早期康复理疗对危重症患者肌肉质量和功能的影响

Effect of early rehabilitation physiotherapy on muscle quality and function in critically ill patients

目的探讨早期康复理疗对危重症患者肌肉质量和功能的影响。方法采用前瞻性随机对照研究方法，选择2016年10月1日至2017年8月31日安徽省立医院重症医学科（ICU）收治的住院时间超过7 d且急性生理学与慢性健康状况评分Ⅱ（APACHEⅡ）〉8分的成人危重症患者，并按照随机数字表法将其分为治疗组和对照组。所有患者均给予常规治疗，在此基础上治疗组于入科24 h内给予康复理疗，包括肢体主动/被动活动、呼吸肌功能训练及经皮神经电刺激等。于治疗1、4、7 d使用床旁超声测量患者左侧股直肌面积和厚度、股中间肌厚度，同时采用英国医学研究委员会（MRC）肌力评定法对清醒患者的肌力进行评估，并记录机械通气时间、ICU住院时间、ICU费用等。结果最终入选40例患者，治疗组和对照组各20例。与对照组比较，治疗组1 d与4 d、4 d与7 d、1 d与7 d的左侧股直肌面积差值（cm2：0.19±0.02比0.31±0.19、0.02±0.01比0.08±0.05、0.04±0.02比0.38±0.23）以及1 d与4 d、1 d与7 d的左侧骨直肌厚度差值（cm：0.01±0.01比0.14±0.13、0.03±0.03比0.16±0.14）和股中间肌厚度差值（cm：0.02±0.02比0.11±0.09、0.03±0.02比0.16±0.12）均明显减小（均P〈0.01）。治疗组治疗7 d时MRC肌力评分明显高于对照组（分：52.06±3.52比47.94±3.96，P〈0.01）。治疗组和对照组分别有15例和13例患者进行机械通气，治疗组机械通气时间明显短于对照组（h：138.5±34.5比185.0±40.9，P〈0.05）。与对照组比较，治疗组ICU获得性肌无力（ICUAW）发生率明显降低〔5.0%（1/20）比40.0%（8/20），P〈0.05〕，ICU住院时间明显缩短（d：17.67±4.91比22.06±5.94，P〈0.05），ICU费用明显减少（万元：7.53±2.09比9.55±1.73，P〈0.05）。 结论早期康复理疗能有效改善危重症患者肌肉质量、功能和肌力，缩短ICU住院时间。

ObjectiveTo investigate the effect of early rehabilitation physiotherapy on muscle quality and function in critical patients.MethodsA prospective randomized controlled study was performed. Adult critically ill patients admitted to intensive care unit （ICU） of Anhui Provincial Hospital from October 1st, 2016 to August 31st, 2017 who had been hospitalized for more than 7 days and had acute physiology and chronic health evaluation Ⅱ（APACHE Ⅱ ） 〉 8 were enrolled, and they were divided into treatment group and control group according to random number table method. All patients were given routine treatment, and on this basis, the treatment group was given rehabilitation therapy within 24 hours after admission, including limb active / passive activities, respiratory muscle function training and transcutaneous electrical nerve stimulation, etc. Bedside ultrasound was used to measure the area and cross sectional thickness of left rectus femoris muscle and the cross sectional thickness of middle thigh muscle of patients at 1, 4 and 7 days after treatment; at the same time, the muscle strength of sober patients was evaluated by medical research council （MRC） muscle strength evaluation method, and the mechanical ventilation time, ICU hospitalization time and ICU expenses were recorded.ResultsForty patients were enrolled in this study, with 20 in each group. Compared with the control group, the difference of left rectus femoris muscle area between 1 day and 4 days, 4 days and 7 days, 1 day and 7 days （cm2： 0.19±0.02 vs. 0.31±0.19, 0.02±0.01 vs. 0.08±0.05, 0.04±0.02 vs. 0.38±0.23）, and the difference in left rectus femoris thickness （cm： 0.01±0.01 vs. 0.14±0.13, 0.03±0.03 vs. 0.16±0.14） and the difference in middle thigh muscle thickness （cm： 0.02±0.02 vs. 0.11±0.09, 0.03±0.02 vs. 0.16±0.12） between 1 day and 4 days, 1 day and 7 days in the treatment group were significantly reduced （all P 〈 0.01）. The MRC strength score in the treatment group was significantly higher than that of the control group at 7 days （52.06±3.52 vs. 47.94±3.96, P 〈 0.05）. The mechanical ventilation time in the treatment group （n = 15） and the control group （n = 13） were （138.5±34.5） hours and （185.0±40.9） hours, respectively, and the difference between two groups were statistical significance （P 〈 0.05）. Compared with the control group, the incidence rate of ICU acquired muscle weakness （ICUAW） in the treatment group was significantly decreased [5.0% （1/20） vs. 40.0% （8/20）, P 〈 0.05], the length of ICU stay was significantly shortened （days： 17.67±4.91 vs. 22.06±5.94, P 〈 0.05）, and the ICU expenses were significantly reduced （ten thousand yuan： 7.53±2.09 vs. 9.55±1.73, P 〈 0.05）.ConclusionEarly rehabilitation physiotherapy can improve the muscle quality and function in critical patients, and decrease the length of ICU stay.