MINERVA ANESTESIOL 2002;68:341-5
Muscle retraining in the ICU patients
One of the most common causes of an ICU
admission is a severe episode of acute respira-
tory failure due either to an exacerbation of
chronic pulmonary disease or its ex-novo
development after a surgical procedure, trau-
ma or medical complications. These patients
usually report, at admission to the ICU, a sed-
entary life before the acute episode, because
the evolution of the disease is characterized
by a progressive decline not only in respirato-
ry function (e.g. FEV1), but also in the func-
tional status, due to the effects of lack of exer-
cise, drug administration, malnutrition and,
later on, gas exchange abnormalities. Togeth-
er with specific vital organ support, such as
mechanical ventilation, patients admitted to
an ICU may require other complex and inte-
grated interventions in order to maintain the
spared function and to prevent further dam-
age. These interventions include nutritional
and psychological support, counselling, nurs-
ing, prevention (e.g. to preserve skin integ-
rity) and in particular a complete physiothe-
rapic program, that may range from simple
help to maintain a correct posture to com-
plete recovery of walking autonomy.
Key words: Intensive care units - Muscle, skele-
tal - Critical care - Physical therapy - Exercise.
T here is general agreement that the term
“rehabilitation” is reserved to a multidis-
ciplinary intervention and that the manage-
Address reprint requests to: S. Nava - Respiratory Intensi-
ve Care Unit, Rehabilitation Center of Pavia, S. Maugeri
Foundation - Via Ferrata, 8 - 27100 Pavia.
E-mail: snava@fsm.it
Vol. 68, N. 5 MINERVA ANESTESIOLOGICA
S. NAVA, G. PIAGGI, E. DE MATTIA, A. CARLUCCI
From the Respiratory Intensive Care Unit
Rehabilitation Center of Pavia
IRCCS, S. Maugeri Foundation, Pavia
ment of each patient should be individual-
ized. A recent official European definition
of Rehabilitation was given by the Europe-
an Respiratory Society Task Force Position
Paper 1 “Pulmonary rehabilitation is a pro-
cess which systematically uses scientifically
based diagnostic management and evalua-
tion options to achieve the optimal daily
functioning and health-related quality of life
of individual patients suffering from impair-
ment and disability due to chronic respira-
tory disease, as measured by clinically
and/or physiologically relevant outcome
measures”. The American Thoracic Society 2
adopted the following definition “a multi-
disciplinary program of care for patients
with chronic respiratory impairment that is
individually tailored and designed to opti-
mize physical and social performance and
autonomy”. These “broad” definitions,
while giving a panoramic view of what
should be achieved do not enter into the
specific details of how. Thus pulmonary
rehabilitation may vary, according to differ-
ent environments, from simple passive
mobilization of a patient to more complex
interventions, such as weaning from
mechanical ventilation. One thing that is
341
NAVA MUSCLE RETRAINING IN THE ICU PATIENTS

Skeletal muscles Cardiovascular functions Respiratory functions

and blood composition
Decrease in muscle bulk
Decrease of cardiac Decrease in functional
Transformation of type output, stroke volume capacity
II fibers and increase of heart rate Decreased lung compliance
Decrease of number and during exercise Retained secretions
density mitochondria Risk of thrombosis Atelectasis

IMMOBILITY

Central nervous system Body composition

Bone demineralization
Decrease in standing and
walking balance Protein wastage
Decrease in total body
Decrease in tests of water and sodium
intelectual function Loss of body weight and
increase in % body fat

Fig. 1.

clear, however, from these official state-
ments is that the common idea that there is
no hope for improvement in patients with
chronic diseases, especially if recovering
from an episode of acute respiratory failure,
is no longer acceptable, either clinically or
scientifically.
The general aims of an ICU respiratory
rehabilitation program is to apply
advanced, cost-effectiveness therapeutic
modalities to spare and eventually to
improve the remaining function, decrease
the patient’s dependency (i.e. on the venti-
lator), and prevent the need of new hospi-
talization, — in brief, to improve the pa-
tient’s measured quality of life.
The earlier the rehabilitation program of
a ventilated patient is started, the greater its
effect is, since later consequences, such as
the limited mobility, or even worse, total
dependency on a ventilator, may make the
high costs spent taking care of the patient
futile.3 As illustrated in Figure 1, the physio-
logical changes caused by inactivity involve
skeletal muscle, cardiovascular and respira-
tory functions, body and blood composi-
tion, and central nervous and endocrine
systems. During a period of inactivity mus-
cle mass declines and the potential efficien-
cy of a muscle to perform aerobic exercise
declines. Skeletal muscles are composed of
two major types of fiber. Type I fibers are
mainly involved in aerobic activity, while
type II fibers have a lower capacity for this
activity. Deconditioning causes a distinct
transformation of subtypes of type II fibers:
type IIa fibers convert to type IIb fibers,4
the former having a higher aerobic capac-
ity. Moreover, during immobility, the num-
ber and density of mitochondria decrease.
The cardiovascular response to exercise is
also dramatically altered after a period of

342 MINERVA ANESTESIOLOGICA Maggio 2002

MUSCLE RETRAINING IN THE ICU PATIENTS
bed rest, since there is a decrease in cardiac
output and stroke volume during maximal
exercise and an increase in heart rate dur-
ing submaximal exercise.5-9 Indeed of par-
ticular importance in bed-ridden patients,
the ability of the system to adjust to chang-
ing posture, such as moving from the
supine to the sitting position, is impaired.10,
11 In postoperative patients, if early rehabili-
tation (i.e. the application of positive end-
expiratory pressure) is not started, the
decrease in functional residual capacity and
lung compliance may lead to atelectasis,
retained secretions and in some cases to
pneumonia, which if occurring in ventilated
patients may dramatically increase the
probability of death.
Immobility also leads to clinically signifi-
cant bone demineralization, together with
protein wastage 12 and a decrease in total
body water and sodium. There is generally
a loss of body weight and an increase in the
percentage of body fat. Deterioration of
central nervous system function results in a
decreased capacity to maintain the standing
position and to walk; the performance of
tests of intellectual function may also be
impaired, and disorientation may occur.13
The first goals of rehabilitation in these
patients are therefore targeted to all the
procedures aimed at obtaining early mobil-
ization. Maintenance of correct posture and
passive mobilization of legs and arms are
the preliminary steps, followed by active
sitting up in bed and thereafter sitting in a
chair. It is also clear that physical therapy
per se may not be enough to obtain satis-
factory outcomes of our ICU patients, so
comprehensive interventions are mandato-
ry in these first steps of treatment. Correc-
tion of electrolyte disturbances, nutritional
and psychological support and a balanced
use of cardiovascular drugs may also help
to improve the clinical picture.
Skeletal muscle strength and endurance
performances are impaired not only as a
consequence of bed rest but also because
of a direct effect of hypercapnia, hypoxia,
malnutrition, treatment with corticosteroids
or other agents, and hemodynamic instabil-
ity. The possible need for heavy sedation of
Vol. 68, N. 5 MINERVA ANESTESIOLOGICA
NAVA
curarization during the first few days of
ventilation may also lead to generalized
myopathy. 14 Training is nevertheless an
important aspect in these patients, since
one of the rehabilitative end points in ICU
is defined as a return of a muscle strength
that allows basic daily life-activities (e.g.
washing, combing hair, cooking) and the
ability to walk 20-50 meters independently.
The patients may undergo sessions aimed
at passively and actively training the lower
and upper extremities, such as lifting light
weights or pushing against a resistance.
Any patient able to walk at one point in
time can start directly with progressive
walking retraining, aided by a rolling plat-
form walker or by the therapist, if needed.
When a patient cannot be weaned from the
ventilator, a portable resistor can be used to
decrease the work of breathing during
walking. As soon as possible, it is useful to
monitor patient’s outcome using dyspnea
scales (VAS, Borg scale, etc.) and exercise
tolerance tests (6 minute walked distance).
Patients, who successfully regain complete
autonomy and, therefore, are discharged
from the ICU to a medical ward should not
be “abandoned” but should be included in
training programs with cyclette, treadmill,
and ergometry for the upper extremities.
The usefulness of gradual retraining has
recently been assessed in COPD patients
recovering from an acute episode of hyper-
capnic respiratory failure,15 most of whome
were admitted to the Respiratory Intensive
Care Unit while still ventilated.
Two aspects of training are basic: thresh-
old and specificity. If the training threshold
is too low, there will not be changes in the
muscle; if it is too high, there will be fiber
damage and muscle degenerative changes.
Specificity of training means that training
produces an increase in VO2max only in the
specific muscles in use.
As for the other skeletal muscles, also the
ventilatory pump may be profoundly
altered by the effects of bed-rest and of the
disease itself and any comorbid conditions.
Indeed the “abuse” of controlled mechani-
cal ventilation in the ICU may lead to the
development of selective diaphragmatic
343
NAVA
atrophy after only 48 hours, as shown in a
laboratory study performed on rats.16 The
weakness of the respiratory muscle and in
particular an imbalance between the load
the respiratory system has to face and its
capacity is, together with the cardiovascular
impairment, the major determinant of
weaning failure in ventilated patients. The
rationale of respiratory muscle training in
the ICU is nevertheless controversial.
Patients affected by COPD for example are
not likely to benefit much from this specific
treatment. Chronic airflow obstruction is
always present, at least in the end-stage of
the disease, leading to acute respiratory fail-
ure by pulmonary hyperinflation.17 It has
been shown that the impaired inotropic
effect of the diaphragm in these patients is
due to the altered geometric shape of the
diaphragm dome rather than to muscle
atrophy. As a matter of fact, Similowski et
al.18 demonstrated how the diaphragm of
patients with COPD was as good as that of
normal subjects in generating pressure in
response to bilateral phrenic nerve stimula-
tion, at the same lung volumes. Their con-
clusions were quite strongly against the use
of inspiratory muscle training since they
stated that “the absence of central inhibition
and the absence of evidence of chronic
fatigue cast doubts on the need to treat
such patients with interventions intended to
improve the contractility of the diaphragm”.
More recently Levine et al.19 added support
to this statement when they showed, after
having obtained diaphragmatic biopsy
specimens from 6 patients with severe
COPD, that the disease increases the slow-
twitch characteristics of the muscle fibers as
an adaptive mechanism which increases
resistance to fatigue. Does this mean that
respiratory muscle training in the ICU
should be definitively abandoned? We do
not think so. We must say that the above
mentioned studies were performed in
patients with severe, but probably (althou-
gh this was not clearly stated in either
paper) normocapnic COPD, likely to have a
different histological picture from critically
ill patients. The load, frequency and inten-
sity of training should be scientifically spec-
344 MINERVA ANESTESIOLOGICA
MUSCLE RETRAINING IN THE ICU PATIENTS
ified since, if it is true that during the train-
ing exercises, the pressure generated per
breath should be at least 30% of the maxi-
mal generated in order to achieve signifi-
cant improvement, it should also be kept in
mind that high resistances may induce
structural changes in the diaphragm. It has
been shown in animal trained for 4 days (2
hr/day) that this protocol induces dia-
phragm membrane damage, sarcomere dis-
ruption and damage predominantly to type
I fibers.20 Muscle training does not, howev-
er, necessarily mean performing loading
breathing, since in ICU patients, potentia-
tion of the expiratory muscles may be non-
specifically obtained with cough exercises,
which reinforcing the abdominal muscles,
may also improve clearance of the airways.
Despite COPD patients being by far the
most likely to experience weaning prob-
lems, inspiratory muscle training may also
have a rationale in other kinds of patholo-
gies. 21 An interesting potential role of
inspiratory muscle training may be its use in
preventing steroid-induced myopathy. In
fact, Weiner et al.22 showed, in a random-
ized-controlled trial, that the inotropic and
endurance capacity of inspiratory muscles
were spared from the damage due to 2
weeks’ administration of this drug only in
the group of patients undergoing specific
training.
Riassunto
Riabilitazione motoria nel paziente in Terapia
Intensiva
L’Insufficienza Respiratoria Acuta (IRA), sia essa
secondaria ad una riacutizzazione di una patologia
respiratoria cronica o ad interventi chirurgici, traumi
o complicazioni di patologie sistemiche, è una delle
cause più comuni di ricovero in Terapia Intensiva.
Questi pazienti molto spesso hanno alle loro
spalle una vita molto sedentaria dovuta all’evoluzio-
ne della patologia e caratterizzata non solo da un
progressivo declino della funzionalità respiratoria
(es.FEV1), ma anche da un decadimento dello stato
funzionale generale, dovuto alla mancanza di eserci-
zio fisico, alla somministrazione di farmaci (es. ste-
roidi), ad uno stato di malnutrizione e, successiva-
mente, a variazioni nello scambio dei gas.
Oltre al supporto degli organi vitali (es. ventila-
zione meccanica) il paziente in TI richiede altri
Maggio 2002
MUSCLE RETRAINING IN THE ICU PATIENTS
interventi, complessi ed integrati, che mirano a
mantenere la funzionalità residua e prevenire ulte-
riori peggioramenti. Questi interventi includono il
mantenimento dello stato nutrizionale e psicologi-
co, il nursing, la prevenzione (es. lesioni da decubi-
to) e la stesura di un programma di riabilitazione
completo, che può variare da una semplice impo-
stazione di posture corrette al raggiungimento di
un’autonomia motoria.
Parole chiave: Terapia intensiva - Muscoli, scheletri-
ci - Esercizio - Terapia fisica.
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