in patients admitted to intensive care. Methods: In this mixed-methods, randomised controlled feasibility trial we recruited participants from intensive care units at two university hospitals in the United Kingdom. Eligible participants who were able to respond to verbal stimulus (Richmond agitation and sedation scale ≥3) and expected to stay in intensive care for at least 24 h were randomly assigned (1:1) to receive usual care or usual care plus evening mobilisation. The evening mobilisation was delivered between 19:00 and 21:00, for up to seven consecutive evenings or ICU discharge, whichever was sooner. All outcome assessments were completed by a team member blinded to randomisation and group allocation. Primary objective was to assess feasibility and acceptability of evening mobilisation. Primary feasibility outcomes were recruitment, consent and retention rates, and intervention fidelity. Intervention acceptability was evaluated through semi-structured interviews of participants and staff. Secondary outcomes included prevalence in incidence and duration of delirium, measured using the Confusion Assessment Method for ICU. This trial is registered at ClinicalTrials.gov, NCT05401461. Findings: Between July 16th, 2022, and October 31st, 2022, 58 eligible patients (29 usual care; 29 usual care plus evening mobilisation) were enrolled. We demonstrated the feasibility and acceptability of both the trial design and evening mobilisation intervention. Consent and retention rates over three months were 88% (58/66) and 90% (52/58) respectively, with qualitative analysis demonstrating good acceptability reported by both participants and staff. Secondary outcomes for the evening intervention group compared with the control group were: delirium incidence 5/26 (19%; 95% CI: 6-39%) vs 8/28 (29%; 95% CI: 13-49%) and mean delirium duration 2 days (SD 0.7) vs 4.25 days (SD 2.0). Interpretation: Results of this trial will inform the development of a definitive full-scale randomised controlled trial investigating the effects of evening mobilisation to treat delirium and improve health-related outcomes. Funding: None.

Musculoskeletal complications following critical illness: A scoping review.

PURPOSE: To explore the extent to which musculoskeletal (MSK) complications have been reported following critical illness, identifying evidence gaps and providing recommendations for future research. MATERIALS AND METHODS: We searched five databases from January 1st 2000 to March 31st 2021. We included published original research reporting MSK complications in patients discharged from hospital following an admission to an intensive care unit (ICU). Two reviewers independently screened English language articles for eligibility. Data extracted included the MSK area of investigation and MSK outcome measures. The overall quality of study was evaluated against standardised reporting guidelines. RESULTS: 4512 titles were screened, and 32 met the inclusion criteria. Only one study included was interventional, with the majority being prospective cohort studies (n = 22). MSK complications identified included: muscle weakness or atrophy, chronic pain, neuromuscular dysfunction, peripheral joint impairment and fracture risk. The quality of the overall reporting in the studies was deemed adequate. CONCLUSIONS: We identified a heterogenous body of literature reporting a high prevalence of a variety of MSK complications extending beyond muscle weakness, therefore future investigation should include evaluations of more than one MSK area. Further investigation of MSK complications could inform the development of future post critical illness rehabilitation programs.