Eficacia del protocolo Start to move en funcionalidad, DA-UCI y delirio: ensayo clínico aleatorizado / Efficacy of the «Start to move» protocol on functionality, ICU-acquired weakness and delirium: Randomized clinical trial

Objetivo Evaluar la eficacia del protocolo Start to move comparado con el tratamiento convencional en sujetos mayores de 15 años hospitalizados en la UCI sobre una mejoría en funcionalidad, disminución de debilidad adquirida en la UCI (DA-UCI), incidencia de delirio, días de ventilación mecánica (VM), estadía en la UCI y mortalidad a los 28 días. Diseño Ensayo clínico controlado aleatorizado. Ámbito Unidad de paciente crítico. Participantes Incluye adultos mayores a 15 años con VMI mayor a 48h, asignación aleatoria. Intervenciones Protocolo «Start to move» y tratamiento convencional. Variables de interés principales Se analizó funcionalidad, incidencia DA-UCI, incidencia delirio, días VM, estadía UCI y mortalidad-28 días, ClinicalTrials.gov número, NCT05053724. Resultados Sesenta y nueve sujetos fueron ingresados al estudio, 33 al grupo Start to move y 36 a tratamiento convencional, comparables clínico y sociodemograficamente. En el grupo Start to move la incidencia DAUCI al egreso de la UCI fue de 35,7 vs. 80,7% grupo tratamiento convencional (p=0,001). La funcionalidad (FSS-ICU) al egreso de la UCI corresponde a 26 vs. 17 puntos a favor del grupo Start to move (p=0,001). La diferencia en Barthel al egreso de la UCI fue del 20% a favor del grupo Start to move (p=0,006). No hubo diferencias significativas en incidencia de delirio, días de VM, estadía UCI y mortalidad-28 días. El estudio no reportó eventos adversos, ni suspensión de protocolo. Conclusiones La aplicación del protocolo Start to move en la UCI se asoció reducción en la incidencia DA-UCI, aumento en funcionalidad y menor caída en puntaje Barthel al egreso. (AU)

Objective To evaluate the efficacy of the Start to move protocol compared to conventional treatment in subjects over 15 years of age hospitalized in the ICU on an improvement in functionality, decrease in ICU-acquired weakness (IUCD), incidence of delirium, days of mechanical ventilation (MV), length of stay in ICU and mortality at 28 days. Design Randomized controlled clinical trial. Setting Intensive care unit. Participants Includes adults older than 15 years with invasive mechanical ventilation more than 48h, randomized allocation. Interventions Start to move protocol and conventional treatment. Main variables of interest Functionality, incidence of ICU-acquired weakness, incidence of delirium, days on mechanical ventilation, ICU stay and mortality-28 days, ClinicalTrials.gov number, NCT05053724. Results Sixty-nine subjects were admitted to the study, 33 to the Start to move group and 36 to conventional treatment, clinically and sociodemographic comparable. In the “Start to move” group, the incidence of IUCD at ICU discharge was 35.7% vs. 80.7% in the “conventional treatment” group (P=.001). Functionality (FSS-ICU) at ICU discharge corresponds to 26 vs. 17 points in favor of the “Start to move” group (P=.001). The difference in Barthel at ICU discharge was 20% in favor of the “Start to move” group (P=.006). There were no significant differences in the incidence of delirium, days of mechanical ventilation, ICU stay and 28-day mortality. The study did not report adverse events or protocol suspension. Conclusions The application of the “Start to move” protocol in ICU showed a reduction in the incidence of IUCD, an increase in functionality and a smaller decrease in Barthel score at discharge. (AU)

Functional electrical stimulation cycling-based muscular evaluation method in mechanically ventilated patients.

BACKGROUND: Intensive care acquired muscle weakness is a common feature in critically ill patients. Beyond the therapeutic uses, FES-cycling could represent a promising nonvolitional evaluation method for detecting acquired muscle weakness. OBJECTIVES: To assess whether FES-cycling is able to identify muscle dysfunctions, and to evaluate the survival rate in patients with detected muscle dysfunction. METHODS: A prospective observational study was carried out, with 29 critically ill patients and 20 healthy subjects. Maximum torque and power achieved were recorded, in addition to the stimulation cost, and patients were followed up for six months. RESULTS: Torque (2.64 [1.53 to 4.81] vs 6.03 [4.56 to 6.73] Nm) and power (3.31 [2.33 to 6.37] vs 6.35 [5.22 to 10.70] watts) were lower and stimulation cost (22 915 [5069 to 37 750] vs 3411 [2080 to 4024] µC/W) was higher in patients compared to healthy people (p < 0.05). Surviving patients showed a nonsignificant difference in power and torque in relation to nonsurvivors (p > 0.05), but they had a lower stimulation cost (4462 [3598 to 11 788] vs 23 538 [10 164 to 39 836] µC/W) (p < 0.05). In total, 34% of all patients survived during the six months of follow-up. Furthermore, 62% of patients with a stimulation cost below 15 371 µC/W and 7% of patients with a stimulation cost above 15 371 µC/W survived. CONCLUSIONS: FES-cycling has good sensitivity and specificity for detecting muscle disorders. Critical patients have low torque and power and a high stimulation cost. Stimulation cost is related to survival. A low stimulation cost was related to a 3 times greater chance of survival.

"Inspiratory muscle weakness in acutely hospitalized patients 75 years and over": a secondary analysis of a randomized controlled trial on the effectiveness of multicomponent exercise and inspiratory muscle training.

PURPOSE: The impact of hospitalization for acute illness on inspiratory muscle strength in oldest-old patients is largely unknown, as are the potential benefits of exercise and inspiratory muscle training (IMT) during in-hospital stay. DESIGN AND METHODS: This was a sub-study of a randomized clinical trial that evaluated the efficiency of a multicomponent exercise program in preventing hospitalization-associated disability. Patients were randomized into control (CG) and intervention (IG) groups. The intervention included two daily sessions of supervised walking, squat, balance, and IMT. Baseline and discharge maximal inspiratory pressure (MIP) and inspiratory muscle weakness (IMW) were determined. The effect of the intervention on inspiratory muscle strength was assessed by analyzing (1) the differences between groups in baseline and discharge MIP and IMW, (2) the association, patient by patient, between baseline and discharge MIP, and the improvement index (MIP discharge/baseline) in patients with or without IMW. RESULTS: In total, 174 patients were assessed (mean age of 87), 57 in CG and 117 in IG. Baseline MIP was lower than predicted in both sexes (women 29.7 vs 44.3; men 36.7 vs 62.5 cmH2O, P < 0.001, baseline vs predicted, respectively). More than 65% of patients showed IMW at admission. In women in IG, the mean MIP was higher at discharge than at admission (P = 0.003) and was the only variable that reached expected reference levels at discharge (Measured MIP 39.2 vs predicted MIP 45 cmH2O, P = 0.883). Patients with IMW on admission showed a statistically significant improvement in MIP after the intervention. CONCLUSION: IMW is very prevalent in oldest-old hospitalized with acute illness. Patients might benefit from a multicomponent exercise program including IMT, even during short-stay hospitalization. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NTC03604640. May 3, 2018.

Illness Weakness, Polyneuropathy and Myopathy: Diagnosis, treatment, and long-term outcomes.

BACKGROUND: Severe weakness associated with critical illness (CIW) is common. This narrative review summarizes the latest scientific insights and proposes a guide for clinicians to optimize the diagnosis and management of the CIW during the various stages of the disease from the ICU to the community stage. MAIN BODY: CIW arises as diffuse, symmetrical weakness after ICU admission, which is an important differentiating factor from other diseases causing non-symmetrical muscle weakness or paralysis. In patients with adequate cognitive function, CIW can be easily diagnosed at the bedside using manual muscle testing, which should be routinely conducted until ICU discharge. In patients with delirium or coma or those with prolonged, severe weakness, specific neurophysiological investigations and, in selected cases, muscle biopsy are recommended. With these exams, CIW can be differentiated into critical illness polyneuropathy or myopathy, which often coexist. On the general ward, CIW is seen in patients with prolonged previous ICU treatment, or in those developing a new sepsis. Respiratory muscle weakness can cause neuromuscular respiratory failure, which needs prompt recognition and rapid treatment to avoid life-threatening situations. Active rehabilitation should be reassessed and tailored to the new patient's condition to reduce the risk of disease progression. CIW is associated with long-term physical, cognitive and mental impairments, which emphasizes the need for a multidisciplinary model of care. Follow-up clinics for patients surviving critical illness may serve this purpose by providing direct clinical support to patients, managing referrals to other specialists and general practitioners, and serving as a platform for research to describe the natural history of post-intensive care syndrome and to identify new therapeutic interventions. This surveillance should include an assessment of the activities of daily living, mood, and functional mobility. Finally, nutritional status should be longitudinally assessed in all ICU survivors and incorporated into a patient-centered nutritional approach guided by a dietician. CONCLUSIONS: Early ICU mobilization combined with the best evidence-based ICU practices can effectively reduce short-term weakness. Multi-professional collaborations are needed to guarantee a multi-dimensional evaluation and unitary community care programs for survivors of critical illnesses.

[Neuromuscular weakness in the critically post COVID-19 patient: functional recovery results in two third-level centers]. / Debilidad neuromuscular del paciente crítico post COVID-19: resultados de recuperación funcional en dos centros de tercer nivel.

INTRODUCTION: The effectiveness of physical rehabilitation therapies on patients who required prolonged mechanical ventilation and were discharged from the Intensive Care Unit (ICU) with post-COVID-19 neuromuscular weakness is known in the acute period. The objective of this study was to characterize the functional recovery in people hospitalized with post-ICU neuromuscular weakness due to COVID-19 admitted to rehab. METHODS: Retrospective study which included 42 patients with post-COVID-19 neuromuscular weakness, who were admitted to two tertiary care rehabilitation centers, from April 2020 to April 2022. RESULTS: We found statistically significant differences between the functional evaluations of admission and discharge. The Functional Independence Measure improved from 49 [41-57] a 107 [94-119] (p < 0.001). The Berg scale from 4 [1-6] a 47 [36-54] (p < 0.001), the 6-minute test from 0 [0-0] a 254 [167-400] (p < 0.001), and the 10-meter test from 0 [0-0] a 0.83 [0.4-1.2] (p < 0.001). There were no statistically significant differences between the admission and discharge total score of the functional assessments with age and respiratory complexity. DISCUSSION: Treatment for functional recovery in a tertiary and long-term center is beneficial for people with severe post-ICU neuromuscular weakness due to COVID-19, even though 43% did not reach the previous level of mobility. Age and respiratory complexity are variables that did not impact the final recovery.

Introducción: La efectividad de las terapias de rehabilitación física sobre los pacientes que requirieron ventilación mecánica prolongada y egresaron de Unidad de Cuidados Intensivos (UCI) con debilidad neuromuscular post COVID-19 se conoce principalmente en el periodo agudo. El objetivo de este estudio fue caracterizar la recuperación funcional en personas con debilidad neuromuscular post UCI por COVID-19 admitidas a rehabilitación. Métodos: Estudio retrospectivo que incluyó a 42 pacientes con debilidad neuromuscular post COVID-19, de dos centros de rehabilitación de tercer nivel, desde abril de 2020 hasta abril de 2022. Resultados: Encontramos diferencias estadísticamente significativas entre las valoraciones funcionales de ingreso y alta. La Medida de Independencia Funcional (FIM) mejoró de 49 [41-57] a 107 [94-119] (p < 0.001). La escala de Berg de 4 [1-6] a 47 [36-54] (p < 0.001), el test de 6 minutos de 0 [0-0] a 254 [167-400] (p < 0.001), y el test de 10 metros de 0 [0-0] a 0.83 [0.4-1.2] (p < 0.001). No hubo diferencias estadísticamente significativas entre la puntuación total al ingreso y al alta de las evaluaciones funcionales con la edad y la complejidad respiratoria. Discusión: El tratamiento para la recuperación funcional en un centro de tercer nivel y larga duración, sería beneficioso para personas con grave debilidad neuromuscular post UCI a causa del COVID-19, a pesar que el 43% no alcanzó el nivel de movilidad previo. La edad y la complejidad respiratoria son variables que no impactaron en la recuperación final.

[Traditional Chinese therapy in the treatment of ICU-acquired weakness: a Meta-analysis].

OBJECTIVE: To systematically assess the efficacy of traditional Chinese therapy in the treatment of ICU-acquired weakness (ICU-AW). METHODS: PubMed, Cochrane Library, Embase, Web of Science, CNKI, Wanfang, VIP were retrieved by computer and were used to collect a randomized controlled trials (RCT) of traditional Chinese therapy for ICU-AW. The retrieval time was from databases establishment to December 2021. After 2 researchers independently screened the literature, extracted data and evaluated the risk of bias included in the study, and RevMan 5.4 software was used for Meta-analysis. RESULTS: 334 articles were selected, totally 13 clinical studies and 982 patients were included, including 562 in the trial group and 420 in the control group. Meta-analysis results showed that traditional Chinese therapy could improve clinical efficacy of ICU-AW patients [relative risk (RR) = 1.35, 95% confidence interval (95%CI) was 1.20 to 1.52, P < 0.000 01], improve the muscle strength [Medical Research Council score (MRC score); standardized mean difference (SMD) = 1.00, 95%CI was 0.67 to 1.33, P < 0.000 01], improve daily life ability [modified Barthel index score (MBI score); SMD = 1.67, 95%CI was 1.20 to 2.14, P < 0.000 01], shorten mechanical ventilation time (SMD = -1.47, 95%CI was -1.84 to -1.09, P < 0.000 01), reduce the length of intensive care unit (ICU) stay [mean difference (MD) = -3.28, 95%CI was -3.89 to -2.68, P < 0.000 01], reduce the total hospitalization time (MD = -4.71, 95%CI was -5.90 to -3.53, P < 0.000 01), reduce tumor necrosis factor-α (TNF-α; MD = -4.55, 95%CI was -6.39 to -2.70, P < 0.000 01) and interleukin-6 (IL-6; MD = -5.07, 95%CI was -6.36 to -3.77, P < 0.000 01). There was no obvious advantage in reducing the severity of the disease [acute physiology and chronic health evaluation II (APACHE II; SMD = -0.45, 95%CI was -0.92 to 0.03, P = 0.07). CONCLUSIONS: Based on the current research, traditional Chinese therapy can improve the clinical efficacy of ICU-AW, improve muscle strength and daily life ability, shorten mechanical ventilation, the length of ICU stay and total hospitalization time, reduce TNF-α and IL-6. But traditional Chinese therapy can not reduce the overall disease severity.

The combined intervention of neuromuscular electrical stimulation and nutrition therapy: A scoping review.

BACKGROUND & AIMS: Neuromuscular electrical stimulation (NMES) is a safe and appropriate complement to voluntary resistance training for muscle weakness. However, its feasibility and effectiveness in combination with nutritional therapy remains unclear. This scoping review aimed to summarize the evidence on combined interventions for individuals with or at risk of sarcopenia for guiding future relevant research. METHODS: A systematic electronic search was conducted using the following databases and registry: MEDLINE, CINAHL, Web of Science, PEDro, and ClinicalTrials. gov. Two independent reviewers summarized the characteristics, effectiveness, and feasibility of the combined intervention and the risk of bias in the literature. RESULTS: Nine RCTs and four non-RCTs involving 802 participants were eligible. A diverse group of participants were included: older adults with sarcopenic obesity, patients in intensive care, and patients with cancer. Evidence-based interventions combining NMES and nutritional therapy were tailored to each patient's underlying disease. Although most studies were of low to moderate quality, it can be suggested that combined interventions may be feasible and effective for increasing skeletal muscle mass. CONCLUSION: This scoping review demonstrates the potential of combined interventions as a new sarcopenia treatment strategy and highlights the need to examine the effects in high-quality RCTs with larger sample sizes.

Short-Term Outcomes of Neuromuscular Electrical Stimulation in Critically Ill Patients.

Muscle weakness acquired in the intensive care unit (ICU) adversely affects outcomes of ICU patients. This article reports the short-term respiratory effects of neuromuscular electrical stimulation (NMES) in critically ill patients. Patients were randomly assigned to an intervention group (NMES + conventional physiotherapy) and a control group (sham NMES + conventional physiotherapy). The application of NMES in the intervention group resulted in a significant decrease in the duration of mechanical ventilation and reduced the number of weaning trial failures. Other positive outcomes included reductions in the length of ICU stays and decreased mortality when compared with the control group.

Neuromuscular Weakness in Intensive Care.

Diseases of the peripheral nervous system create an additional diagnostic conundrum within the intensive care setting. Causes are vast, presentations are myriad, and symptoms are often ill-defined or misidentified. Care benefits from a multidisciplinary approach including a neuromuscular specialist, rehabilitation services, and a specialty pharmacist in addition to the neurocritical care team. In general, survivors achieve a good functional recovery relative to their preintensive care unit baseline.

Traditional Chinese therapy in the treatment of ICU-acquired weakness: a Meta-analysis / 中华危重病急救医学

OBJECTIVE@#To systematically assess the efficacy of traditional Chinese therapy in the treatment of ICU-acquired weakness (ICU-AW).@*METHODS@#PubMed, Cochrane Library, Embase, Web of Science, CNKI, Wanfang, VIP were retrieved by computer and were used to collect a randomized controlled trials (RCT) of traditional Chinese therapy for ICU-AW. The retrieval time was from databases establishment to December 2021. After 2 researchers independently screened the literature, extracted data and evaluated the risk of bias included in the study, and RevMan 5.4 software was used for Meta-analysis.@*RESULTS@#334 articles were selected, totally 13 clinical studies and 982 patients were included, including 562 in the trial group and 420 in the control group. Meta-analysis results showed that traditional Chinese therapy could improve clinical efficacy of ICU-AW patients [relative risk (RR) = 1.35, 95% confidence interval (95%CI) was 1.20 to 1.52, P < 0.000 01], improve the muscle strength [Medical Research Council score (MRC score); standardized mean difference (SMD) = 1.00, 95%CI was 0.67 to 1.33, P < 0.000 01], improve daily life ability [modified Barthel index score (MBI score); SMD = 1.67, 95%CI was 1.20 to 2.14, P < 0.000 01], shorten mechanical ventilation time (SMD = -1.47, 95%CI was -1.84 to -1.09, P < 0.000 01), reduce the length of intensive care unit (ICU) stay [mean difference (MD) = -3.28, 95%CI was -3.89 to -2.68, P < 0.000 01], reduce the total hospitalization time (MD = -4.71, 95%CI was -5.90 to -3.53, P < 0.000 01), reduce tumor necrosis factor-α (TNF-α; MD = -4.55, 95%CI was -6.39 to -2.70, P < 0.000 01) and interleukin-6 (IL-6; MD = -5.07, 95%CI was -6.36 to -3.77, P < 0.000 01). There was no obvious advantage in reducing the severity of the disease [acute physiology and chronic health evaluation II (APACHE II; SMD = -0.45, 95%CI was -0.92 to 0.03, P = 0.07).@*CONCLUSIONS@#Based on the current research, traditional Chinese therapy can improve the clinical efficacy of ICU-AW, improve muscle strength and daily life ability, shorten mechanical ventilation, the length of ICU stay and total hospitalization time, reduce TNF-α and IL-6. But traditional Chinese therapy can not reduce the overall disease severity.

[Guillain-Barré syndrome and other autoimmune neurophaties: current therapy]. / Síndrome de Guillain-Barré y otras neuropatías autoinmunes: tratamiento actual.

Guillain-Barré syndrome (GBS) is characterized by rapidly progressive and generally ascending symmetrical muscle weakness, accompanied by decreased or absent osteotendinous reflexes. The inflammatory process may affect the myelin or the axon. There are 4 clinical forms of GBS: 1) acute inflammatory demyelinating polyradiculoneuropathy, 2) acute motor axonal neuropathy, 3) acute sensory and motor axonal neuropathy, and 4) the Miller-Fisher variant, which is characterized by ophthalmoplegia, ataxia and areflexia, with little muscle weakness. Diagnosis is based on the albumin-cytological dissociation observed at the end of the first week after the onset of symptoms and may persist until the third week, as well as on the specific neurophysiological alterations of each clinical form. The treatment of GBS will depend on the degree of severity, if the patient presents grade IV or less according to the Paradiso scale, it will be treated with Ig IV, if it presents grade V, the use of plasmapheresis and/or immunoadbosorption is recommended. In severe axonal cases, the use of corticosteroid bolus is recommended in initial stages. There is a clinical picture that overlaps GBS and chronic demyelinating polyneuropathy related to antibodies against neurophysin and contactin, in this case the appropriate therapy is rituximab.

El síndrome de Guillain-Barré (SGB) se caracteriza por debilidad muscular simétrica rápidamente progresiva y generalmente ascendente, acompañada de disminución o ausencia de reflejos osteotendinosos. El proceso inflamatorio puede afectar a la mielina o al axón. Existen 4 formas clínicas de SGB: 1) polirradiculoneuropatía desmielinizante inflamatoria aguda, 2) neuropatía axonal motora aguda, 3) neuropatía axonal sensitiva y motora aguda, y 4) la variante Miller-Fisher, que se caracteriza por oftalmoplejía, ataxia y arreflexia, con escasa debilidad muscular. El diagnóstico se basa en la disociación albúmino-citológica que se observa a final de la primera semana del inicio de los síntomas y puede persistir hasta la tercera semana, así como en las alteraciones neurofisiológicas específicas de cada forma clínica. El tratamiento el SGB, dependerá de la gravedad, si el paciente presenta grado IV o menor según la escala de Paradiso, se tratará con Ig IV, si presenta grado V, se recomienda el uso de plasmaféresis y/o inmunoadbosorción. En los casos axonales graves se recomienda el uso de bolus de corticoides en etapas iniciales. Existe un cuadro clínico que solapa SGB y polineuropatía desmielinizante crónica relacionado con anticuerpos contra neurofisina y contactina, en este caso la terapia adecuada es rituximab.

Neuropatía motora multifocal: ¿cómo diagnosticar un caballo de Troya? / Multifocal motor neuropathy: how to diagnose a trojan horse?

Introducción: La neuropatía motora multifocal con bloqueos de la conducción (NMMBC) es una enfermedad crónica inmunomediada, con un compromiso exclusivo de los nervios motores. Es importante diferenciarla de otras enfermedades que cursan con afectación motora, debido a que ésta es una enfermedad tratable. Cuadro clínico: Paciente varón de 56 años, con compromiso motor progresivo en el miembro superior del lado derecho desde el año 2016. El examen neurofisiológico demostró la presencia de múltiples bloqueos de la conducción nerviosa. Los anticuerpos antigangliósidos fueron negativos. Se indicó tratamiento con inmunoglobulina endovenosa en varios ciclos, con mejoría progresiva del cuadro. Discusión: Se discute el plan diagnóstico clínico y electrofisiológico, los diagnósticos diferenciales, las hipótesis fisiopatológicas y el tratamiento de esta enfermedad de rara ocurrencia

Introduction: Multifocal motor neuropathy with conduction blocks (NMMBC) is a chronic immunemediated disease that exclusively involves the motor nerves. It is important to differentiate it from other diseases that present with motor involvement, because this is a treatable disease. Clinical picture: A 56-year-old male patient, with progressive motor involvement in the right upper limb since 2016. A neurophysiological examination revealed multiple nerve conduction blocks. Antiganglioside antibodies were negative. Treatment with intravenous immunoglobulin was indicated for several cycles with progressive improvement of the condition. Discussion: Clinical and electrophysiological diagnostic plans, differential diagnoses, pathophysiological hypotheses, and treatment of this rare disease are discussed

Poor physical recovery after critical illness: incidence, features, risk factors, pathophysiology, and evidence-based therapies.

PURPOSE OF REVIEW: To summarize the incidence, features, pathogenesis, risk factors, and evidence-based therapies of prolonged intensive care unit (ICU) acquired weakness (ICU-AW). We aim to provide an updated overview on aspects of poor physical recovery following critical illness. RECENT FINDINGS: New physical problems after ICU survival, such as muscle weakness, weakened condition, and reduced exercise capacity, are the most frequently encountered limitations of patients with postintensive care syndrome. Disabilities may persist for months to years and frequently do not fully recover. Hormonal and mitochondrial disturbances, impaired muscle regeneration due to injured satellite cells and epigenetic differences may be involved in sustained ICU-AW. Although demographics and ICU treatment factors appear essential determinants for physical recovery, pre-ICU health status is also crucial. Currently, no effective treatments are available. Early mobilization in the ICU may improve physical outcomes at ICU-discharge, but there is no evidence for benefit on long-term physical recovery. SUMMARY: Impaired physical recovery is observed frequently among ICU survivors. The pre-ICU health status, demographic, and ICU treatment factors appear to be important determinants for physical convalescence during the post-ICU phase. The pathophysiological mechanisms involved are poorly understood, thereby resulting in exiguous evidence-based treatment strategies to date.

Effect of early mobilization combined with early nutrition on acquired weakness in critically ill patients (EMAS): A dual-center, randomized controlled trial.

AIM: The study aimed to investigate the effect of early mobilization combined with early nutrition (EMN) on intensive care unit-acquired weakness (ICU-AW) in intensive care unit (ICU) settings compared with early mobilization (EM) or routine care. METHODS: A prospective, dual-center, randomized controlled trial was conducted. The control group underwent standard care without a pre-established routine for mobilization and nutrition. The EM group underwent early, individualized, progressive mobilization within 24 h of ICU admission. The EMN group underwent early mobilization, similar to the EM group plus guideline-based early nutrition (within 48 h of ICU admission). The primary outcome was the occurrence of ICU-AW at discharge from the ICU. Secondary outcomes included muscle strength, functional independence, organ failure, nutritional status, duration of mechanical ventilation (MV), length of ICU stay, and ICU mortality at ICU discharge. RESULTS: A total of 150 patients were enrolled and equally distributed into the three groups. Patients undergoing routine care only were more susceptible to ICU-AW upon ICU discharge than those in the EM or EMN groups (16% vs. 2%; p = 0.014 for both), and had a lower Barthel Index than others (control vs. EM/EMN: 57.5 vs 70.0; p = 0.022). The EMN group had improved muscle strength (p = 0.028) and better nutritional status than the control group (p = 0.031). Both interventions were associated with a lower ICU-AW (EM vs. control: p = 0.027, OR [95% CI] = 0.066 [0.006-0.739]; EMN vs. control: p = 0.016, OR [95% CI] = 0.065 [0.007-0.607]). CONCLUSION: EM and EMN had positive effects. There was little difference between the effects of EM and EMN, except for muscle strength improvement. Both EM and EMN may lead to a lower occurrence of ICU-AW and better functional independence than standard care. EMN might benefit nutritional status more than usual care and promote improvement in muscle strength.

Effects of physical therapy with neuromuscular electrical stimulation in acute and late septic shock patients: A randomised crossover clinical trial.

BACKGROUND: Patients with sepsis and immobility in the intensive care unit are associated with muscle weakness, and early mobilisation can counteract it. However, during septic shock, mobilisation is often delayed due to the severity of the illness. Neuromuscular electrical stimulation (NMES) may be an alternative to mobilise these patients early. This study aims to identify whether NMES performed within the first 72 hours of septic shock diagnosis or later is safe from a metabolic perspective. METHODS: This is the analysis of two randomised controlled crossover studies. Patients with acute septic shock (within the first 72 hours of diagnosis) and sepsis and septic shock in the late phase (after 72 hours of diagnosis) were eligible. Patients were submitted in a random order to the intervention protocol (dorsal decubitus position with the lower limbs raised and NMES) and control (dorsal decubitus position with the lower limbs raised without NMES). The patients were allocated in group 1 (intervention and control) or group 2 (control and intervention) with a wash-out period of 4 to 6 hours. Metabolic variables were evaluated by indirect calorimetry. RESULTS: Sixteen patients were analysed in the acute septic shock study and 21 in the late sepsis/septic shock study. There were no significant differences between Oxygen Consumption (VO2) values in the acute phase of septic shock when the baseline period, intervention, and control protocols were compared (186.59 ± 46.10; 183.64 ± 41.39; 188.97 ± 44.88, p>0.05- expressed in mL/Kg/min). The same was observed when the VO2 values in the late phase were compared (224.22 ± 53.09; 226.20 ± 49.64; 226.79 ± 58.25, p>0.05). The other metabolic variables followed the same pattern, with no significant differences between the protocols. When metabolic variables were compared between acute to late phase, significant differences were observed (p<0.05). CONCLUSIONS: As metabolic rates in septic shock patients had no increase during NMES, either in the first 72 hours of diagnosis or later, NMES can be considered safe from a metabolic viewpoint, even despite the higher metabolic demand in the acute phase of shock. TRIAL REGISTRATION: NCT03193164; NCT03815994. Registered on June 5, 2017; November 13, 2018 (clinicaltrials.gov/).

The Manual Therapy and Strengthening for the Hip (MASH) Trial: Protocol for a Multisite Randomized Trial of a Subgroup of Older Adults With Chronic Back and Hip Pain.

OBJECTIVE: Chronic low back pain (CLBP) is a disabling and costly condition for older adults that is difficult to properly classify and treat. In a cohort study, a subgroup of older adults with CLBP who had elevated hip pain and hip muscle weakness was identified; this subgroup differentiated itself by being at higher risk for future mobility decline. The primary purpose of this clinical trial is to evaluate whether a hip-focused low back pain (LBP) treatment provides better disability and physical performance outcomes for this at-risk group compared with a spine-focused LBP treatment. METHODS: This study is a multisite, single-blinded, randomized controlled, parallel arm, Phase II trial conducted across 3 clinical research sites. A total of 180 people aged between 60 and 85 years with CLBP and hip pain are being recruited. Participants undergo a comprehensive baseline assessment and are randomized into 1 of 2 intervention arms: hip-focused or spine-focused. They are treated twice weekly by a licensed physical therapist for 8 weeks and undergo follow-up assessments at 8 weeks and 6 months after randomization. Primary outcome measures include the Quebec Low Back Disability Scale and the 10-Meter Walk Test, which are measures of self-report and performance-based physical function, respectively. IMPACT: This multicenter, randomized clinical trial will determine whether a hip-focused or spine-focused physical therapist intervention results in improved disability and physical performance for a subgroup of older adults with CLBP and hip pain who are at increased risk of mobility decline. This trial will help further the development of effective interventions for this subgroup of older adults with CLBP.

A randomized controlled trial of high-intensity interval training and inspiratory muscle training for chronic heart failure patients with inspiratory muscle weakness.

OBJECTIVES: Chronic heart failure is a major public health problem in which supervised exercise programs are recommended as part of non-pharmacological management. There are various reports of the success of high-intensity aerobic interval training (HI-AIT) and inspiratory muscle training (IMT) in the management of chronic heart failure patients. This study tested the hypothesis that the combination of HI-AIT and IMT could result in additional benefits over the IMT and the HI-AIT alone in terms of inspiratory muscle function, exercise capacity, and quality of life in patients with chronic heart failure and inspiratory muscle weakness. METHODS: Forty patients with ejection fraction ≤45% and inspiratory muscle weakness described by maximal inspiratory pressure <70% predicted, underwent three exercise training sessions per week for 12 weeks. Patients were randomly allocated to one of four groups: the HI-AIT group, the IMT group, the combined (HI-AIT & IMT) group, and the control group. Before and after completing their training period, all patients underwent different tests that are mentioned above. RESULTS: No changes were detected in the control group. However, the combined group, when compared to HI-AIT and IMT groups, respectively, resulted in additional significant improvement in maximal inspiratory training (62%, 24%, 25%), exercise time (62%, 29%, 12%), the 6-minute walk test (23%, 15%, 18%), and the Minnesota Living with Heart Failure Questionnaire (56%, 47%, 36%). CONCLUSION: In patients with chronic heart failure and inspiratory muscle weakness, the combination of the HI-AIT and the IMT resulted in additional benefits in respiratory muscle function, exercise performance, and quality of life compared to that of HI-AIT or IMT alone.Trial Registration number: NCT03538249.

Efficacy and safety of manual acupuncture for the treatment of upper limb motor dysfunction after stroke: Protocol for a systematic review and meta-analysis.

INTRODUCTION: The incidence of stroke sequelae among patients is as high as 70%-80%. Flexor spasm is the most common stroke sequela, presenting a heavy burden to the patients and their families. This study will evaluate the results of randomized controlled trials to determine the efficacy and safety of hand manipulation acupuncture for the treatment of upper limb motor dysfunction after stroke. METHODS: Eight databases, including China National Knowledge Infrastructure, Chinese Scientific Journal Database, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PubMed, Wanfang Database, and Web of Science, will be searched using English and Chinese search strategies. In addition, manual retrieval of research papers, conference papers, ongoing experiments, and internal reports, among others, will supplement electronic retrieval. All eligible studies published on or before January 15, 2021 will be selected. To enhance the effectiveness of the study, only clinical randomized controlled trials related to the use of manual acupuncture for the treatment of upper limb motor dysfunction after stroke will be included. ANALYSIS: The Fugl-Meyer upper extremity assessment will be the primary outcome measure, whereas the Wolf Motor Function Test, Modified Ashworth Scale, arm movement survey test table, and upper extremity freehand muscle strength assessment scores will be the secondary outcomes. Side effects and adverse events will be included as safety evaluations. To ensure the quality of the systematic evaluation, study selection, data extraction, and quality assessment will be independently performed by two authors, and a third author will resolve any disagreement. ETHICS AND DISSEMINATION: This systematic review will evaluate the efficacy and safety of manual acupuncture for the treatment of upper limb motor dysfunction after stroke. Since all included data will be obtained from published articles, it does not require ethical approval and will be published in a peer-reviewed journal. INPLASY registration number: INPLASY202110071.

Approach to Limb Weakness.

"Approach to limb weakness" provides an overview of the pathways of the motor system and the type of weakness seen with pathology at each level from the cortex to the muscle. This article provides the clinical pearls needed to identify different patterns of weakness and accurately localize the level of weakness. It offers important pointers that help distinguish among the different etiologies of weakness at each level, as well as various diagnostic approaches and treatments of diseases that lead to limb weakness. The diagnoses discussed are meant to be representative and not exhaustive, as a complete differential for each pattern of weakness is beyond the scope of this article.