Several studies show that symptoms such as muscle weakness, pain, cognitive disorders, delirium, anxiety, depression and post-traumatic stress disorders are a direct result of the critical illness.

The cause of muscle weakness can be both in the muscle (critical illness polymyopathy) and in the nerve (critical illness polyneuropathy). Because these conditions often occur simultaneously and are difficult to differentiate, the term 'intensive care unit acquired weakness' (ICU-AW) is used. This muscle weakness adversely affects ventilation recovery in the short and long term.

The goal of NMES in Critical Illness and Advanced Disease States (conditions include advanced COPD, CHF, sepsis, and reduced consciousness during critical illness, malignancy, and periods of mechanical ventilation) is to prevent or reverse skeletal muscle wasting for persons who are not able to exercise. Muscle weakness and fatigue impede patients' capacity to exercise, are known to delay extubation, extend length of stay in ICU, and delay patients achieving independent mobility and returning to their former independence (25).
Intensive care unit-acquired weakness (ICUAW) is a common condition in critically ill patients who are mechanically ventilated for prolonged periods of time (27, 29).

Only recently have mechanistic studies shown that muscle atrophy and loss of muscle mass develops rapidly during critical illness - within hours of the patient being intubated and mechanically ventilated (28). Physiotherapists play an integral role in the prevention and treatment of ICUAW within the intensive care unit (ICU), with studies showing benefit from early mobilization and inspiratory muscle training for patients in the ICU to improve duration of weaning and functional independence at hospital discharge (29 , 30). Most importantly, as survival from ICU increases, physiotherapists will have a greater role in the management of ICUAW after discharge from ICU and hospital.
It is therefore essential to prevent muscle weakness as early as possible. This can be done by applying Neuromuscular Electrostimulation (NMES).

This form of "electro training" (NMES) can and should be applied from the moment of admission to an ICU. Even if ICU patients are still ventilated (26, 32, 33, 39).

The use of electrical stimulation (ES) has been proven to improve muscle strength (34, 35). Moreover, it has been shown (34) that to realise an equivalent rate of muscle strengthening, a higher intensity of muscle contraction must be used during voluntary exercise than during ES. This may lead to an increase in heart rate (HR), particularly in elderly subjects. Using ES, a similar degree of muscular contraction can be reached without increasing cardiovascular work (36).

Wageck et al (2014) concluded that "NMES might be an attractive intervention for critically ill patients and it may have the ability to maintain muscle mass and strength in the ICU setting".

Sillen et al (2014) reported that ‘Previous research has shown that NMES is equally effective as strength training in severely dyspnoeic individuals with COPD and muscle weakness in strengthening the quadriceps muscles and thus may be a good alternative in this particular group of patients. Previously, these patients were unable to exercise on a bicycle or treadmill. NMES and strength training were effective in improving exercise performance in severely dyspnoeic individuals with COPD and quadriceps weakness. NMES leads to an improvement in muscle strength and endurance in the leg muscles, improves quality of life and walking distance. These results are great because there is a great demand for new forms of training that do not provoke complaints of shortness of breath. Lung function itself does not improve by NMES. But by improving the condition of the leg muscles, these patients can do more at home with fewer complaints’.

Zanotti (2003) concluded that: ‘in bed-bound patients with severe COPD and still receiving invasive mechanical ventilation, with marked peripheral muscle hypotonia and atrophy, application of ES (Electrical Stimulation) in addition to classical ALM (Active Limb Mobilization) significantly improved peripheral muscle strength and decreased the number of days needed to transfer from bed to chair. This combined technique was well tolerated and, in comparison to ALM only, led to a reduction in RR. Patients were able to sit earlier than usual; this means an increase of functional ability and improvement of quality of life. The application of ES is safe, cheap, and reliable. It can be performed in any hospital setting, from the ICU to the general ward, and likely could shorten the duration of hospital stay in less severely ill patients

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