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Vibrotherapy in intensive care units; implications for the fight against COVID-19.

Whole body vibration (WBV) training can affect the neuromuscular system even in unconscious patients because the signals influencing muscle contractions can be controlled from the spinal cord without the involvement of the cerebral cortex. In addition, as already shown in healthy volunteers, athletes, the elderly, and patients of various hospital departments outside the Intensive Care Units (ICU), prolonged WBV administration helps maintain muscle mass and strength, increases bone density, improves recovery, and increases glucose metabolism. These benefits meet the needs of critically ill patients and can aid recovery, although appropriate testing has not yet been conducted. Therefore, the aim of the Charite Hospital researchers (Medical University of Berlin) was to investigate the safety and feasibility of vibrotherapy in critically ill (mechanically ventilated) patients. The metabolic response to WBV was also analyzed. {Since the severe course of COVID-19 is often associated with ICU care and mechanical ventilation, and the pandemic of this disease continues worldwide, the editors would like to emphasize the importance of this article also in the context of fight against 2020-2021 pandemic of COVID-19; editorial note.}

  • All patients completed the experimental procedure. The WBV training did not cause any side effects.
  • None of the devices, such as the endotracheal tube, endotracheal cannula, drain, etc., was moved.
  • Vital signs did not change significantly during and after the intervention as compared to baseline.
  • In the passive phase of physiotherapy without WBV, diastolic blood pressure was significantly elevated compared to the baseline values ​​(by about 2 mmHg), which was not present in the WBV exercise phase or the following rest phase.
  • Heart rate, mean arterial blood pressure, systolic blood pressure, and blood oxygen saturation did not differ significantly from baseline values ​​during physical therapy without WBV, during performance of WBV exercise, or during rest following interventions.
  • Neither passive physiotherapy nor WBV training had a significant effect on cardiac output (CO), mean stroke volume (SV) or its range. These parameters also remained stable during rest.
  • In the phase of passive physiotherapy without WBV, the variability of SV increased significantly, while the variability of SV did not change significantly under the influence of WBV training or during rest periods, compared to the baseline state.
  • Increased energy expenditure was observed only during WBV training. Compared to the initial phase, the levels of oxygen uptake and carbon dioxide production were increased by approx. 30, and approx. 20 ml/min, respectively, showing an increased energy expenditure (by approx. 200 kcal/24h).
  • Physiotherapy without WBV, as well as WBV training, significantly increased the respiratory rate compared to the baseline values ​​(by about 1.5 or about 1.8 breaths/min, respectively).
  • Gasometry showed stable ventilation of patients throughout the study, as evidenced by unchanging pO2 and pCO2 values, acid-base status and pulse oximetry.
  • WBV training was associated with a significant increase in serum potassium compared to the baseline values (by about 0.05 mmol/l). This effect was not observed during the physiotherapy phase without WBV.

Prepared on the basis of:

Whole-body vibration to prevent intensive care unit-acquired weakness: safety, feasibility, and metabolic response. Wollersheim T et al. Crit Care. 2017 Jan 9;21(1):9.

Study population

There were 19 people qualified for the research. The following exclusion criteria were used: lack of informed consent (obtained from a legal representative), age <18 years, prior neuromuscular disease, implanted pacemaker or defibrillator, pregnancy, acute venous thrombosis, unhealed fractures or recently placed implants in the vicinity of vibrating stimulant, recent eye surgery, a history of herniated discs with acute symptoms, participation in another study, terminal cases.

Test procedure

The full intervention time was 90 min. According to the previously defined protocol, the following experimental phases were established:

  1. baseline (10 min),
  2. passive physiotherapy without WBV (7.5 min),
  3. WBV training (15 min),
  4. early rest (10 minutes),
  5. late rest (47.5 minutes).

To analyze the metabolic response, pO2, pCO2, pH, sodium, potassium, and serum glucose levels were measured with an ABL 800 radiometer. From the start of measurements to 1 h after the intervention, vital signs, circulatory dynamics and energy metabolism were continuously monitored. Serum biochemical analysis was performed at the end of phases 1, 3, 4, and 5. Gasometric analysis was performed at the end of each phase. Additionally, the serum levels of systemic anabolic and catabolic hormones significantly affecting skeletal muscles, represented by insulin-like growth factor I (IGF-1) and cortisol, were examined before the intervention and twice afterwards. Both hormones showed significant changes under the influence of WBV in healthy subjects of previous studies.

The patients were supine throughout the duration of the experimental protocol. The body position was not changed not to disturb the measured vital and circulatory parameters.

Criteria for terminating the WBV session were defined. Treatments were to be stopped if any of the events occurred: heart rate < 40 or > 180 beats per minute; systolic blood pressure < 80 or > 200 mmHg; mean blood pressure < 60 or > 120 mmHg; increase in intracerebral pressure > 20 mmHg; SpO2 < 88%; potassium level < 3.0 or > 5.5 mmol / L.

Use of vibration in the study

After the measurements, at the end of the baseline phase patients were passively mobilized by the physiotherapist for 6 min as a warm-up. Patients were then prepared for WBV training, and a vibration device positioned under the patient’s feet started to deliver vibrations. The patient’s hips and knees were bent to an angle of approximately 20°. The WBV session lasted 15 min, with the vibrations administered intermittently for a total of 9 min. Two different devices were used: one generating synchronous vibrations (Promedi, Vibrosphere®, 26 Hz, 9 x 1 min), the second – side alternating vibrations (Galileo, home-ICU®, 24 Hz, 3 x 3 min).

Results

All patients completed the experimental protocol. Vibration training did not cause any side effects in any of the patients. None of the devices, such as endotracheal tube, tracheal cannula, drain, infusion line, ECMO-cannula central venous catheter, or dialysis catheter has been dislocated. The use of WBV was a simple procedure for the physiotherapist and did not disturb clinical practice more than standard physiotherapy. Preparing for WBV training was easy and took less than 3 min.

Vital signs

Vital signs did not change significantly during and after the intervention as compared to baseline. The observed minimal changes were not of concern in terms of patient safety. Baseline values ​​varied between patients, but to a minor extent. In the phase of physiotherapy without WBV, diastolic blood pressure was significantly increased compared to the baseline values ​​(by approx. 2 mmHg; p = 0.014), which was not observed in the WBV training phase, as well as in early or late rest. Heart rate, mean arterial blood pressure, systolic blood pressure, and oxygen saturation did not differ significantly from baseline values ​​during physical therapy without WBV, WBV exercise, or during rest.

Intracranial pressure

Both physiotherapy without WBV and WBV exercises did not significantly affect the level of intracranial pressure checked in 7 out of 19 patients.

Hemodynamics

The hemodynamic parameters were measured (PiCCO2 Medical-System) in 15 patients. The interventions had no significant effect on the CO or both SV mean and its range. These parameters also remained stable during rest. The variability of SV increased significantly in the phase of physiotherapy without WBV (p <0.001), but it did not change significantly under the influence of WBV or in the rest phases, compared to the baseline state.

Energy metabolism

Indirect calorimetry in 16 patients showed increased energy expenditure only during WBV training. Compared to the baseline, the levels of oxygen uptake and carbon dioxide production were increased in the WBV training phase by approx. 30 (p = 0.012) or 20 ml/min (p < 0.001), respectively, showing an increased energy expenditure (about 200 kcal/24h; p = 0.007) only during WBV. On the other hand, physiotherapy without WBV led to the increased elimination of carbon dioxide (by approx. 10 ml/min; p = 0.041), but without increasing oxygen consumption or energy expenditure. In the early and late phase of rest, oxygen uptake and energy expenditure returned to baseline values. The levels ​​of carbon dioxide elimination remained increased in the early phase of rest (by about 6 ml/min; p < 0.01) and reached basal levels only in the late phase of rest. Physiotherapy without WBV and WBV training significantly increased the respiratory rate compared to the baseline value by about 1.5 (p < 0.01) or 1.8 (p < 0.001) breaths per min, respectively.

Blood analysis

Blood gas analysis (n = 19) showed that patients’ ventilation remained stable throughout the study, as indicated by stable pO2 and pCO2 values, acid-base status and pulse oximetry. WBV training was associated with a significant increase in serum potassium compared with the baseline values (by approx. 0.05 mmol/L; p = 0.048). This effect was not observed during the phase of physiotherapy without WBV. Sodium concentrations in the same blood samples remained unchanged indicating no sampling errors. Furthermore, no expected changes in glucose or lactate levels were observed. The measurement of IGF-1 and cortisol levels resulted in a wide range of baseline values ​​which may have contributed to the fact that no significant changes were observed in response to the interventions.

Comment

The ICU acquired weakness is a frequent and significant complication. It is connected with a reduction in the synthesis of muscle proteins, their increased degradation, the extension of the treatment period, and increases the risk of complications and mortality. It was noticed that the earlier mobilization of conscious patients shortens the use of mechanical ventilation and the time spent in the ICU (as well as in other hospital wards), and also helps to regain greater functional independence upon discharge from the hospital.

WBV training is known to be effective, yet passive, physical training for the muscles and can be an option in the fight against muscle weakness and their loss. This form of physiotherapy should be particularly desired by immobilized patients for whom active physical exercise is not available {then it may also be of importance in COVID-19 therapy/ rehabilitation [Sañudo et al., 2020] – editorial note}. WBV therapy is already used to counteract muscle atrophy (mass wasting) and loss of bone density occurring in the absence of gravity in space, also as a training of professional athletes, as well as in patients with various diseases.

The presented research shows that WBV training can be safely used even in critically ill patients undergoing mechanical ventilation.

WBV provides a strong stimulus for skeletal muscle, leading to the physiological adaptation of bones and muscles to growth. In previous clinical studies, WBV was shown to improve mean speed, mean strength, and mean power in healthy volunteers. Depending on the frequency of the vibration stimulus, WBV can induce more than 1,000 muscle contractions per min, which can lead to an increase in muscle strength and mass. Such muscle activation would be expected for ICU patients.

In the presented study passive physiotherapy without WBV increased the production of carbon dioxide. This can be explained by the passive mobilization of resting blood in the capacity vessels. The lack of active muscle contraction during passive mobilization was reflected by the lack of increase in oxygen uptake. In contrast, WBVs increased both carbon dioxide production and oxygen uptake. This effect of WBV has also been shown in other studies on overweight and obese women.

The levels of pO2, pCO2, pH, HCO3-, and base excess, maintained at a constant level with increased energy expenditure, indicate that there is no metabolism dysregulation and that its increase during the WBV training is most likely due to muscle activation. Moreover, serum potassium concentration was significantly increased only during WBV training and probably due to muscle contraction, which could be confirmed by unchanged serum sodium level. Moreover, previous molecular studies show the beneficial effects of vibration on isolated stem cells, myoblasts and muscle tissue. That’s why vibration may have a significant effect on muscle maintenance and may preserve the development of ICU acquired weakness.

CONCLUSIONS

Considering the absolute contraindications, the authors conclude that the use of WBV in critically ill patients is a safe and feasible form of physiotherapy. The results obtained confirm the ability of WBV to stimulate muscles and improve their metabolism during immobilization resulting from critical illness, when patients cannot participate in active physiotherapy, whether due to sedation or loss of consciousness due to neurological reasons. WBV therefore has the potential to prevent and/ or treat muscle weakness in critically ill patients. Additionally, WBV may be an option of rehabilitation throughout the ICU stay but may also be continued after regaining consciousness.

{The presented results suggest the need for further clinical trials to investigate the beneficial effects of vibrotherapy on convalescence also in other hospital wards and also in relation to the COVID-19 pandemic which paralyses the work of healthcare. Reducing the time spent by covid patients in hospital wards, including ICUs, seems to be extremely important in the fight against COVID-19 [Sañudo et al., 2020]. Editorial note.}

More in:

Whole-body vibration to prevent intensive care unit-acquired weakness: safety, feasibility, and metabolic response. Wollersheim T et al. Crit Care. 2017 Jan 9;21(1):9.

Author of the coverage:
Rafal Aleksander Guzik, PhD (med. sci)

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