The effect of early mobilization on quadriceps architecture among critically ill patients

Abstract Description

Authors (including presenting author) :

Tse PY, Chan WY, Hau CY, Lau KT, Wong HL, Tsang HC, To YL

Affiliation :

Physiotherapy Department, North District Hospital

Introduction :

Muscle wasting is common in critically ill patients. Intensive care unit (ICU) acquired weakness is associated with longer length of stay(LoS) and intubation duration. [1]. Quadriceps thickness (QT) and pennation angle(PA) of vastus lateralis measured by ultrasound had been proven to be reliable to reflect changes in muscle architecture during ICU stay.[2,4] PA was found to be related to better force generation in both isometric and dynamic contractions.[3] Both QT and PA significantly decreased during ICU stay due to disuse.[4] This study aimed to investigate the change of QT and PA over time and the effect of early mobilization(EM) on QT and PA in intubated patients.

Objectives :

To study the changes of ultrasound measured QT and PA and their relationship between EM for intubated patients during ICU stay.

Methodology :

This was a prospective cohort pilot study conducted in the ICU of North District Hospital from February 2024 to November 2024. Ultrasound measurement of QT and PA of right leg was performed in intubated patients in ICU at Day1,4,7,10 and upon discharge. EM including in-bed cycling, bedside standing/stepping and assisted walking were prescribed to all patients according to their capability. QT was measured on right leg at the junction of lower third and upper two-thirds between anterior superior iliac spine and the upper border of patella. The transducer then moved lateral by one fifth of the thigh circumference to measure PA. Patients with pre-existing neuromuscular pathology, lower-limb amputation, lower limb orthopedic surgery, terminal illness and patients undergoing continuous renal replacement therapy were excluded. Spearman’s Rho test was used to review the correlation between percentage decreased in QT and PA from Day1 to discharge day and initial date of weight bearing (WB) exercise (i.e. standing/ walking).
Simple linear regression was used to predict the percentage decrease in QT with the initial date of WB exercise.

Result & Outcome :

47 patients were recruited in this study (34%female, 66%male). The mean age was 58.32. Average LoS was 15.04days. QT decreased 8.39%, 11.35%, 21.97% and 22.445, while PA decreased 6.00%, 7.89%, 17.84% and 12.05% on Day4,7,10 and upon discharge respectively.

Moderately strong significant positive correlation was found between percentage decrease in QT and the initial date of WB exercise(r=0.440, p=0.009). Simple linear regression showed that starting WB exercise one day earlier was associated with a reduction in percentage decrease in QT by 1.49 upon discharge, which means earlier WB exercise might reduce the loss in QT.

However, no significant correlation was found between PA and the initial date of WB exercise(r=0.093, p=0.599).
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In conclusion, QT and PA of intubated patients decreased over time during ICU stay despite EM was provided. However, earlier WB exercise appears to have an attenuation effect on their muscle loss.

Reference:

1. Moisey, L. L., Mourtzakis, M., Cotton, B. A., Premji, T., Heyland, D. K., Wade, C. E., Bulger, E. M., & Kozar, R. A. (2013). Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Critical Care, 17(5), R206.
2. Pardo, E., El Behi, H., Boizeau, P., Verdonk, F., Alberti, C., & Lescot, T. (2018). Reliability of ultrasound measurements of quadriceps muscle thickness in critically ill patients. BMC Anesthesiology, 18(1).
3. Toledo DO, Jardini de Freitas B, Dib R, Julie do Amaral Pfeilsticker F, Marques dos Santos D, Gomes BC, et al. Peripheral muscular ultrasound as outcome assessment tool in critically ill patients on mechanical ventilation: An observational cohort study. Clinical Nutrition ESPEN. 2021 Apr
4. Turton, P., Hay, R., Taylor, J., McPhee, J., & Welters, I. (2016). Human limb skeletal muscle wasting and architectural remodeling during five to ten days intubation and ventilation in critical care – an observational study using ultrasound. BMC Anesthesiology, 16(1)