Title: Evaluating the musculoskeletal health state of Intensive Care Unit Survivors: The MSK-ICU study
Funder: Health Education England

Abstract: Background Survivors of critical illness frequently experience long-term physical impairment, decreased health related quality of life (QoL) and low rates of return to employment. There has been limited investigation of the underlying problems affecting physical function post-Intensive Care Unit (ICU) admission. Recent post-ICU rehabilitation studies have failed to demonstrate improvements in physical function. To develop effective rehabilitation interventions to improve long term physical function and QoL post-ICU, more detail regarding the underlying reasons for physical impairment needs to be established. Musculoskeletal (MSK) conditions are wide raging, with ICU survivors potentially at risk of their development due to the rapid muscle mass loss seen in ICU. A small number of studies in ICU survivors have identified some MSK complications, however the MSK health state and its impact on physical function remains largely unknown. Research question What is the MSK health state of, and how does it impact physical function in, ICU survivors six months after admission to ICU? Aim and objectives The aim is to conduct a longitudinal investigation to determine and characterise the MSK health state of ICU survivors six months following admission to ICU, in order to inform future development of targeted rehabilitation interventions. The study will achieve this aim through the following objectives: 1. Quantify the MSK health state using the MSK Health Questionnaire (MSK-HQ) and assess its relationship with QoL, employment, anxiety and depression, and symptoms of post-traumatic stress disorder (PTSD). 2. Identify prognostic factors for a lower MSK-HQ score after critical illness. 3. Characterise the specific MSK complications experienced by patients using a standardised comprehensive MSK assessment.4. Evaluate patient mobility and upper limb function, and the extent of the relationship to muscle structure and function in those patients with poor MSK health state.Methods The proposed study is a multicentre prospective longitudinal cohort study with three components to address the study objectives. Objective 1 & 2 Baseline measurement prior to hospital discharge of 400 patients from three centres with an ICU length of stay of greater than 48 hours, and a telephone follow-up at six months post-ICU admission. MSK health state will be measured by the MSK-HQ, with measurements of health related QoL, employment, anxiety and depression and symptoms of PTSD also collected. Multivariable linear regression will be used to identify prognostic factors for a lower MSK-HQ score. Objective 3 A detailed MSK physical assessment of: pain; peripheral joint range of movement; and strength in 150 patients. Objective 4A detailed assessment of mobility, function and muscle architecture and function in 35 patients presenting with a low MSK-HQ score. Assessments will include: muscle ultrasound; isokinetic dynamometry; exercise capacity; physical activity; participation; and upper limb function. Anticipated impactThe findings from this research will be essential in developing future rehabilitation interventions aimed at improving long term physical function in ICU survivors. This will subsequently improve patients QoL, expedite return to work and decrease healthcare and social services utilisation.

Lay abstract: Background The Intensive Care Unit (ICU) is a vital part of hospital care, with more patients requiring treatment in ICUs each year. With improvements in ICU care, more patients are surviving serious illnesses. However, patients who survive ICU often experience long term physical problems resulting in a poor quality of life. The number of patients that successfully return to work after ICU is also low. Although there have been several studies investigating rehabilitation after ICU, these studies have not demonstrated any benefit on physical function, exercise capacity or quality of life. There has been little research looking into the reasons for poor physical function and resulting unemployment of ICU survivors. Musculoskeletal (MSK) problems are those that affect bone, muscle and joints. MSK problems affect 25% of the UK population and limits people's ability to work. In their first week on ICU, patients can lose up to 20% of their muscle. This puts them at risk of developing debilitating MSK problems. There has been a small amount of research so far that has shown that ICU survivors may experience MSK problems. These include joint pain, shoulder and muscle problems.Aim To evaluate the overall MSK health and physical function of patients, six months after they were admitted to ICU with critical illness. This will guide the development of treatments to improve long term physical function of ICU survivors. Study design There will be three parts to this research study: Firstly, patients will be telephoned six months after they were admitted to ICU and interviewed using specific questionnaires. The questionnaires will gather information on their MSK health, employment and quality of life. I will also collect information about their time on ICU. This part of the study will outline the MSK health of patients, assess if it is linked to employment and quality of life, and identify which factors put patients at risk of developing an MSK problem.Secondly, a smaller group of these patients will undergo a full MSK assessment with a physiotherapist. This will be an assessment of pain, and muscle and joint function. From these assessments, the types of MSK problems that patients experience will be described.Finally, a subgroup of patients with MSK problems will have a detailed assessment which includes a muscle ultrasound scan and strength test. Patients will also be asked about their function, undertake a walking test and wear a wristband which records how active they are. This part of the study will explore the links between muscle structure and function and patients ability to undertake everyday activities.Patient and public involvement I have spoken to patients from the ICU Patient Forum at our hospital. Many of them have experienced bone, muscle or joint problems after their stay in ICU. They felt that this was an important area for research as they had a varied experience of treatment of their MSK problems once discharged from hospital. Three members of the Patient Forum have agreed to be part of the study Patient and Public Advisory Group, and have worked with me to design the study. This group will meet at several points throughout the study. Dissemination The findings of this research study will be published in research journals, presented at national and international conferences, and by social media such as Facebook and Twitter. Locally the findings will be presented to the study Patient and Public Advisory Group, the hospital ICU Patient Forum and support group, to the other hospitals involved in the study and to regional research groups.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MUSCULOSKELETAL