ORIGINAL ARTICLE
The Clinical Respiratory Journal
Effect of physical therapy on muscle strength, respiratory muscles and functional parameters in patients with intensive care unit-acquired weakness Orna Yosef-Brauner1, Nimrod Adi2, Tamar Ben Shahar1, Ester Yehezkel1 and Eli Carmeli3 1 Physical Therapy Department, Kaplan Medical Center, Rehovot., Israel 2 Intensive Care Unit, Kaplan Medical Center, Rehovot., Israel 3 Department of Physical Therapy, Faculty of Social Welfare and Health Sciences. University of Haifa, Haifa, Israel
Abstract Objectives: The aim of this study was to evaluate the effect of an intensive physical therapy protocol in patients who contract ‘intensive care unit-acquired weakness’ (ICUAW), in terms of muscle strength, breathing and functional indices. Methods: This was a prospective, single-blinded study in a general hospital intensive care unit (ICU). Patients who required mechanical ventilation longer than 48 h and who were expected to remain mechanically ventilated for at least another 48 h were randomly divided into two intervention groups: group I (n = 9) – the routine care group, received physical therapy according to our daily custom protocol; and group II (n = 9) – the intensive treatment group, were treated by the same protocol twice a day. The main outcome measures included the Medical Research Council (MRC) physical strength examination, maximal inspiratory pressure (MIP), hand grip dynamometer and sitting balance test. Results: Significant strength improvement from first (T1) to second (T2) measurements was demonstrated for variables MIP and MRC physical strength examination in favor of the intensive treatment group (P < 0.05). The intensive treatment group also required shorter intensive care length of stay than the routine care group (P = 0.043). Conclusions: It is possible that an intensive therapy protocol may facilitate the initial recovery process in patients who suffer from ICUAW. Please cite this paper as: Yosef-Brauner O, Adi N, Ben Shahar T, Yehezkel E and Carmeli E. Effect of physical therapy on muscle strength, respiratory muscles and functional parameters in patients with intensive care unit-acquired weakness. Clin Respir J 2014; ••: ••–••. DOI:10.1111/crj.12091. Ethics This study has been reviewed by the appropriate ethics committee and been performed in accordance with the ethical standards laid down in the Declaration of Helsinki.
Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Introduction Research development, along with the use of advanced medical technologies, has led to increased survival among patients hospitalized in intensive care units (ICUs). As a result, neuromuscular dysfunction syndromes, which develop in intensive care without a clear etiology, are currently routinely identified and charac-
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
Key words intensive care unit acquired weakness – maximal inspiratory pressure – Medical Research Council physical strength examination – sitting balance Correspondence Eli Carmeli, PhD, Department of Physical Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, 199 Abba Hushi Blvd., Mt. Carmel, Haifa 3190501, Israel. Tel: 04 8288140 Fax: 04 8288140 email: [email protected] Received: 01 February 2013 Revision requested: 01 November 2013 Accepted: 02 December 2013 DOI:10.1111/crj.12091 Authorship and contributorship Orna Yosef-Brauner designed and performed the study, discussed and analyzed finding, and wrote the paper. Nimrod Adi designed and performed the study, discussed and analyzed findings. Eli Carmeli designed the study, discussed and analyzed findings, and wrote the paper. Tamar Ben Shahar designed the study, discussed and analyzed findings. Ester Yehezkel performed the study and discussed the findings.
terized. These are not necessarily derived from the basic acute disease etiology and its treatment (1). The critically ill patient is usually sedated and ventilated and might experience multiorgan failure, while medical treatment aims primarily to stabilize acute life-threatening disease. Medical interventions such as anesthesia, neuromuscular blockade and corticosteroids administration, as well as concurrent systemic
1
Intensive care-acquired weakness physical therapy
inflammation, catabolic processes and extended immobility were found to cause neurocognitive and neuromuscular deficits. ICU-acquired weakness (ICUAW) is a significant complication in patients hospitalized in ICUs, with an incidence of at least 25%–33% (2–4). Recognition of muscle weakness, immobility and failure of voluntary physical function as ICUAW risk factors positions physical therapy as a relevant treatment. Early physical therapy is associated with reduced ventilation time; ICU and hospital stay [length of stay (LOS)] (5, 6). Several studies demonstrated the benefits of early mobilization on functional outcomes in mechanically ventilated critically ill patients (7–10). The aim of this study was to evaluate the effect of an intensive physical therapy protocol on patients with muscle weakness acquired in the ICU (ICUAW) in terms of muscle strength indices and respiratory and functional ability, as well as to assess whether there is a correlation between the various tests, including extremity and respiratory muscles strength, hand grip strength and trunk control.
Methods
Yosef-Brauner et al.
group I – the conventional treatment group, received a daily custom physical therapy protocol; and group II – the intensive treatment group, were treated twice a day by the same protocol. All enrolled patients were tested at baseline (T1) for right and left hand grip strength using a Jamar dynamometer (Lafayette Co., Lafayette, IN, USA), and maximal inspiratory pressure (MIP), and sitting balance (SB) according to Stolov (13). The tests were conducted in the presence of a physician who was blinded to the randomization. The second set of measurements (T2) was preformed after 48–72 h. The last test (T3) was carried out at the time of discharge from the ICU. From June 2011 to February 2012, all patients who were admitted to the ICU and required mechanical ventilation were evaluated. One hundred patients who were intubated longer than 48 h and were expected to be ventilated for at least another 48 h were designated as potential participants in this prospective study. Sixty-three of them were not eligible for inclusion because of severe medical status or central neurologic damage; another twelve did not cooperate with the tests and seven patients did not have ICUAW. Eventually, 18 patients participated in the study after meeting the inclusion and exclusion criteria (Table 1).
Study design and participants Patients who were admitted to the ICU at Kaplan Medical Center, who required mechanical ventilation over 48 h duration and who were expected to remain ventilated for at least 48 additional hours, were potential participants in this study. The inclusion criteria consisted of patients over the age of 18 who were independent before the current hospitalization, were fully conscious and able to perform simple commands, and had a Medical Research Council (MRC) physical strength examination score lower than 48 points. The exclusion criteria were: unconsciousness; central or peripheral neurological damage; hemodynamic instability (i.e., blood pressure >200 or
The Clinical Respiratory Journal
Effect of physical therapy on muscle strength, respiratory muscles and functional parameters in patients with intensive care unit-acquired weakness Orna Yosef-Brauner1, Nimrod Adi2, Tamar Ben Shahar1, Ester Yehezkel1 and Eli Carmeli3 1 Physical Therapy Department, Kaplan Medical Center, Rehovot., Israel 2 Intensive Care Unit, Kaplan Medical Center, Rehovot., Israel 3 Department of Physical Therapy, Faculty of Social Welfare and Health Sciences. University of Haifa, Haifa, Israel
Abstract Objectives: The aim of this study was to evaluate the effect of an intensive physical therapy protocol in patients who contract ‘intensive care unit-acquired weakness’ (ICUAW), in terms of muscle strength, breathing and functional indices. Methods: This was a prospective, single-blinded study in a general hospital intensive care unit (ICU). Patients who required mechanical ventilation longer than 48 h and who were expected to remain mechanically ventilated for at least another 48 h were randomly divided into two intervention groups: group I (n = 9) – the routine care group, received physical therapy according to our daily custom protocol; and group II (n = 9) – the intensive treatment group, were treated by the same protocol twice a day. The main outcome measures included the Medical Research Council (MRC) physical strength examination, maximal inspiratory pressure (MIP), hand grip dynamometer and sitting balance test. Results: Significant strength improvement from first (T1) to second (T2) measurements was demonstrated for variables MIP and MRC physical strength examination in favor of the intensive treatment group (P < 0.05). The intensive treatment group also required shorter intensive care length of stay than the routine care group (P = 0.043). Conclusions: It is possible that an intensive therapy protocol may facilitate the initial recovery process in patients who suffer from ICUAW. Please cite this paper as: Yosef-Brauner O, Adi N, Ben Shahar T, Yehezkel E and Carmeli E. Effect of physical therapy on muscle strength, respiratory muscles and functional parameters in patients with intensive care unit-acquired weakness. Clin Respir J 2014; ••: ••–••. DOI:10.1111/crj.12091. Ethics This study has been reviewed by the appropriate ethics committee and been performed in accordance with the ethical standards laid down in the Declaration of Helsinki.
Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Introduction Research development, along with the use of advanced medical technologies, has led to increased survival among patients hospitalized in intensive care units (ICUs). As a result, neuromuscular dysfunction syndromes, which develop in intensive care without a clear etiology, are currently routinely identified and charac-
The Clinical Respiratory Journal (2014) • ISSN 1752-6981 © 2013 John Wiley & Sons Ltd
Key words intensive care unit acquired weakness – maximal inspiratory pressure – Medical Research Council physical strength examination – sitting balance Correspondence Eli Carmeli, PhD, Department of Physical Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, 199 Abba Hushi Blvd., Mt. Carmel, Haifa 3190501, Israel. Tel: 04 8288140 Fax: 04 8288140 email: [email protected] Received: 01 February 2013 Revision requested: 01 November 2013 Accepted: 02 December 2013 DOI:10.1111/crj.12091 Authorship and contributorship Orna Yosef-Brauner designed and performed the study, discussed and analyzed finding, and wrote the paper. Nimrod Adi designed and performed the study, discussed and analyzed findings. Eli Carmeli designed the study, discussed and analyzed findings, and wrote the paper. Tamar Ben Shahar designed the study, discussed and analyzed findings. Ester Yehezkel performed the study and discussed the findings.
terized. These are not necessarily derived from the basic acute disease etiology and its treatment (1). The critically ill patient is usually sedated and ventilated and might experience multiorgan failure, while medical treatment aims primarily to stabilize acute life-threatening disease. Medical interventions such as anesthesia, neuromuscular blockade and corticosteroids administration, as well as concurrent systemic
1
Intensive care-acquired weakness physical therapy
inflammation, catabolic processes and extended immobility were found to cause neurocognitive and neuromuscular deficits. ICU-acquired weakness (ICUAW) is a significant complication in patients hospitalized in ICUs, with an incidence of at least 25%–33% (2–4). Recognition of muscle weakness, immobility and failure of voluntary physical function as ICUAW risk factors positions physical therapy as a relevant treatment. Early physical therapy is associated with reduced ventilation time; ICU and hospital stay [length of stay (LOS)] (5, 6). Several studies demonstrated the benefits of early mobilization on functional outcomes in mechanically ventilated critically ill patients (7–10). The aim of this study was to evaluate the effect of an intensive physical therapy protocol on patients with muscle weakness acquired in the ICU (ICUAW) in terms of muscle strength indices and respiratory and functional ability, as well as to assess whether there is a correlation between the various tests, including extremity and respiratory muscles strength, hand grip strength and trunk control.
Methods
Yosef-Brauner et al.
group I – the conventional treatment group, received a daily custom physical therapy protocol; and group II – the intensive treatment group, were treated twice a day by the same protocol. All enrolled patients were tested at baseline (T1) for right and left hand grip strength using a Jamar dynamometer (Lafayette Co., Lafayette, IN, USA), and maximal inspiratory pressure (MIP), and sitting balance (SB) according to Stolov (13). The tests were conducted in the presence of a physician who was blinded to the randomization. The second set of measurements (T2) was preformed after 48–72 h. The last test (T3) was carried out at the time of discharge from the ICU. From June 2011 to February 2012, all patients who were admitted to the ICU and required mechanical ventilation were evaluated. One hundred patients who were intubated longer than 48 h and were expected to be ventilated for at least another 48 h were designated as potential participants in this prospective study. Sixty-three of them were not eligible for inclusion because of severe medical status or central neurologic damage; another twelve did not cooperate with the tests and seven patients did not have ICUAW. Eventually, 18 patients participated in the study after meeting the inclusion and exclusion criteria (Table 1).
Study design and participants Patients who were admitted to the ICU at Kaplan Medical Center, who required mechanical ventilation over 48 h duration and who were expected to remain ventilated for at least 48 additional hours, were potential participants in this study. The inclusion criteria consisted of patients over the age of 18 who were independent before the current hospitalization, were fully conscious and able to perform simple commands, and had a Medical Research Council (MRC) physical strength examination score lower than 48 points. The exclusion criteria were: unconsciousness; central or peripheral neurological damage; hemodynamic instability (i.e., blood pressure >200 or
