Online Letters to the Editor
To the Editor:
Gustafson et al (1) recently published in Critical Care Medicine present an excellent overview of shoulder impairment following critical illness, which builds on previous research into the long-term recovery process, posthospital discharge. Clear definitions of shoulder impairment, pain and dysfunction are provided, with both valid and repeatable measures of each variable described for the reader. As a critical care therapist, I believe the study by Gustafson et al (1) provides the long-awaited evidence that the shoulder joint needs careful handling and rehabilitation in both the acute phase and later stages of recovery from critical illness.
The authors describe the similarity between the shoulder joint in the critically ill patient and the stroke patient, with a loss of muscle strength in the dynamic muscle stabilizers, leading to glenohumeral joint instability. As the authors state, the study by Gustafson et al (1) cohort was not sufficient in size to be confident that the use of neuromuscular blocking agents contributed to shoulder impairment. However, patients who developed shoulder impairment were significantly weaker than patients without impairment. Both variables would potentially lead to instability of the shoulder joint. A lack of knowledge of the specialist handling techniques used for an unstable shoulder (more commonly used in stroke management) could be exacerbating the long-term outcomes of this cohort. To counteract this risk when moving and handling the patient, an education programme for management of the shoulder joint could be introduced to critical care units.
Although the study by Gustafson et al (1) did not report any statistically significant risk factors for shoulder impairment on multivariate analysis, older and weaker patients were found to be more at risk. Knowledge of preadmission morbidity and functional status is now considered important in studies of long-term outcomes in critical illness (2), and although these data can be difficult to obtain, future studies investigating risk factors for shoulder impairment should include this variable. The inclusion of patients with an ICU length of stay (LOS) of 72 hours may have influenced the study’s results, as it could be argued that a patient discharged within 72 hours of admission may not have been critically ill. A standardized LOS to categorize a patient as having had critical illness is needed for such outcome studies. Similarly, authors may need to report the level of care provided during the ICU stay, including delayed transfer of care data, which may be impacting true LOS.
Patients with shoulder impairment at the 3 months follow-up assessment were advised to complete range of movement exercises and to visit their general practitioner. It would appear that this advice/exercise regime appeared to benefit the patients, as by the 6-month follow-up assessment, shoulder impairment, range of movement and dysfunction had all improved. Interestingly, however, reported cases of shoulder pain had more than doubled. I would be keen to learn why the authors think this was the case. A knowledge of the exercises given to patients and compliance with completing them would also be beneficial in guiding future interventions to address shoulder impairment. The authors have successfully completed a study (1) that should encourage critical care practitioners to reevaluate current practice.
Ceri Elisabeth Battle, PhD
, Ed Major Critical Care Unit, Morriston Hospital, ABMU Health Board, Swansea, Wales, United Kingdom
1. Gustafson OD, Rowland MJ, Watkinson PJ, et al. Shoulder Impairment Following Critical Illness: A Prospective Cohort Study. Crit Care Med 2018; 46:1769–1774
2. Lone NI, Lee R, Salisbury L, et al. Predicting risk of unplanned hospital readmission in survivors of critical illness: A population-level cohort study. Thorax 2018 Apr 5. [Epub ahead of print]