ICUAWのPTとリハ

ICUAW（ICU-acquired weakness）のPTとリハに関するレビュー論文を紹介します。

Fan E. Critical illness neuromyopathy and the role of physical therapy and rehabilitation in critically ill patients. Respir Care. 2012 Jun;57(6):933-44; discussion 944-6.

ICUAWのよい日本語訳はまだありませんが、長い順に訳してみると、集中治療関連無力症、ICU関連無力症、ICU無力症あたりでしょうか。

ICUAWでは、直接的な要因（critical illness neuromyopathy）と間接的な要因（不動、廃用性筋萎縮）の両者があるようです。急性期での診断はしばしば困難です。電気生理学的検査や筋生検の前に、まずは身体診察で評価します。

治療や予防の介入方法は限られていますが、血糖コントロールが有用です。早期リハに関するエビデンスは乏しいですが、慢性人工呼吸器患者に対する集中的なリハの有用性はあります。早期リハの安全性、実現可能性、潜在的な長所に関しても示されつつあります。

ICUAWを広義のサルコペニアの原因の視点で考えると、廃用＋疾患（神経筋疾患＋侵襲）は必須で、低栄養や加齢を合併する可能性があります。低栄養を合併していなければ、早期離床・リハ・筋トレでよいのかもしれませんが、実際にはリハ栄養を要することが多いと思います。

Abstract
Neuromuscular complications of critical illness are common, and can be severe and persistent, with substantial impairment in physical function and long-term quality of life. While the etiology of ICU-acquired weakness (ICUAW) is multifactorial, both direct (ie, critical illness neuromyopathy) and indirect (ie, immobility/disuse atrophy) complications of critical illness contribute to it. ICUAW is often difficult to diagnose clinically during the acute phase of critical illness, due to the frequent use of deep sedation, encephalopathy, and delirium, which impair physical examination for patient strength. Despite its limitations, physical examination is the starting point for identification of ICUAW in the cooperative patient. Given the relative cost, invasiveness, and need for expertise, electrophysiological testing and/or muscle biopsy may be reserved for weak patients with slower than expected improvement on serial clinical examination. Currently there are limited interventions to prevent or treat ICUAW, with tight glycemic control having the greatest supporting evidence. There is a paucity of clinical trials evaluating the specific role of early rehabilitation in the chronic critically ill. However, a number of studies support the benefit of intensive rehabilitation in patients receiving chronic mechanical ventilation. Furthermore, emerging data demonstrate the safety, feasibility, and potential benefit of early mobility in critically ill patients, with the need for multicenter randomized trials to evaluate potential short- and long-term benefits of early mobility, including the potential to prevent the need for prolonged mechanical ventilation and/or the development of chronic critical illness, and other novel treatments on patients' muscle strength, physical function, quality of life, and resource utilization. Finally, the barriers, feasibility, and efficacy of early mobility in both medical and other ICUs (eg, surgical, neurological, pediatric), as well as in the chronic critically ill, have not been formally evaluated and require exploration in future clinical trials.