Jura of cael are 65 (2021) 60-65 Contents lets available at ScieneeDicect Journal of Critical Care ELSEVIER journal homepage: www.journals.elsevier.com/journal-of-critical-care Musculoskeletal complications following critical illness: ® sar Ascoping review Owen D. Gustafson ®*, Mark A. Williams ™*, Stuart McKechnie “, Helen Dawes »*, Matthew J. Rowland “* * cot Alia Heath Profesor Rca Imovaton Unico Unversty Hop NHS out Tras, fr OX 904, UK ® Cane for Movement, ecypatenal an RehdiaronSeces Flt of Heath and fe scenes, noe Brookes Unversity, ford OX PUK Deparment Heath Seces and SacalWor, nord Brakes Unversity, Heaton Car xd OX3 OBE, OK * Ait resi Cae Unc fod UnvesyHosptas MS undation Tras Ord OX SOU. UK * Kare entre for cial ae Rsearh, Oxford NR Biomedical esearch entre, Nel Department of Clio Neurosciences, University of Oxford, John Ralf Hosp (ord 0X3 900 Ue ARTICLE INFO ApstRact rata apes Tocris extent 6 which masala (NSW conpliatos ave be pated lowing ie itn ening evence gaps and providing reconmeratons fo fea Keyort Mura nd meds We eacea ve databases onary 15 200010 March 352021, We inde pab- fcr Ise gna reseneh eportng HSK complications in pass dachages ahs lowing a ad Innit sion to a intense care ul (1CU). Two fevers Independently screened Eng language ates fr Gay sgt Dasexrade nuded te MSK are ofnexigatan and MSK ome meses The ver gy Fert oucone of st fs vated gas sda reporting gees ai Results: 4512 titles were screened, and 32 met the inclusion criteria. Only one study included was interventional, wh se majority beng prospective aka studs (n= 2) MSK complications ented clued muscle tweaks or aopy. cel pan, ners func, periph on impale! nd acre ‘The quay ofthe over eporngin he tes was dees adequate. Concho Weide seeps bay oleate repeting aig prevalence of varity OMSK con plestonsextendng bond mie wennc here Mire lvegatonshoalncde evans nore thanoneMSKare Further investigation MK compas cour he development a ate pos tines rebabitaton prams {©2121 The Authors) Pais by Ese Tisisan open acs are under the CCBY-NCND ese (ht foeatcemmonsriemsesty- acd) 1-tneroduction yscal complications that may be underlying poor patient reported physical function following critical illness. “Musculoskeletal (MSK) conditions are wide ranging, include prob- Jems affecting bone, muscle and joint, and are the leading cause of Survivors of critical illness frequently experience long-term physical, impairment, persistent exercise imitation and decreased health related ‘quality of life (QoL) [1,2}-The subsequent socioeconomic burden of crit- ‘cal llnessis also high [3], with patients reporting significant healthcare utilisation and high rates of hospital re-admission within the frst year after discharge [4], Rates of etum to employment following admission ‘to an intensive care unit (ICU) are extremely low, with up to 31% of pa- tients not returning to work within five years of admission to ICU |S}. Long term poor physical function following critical illness may be par= tially due to muscle weakness which occurs rapidly in ICU [6] nd is as- sociated with worse health related QoL [7] and five year survival [8]. However, there has been limited investigation into other potential > caresponing autor at Pysothetapy Deparment, Level 2 John Ralf Hosp, rd 3 90, mal edie: wen gtasonBou ak (0D. Custom, wepdoor 40.1016 202.8, 002 pain and disability in the UK (9 ICU survivors may be at increased risk of developing long-term MSK complications given the rates of mus- «le mass oss seen in ICU [6]. Recent studies evaluating post-ICU rehabil- itation interventions aimed at increasing general strength and exercise tolerance have provided mixed results [10-12]. This may be, in part, {due toa lack of identification of specific MSK complications patients are presenting with, and therefore a lack f targeted intervention Iden- tification of the MSK complications present following critical illness, may help to develop future interventions aimed at improving physical function in ICU survivors. However, the types and severity of MSK com- plications encountered by ICU survivors are unclear, as are the out- comes used to assess them. Therefore the purpose of ths review isto ‘examine the MSK outcomes reported following critical illness and the characteristics of the studies that include them. Our research question was: What is the extent of the original research reporting MSK (Hs 941/02021 The tho) Publi by Heer I. Tiss an open acs ate unr the CCBY-NCND ices (tp reatvecommonsorgicensesby-n-n40)(00, Castaon MA Wits SMe tak ‘outcomes following discharge from hospital after critical ilness, and how are these outcomes reported and measured? 2. Material and methods ‘This scoping review was conducted according to the methodology described by Arksey and O'Malley (13] and Levac etal. [14], and re- ported using the Preferred Reporting Items for Systematic reviews and ‘Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)[15}. The review protocol and PRISMA-ScR checklist ae available as Supplemen- tal Digital Content (51,2). We consulted a health research librarian, identified relevant databases and subsequently developed a search strategy (Supplemental Digital Content $3). To ensure studies were a representation of current ICU patient population, we searched the fol- lowing databases from January 1st 2000 until March 31st 2021: OVID Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), ‘Exerpta Medica database (EMBASE), Physiotherapy Evidence Database (PEDro). Authors’ personal files were also searched, and reference lists ‘of studies deemed eligible for inclusion were scanned for other studies of relevance. 2.1 Incusionexctusion criteria ‘We included: Population - adult patients discharged from hospital following an admission to ICU; Concept - the assessment and reporting ‘of MSK outcomes (e.g, muscle weakness, peripheral joint range of ‘movernent (ROM), chronic MSK pain, neuromuscular function); Context ~ Prospective and retrospective original research. In ine with our research question, we excluded studies which only, reported on MSK outcomes prior to hospital discharge. We also ex- ‘cluded studies that evaluated handgrip strength alone without addi- tional evaluation of peripheral muscle strength, as it would not indicate the presence of an MSK complication. Case studies, case series and abstracts from conference proceedings were excluded, For prag- matic reasons, we did not include non-English language studies One reviewer (0G) assessed al titles and abstracts, removing obvi ‘ous exclusions, Te fll text citations selected for potential inclusion ‘were assessed independently by two reviewers (OG, MR) with a third reviewer (MW) available where there was disagreement. 2.2. Data collection and analysis One reviewer (0G) reviewed all publications and extracted data, prior toa second independent review (MR) and data extraction to en- sure accuracy. We extracted data on study characteristic (study design, ‘sample size and duration of follow-up) and MSK assessment (area of [MSK evaluation, outcome measure, main findings). We undertook a narrative synthesis [16] to describe our findings ofthe characteristics nd result of the studies. The overall quality of study reporting was in- ‘dependently assessed by two reviewers (OG, MR) using the Strengthen- ingthe Reporting of Observational Studies in Epidemiology (STROBE) or Consolidated Standards of Reporting Trials (CONSORT) guidelines [17,18], The completeness of reporting for each study was calculated as the proportion ofthe reported items from the relevant guideline, di- vided by the total items included in the guideline minus items not appli- ‘able to the study. We classified the reporting as: 270% adequate, ‘51-69% moderate, and s 50% poor [19] 3. Results ‘We identified 4512 potentially eligible citations with 32 quantitative and no qualitative studies meeting the Inclusion criteria, as described in ‘our PRISMA study low diagram [20] (Fig. 1) The most common reasons or exclusion at full text were not including a MSK assessment and anin= patient assessment only. Table 1 summarises the characteristics of the a ol of rca Care 6 (201) 0-98 studies which included 31 observational and 1 interventional. There ‘were 11 studies which were prt of arger longitudinal or interventional studies [21-31], and 13 multicentre studies [721,2326-35]. The majority ‘of studies included general ICU patients, however some studies invest- gated specific ICU patient populations including: Acute Respiratory Dis- {tess Syndrome (ARDS) [7.2328,3435}, sepsis [21,36], blunt chest ‘trauma [37] and severe acute respiratory syndrome (SARS) [25]. Almost all studies were published after 2010 (n = 29), and there was wide vat- ation in both the duration of follow-up (Median 12 months, OR 6-30) and the sample size (Median 87, [QR 50-167). Most ofthe studies were ‘conducted in Europe (n= 17) ot North America (n = 10), ‘The majority ofthe studies (n= 25) evaluated an aspect of muscle im- palrment [722.2729 31,32,34-36,38-40] or chronic pain [26,28:37-40- 49]. There was also evahation of neuromuscular function [2123,30.50), peripheral joint impairment [33.51 fracture risk [24] and femora head necrosis [25]. Only six studies evaluated more than one aspect of (MSK health (22,29,31,33,40,51], however the majority of studies ( = 21) did include'a physical examination |7,21-23,25,27,28- 36,39,40,42,44.46,50.51] ‘The outcome measures used varied greatly, with the Medical Re~ search Council Sum Score (MRC SS) the most common (n = 8). The neuromuscular and pain outcome measures used in the studies are summarised in Tables 2 and 3 respectively. Additional outcomes used to evaluate peripheral joint impairment were the: QuickDASH, CConstant-Murley and Harts hip scores [25,51]. Three studies included, ‘outcome measures that were not validated [33.40.41] 3.1. Musculoskeletal complications Muscle impairment was reported as atrophy [29,34], weakness (7,27,29,35,36,38] or reduced muscle function [31.38], with reported prevalence varying greatly (9-732). Neuromuscular impairment was described as motor sensory deficits [30], mononeuropathies [23] and critical illness polyneuropathy (CIP) [21] The majority of physical as- sessments evaluated the lower limbs, with only thee studies assessing the upper limb [27.33.51] The prevalence of chronic pain was reported asbetween 16 and 74% at 6 months to 5 years following discharge from ICU [26.40.41 44-48}. The shoulder was the most commonly reported site for chronic pain [4142.47], and was the only joint to undergo a de- talled investigation [51]. Fig. 2 demonstrates the musculoskeletal com- plications reported using available pooled data, ‘The single interventional study [22] investigated the effec of seda~ tion versus no sedation in invasively ventilated patients on a series of physical outcomes. They study demonstrated no difference in musculo- skeletal outcomes between the groups. ‘Several studies investigated risk factors for the development of MSK complications [21,28,37,41,42,45,47 49,51], Only pre-admission co- ‘morbidity and severity of illness were reported as independently asso- ciated with weakness (35].In contrast, age, sepsis, smoking history, in- ICU opioid use, duration of ventilation, hospital length of stay, female -gender and days in ICU with hypernflammation were all reported as as- sociated with chronic pain [28,41,42]. However, there was disagree- ‘ment between studies with several reporting no tsk factors for the {development of chronic pain [37.45.4749] ‘Annumber of studies also investigated the association between MSK complications and physical function [728,29,31 32.34.4648], although these were not reported in detail in several studies. However, both pain and weakness were reported as correlating with the physical func~ tion component score ofthe SP-36 [7.4648] 32. Quality of reporting The reporting within the majority ofthe studies was classified as ad- equate according to evaluation against STROBE and CONSORT (Median score 76%, 1063-84), with consistently well reported MSK assessment