Early in-bed cycling and electrical stimulation no different than standard rehabilitation for global muscle strength in ICU patients

1. There was no difference in muscle strength at discharge between intensive care unit (ICU) patients who underwent in-bed cycling and electrical stimulation compared to standard rehabilitation.

2. There was no difference in mortality between study groups at 6-months follow-up.

Evidence Rating Level: 1 (Excellent)

Study Rundown: ICU muscle weakness has severe consequences, such as prolonged mechanical ventilation, that can be remedied by early rehabilitation. However, the most effective form of in-patient rehabilitation has yet to be determined. In this study, ICU patients were randomized to receive early in-bed electrical muscle stimulation and leg cycling (intervention group) or early standardized rehabilitation programs (usual care group). There was no difference in muscle strength scores at discharge between either the intervention or usual care groups. Additionally, there were no significant differences in ventilator-free days, functional autonomy, or mortality 6 months after the initial ICU admission.

While there were no added benefits from the addition of in-bed cycling and electrical muscle stimulation in this study, they begin to highlight additional opportunities for investigation through multi-center randomized control trials. Furthermore, these additional trials should consider tracking muscle strength scores throughout a patient’s ICU stay to allow a more detailed trajectory of their functional status.

Click to read the study in JAMA

Relevant Reading: Early exercise in critically ill patients enhances short-term functional recovery

In-depth [randomized controlled trial]: Among 498 eligible patients, 314 were enrolled and randomized from July 2014 through June 2016 and were followed for 6 months until November 2016. 159 patients were randomized to the intervention group, which consisted of early rehabilitation plus daily electrical muscle stimulation and leg cycling, and 155 patients randomized to the usual care group, which consisted only of early rehabilitation. Patients were eligible if they were >18 years of age, had been admitted <72 hours, were estimated to need >48 hours of ICU care, and were ambulating independently prior to admission. Patients were excluded if they were pregnant, had an ICU admission diagnosis of cardiac arrest, had a pacemaker, internal cardioverter-defibrillator, acute cerebral pathology requiring deep sedation for >72 hours, a neuromuscular disease, advanced dementia, deep venous thrombosis, pulmonary embolism, a contraindication to electrical muscle stimulation, standing or transferring to a chair, or had a lower limb amputation. Per the primary outcome, there was no difference in the median MRC score at ICU discharge between the intervention group and the usual care group (median difference -3.0; CI₉₅ -7.0 to 2.8). The median ICU Mobility Scale score was not different between the intervention and usual care groups (median difference 0; CI₉₅ -1 to 2). Additionally, there were no significant between-group differences in the number of ventilator-free days, functional autonomy at 6-months, nor health-related quality of life at 6-months post-ICU stay (p > 0.05). Finally, there was no difference in mortality between the intervention group and the usual care group at 6-months post-ICU admission (absolute risk reduction 4.4; CI₉₅ -6.1 to 14.8).

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