Efeito da eletroestimulação neuromuscular na arquitetura do tendão e músculo quadricipital em pacientes críticos

Dissertação (mestrado)—Universidade de Brasília, Faculdade de Ceilândia, Programa de Pós-Graduação em Ciências da Reabilitação, 2018.Introdução: As mudanças na arquitetura musculotendínea relacionadas ao repouso prolongado ao leito, em que os pacientes críticos são submetidos, precisam ser melhor estudadas. Não se sabe se a Estimulação Elétrica Neuromuscular (NMES) realizada na Unidade de Terapia Intensiva (UTI) pode minimizar a deterioração dos tendões ou se isso ocorre apenas no sistema muscular. Objetivo: Avaliar o impacto do desuso, bem como os efeitos da NMES sobre a espessura, a ecogenicidade e a área de secção transversa do tendão do quadríceps e do músculo reto femoral em pacientes críticos submetidos à ventilação mecânica. Métodos: Foi realizado um ensaio clínico cego e aleatório em pacientes na UTI com traumatismo crânio encefálico (TCE). Foram elegíveis para o estudo pacientes com trauma agudo (até 48 horas), com expectativa de permanência prolongada em suporte ventilatório invasivo por mais de duas semanas, e idade entre 18 e 60 anos. Os pacientes foram divididos em dois grupos por meio de geração de números aleatórios. O grupo controle foi submetido a fisioterapia convencional, que inclui apenas a sessão de mobilidade. O grupo NMES, além da fisioterapia convencional, foi submetido à NMES no músculo quadríceps femoral. O protocolo NMES foi aplicado uma vez por dia durante os primeiros 14 dias de internação na UTI. A avaliação do tendão do quadríceps (espessura, área de seção transversa e ecogenicidade) e reto femoral (espessura e ecogenicidade) foi realizada com ultrassom (US) em modo B, por um único examinador cego nos dias 1, 3, 7 e 14. Resultados: A espessura e CSA do tendão do quadríceps demonstraram uma interação tempo x grupo significativa, juntamente com a espessura, CSA e ecogenicidade do músculo reto femoral. Conclusão: Foi demonstrado que mesmo o desuso a curto prazo promove efeitos deletérios sobre o tendão do quadríceps e a arquitetura do músculo reto femoral em pacientes críticos. Além disso, a NMES aplicada diariamente pode prevenir a hipotrofia da arquitetura muscular do tendão do quadríceps e do músculo reto femoral nesta população.Background: Tendinous changes related to prolonged bed rest, in which critically ill patients are submitted, need to be better studied. It is not known whether the NMES performed in the ICU can minimize the deterioration of the tendons or if this occurs only on the muscular system. Objective: To evaluate the impact of disuse, as well as the effects of NMES protocol on the thickness, echogenicity and cross-sectional area of the quadriceps tendon and rectus femoris muscle in critically ill patients submitted to mechanical ventilation. Methods: We carried out a single blinded, randomized clinical trial in mechanical ventilated traumatic brain injury patients in ICU patients with aged between 19 and 55 years. Patients were randomized in two groups. The control group performed the conventional physiotherapy, which only included mobility session. The NMES group beyond conventional physiotherapy has undergone NMES on quadriceps femoris muscle. NMES protocol was applied once daily during the first 14 days of ICU internship. Quadriceps Tendon (thickness, cross-sectional area and echogenicity) and rectus femoris (thickness and echogenicity) assessment were performed using B mode ultrasound and performed by a single blind examiner on days 1, 3, 7 and 14. Results: Quadriceps tendon thickness and CSA showed a significant time x group interaction, along with rectus femoris muscle thickness, CSA and echogenicity. Conclusion: we showed that even short-term disuse promotes deleterious effects on the quadriceps tendon and rectus femoris muscle architecture in critical ill patients. Moreover, NMES applied daily can prevent quadriceps tendon and rectus femoris muscle architecture atrophy in that population

Intra- and inter-rater reproducibility of ultrasound imaging of patellar and quadriceps tendons in critically ill patients

Since the outset of body image reconstruction for diagnosis purposes, ultrasound has been used to investigate structural changes located in tendons. Ultrasound has clinical applications in the intensive care unit, but its utility for tendon imaging remains unknown. Thus, we aimed to determine intra- and inter-rater reproducibility of measures obtained by images generated through morphological tendon sonographic analysis recorded from critically ill patients. We designed a cross-sectional study to assess thickness, cross-sectional area, and echogenicity of patellar and quadriceps tendons in a convenience sample formed with 20 critically ill patients. Two independent raters (experienced and novice) recorded repeated measures, checking for agreement (Kappa statistics) and reliability (Intraclass coefficient Correlation-ICC and Bland-Altman). The quality of images acquired by the two independent raters substantially agreed (k = 0.571–1.000), regardless of the region on the patellar tendon or the studied tendon (patellar or quadriceps). Regardless of how much experience the rater had, their repeated records (intra-rater reliability) always demonstrated almost complete correlation, ICC ranging from 0.89 to 0.98 for both tendons in all outcomes. At the same way, the statistically significant inter-rater ICC ranging from 0.87 to 0.97. Both repeated measures by the raters (intra-rater) and the repeated single and double measures between the raters (inter-rater) presented a minimum measurement error constituting a predominant pattern of random variability. We conclude that ultrasound imaging acquisition performed by independent raters for tendon thickness, CSA, and echogenicity monitoring of critically ill patients are acceptable and are not influenced by rater experience

Height, Weight, and Age Predict Quadriceps Tendon Length and Thickness in Skeletally Immature Patients: Letter to the Editor

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Neuromuscular electrophysiological disorders and muscle atrophy in mechanically-ventilated traumatic brain injury patients: New insights from a prospective observational study.

International audienceErratum inCorrigendum to "Neuromuscular electrophysiological disorders and muscle atrophy in mechanically-ventilated traumatic brain injury patients: New insights from a prospective observational study" [J Crit Care 44 (2018) 87-94]. [J Crit Care. 2019]AbstractPURPOSE:It is unclear whether the muscular changes in mechanically-ventilated traumatic brain injury patients (TBI) are only associated with disuse or additionally to neuromuscular electrophysiological disorders (NED). The correlation between muscle atrophy and NED may affect functional outcomes and rehabilitation programs significantly.MATERIAL AND METHODS:An observational study was performed to investigate the presence of NED and muscle atrophy in TBI patients undergoing mechanical ventilation. NED was diagnosed by the stimulus electrodiagnosis test when chronaxie was ≥1000μs. The muscle structure (thickness and echogenicity) was assessed by B-mode ultrasound. Tibialis anterior (TA), rectus femoris (RF), and biceps brachialis (BB) muscles were analyzed. Patients were followed from the first day of admission in the intensive care unit (ICU) to the fourteenth day.RESULTS:Twenty-two patients were analyzed. An increase of 48% in NED from day 1 to day 14 was detected in TA (p=0.004). All muscles presented a significant decrease in thickness (~18%, p<0.05), but echogenicity increased only in TA (19%), p<0.01 and RF (23%), p<0.01.CONCLUSIONS:Mechanically-ventilated patients with TBI developed NED in addition to changes in muscle structure during their stay in the ICU.Copyright © 2017 Elsevier Inc. All rights reserved

Corrigendum to “Neuromuscular electrophysiological disorders and muscle atrophy in mechanically-ventilated traumatic brain injury patients: New insights from a prospective observational study” [J Crit Care 44 (2018) 87–94]

International audienceIt was identified a mistake in the introduction, second paragraph. The authors regret that the term ICUAW has been established as a “clinically-detected weakness in critically-ill patients who can have any number of possible etiologies beyond the critical illness itself” [7].The correct definition should be: “ICUAW has been established as a clinically-detected weakness in critically-ill patients which cannot be attributed to any etiologies outside to critical illness itself” [7].The authors would like to apologize for any inconvenience caused

Efficacy Of Neuromuscular Electrical Stimulation For Decreasing Neuromuscular Electrophysiological Disorders In Critical Ill Patients

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Neuromuscular electrical stimulation in critically ill traumatic brain injury patients attenuates muscle atrophy, neurophysiological disorders, and weakness: a randomized controlled trial

International audienceBackground Critically ill traumatic brain injury (TBI) patients experience extensive muscle damage during their stay in the intensive care unit. Neuromuscular electrical stimulation (NMES) has been considered a promising treatment to reduce the functional and clinical impacts of this. However, the time needed for NMES to produce effects over the muscles is still unclear. This study primarily aimed to assess the time needed and effects of an NMES protocol on muscle architecture, neuromuscular electrophysiological disorder (NED), and muscle strength, and secondarily, to evaluate the effects on plasma systemic inflammation, catabolic responses, and clinical outcomes. Methods We performed a randomized clinical trial in critically ill TBI patients. The control group received only conventional physiotherapy, while the NMES group additionally underwent daily NMES for 14 days in the lower limb muscles. Participants were assessed at baseline and on days 3, 7, and 14 of their stay in the intensive care unit. The primary outcomes were assessed with muscle ultrasound, neuromuscular electrophysiology, and evoked peak force, and the secondary outcomes with plasma cytokines, matrix metalloproteinases, and clinical outcomes. Results Sixty participants were randomized, and twenty completed the trial from each group. After 14 days, the control group presented a significant reduction in muscle thickness of tibialis anterior and rectus femoris, mean of - 0.33 mm (- 14%) and - 0.49 mm (- 21%), p < 0.0001, respectively, while muscle thickness was preserved in the NMES group. The control group presented a higher incidence of NED: 47% vs. 0% in the NMES group, p < 0.0001, risk ratio of 16, and the NMES group demonstrated an increase in the evoked peak force (2.34 kg/f, p < 0.0001), in contrast to the control group (- 1.55 kg/f, p < 0.0001). The time needed for the NMES protocol to prevent muscle architecture disorders and treat weakness was at least 7 days, and 14 days to treat NED. The secondary outcomes exhibited less precise results, with confidence intervals that spanned worthwhile or trivial effects. Conclusions NMES applied daily for fourteen consecutive days reduced muscle atrophy, the incidence of NED, and muscle weakness in critically ill TBI patients. At least 7 days of NMES were required to elicit the first significant results