125 PROTEIN PROVISION AND EXERCISE THERAPY TO IMPROVE OUTCOMES IN ICU-SURVIVORS 7 statistically significant differences in activity limitations in favour of both intervention and comparator groups (SMD ≤ 0.33 and ≥ -0.41). 7.3.6 Effects of protein provision on muscle health Muscle health measures are demonstrated in four studies (Figure 4 and Appendix 2; table S3). 51,54,57,63 A diversity in measurement tools (Computed Tomography scan, Ultra Sound technology) and location (femoral, biceps, leg circumference, quadriceps muscle) were used. A moderate to large statistically significant effect in the intervention group was seen on day seven of ICU-admission, in several US measurements in the study by Ferrie et al.55 This Figure 3. Forest plot of the effects of protein provision on physical functioning (standardised mean difference). SMD > 0 favours intervention. Abbreviations: CI: confidence interval. Barthel Index: Barthel performance and Activities of Daily Living index (score range: 0-100). FSS-ICU: Functional Status Score for the ICU (score range: 0-35). HGS: Handgrip strength (expressed in kg; reference values are age and sex-dependent). Katz ADL: Katz Activities of Daily Living score (score range: 0-6; higher is more independent). MRC-ss: Medical Research Council sum score (score range: 0-60). PCS-SF36: Physical Component Score-Short Form 36 health survey (score range: 0-100). PFIT: Physical Function in Intensive Care Unit test (score range: 0-12). SMD: standardised mean difference. Notes: Allingstrup (2017): multiple imputation required, completed questionnaires 51%/54% (intervention / comparator). Azevedo (2019): a score of zero was given at patients who died. Available PCS-SF36 scores (intervention/comparator) at 6-months: n=30(71.4%)/n=31(55.5%) and at 3-months: n=29(52.7%)/n=31 (52.5%). Wandrag (2019): Barthel and Katz ADL scores remained zero throughout the study. Fetterplace (2018): missing values of MRC-SS not imputated (77%/53% missing, intervention/comparator). Ferrie (2016): results in table displayed without covariate adjustment for HGS. Missing values assumed missing at random, not replaced (n=7/n=4, intervention/comparator). Fetterplace (2016): missing values for HGS and PFIT scores not imputated (80%/47% and 73%/53% missing respectively, intervention/comparator). Study Participation restriction Activity limitation Allingstrup 2017 PCS-SF36 (6 months) Azevedo 2019 PCS-SF36 (6 months) Azevedo 2019 PCS-SF36 (3 months) Nakamura 2021 Barthel (Hosp. discharge) Fetterplace 2018 MRC-SS (ICU-discharge) Azevedo 2019 HGS male (ICU-d.) Azevedo 2019 HGS female (ICU-d.) Ferrie 2016 HGS (Hosp.d.) Ferrie 2016 HGS (day 7) Fetterplace 2018 HGS (ICU-d./d15) Nakamura 2021 FSS-ICU (ICU-d.) Fetterplace 2018 PFIT (ICU-d./d15) Total 232 188 100 52 55 25 7 15 9 59 59 6 25 8 Mean 22.9 92.0 93.6 44.2 55.0 19.3 9.0 18.5 22.1 20.0 13.8 6.8 SD 21.8 133.4 126.1 66.8 5.9 8.2 13.1 10.4 10.1 6.1 22.8 3.8 Intervention Total 247 222 99 58 59 31 14 14 13 60 60 16 31 14 Mean 23.0 90.0 85.2 8.3 52.0 23.1 14.5 15.8 18.5 21.0 13.7 7.9 SD 22.3 120.6 110.6 19.4 9.6 15.1 12.9 10.3 11.8 9.3 26.4 3.4 Comparator -1 -0.5 0 0.5 1 Standardised Mean Di erence Effect of protein provision (PP) on Physical functioning; SMD>0 favours intervention SMD -0.00 0.02 0.07 0.76 0.33 -0.31 -0.41 0.26 0.33 -0.11 0.00 -0.30 95%-CI [-0.28; 0.27] [-0.36; 0.39] [-0.30; 0.44] [ 0.21; 1.30] [-0.58; 1.25] [-1.04; 0.43] [-1.27; 0.45] [-0.10; 0.62] [-0.04; 0.69] [-1.05; 0.83] [-0.52; 0.53] [-1.17; 0.58]
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