Manual muscle strength testing of critically ill patients: feasibility and interobserver agreement

Catherine L Hough, Binh K Lieu, Ellen S Caldwell, Catherine L Hough, Binh K Lieu, Ellen S Caldwell

Abstract

Introduction: It has been proposed that intensive care unit (ICU)-acquired weakness (ICUAW) should be assessed using the sum of manual muscle strength test scores in 12 muscle groups (the sum score). This approach has been tested in patients with Guillain-Barré syndrome, yet little is known about the feasibility or test characteristics in other critically ill patients. We studied the feasibility and interobserver agreement of this sum score in a mixed cohort of critically ill and injured patients.

Methods: We enrolled patients requiring more than 3 days of mechanical ventilation. Two observers performed systematic strength assessments of each patient. The primary outcome measure was interobserver agreement of weakness as a binary outcome (ICUAW is sum score less than 48; "no ICUAW" is a sum score greater than or equal to 48) using the Cohen's kappa statistic.

Results: We identified 135 patients who met the inclusion criteria. Most were precluded from study participation by altered mental status or polytrauma. Thirty-four participants were enrolled, and 30 of these individuals completed assessments conducted by both observers. Six met the criteria for ICUAW recorded by at least one observer. The observers agreed on the diagnosis of ICUAW for 93% of participants (Cohen's kappa = 0.76; 95% confidence interval (CI), 0.44 to 1.0). Observer agreement was fair in the ICU (Cohen's kappa = 0.38), and agreement was perfect after ICU discharge (Cohen's kappa = 1.0). Absolute values of sum scores were similar between observers (intraclass correlation coefficient 0.83; 95% CI, 0.67 to 0.91), but they differed between observers by six points or more for 23% of the participants.

Conclusions: Manual muscle testing (MMT) during critical illness was not possible for most patients because of coma, delirium and/or injury. Among patients who were able to participate in testing, we found that interobserver agreement regarding ICUAW was good, particularly when evaluated after ICU discharge. MMT is insufficient for early detection of ICU-acquired neuromuscular dysfunction in most patients and may be unreliable during critical illness.

Figures

Figure 1
Figure 1
Flowchart showing screening, enrollment and evaluation.

References

    1. Bolton CF. Neuromuscular manifestations of critical illness. Muscle Nerve. 2005;32:140–163. doi: 10.1002/mus.20304.
    1. Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, Pronovost PJ, Needham DM. Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med. 2007;33:1876–1891. doi: 10.1007/s00134-007-0772-2.
    1. Stevens RD, Marshall SA, Cornblath DR, Hoke A, Needham DM, de Jonghe B, Ali NA, Sharshar T. A framework for diagnosing and classifying intensive care unit-acquired weakness. Crit Care Med. 2009;37(10 Suppl):S299–S308. doi: 10.1097/CCM.0b013e3181b6ef67.
    1. De Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-Zaleski I, Boussarsar M, Cerf C, Renaud E, Mesrati F, Carlet J, Raphaël JC, Outin H, Bastuji-Garin S. Groupe de Réflexion et d'Etude des Neuromyopathies en Réanimation. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA. 2002;288:2859–2867. doi: 10.1001/jama.288.22.2859.
    1. Schweickert WD, Hall J. ICU-acquired weakness. Chest. 2007;131:1541–1549. doi: 10.1378/chest.06-2065.
    1. Kleyweg RP, van der Meché FG, Schmitz PI. Interobserver agreement in the assessment of muscle strength and functional abilities in Guillain-Barré syndrome. Muscle Nerve. 1991;14:1103–1109. doi: 10.1002/mus.880141111.
    1. Ali NA, O'Brien JM Jr, Hoffmann SP, Phillips G, Garland A, Finley JC, Almoosa K, Hejal R, Wolf KM, Lemeshow S, Connors AF Jr, Marsh CB. Midwest Critical Care Consortium. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008;178:261–268. doi: 10.1164/rccm.200712-1829OC.
    1. De Jonghe B, Bastuji-Garin S, Sharshar T, Outin H, Brochard L. Does ICU-acquired paresis lengthen weaning from mechanical ventilation? Intensive Care Med. 2004;30:1117–1121. doi: 10.1007/s00134-004-2174-z.
    1. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guérin C, Prat G, Morange S, Roch A. ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107–1116. doi: 10.1056/NEJMoa1005372.
    1. Fan E, Ciesla ND, Truong AD, Bhoopathi V, Zeger SL, Needham DM. Inter-rater reliability of manual muscle strength testing in ICU survivors and simulated patients. Intensive Care Med. 2010;36:1038–1043. doi: 10.1007/s00134-010-1796-6.
    1. The Editorial Committee for the Guarantors of Brain. Aids to the Examination of the Peripheral Nervous System. London: Bailliere Tindall; 1986.
    1. Guggenmoos-Holzmann I. The meaning of kappa: probabilistic concepts of reliability and validity revisited. J Clin Epidemiol. 1996;49:775–782. doi: 10.1016/0895-4356(96)00011-X.
    1. Fleiss JL, Levin BA, Paik MC. Statistical Methods for Rates and Proportions. 3. Hoboken, NJ: Wiley; 2003.
    1. Byrt T, Bishop J, Carlin JB. Bias, prevalence and kappa. J Clin Epidemiol. 1993;46:423–429. doi: 10.1016/0895-4356(93)90018-V.
    1. Rousson V, Gasser T, Seifert B. Assessing intrarater, interrater and test-retest reliability of continuous measurements. Stat Med. 2002;21:3431–3446. doi: 10.1002/sim.1253.
    1. Cicchetti DV, Feinstein AR. High agreement but low kappa: II. Resolving the paradoxes. J Clin Epidemiol. 1990;43:551–558. doi: 10.1016/0895-4356(90)90159-M.
    1. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174. doi: 10.2307/2529310.
    1. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420–428. doi: 10.1037/0033-2909.86.2.420.
    1. Bolton CF, Young GB. Managing the nervous system effects of sepsis. Chest. 2007;131:1273–1274. doi: 10.1378/chest.07-0367.
    1. Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–1477. doi: 10.1056/NEJM200005183422002.
    1. Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375:475–480. doi: 10.1016/S0140-6736(09)62072-9.
    1. Latronico N, Fenzi F, Recupero D, Guarneri B, Tomelleri G, Tonin P, De Maria G, Antonini L, Rizzuto N, Candiani A. Critical illness myopathy and neuropathy. Lancet. 1996;347:1579–1582. doi: 10.1016/S0140-6736(96)91074-0.
    1. Perry J, Weiss WB, Burnfield JM, Gronley JK. The supine hip extensor manual muscle test: a reliability and validity study. Arch Phys Med Rehabil. 2004;85:1345–1350. doi: 10.1016/j.apmr.2003.09.019.
    1. Pollard H, Lakay B, Tucker F, Watson B, Bablis P. Interexaminer reliability of the deltoid and psoas muscle test. J Manipulative Physiol Ther. 2005;28:52–56. doi: 10.1016/j.jmpt.2004.12.008.
    1. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA. 2001;286:2703–2710. doi: 10.1001/jama.286.21.2703.
    1. Garnacho-Montero J, Madrazo-Osuna J, Garcia-Garmendia JL, Ortiz-Leyba C, Jiménez-Jiménez FJ, Barrero-Almodóvar A, Garnacho-Montero MC, Moyano-Del-Estad MR. Critical illness polyneuropathy: risk factors and clinical consequences: a cohort study in septic patients. Intensive Care Med. 2001;27:1288–1296. doi: 10.1007/s001340101009.
    1. Bolton CF. Sepsis and the systemic inflammatory response syndrome: neuromuscular manifestations. Crit Care Med. 1996;24:1408–1416. doi: 10.1097/00003246-199608000-00022.
    1. Latronico N, Bertolini G, Guarneri B, Botteri M, Peli E, Andreoletti S, Bera P, Luciani D, Nardella A, Vittorielli E, Simini B, Candiani A. Simplified electrophysiological evaluation of peripheral nerves in critically ill patients: the Italian multi-centre CRIMYNE study. Crit Care. 2007;11:R11. doi: 10.1186/cc5671.
    1. Rich MM, Teener JW, Raps EC, Schotland DL, Bird SJ. Muscle is electrically inexcitable in acute quadriplegic myopathy. Neurology. 1996;46:731–736.
    1. Hough CL, Needham DM. The role of future longitudinal studies in ICU survivors: understanding determinants and pathophysiology of weakness and neuromuscular dysfunction. Curr Opin Crit Care. 2007;13:489–496. doi: 10.1097/MCC.0b013e3282efea3a.
    1. Bittner EA, Martyn JA, George E, Frontera WR, Eikermann M. Measurement of muscle strength in the intensive care unit. Crit Care Med. 2009;37:S321–S330. doi: 10.1097/CCM.0b013e3181b6f727.
    1. Helliwell TR, Coakley JH, Wagenmakers AJ, Griffiths RD, Campbell IT, Green CJ, McClelland P, Bone JM. Necrotizing myopathy in critically-ill patients. J Pathol. 1991;164:307–314. doi: 10.1002/path.1711640406.
    1. Gruther W, Benesch T, Zorn C, Paternostro-Sluga T, Quittan M, Fialka-Moser V, Spiss C, Kainberger F, Crevenna R. Muscle wasting in intensive care patients: ultrasound observation of the M. quadriceps femoris muscle layer. J Rehabil Med. 2008;40:185–189. doi: 10.2340/16501977-0139.
    1. Carson SS, Kress JP, Rodgers JE, Vinayak A, Campbell-Bright S, Levitt J, Bourdet S, Ivanova A, Henderson AG, Pohlman A, Chang L, Rich PB, Hall J. A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients. Crit Care Med. 2006;34:1326–1332. doi: 10.1097/01.CCM.0000215513.63207.7F.
    1. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled Trial): a randomised controlled trial. Lancet. 2008;371:126–134. doi: 10.1016/S0140-6736(08)60105-1.
    1. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874–1882. doi: 10.1016/S0140-6736(09)60658-9.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe