Eccentric Exercise and the Critically Ill Patient

Critically ill patients demonstrate established or impending multi-organ failure which may be due an acute condition such as sepsis or trauma, a deterioration in a chronic condition, or failure to progress during the recovery process and is often in part due to intrinsic risk factors such as age and concomitant disease processes (Loftus and Royal College of Surgeons of England, 2010). Survivors of critical illnesses commonly experience persisting, and sometimes permanent, disability because of loss of muscle mass, compromised muscle function, and the subsequent loss of strength (Iwashyna et al., 2010; Herridge et al., 2011). This process is detectable from early in the course of the illness. Human diaphragm shows decreased fiber cross-sectional area and altered gene expression with <2 days of mechanical ventilation (Levine et al., 2008). Healthy volunteer studies show that within 5 days of leg immobilization there is a detectable decrease in quadriceps cross-sectional area and strength (Dirks et al., 2014), muscle weakness is observed in patients suffering sepsis, acute pancreatitis (Gordon et al., 2013), trauma, burns (Cioffi, 2001), and the post-operative period, especially in those who have experienced complications of surgery. Weakness and loss of muscle mass significantly predict mortality in older people and patients with conditions such as chronic obstructive pulmonary disease (COPD; Marquis et al., 2002; Landi et al., 2005). A potentially lethal combination of immobilization and inflammation combine to achieve rapid and often catastrophic atrophy (Rudrappa et al., 2016). Sarcopenia and cachexia of chronic illness put the older patient with significant co-morbidities at greatest risk (Unroe et al., 2010). Poor mobility and weakness are established predictors of poor outcomes in critically ill patients (Kasotakis et al., 2012). Future advances in the management of the critically ill patient demand effective therapies to minimize the decrement in skeletal muscle function. Evidence exists to support a role for early physical therapy or rehabilitation in minimizing weakness and muscle atrophy of critical illness (Adler and Malone, 2012; Hashem et al., 2016). However, compliance with exercise programs may be reduced by common features of critical illness such as the circulatory instability associated with decreased systemic resistance and vasopressor administration or compromised gas exchange with acute respiratory distress syndrome and hospital-acquired/ventilator-associated pneumonia. Strategies to maximize compliance with, and benefit from, physical therapy in the critically ill patient should take these complicating features into account and provide maximal anabolic stimulation whilst not exceeding the compromised cardiorespiratory capacity of the patient. …