710
K. Nakamura et al.
may have been unable to capture the region of the
muscle on which the rehabilitation or EMS had an
effect. If the same intervened muscle was evaluated,
then it is possible that a portion other than the thickness
evaluated had changed with the intervention. In this
study, 3-dimensional evaluation of the bilateral whole
femoral muscle by CT may have detected the change
in the EMS-intervened muscle. An earlier study of
EMS evaluated muscle volume using CT, but the study
design, in which randomization was performed in the
same patient by using one foot for EMS and the other
as a control, might explain the negative result.
A further important factor is that the current study
used B-SES, which can induce simultaneous contrac-
tion in all muscles from the abdomen to the toes. The
efficacy of B-SES has been shown in healthy indivi-
duals and orthopaedic patients (17, 18); however, no
studies have been published on the use of B-SES in an
ICU or with critically ill patients. B-SES may be better
suited for use in the rehabilitation of such severely ill
patients. B-SES stimulation and 3-dimensional evalua-
tion of the whole femoral muscle could be used based
on the verified efficacy of EMS.
Although the current study did not find any sig-
nificant difference between the groups in terms of
total Barthel Index at discharge, higher Barthel Index
scores were observed in the EMS group and the score
for stair-climbing was significantly better. The rate of
muscle volume loss may be associated with muscle
weakness and impaired physical function (19, 20). In
this study, EMS intervened in the whole lower body
and maintained the muscle volume of the lower body.
The reduced the rate of loss of muscle volume might
be associated with areas of walking ability that require
much more muscle function, such as the ability to climb
stairs. Further research is needed to clarify the effect
of EMS on physical function, using evaluation with
many other functional tests.
Limitations
This study has a number of limitations. The study is
an RCT, but some bias may be present as the treatment
was not blinded to physicians, other medical staff or
patients. The analysis was blinded only regarding the
final evaluation of muscle volume and Barthel Index.
This RCT was a single-centre study with a small
sample size, and high rates of exclusion and drop-out.
Caution is therefore warranted when interpreting the
results with regard to general clinical practice. CT
evaluation involves the problem of exposure to radia-
tion. Although effort was made to minimize exposure,
young patients could not be included in the study. Due
to the ageing of Japanese society and national health
insurance the study included many older adults (mean
www.medicaljournals.se/jrm
age over 70 years). The primary outcome was muscle
volume. However, physical functions, such as muscle
strength or endurance, and a long follow-up outcome,
should be measured for ICU-AW. The given nutrition
in this study was 22 kcal/kg/day, with protein 0.9 g/kg/
day, on day 7 in both groups, which was lower than is
recommended by critical care guidelines (35). While
the nutrition target was higher, there were a number of
reasons for this shortfall, especially for enteral nutri-
tion. If more nutrition and protein had been delivered,
the results may have been different to some degree.
Conclusion
B-SES can be introduced for critically ill patients
during the acute phase of intensive care. It can signi-
ficantly inhibit rate of loss of muscle volume.
ACKNOWLEDGEMENTS
The authors thank all the nursing specialists for their support
for the study in their everyday work. Natsumi Koizumi, the
research nurse in our department, deserves our special gratitude.
The authors have no conflicts of interest to declare.
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