key: cord-1051936-d1l4t5ac
authors: Mateo, Sébastien; Bergeron, Vance; Cheminon, Maxime; Guinet-Lacoste, Amandine; Pouget, Marie-Caroline; Jacquin-Courtois, Sophie; Luauté, Jacques; Nazare, Julie-Anne; Simon, Chantal; Rode, Gilles
title: Functional electrical stimulation-cycling favours erectus position restoration and walking in patients with critical COVID-19. A proof-of-concept controlled study
date: 2021-04-23
journal: Ann Phys Rehabil Med
DOI: 10.1016/j.rehab.2021.101516
sha: dd5c7599ba65c0e44a9e49a65748cdaadb4ef329
doc_id: 1051936
cord_uid: d1l4t5ac

nan

J o u r n a l P r e -p r o o f cases worldwide as of early February 2021 [1] . Although most patients have moderate symptoms, severe acute respiratory distress syndrome develops in about 17% of cases, including 5% with critical forms, which results in hospitalization [2] . Patients are admitted to intensive care units (ICUs) [3] for unusually long periods of time [4, 5] . As a result of prolonged strict bed rest, virus infection and associated medical procedures such as endotracheal intubation and deep sedation, patients surviving this critical form of COVID-19 exhibit considerable musculoskeletal loss and dysfunction [6, 7] . In association with altered pulmonary and cardiac function along with fatigue and containment measures, this situation results in a marked reduction in physical activity, which in turn hampers clinical recovery.

Rehabilitation of patients with critical COVID-19 presents new challenges, reinforced by the novelty of the disease and the preventive measures related to patient contagiousness [8] . Functional electrical stimulation (FES) applied during cycling (FEScycling) is used in patients with chronic lung disease to increase exercise intensity [9] , and electrical stimulation is known to improve functional exercise capacity and quadriceps strength [10] . FES-cycling is widely used for patients with spinal cord injury and complete motor paralysis and allows for synchronized contractions and restoring lower-limb mobility [11] ; electrical stimulation may improve muscle strength after an incomplete lesion [12] .

In this 4-week pragmatic proof-of-concept controlled study, we hypothesized that FES-cycling could be safely used in combination with physiotherapy early after ICU discharge in patients with critical COVID-19 and favour erectus position restoration and spontaneous walking resumption more rapidly than rehabilitation without FES-cycling.

We included 14 patients admitted to the rehabilitation department of the Hospices Civils de Lyon during the first pandemic wave in France (i.e., from April 20, 2020 to July 16, 2020) after hospitalisation in the ICU for a critical form of COVID-19. Cycling was part of the rehabilitation program with FES for 8 patients (FES-cycling group) or without FES for 6 (cycling group). Exclusion criteria were cognitive deficit or neurological or the muscle surface of the quadriceps, hamstrings, tibialis anterior and gluteus maximus or triceps surae (see movie). Using the "adaptive mode", the stimulator progressively adjusted the current intensity to attain exercise targets (e.g., pedalling speed 60 rpm and resistance 2-3 Nm). Patients were instructed to maintain a plateau of at least 60% of the maximum stimulation intensity setting and to slow down the pedalling (i.e., >60 rpm) to maintain a constant stimulation level. For both groups, the cycling duration was J o u r n a l P r e -p r o o f progressively extended by 5 min/session, starting from 15 min up to 30 min to ensure tolerance. Across sessions, FES-cycling training was adjusted by increasing the plateau of stimulation up to 100% of the maximum stimulation intensity setting (the maximum was then progressively increased) for the FES-cycling group or by increasing the pedalling resistance to target a rated perception of effort equal to 4-5/10 (no effort=0, maximum effort=10) for the cycling alone group. Because the FES-cycling tolerance was unknown, oxygen saturation and heart rate were monitored with an infrared finger sensor; dyspnea and pain were evaluated by using the Borg CR-10 scale and a visual analog scale (0-10).

week rehabilitation program. Sedentary and physical activity patterns were determined by using a tri-axial accelerometer (Actigraph, wGT3X, Pensacola, FL, USA) that was worn on the right hip throughout the 24-hr cycle, during both night and day, for a minimum of 2 days at the beginning of each week. Days including < 10 hr of daytime registration were excluded from the analyses. After excluding non-wearing time, time spent in different sedentary/activity postures was estimated by using an automatic posture/activity recognition algorithm coupled with an activity-specific model as described [13] . [14] . All available patient data were used on an intention-to-treat basis; models were fit by using REML estimation and a compound symmetry covariance structure, as selected with the Bayesian information criterion. Standardized residuals from statistical models were tested for normality by using Kolmogorov-Smirnov tests. Our primary statistical inference was between-group differences in 4-week net changes in sedentary and daytime walking/running, estimated with their 95% confidence intervals (CIs) with 2-sided hypothesis tests and p<0.05 considered statistically significant. The effect size was estimated by dividing the between-group difference in 4-week mean net changes by the estimation of their common standard deviation. Results are presented as least square means (SE) unless otherwise noted. Additional exploratory analyses were performed to FES-cycling may be a promising rehabilitation method for early mobilization during and immediately after ICU hospitalization to limit the marked reduction in physical activity and favour erectus position restoration in patients with a critical form of COVID-19 [2, 5, 7] . Further randomized controlled studies are necessary to confirm its efficacy, including for specific clinical outcomes, and to understand the underlying mechanisms.

Funding. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions. All authors participated in the study conceptualization, data collection, writing the original draft and revising the manuscript. Both SM and GR supervised the study. GR provided the institutional facilities. CS performed accelerometry analyses. CS and SM performed the statistical analyses. All authors approved the final draft before submission. 

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Analyses with unpaired Student t test, Mann-Whitney Wilcoxon test or chi-square test as appropriate showed no differences between groups. BMI, body mass index; HAD, Hospital Anxiety and Depression; MMT: Manual Muscle Test using the Medical Research Council score

†A common intercept was assumed † †Longitudinal mixed-effects models were used to test the effect of functional electrical stimulation [FES] on the EGD, on an intention-to-treat basis (n=6 in cycling group and n=8 in FES cycling group). FEV1, forced expiratory volume in 1 sec; FVC, forced vital capacity; MMT