2011 Annual Conference

Johnson, Merri Leigh, PT, NCS

Background and Purpose: Acquired weakness syndromes are a cause of high mortality and long term morbidity in critically ill intensive care unit (ICU) patients with septic shock and multi-organ failure who have been on mechanical ventilation. There are a number of names in the literature for these critical illness neuromuscular syndromes: ICU-acquired weakness, Critical Illness Myopathy, Critical Illness Polyneuropathy, Critical Illness Neuromyopathy, and Critical Illness Polyneuropathy. These disorders are characterized by severe, generally symmetrical weakness, reduced or absent limb reflexes, muscle wasting, and difficulty weaning from mechanical ventilation. Descriptions of presentation and treatment in the ICU, possible risk factors and causes, and the tendency for long term residual disability have been reported in the literature. No reports have addressed the clinical progression of patients from the acute care setting back to the community. The purpose of this case study will be to describe the physical and functional recovery of a single middle aged female with severe ICU-acquired weakness during her acute rehabilitation hospital stay from her post-acute care discharge to her return home.

Case Description: The patient was a 50 year old female who developed severe quadriparesis after prolonged critical illness with respiratory failure leading to ventilator support for > 3 weeks, septic shock, and multi-organ failure. Upon admission to the acute rehabilitation hospital, the patient demonstrated profound upper and lower extremity weakness with little to no anti-gravity movement. Her Barthel Index was 30/100. She was functionally dependent to maximal assist for bed mobility and level transfers using a sliding board. She was unable to stand or ambulate but she could push a manual wheelchair 25 feet over smooth, level surfaces with minimal assist. Treatment consisted of a minimum of 3 hours of therapy a day 5-7 days a week for 5 1/2 weeks. Interventions included general strengthening exercises/activities, functional mobility practice, gait training, developmental activities, proprioceptive neuromuscular facilitation and aquatics.

Outcomes: Upon discharge the patient's Barthel Index was 90/100. She was modified independent with ambulation within the hospital using a rolling walker and supervision for short community distances. Her gait speed over 10 meters was 0.74 meters/second and her gait capacity was 1,041 feet with a rolling walker and no rest breaks during a 6 Minute Walk Test. The patient was able to climb 5 steps with bilateral rails and minimal assistance and scored a 46/56 on the Berg Balance Scale.

Discussion/Conclusions: The patient demonstrated dramatic improvement in her functional mobility and Barthel Index which allowed her to discharge home. However, she continued to have significant weakness of her bilateral upper and lower extremities with manual muscle testing. She also complained of poor endurance and stamina for community outings. Her 6 Minute Walk test, though over the 1,000 feet considered by many to be community distance, falls in the 57th percentile for height, weight, and age matched healthy females. In spite of the patient's considerable functional improvement and discharge to her home setting, the patient complained of frustration with her significant residual weakness, decreased endurance/stamina, her reliance on a rolling walker for gait, a manual wheelchair for longer distances or when too fatigued to walk safely, and a tub bench for bathing safety. These results are consistent with those found in the literature for the long term outcomes in patients with ICU-acquired weakness. The residual weakness can remain for weeks, months or years post ICU stay with a notable deleterious impact on health related quality of life.