1. Critical Illness Polyneuropathy (CIP) vs Critical Illness Myopathy (CIM): Inpatient Examination and Treatment Techniques
By: Evan Hammons, SPT

2. Objectives
Outline of diagnosis criteria for CIP/CIM/combination of the two and how they contribute to ICU-Acquired Weakness (AW)
Identify PT implications of patients with ICU-AW/CIM/CIP
Identify treatment strategies and progressions to safely and appropriately treat and progress patients with ICU-AW/CIM/CIP with considerations with co-morbidities, complications and plateau effects
Discuss treatment and outcome measures to evaluate and track lower-level functional mobile patients progress

3. Evidence in Literature: Spectrum of Neuromuscular Complications in Critically Ill1,2
Peripheral neuropathy:
Critical illness polyneuropathy
Acute motor neuropathy
Neuromuscular junction dysfunction
Transient neuromuscular blockade (pharmacologic)
Myopathy
Disuse/Type II muscle fiber atrophy
Thick-filament myopathy
Necrotizing myopathy
Acute motor neuropathy: acute paralysis and loss of reflexes without sensory loss
Thick filament myopathy: myosin loss (paralysis)
Necrotizing myopathy: rare form of idiopathic inflammatory myopathy characterized clinically by acute or subacute proximal muscle weakness, and histopathologically by myocyte necrosis and regeneration without significant inflammation.

4. Evidence in Literature: CIP1,2,3
CIP Features
CIP Criteria
Distal sensory-motor polyneuropathy
Recovery weeks to months
No medication therapy (only conservative, physical therapy tx)
Occurs in 70% of septic pt’s (not all are symptomatic)
50% have complete recovery
Sepsis, multi-organ failure, respiratory failure, SIRS
Difficulty weaning from vent or limb weakness
Electrophysiological evidence of motor and sensory polyneuropathy
Absence of decremental response on repetitive nerve stimulation
Polyneuropathy: is damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain.
Symptoms may be "positive" (including pain and dysesthesia), may be negative (including loss of sensation, weakness or loss of reflexes-early), or may be irritative (such as fasciculations (brief spontaneous contraction) or paresthesias (abnormal sensation, burning/tingling).
Protein usually elevated in CSF

5. Evidence in Literature: Criteria of CIM1,2
Clinical appearance similar to CIP
Commonly proximal flaccid weakness and are symmetrical
Possible contribution from neuromuscular blockers, steroids, sepsis or prolonged immobility
Most common predisposing factors: acute respiratory distress syndrome, pneumonia, liver/lung transplants, hepatic failure
Myopathy: characterized by a primary structural or functional impairment of skeletal muscle. They usually affect muscle without involving the nervous system, resulting in muscular weakness, cramping or aching
Measurement of serum enzymes: creatine kinase (CK), represents preferable screening tool because (unlike other enzymes) it has relative predominance in skeletal muscle

6. Evidence in Literature: CIP/CIM Testing1,2
MRI C-spine
EMG/NCV (nerve conduction velocity)
Repetitive stimulation
Creatine kinase serum levels
Muscle biopsy (rarely used)
Muscle strength testing: ICU-MRC sum scale, handgrip dynamometry
Medical research council: medical funding in United Kingdom
5 standardized questions: A. Open and close your eyes B. Look at me C. Open your mouth and put out your tongue D. Nod your head E. Raise your eyebrows when I have counted up to five
MRC scale: 0 = No visible contraction 1 = Visible contraction without movements of the limbs 2= Movements of the limbs but not against the gravity 3 = Movement against gravity over (almost) the full range 4 = Movement against gravity and resistance 5 = Normal
Testing of R/L: shoulder ABD, elbow flex, wrist EXT, hip flex, knee EXT, ankle DF

7. CIP/CIM1,2,3
ICU-AW includes CIM or CIP, but majority is combination of both
Common in mechanically ventilated population (25-60% in pts vented >7 days)
Pathophysiology: complex and remains unclear (electrical, microvascular, metabolic and bioenegetic mechanisms)
Risk factors: sepsis, SIRS, multiple organ failure, poor glycemic control, corticosteroids, neuromuscular blocking agents, immobility, malnutrition, >1 week stay in ICU, female>male
Receiving mechanical vent risk of developing CIP/CIM is 30% and 50% for acute respiratory distress syndrome.
Mildly affected can recover within weeks, more severe weakness can take months or remain severely affected with partial/no recovery
Literature incidence of CIP and CIM at 46% among adults who had ICU stay > 2 weeks with mech vent and sepsis/multi organ failure
Bioenergetic: energy involved in making and breaking of chemical bonds in the molecules found in biological organisms

8. Accessed at: https://www.cdc.gov/nchs/data/icd/icd501a.pdf
Literature suggest that CIP/CIM stem from SIRS as a pre-factor
Systemic inflammatory response syndrome: 2 of the following
Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
Heart rate of more than 90 beats per minute
Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO 2) of less than 32 mm Hg
Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms)
Accessed at:

9. Literature: Management of CIP/CIM3,4,5
4 methods
Intensive insulin therapy
Minimize sedation
Physical therapy (early mobilization)
Electrical muscular stimulation
Sedation: sedation holidays for mobility
PT: OOB, functional mobility, positioning, balance and transfers, patient education, WB activities, supine exercises,
E-stim: improvements in days before pt able to transfer bed to chair, significant improvements in muscle strength and mass. Parameters: duration from 7 days-6 weeks, muscles (glutes, quads, HS, peroneals, biceps brachii. Intensity: per pt report. Frequency: Hz. Pulse durations: micro seconds

10. Literature: Mobility Strategies for ICU-AW6
Used for the lower level patients who are highly immobile
The patient had severe weakness (Medical Research Council [MRC] sum score of 18/60) and displayed complete dependence for all functioning. She progressed to being able to ambulate 150 ft (1 ft= m) using a rolling walker with accompanying strength increases to an MRC sum score of 52/60 on day 89.
Accessed at:

11. Patient History 51 year old female
Prior to admission: lives with husband and functionally independent
PMH: HBV/HCV, DM II, ETOH cirrhosis (chronic liver damage)
S/p kidney (12/16/2016) and liver (12/15/2016) transplant

12. Initial PT evaluation
12/28/2016 (13 days post-op) d/t difficulty weaning from vent
EOB sitting for 8 minutes: static sitting balance min-mod A
Total A for all functional mobility (rolling, supine to sit, scooting, sit to supine)
LE strength: 1/5
Current DC recommendations: subacute/SNF
AM-PAC 6 score: 6

13. Overview of Important PT sessions
1/3: progress sit to stand (total A)
1/6: bed to chair (total A)
1/10: coccyx pressure injury (progressed to stage 4 sacral pressure ulcer), MOVEO introduced (10’ )
1/16: NuStep introduced (15’ ) and wheelchair mobility (200 ft)
2/17: DC update to LTAC
February-March: multiple ICU/RNF stays with supine exercises, total A mobility, MOVEO and NuStep
DC to LTAC on 4/12 (UE: 4-/5, LE: 2/5, foot drop; given PRAFO’s)
4/17: re-admit from LTAC
4/20: LE 2/5, decreased R lateral malleolus and L medial knee
4/25: FIST score 20/56
4/28 (most recent): WC mobility with SBA 350 ft, sit-stand x5 with total A and UE supported on RNF counter x 1’ each
Patient was traveling between RNF and ICU d/t vent support and constant pulling at trach, respiratory insufficiency, tachy on sedation holidays, ordered IVC (inferior vena cava) filter for LE DVT check on 3/6
1/16: CK 23, 1/17: CK 17, 1/23: CK 12, 2/8: CK 12, 3/6: CK: 11 (*Last CK value ordered); from 1/16-3/6 CK levels ranged from and on 3/6 that was the last value ordered
Normal CK levels range from
So as you can see, it was difficult to appropriately and necessarily progress her in a timely manner.

14. Physical Therapy and Training: January 2017-Present
Supine exercises: QS, SAQ, heel slides, AP, hip ABD/ADD, gastroc and hamstring stretching
EOB exercises: LAQ, hip flexion, balance exercises (UE reaching for object), minor perturbations for balance
Sit-to-stand exercises: total A with sheet under hips (knee blocks), use of counter for UE support
MOVEO table: varying angles for WB and LE “squats”
NuStep: varying resistance for UE+LE use and only LE use
Wheelchair training: trunk stabilization, UE use, mental factor to mobilize ”independently”
From January-present:
Max tactile and verbal cues needed for trunk and LE extension in standing

15. Clinical Impressions
Stage 4 sacral pressure injury difficulty for activity tolerance/sitting/movement
Trach placement and difficulty weaning from vent/O2 support
LE weakness/atrophy and showing no drastic improvements since admission
EOB sitting requiring CGA-max A depending on day-to-day basis
Husband drives 1.5 hours to see pt in hospital 3-4x/week
Emotionally and mentally taxing on family
Unable to stand/ambulate (requires total A to stand) use of WC for mobility on RNF
Used positioning and pillow so we could safely and effectively use the MOVEO table.

16. Function In Sitting Test (FIST)7,8
Use: Assess functional sitting abilities/dysfunctions, focus interventions, track changes in sitting balance over time, assessment of lower level patients, help bridge the gap between simple observation of sitting balance and standing/gait
56 point total (<42 = indicating DC unsafe for home with/without assistance)
14-item, performance based
Test-retest reliability: .97
Inter-rater reliability: .99
Minimal detectable change: 5.5
Pt score: 20/56
Developed & created by Sharon L. Gorman PT from Samual Merritt University in Oakland, CA
Implemented on 4/20:
Given for use of outcome to measure current sitting balance d/t no improvements in mobility towards standing, used for tracking over time to see any improvements in static/dynamic sitting balance.
PT sitting EOB

17. Function In Sitting Test (FIST)7,8
5 point ordinal scale:
0= dependent
1= assistance needs (min-total)
2= UE support
3= verbal cues or increased time needed
4= independent
Test items: static sitting, sitting with head turns, sitting eyes closed, sitting lift dominant foot, pick up object from behind, forward reach (dominant), lateral reach (dominant), pick up object off floor, posterior scooting, anterior scooting, lateral scooting
3 randomized nudges given throughout exam (anterior, posterior, lateral)

18. Discussion
Early detection and understanding of patients with CIP/CIM/combination and plateau effects
Early mobilization strategies for patients with vent support/sedation
Consult whether or not patients can tolerate sedation holidays
Skilled strategies for mobilization with patients on vent support (RT consult)
Potential use of e-stim for critically ill patients
Rehab techniques for lower level patients with ICU-AW/CIP/CIM
4 phase mobility strategies
Use of FIST for observation of changes over time in trunk strength, static/dynamic sitting balance

19. References
Critical Illness Polyneuropathy Criticall Illness Myopathy. Critical Illness Polyneuropathy Criticall Illness Myopathy. Published Accessed April 30, 2017.
Ydemann M, Eddelien H. Treatment of critical illness polyneuropathy and/or myopathy – a systematic review. Danish Medical Journal. October 2012: Accessed April 30, 2017.
Mehrholz J, Pohl M, Kugler J, Burridge J, Mückel S, Elsner B. Physical rehabilitation for critical illness myopathy and neuropathy. Cochrane Database of Systematic Reviews. April doi: / cd pub2.
Hermans G, Jonghe BD, Bruyninckx F, Berghe GVD. Interventions for preventing critical illness polyneuropathy and critical illness myopathy. Cochrane Database of Systematic Reviews doi: / cd pub3.
Maffiuletti NA, Roig M, Karatzanos E, Nanas S. Neuromuscular electrical stimulation for preventing skeletal-muscle weakness and wasting in critically ill patients: a systematic review. BMC Medicine. 2013;11(1). doi: /
Trees DW, Smith JM, Hockert S. Innovative mobility strategies for the patient with intensive care unit-acquired weakness: a case report. Physical therapy. Published February Accessed April 30, 2017.
Rehab Measures - Function in Sitting Test. The Rehabilitation Measures Database. Accessed April 30, 2017.
Function in Sitting Test (FIST). Samuel Merritt University. Published January 24, Accessed April 30, 2017.