Assessment protocol of limb muscle strength in critically ill. patients admitted to the ICU: Dynamometry

Size: px

Start display at page:

Download "Assessment protocol of limb muscle strength in critically ill. patients admitted to the ICU: Dynamometry"

Merryl King
5 years ago
Views:

1 Assessment protocol of limb muscle strength in critically ill patients admitted to the ICU: Dynamometry To proceed to voluntary muscle strength assessment, the neurologic en hemodynamic stability of the patient should be guaranteed by a medical doctor. Evaluation of the level of cooperation Two options: A. Five standardized questions 1 Open and close your eyes Look at me Open your mouth and put out your tongue Nod your head Raise your eyebrows after I have counted to five Each correct answer is worth 1 point. The commands may be repeated twice. It is allowed to slightly pinch the patient once to increase the attention of the patient. A patient that is fully awake and cooperative achieves a score of 5 on 5. A score of 5 on 5 is required to assess volitional muscle strength. B. Confusion Assessment method for the intensive care unit (CAM-ICU) 2 Delirium has four features: (1) acute onset of changes or fluctuations in the course of mental status, (2) inattention, (3) disorganized thinking and (4) altered level of consciousness (other than alert) 3. The patient is determined to be delirious according to the CAM-ICU if he/she manifests both features 1 and 2, plus either feature 3 or

2 Assessment of handgrip strength: handgrip dynamometry 4,5,6 o Conditions Patients should be strong enough to obtain an MRC-score of 3 in elbow flexion and wrist extension. o Standardized test positions Patient should be seated in bed with the head end of the bed in 45. Make sure that when a patient is retested, the same test position is used. The upper arm is alongside the chest. The elbow is flexed to 90 and the wrist is in neutral position (between supination and pronation). The bar of the dynamometer should reach between the metacarpophalangeal and the proximal interphalangeal joint. The standardized test position should be maintained during testing (the patient is not allowed to stretch the elbow during the test). The dynamometer is supported by the tester. 2

Handgrip Dynamometry o Learning attempts, repetitions, rest in between repetitions One or two learning attempts are required. Three repetitions can be performed.

3 Handgrip Dynamometry o Learning attempts, repetitions, rest in between repetitions One or two learning attempts are required. Three repetitions can be performed. Thirty seconds of rest in between repetitions is sufficient. o Contraction time Since contraction time is delayed in critically ill patient, encourage the patients to maintain the effort for at least 5-6 seconds 5. o Verbal encouragement Encourage the patient during the testing o Interpretation The highest value obtained is used to report 3

4 Handgrip strength is reported in kgf and as percentage of the predicted value 6. Assessment of limb muscle strength: Handheld dynamometry 5,7 o Conditions To assess maximal isometric muscle strength in different muscle groups, patients need to be strong enough to overcome gravity (MRC 3) 8,9. o Standardized test positions The patient is in supine position with the head end of the bed in 10 above the horizontal line (table 1). Two methods of isometric testing with HHD have been described. The make technique requires the patient to exert a maximal isometric contraction while the examiner holds the dynamometer in a fixed position. The break technique, in contrast, requires the examiner to overpower a maximal effort by the patient, thereby producing a measurement of eccentric muscle strength 10. 4

5 Table 1: Standardized test positions to apply handheld dynamometry Muscle group Shoulder abduction Elbow flexion Wrist extension Hip flexion Knee extension Ankle dorsilfexion Test position of the limb Shoulder abducted 45, elbow extended Shoulder neutral, elbow flexed 90, supination of forearm Shoulder neutral, elbow flexed 90, pronation of the forearm, wrist at neutral, fingers relaxed Hip flexed 90, knee relaxed and lower leg supported by the arm of the tester, contralateral limb neutral Hip flexed 90, knee flexed 90, contralateral limb in neutral position OR neutral position of the tested limb with a bolster under the knee; contralateral limb in neutral position Hip, knee and ankle at 0 Placing of the dynamometer Just proximal of the epicondyles of the humerus Just proximal to styloid processes Just proximal to metacarpophalangeal joints Anterior surface of the femoral condyles Just proximal to the anterior surface of the malleoli Just proximal to the metatarso phalangeal joints 5

Muscle test 1: Shoulder abduction Commands: - Move your elbow/arm upwards

6 Muscle test 1: Shoulder abduction Commands: - Move your elbow/arm upwards or push against the dynamometer as hard as possible. Do not let me overcome you. Muscle test 2: Elbow flexion Commands:- Move your hand towards your shoulder and pull as hard as possible. Do not let me overcome you. Remarks: Patients can experience discomfort due to the arterial lines. Place the dynamometer just below, above or next to the insertion point of the arterial line. 6

The center of the dynamometer should be placed on the metacarpophalangeal joints.

7 Muscle test 3: Wrist extension Commands: Move your hand upwards and push as hard as possible. Do not let me overcome you Remarks: Make sure that the forearm is pronated and the wrist is in line with the forearm. The center of the dynamometer should be placed on the metacarpophalangeal joints. Muscle test 4: Hip flexion Commands: Move your knee towards your shoulder and pull as hard as possible. Do not let me overcome you. Remarks: The lower limb of the patient can rest on the arm or shoulder of the tester, provided that 90 knee flexion is preserved. 7

Muscle test 6: Ankle dorsiflexion Commands: Pull up your toes and push against the dynamometer. Do not let me overcome you.

8 Muscle test 5: Knee extension Commands: Put your leg in the air and push as hard as possible against the dynamometer. Do not let me overcome you. Remarks: Place the dynamometer in perpendicular position on the lower limb to avoid skin tears. Muscle test 6: Ankle dorsiflexion Commands: Pull up your toes and push against the dynamometer. Do not let me overcome you. Remarks: Place the dynamometer in line with the forces exerted by the patient. Start at a range of -10 and let the patient pull up his toes so that on 0 ankle dorsiflexion, maximal force is reached. 8

9 o Learning attempts, repetitions and rest in between repetitions First the tester will show the required movement passively to the patient. Next the patient is asked to perform the movement actively. If the movement is performed correctly, the dynamometer is placed in the correct position. If the movement is not performed correctly, than show the movement once more to the patient. Each measurement is performed 3 times. If the highest strength value differs more than 10% with the other values, a fourth measurement is performed. Thirty seconds of rest is allowed in between measurements o Contraction time Since contraction time is delayed in critically ill patient, encourage the patients to maintain the effort for at least 5-6 seconds 5. When you have feedback from a software program, the contraction should be continued until a plateau phase in the strength curve is reached 7. o Verbal encouragement Encourage the patient on regularly basis during testing o Interpretation The average value of different trials are reported in Newton or kgf or as percentage of the predicted value 9. 9

10 Reference List 1. De Jonghe B, Sharshar T, Lefaucheur JP, et al: Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA 2002; 288: Ely EW, Inouye SK, Bernard GR, et al: Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001; 286: Inouye SK, van Dyck CH, Alessi CA, et al: Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113: Hermans G, Clerckx B, Vanhullebusch T, et al: Interobserver agreement of Medical Research Council sum-score and handgrip strength in the intensive care unit. Muscle Nerve 2012; 45: Baldwin CE, Paratz JD, Bersten AD: Muscle strength assessment in critically ill patients with handheld dynamometry: An investigation of reliability, minimal detectable change, and time to peak force generation. J Crit Care 2013; 28: Mathiowetz V, Dove M, Kashman N, et al: Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 1985; 66: Vanpee G, Segers J, Van Mechelen H, et al: The interobserver agreement of handheld dynamometry for muscle strength assessment in critically ill patients. Crit Care Med 2011; 39: Andrews AW, Thomas MW, Bohannon RW: Normative values for isometric muscle force measurements obtained with hand-held dynamometers. Phys Ther 1996; 76:

11 9. Bohannon RW: Reference values for extremity muscle strength obtained by hand-held dynamometry from adults aged 20 to 79 years. Arch Phys Med Rehabil 1997; 78: Burns SP, Spanier DE: Break-technique handheld dynamometry: relation between angular velocity and strength measurements. Arch Phys Med Rehabil 2005; 86:

Maximal isokinetic and isometric muscle strength of major muscle groups related to age, body weight, height, and sex in 178 healthy subjects

Maximal isokinetic and isometric muscle strength of major muscle groups related to age, body weight, height, and sex in 178 healthy subjects Test protocol Muscle test procedures. Prior to each test participants