Physiotherapy - Theses
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ItemAssessment and rehabilitation for intensive care unit acquired weakness( 2014)Intensive care unit-acquired weakness (ICU-AW) is a significant problem for individuals who are critically ill. Longitudinal studies have demonstrated ongoing impairments in muscle strength and physical functioning five years post initial critical illness. This resultant morbidity significantly affects survivors’ ability to carry out daily activities, return to work and resume family duties. Muscle wasting has been shown to occur early and rapidly within the first week of an ICU admission. There is a strong and growing body of research on the potential benefit of rehabilitation and a wide range of endpoints have been used to evaluate efficacy in clinical trials within respect to muscle mass, muscle strength and functional outcomes. However, there has been limited research undertaken to specifically examine the clinimetric properties of outcome measures utilised in the ICU and the role of non-volitional exercise strategies such as electrical muscle stimulation (EMS). This thesis addresses some of these gaps in our current understanding in terms of assessment and rehabilitation of individuals with critical illness. The first part of this thesis reports on a systematic review undertaken to examine the clinimetric properties (reliability, validity and responsiveness) of outcome measures used to evaluate muscle mass, muscle strength and functional outcomes. The subsequent three studies report on the development of a two-tier approach to the diagnosis of ICU-AW in clinical practice; the reliability of different neuromuscular ultrasound imaging approaches in the assessment of muscle echointensity; and the clinical utility of ultrasonography in a longitudinal observational study. The second part of this thesis is focused on the safety, feasibility and efficacy of EMS and functional electrical stimulation (FES) cycling. A systematic review was undertaken to synthesise the evidence regarding the safety and efficacy of EMS in the ICU setting. Greatest attenuation of muscle mass changes appears to be seen in individuals with less acuity and the chronically critically ill. There are significant methodological limitations within the studies conducted to date. These limitations include: small sample sizes, heterogeneity in terms of outcome measures used and no follow up beyond intervention cessation. Therefore it is currently unknown what the long-term efficacy of EMS might be. Functional electrical stimulation cycling was shown to be safe, feasible and on preliminary examination using a case-control study methodology to potentially improve functional outcomes and reduce the incidence and duration of delirium. The methodology for a randomised controlled trial examining the efficacy of FES-cycling on muscle mass, muscle strength and functional outcomes are also presented. The findings of this thesis strongly support the need for targeted early rehabilitation strategies, which may assist in preventing the debilitating and negative consequences that occur as a result of being critically unwell. The need for a standardised approach to the diagnosis of ICU-AW and the measurement of efficacy are also identified, to enable generalizability across studies to improve the recovery trajectory and thus reduce the burden of post intensive care syndrome on survivors and their families.