- •Combining physical therapy, NMES and high protein nutrition with standard care restored positive nitrogen balance in critically ill subjects.
- •The intervention group experienced less muscle lower extremity muscle loss (volume and cross-sectional area) when compared to standard care.
- •The intervention group experienced less delirium compared to the group who received standard care.
Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.
To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.
Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.
The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.
The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.
Trial Registration: Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015
Abbreviations:NMES (neuromuscular electrical stimulation), HPRO (high protein supplementation), PT (physical therapy), SC (standard care), LOS (length of stay), EMR (electronic medical record), NUTRIC (Nutrition Risk in Critically ill), MRC (medical research council), LTACH (long-term acute care hospital), PD (pulse duration), PR (pulse rate), CAM (confusion Assessment Method), CSA (cross-sectional area), SPPB (short physical performance battery)
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- Acute muscle wasting among critically ill patients–reply.JAMA. 2014; 311: 622-623
- Protein metabolism and gene expression in skeletal muscle of critically ill patients with sepsis.Clin Sci. 2012; 122: 133-142
- Atrophy and impaired muscle protein synthesis during prolonged inactivity and stress.J Clin Endocrinol Metab. 2006; 91: 4836-4841
- Tissue protein synthesis rates in critically ill patients.Crit Care Med. 1998; 26: 92-100
- Necrotizing myopathy in critically-ill patients.J Pathol. 1991; 164: 307-314
- Earlier and enhanced rehabilitation of mechanically ventilated patients in critical care: a feasibility randomised controlled trial.J Crit Care. 2018; 44: 407-412
- Intensive care unit structure variation and implications for early mobilization practices. An international survey.Ann Am Thorac Soc. 2016; 13: 1527-1537
- Receiving early mobility during an Intensive Care Unit admission is a predictor of improved outcomes in acute respiratory failure.Am J Med Sci. 2011; 341: 373-377
- Intensive care unit-related generalized neuromuscular weakness due to critical illness polyneuropathy/myopathy in critically ill patients.J Anesth. 2015; 29: 112-121
- Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation.Crit Care Med. 2010; 38: 2089-2094
- Rehabilitation in the Intensive Care Unit.Semin Respir Crit Care Med. 2009; 30: 656-669
- A multimodal rehabilitation program for patients with ICU acquired weakness improves ventilator weaning and discharge home.J Crit Care. 2018; 47: 204-210
- Efficacy of neuromuscular electrical stimulation in patients with COPD followed in Intensive Care Unit.Clin Respir J. 2017; 11: 743-750
- Feasibility of neuromuscular electrical stimulation immediately after cardiovascular surgery.Arch Phys Med Rehabil. 2015; 96: 63-68
- Neuromuscular electrical stimulation prevents muscle wasting in critically ill comatose patients.Clin Sci. 2015; 128: 357-365
- Feasibility of neuromuscular electrical stimulation in critically ill patients.J Crit Care. 2014; 29: 1082-1088
- The effect of electrical muscle stimulation on the prevention of disuse muscle atrophy in patients with consciousness disturbance in the Intensive Care Unit.J Crit Care. 2013; 28: e1-7https://doi.org/10.1016/j.jcrc.2013.02.010
- Use of neuromuscular electrical stimulation to preserve the thickness of abdominal and chest muscles of critically ill patients: a randomized clinical trial.J Rehabil Med. 2017; 49: 40-48
- Neuromuscular electrical stimulation acutely mobilizes endothelial progenitor cells in critically ill patients with sepsis.Ann Intensive Care. 2016; 6: 21
- Defining anabolic resistance: implications for delivery of clinical care nutrition.Curr Opin Crit Care. 2018; 24: 124-130
- A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults.Br J Sports Med. 2018; 52: 376-384
- Exploring the potential effectiveness of combining optimal nutrition with electrical stimulation to maintain muscle health in critical illness: a narrative review.Nutr Clin Pract. 2018; Dec33: 772-789https://doi.org/10.1002/ncp.10213
- Timing of protein intake and clinical outcomes of adult critically ill patients on prolonged mechanical ventilation: the protinvent retrospective study.Clin Nutr. 2018;
- Protein turnover and metabolism in the elderly Intensive Care Unit patient.Nutr Clin Pract. 2017; 32: 112S-120S
- Greater protein and energy intake may be associated with improved mortality in higher risk critically ill patients: a multicenter, multinational observational study.Crit Care Med. 2017; 45: 156-163
- Association of energy and protein delivery on skeletal muscle mass changes in critically ill adults: a systematic review.JPEN J Parenter Enter Nutr. 2018; 42: 1112-1122
- Nutrition and exercise in critical illness trial [NEXIS Trial]: a protocol of a multicentred, randomised controlled trial of combined cycle ergometry and amino acid supplementation commenced early during critical illness.BMJ Open. 2019; 9e027893
- ESPEN guideline on clinical nutrition in the Intensive Care Unit.Clin Nutr. 2019; 38: 48-79
- Cadaver validation of skeletal muscle measurement by magnetic resonance imaging and computerized tomography.J Appl Physiol. 1998; 85 (): 115-122
- Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study.Lancet Oncol. 2008; 9: 629-635
- Atrophy and intramuscular fat in specific muscles of the thigh: associated weakness and hyperinsulinemia in stroke survivors.Neurorehabil Neural Repair. 2011; 25: 865-872
- Strength training for arthritis trial [START]: design and rationale.BMC Musculoskelet Disord. 2013; 14: 208
- Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit [CAM-ICU].Crit Care Med. 2001; 29: 1370-1379
- Energy expenditure during barbiturate coma.Nutr Clin Pract. 2013; 28: 603-608
- Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: society of critical care medicine [SCCM] and American Society for Parenteral and Enteral Nutrition [A.S.P.E.N.].JPEN J Parenter Enter Nutr. 2016; 40: 159-211
- Regression and time series model selection in small samples.Biometrika. 1989; 76: 297-307
- IEEE transactions on automatic control.in: Akaike A New Look at the Statistical Model Identification. 19. IEEE, 1974: 716-723
- Neuromuscular electrical stimulation combined with exercise decreases duration of mechanical ventilation in ICU patients: a randomized controlled trial.Physiother Theory Pract. 2020; 36: 580-588
- Impact of transcutaneous neuromuscular electrical stimulation or resistance exercise on skeletal muscle mRNA expression in COPD.Int J Chronic Obstr Pulm Dis. 2019; 14: 1355-1364
- Mobilizing patients in the Intensive Care Unit: improving neuromuscular weakness and physical function.JAMA. 2008; 300: 1685-1690
- Early mobilization: why, what for and how?.Med Intensiva. 2017; 41: 429-436
- TryCYCLE: a prospective study of the safety and feasibility of early in-bed cycling in mechanically ventilated patients.PLoS ONE. 2016; 11e0167561
- Point prevalence study of mobilization practices for acute respiratory failure patients in the United States.Crit Care Med. 2017; 45: 205-215
- Muscle atrophy in Intensive Care Unit patients.Acta Inform Med. 2014; 22: 406-410
- Effects of neuromuscular electrical stimulation of the quadriceps and diaphragm in critically ill patients: a pilot study.Crit Care Res Pract. 2018; 20184298583
- Safety and feasibility of a neuromuscular electrical stimulation chronaxie-based protocol in critical ill patients: a prospective observational study.J Crit Care. 2017; 37: 141-148
- Effect of neuromuscular stimulation and individualized rehabilitation on muscle strength in Intensive Care Unit survivors: a randomized trial.J Crit Care. 2017; 40: 76-82
- Neuromuscular electrical stimulation in mechanically ventilated patients: a randomized, sham-controlled pilot trial with blinded outcome assessment.J Crit Care. 2015; 30: 32-39
- Neuromuscular electrical stimulation improves clinical and physiological function in COPD patients.Respir Med. 2014; 108: 609-620
- Long-term complications of critical care.Crit Care Med. 2011; 39: 371-379
- Improving long-term outcomes after discharge from Intensive Care Unit: report from a stakeholders' conference.Crit Care Med. 2012; 40: 502-509
- Early nutritional inadequacy is associated with psoas muscle deterioration and worse clinical outcomes in critically ill surgical patients.J Crit Care. 2018; 45: 7-13
- Deficiency of phosphatidylinositol 3-kinase delta signaling leads to diminished numbers of regulatory T cells and increased neutrophil activity resulting in mortality due to endotoxic shock.J Immunol. 2017; 199: 1086-1095
- Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients.Crit Care. 2014; 18: 701
- How soon should we start interventional feeding in the ICU?.Curr Opin Gastroenterol. 2014; 30: 178-181
- Protein for the critically ill patient–what and when?.Eur J Clin Nutr. 2013; 67: 565-568
- National heart, lung, and blood institute Acute Respiratory Distress Syndrome (ARDS) clinical trials. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial.JAMA. 2012; 307: 795-803
Published online: December 03, 2022
Accepted: November 22, 2022
Received in revised form: November 21, 2022
Received: September 19, 2022
© 2022 Elsevier Inc. All rights reserved.
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- Exercise and nutrition in critically ill patients-What is the correct formula?Heart & Lung: The Journal of Cardiopulmonary and Acute CareVol. 58
- PreviewICU-acquired weakness is diagnosed in approximately 1 million mechanically ventilated patients annually.1 This weakness is secondary to multiple mechanisms including myopathy, neuropathy, deconditioning and protein malnutrition. In addition, ICU-acquired weakness is associated with decreased quality of life and increased mortality.2 Physical rehabilitation and nutritional support have the potential to improve muscle strength and help maintain functional status.