Introduction

Intensive care unit (ICU) acquired weakness is increasing due to the improvement in the ICU care of patients with sepsis or after cardiac or abdominal surgery [1]. When adjusted for age, the incidence of critical care polyneuropathy and or myopathy (CIPNM) is 4.2 per 100 000 people. 46.4 % of people with CIPNM are likely to end up with poor function as well as be discharged to a nursing home [2]. Up to 46 % of ICU admissions may develop CIPNM [3]. The main causes of CIPNM are severe sepsis and multi-organ failure [4,5]. Other causes are systemic inflammatory response syndrome (SIRS), hyperglycaemia, renal replacement therapy, and catecholamine administration [3].

Septic encephalopathy has been shown to precede neuro-muscular signs [5]. Acquired sodium channelopathy is postulated to lead to nerve and muscle membrane inexcitability. Axonal nerve degeneration, muscle myosin loss and muscle necrosis occur. In addition, microvascular and cytopathic hypoxic changes may disrupt energy supply and utilisation [6]. Impaired synthesis and degradation of myosin heavy chain (MyHC) has been implicated [7].

CIPNM strains the health economy through increased length of hospital stay (LOS) and rehabilitation [8]. The mean LOS is 76.2+28.1 days [9]. At present there are no specific rehabilitation interventions available to reduce the onset or impact of CIPNM [10]. It is therefore important to find preventative and rehabilitative interventions to address this problem. The aim of this case report is to add onto preliminary evidence for use of optokinetic chart stimulation in reversing the debilitating effects of CIPNM [11]. Optokinetic chart stimulation has successfully been used to treat dense muscle weakness in people with stroke [12], subdural haemorrhage (SDH) [13] and CIPNM [14].

Case Presentation

This is a single case study in an in-patient trauma and orthopaedics ward setting. Written informed consent was obtained from the patient in accordance with institutional review body guidelines for case reports.

The case Study

A 58 year old patient was admitted to ITU with severe left knee septic arthritis that required 4 wash outs. After the washouts she was transferred to a trauma and orthopaedics ward. For 54 days, she remained bed bound, NG fed, unable to roll in bed and unable to move all her 4 limbs. She had no trunk control and could not sit even with maximum assistance of 2 people. She was referred to the author after these 54 days. By then her Oxford Scale totals scores (OST) for each side was 10/205 with an aggregate 0/5 with 1/5 only in bilateral shoulder and hip muscles. Her Barthel Index score was 0/100. She had also developed necrosis of her left foot toes, right hand index finger and right foot toes. These were amputated 4 weeks after the patient had begun optokinetic chart stimulation.

Her co-morbidities included left lower lobe pneumonia, systemic lupus erythematosus, dermatomyositis, none ST segment elevation myocardial infarction (NSTEMI) and multi-organ failure. The past medical history consisted of type II diabetes, rheumatoid arthritis, osteoarthritis and interstitial lung disease. Medications were prednisolone, tazocin, insulin, atorvastatin, bisoprolol, amlodipine, clopidogrel, sertraline, losartan, aspirin, pregabalin, ranitidine, calcichew, and ferrous fumerate.

Intervention

An optokinetic chart was moved in front of the patient for 3 minutes laterally, then 3 minutes vertically and finally 3 minutes forwards and backwards. Sensory interaction for balance was added once patient could stand with assistance of one person. Patient was then mobilised with a wheeled zimmer walking (WZF) aid as she made progress.

Results

The patient was discharged to her own home able to feed herself independently. She was mobile with a WZF and assistance of one person. Manual muscle strength improved from an aggregate 0/5 to an aggregate 5/5. Table 1 gives the detailed outcomes. The OST post-treatment scores were out of 190 as a result of aforementioned amputations of some digits.

1. 

   View Table

   
   

   Table 1:

   Pre-treatment and post-treatment outcomes in the 58year old critical care myopathy patient.
   OST: Oxford Score Totals
   

   ×

   Pre-treatment Post-treatment after 9 weeks
   Right side OST	10/205	176/190
   Left side OST	10/205	176/190
   Barthel Index	0/100	75/100

   Table 1: Pre-treatment and post-treatment outcomes in the 58year old critical care myopathy patient.
   OST: Oxford Score Totals

   Close

Discussion

The multi-morbidities of this case study and her physical state at the commencement of optokinetic chart stimulation (OKCS)militated against impairment and functional recovery. Healthcare professionals asked the author if this was not a futile exercise. "Do you think she will ever walk again?" was a question thrown quite often. The patient did not believe that the intervention would work. The case study confirms what has been noted in earlier work when the author rehabilitated bed bound patients with CIPNM [11,14].

OKCS works on input-processor network recovery [12,15] which then allows recovery of innervation of motor output organs. This starts with restoration of biochemical processes by re-innervation of muscles so that synthesis of (MyHC) [7] can be normalised. In isolation, this case report is limited by lack of control and uncertainty over what the natural course of events would have been if OKCS had not been commenced. However a story is beginning to emerge when all 3 cases are taken together hence further controlled studies are recommended for future research.

Conclusion

Optokinetic chart stimulation is a potential neuro-modulating rehabilitation intervention. It aids in the restoration of muscle strength and function in complex multi-morbidity patients without being at the mercyof natural recovery. However progression to randomised controlled trials is needed to prove efficacy.

Acknowledgements

My first acknowledgement is to the patient who gave consent for her data to be used in this case report. I would also like to acknowledge Charlotte Jeffery, the Allied Healthcare Professional support worker who assisted with the treatment of the patient.

Conflict of interest

The author hereby declares no conflict of interest and states that this entire written work is his sole responsibility.