Impact of inspiratory muscle training and early mobilization program during the peri-weaning period on body composition in critically ill surgical patients: A pilot randomized controlled trial

Main Article Content

Attalekha Thammata
Salinee Worraphan
Kaweesak Chittawatanarat
Kanokkarn Juntaping
Mujalin Prasannarong


Background: A long period of mechanical ventilation and bed rest cause alterations in body composition which are associated with higher mortality. In particular there is an association with loss in muscle mass. Inspiratory muscle training (IMT) and early mobilization (EM) have been used to increase muscle activity, which leads to improvement in muscle mass and strength. IMT and EM have been shown to prevent intensive care unit-acquired weakness in critically ill patients. However, it is still not known whether they have any effect on body composition in critically ill patients.

Objectives: To evaluate the effects of IMT and EM on body composition in critically ill surgical patients.

Materials and methods: Surgical patients at a single center in whom there had been failure at the first attempt of short weaning were randomized into two groups, a control group (n=12) and an experimental group (n=15). Usual care, IMT, and EM were provided in the experimental group, and only usual care was provided for the control group. Both groups were treated twice a day until 48 hours after extubation. The body composition was measured by bioelectrical impedance analysis before and after the treatment.

Results: After treatment, there were significant decreases from baseline in skeletal muscle mass (SMM), segmental lean of right arm (SLRA), segmental lean of left arm (SLLA), and segmental lean of trunk (SLTR) in the experimental group. In the control group, SLRA and SLTR showed significant decreases from baseline. However, there were no significant changes in segmental lean of right leg (SLRL), and segmental lean of left leg (SLLL), fat mass, and percent of body fat (PBF) in either group from baseline to after treatment. The multivariate regression analysis with adjustment for confounding factors showed no significant differences between the groups as regards body composition.

Conclusion: Inspiratory muscle training and early mobilization in conjunction with usual care did not improve body composition when compared to solely usual care in critically ill surgical patients


Download data is not yet available.

Article Details

How to Cite
Thammata, A. ., Worraphan, S. ., Chittawatanarat, K. ., Juntaping, K. ., & Prasannarong, M. (2020). Impact of inspiratory muscle training and early mobilization program during the peri-weaning period on body composition in critically ill surgical patients: A pilot randomized controlled trial. Journal of Associated Medical Sciences, 54(1), 58–66. Retrieved from
Research Articles


De Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-Zaleski I, Boussarsar M, et al. Paresis acquired in the intensive care unit: a prospective multicenter study. Jama. 2002;288:2859-67. doi:

Doorduin J, van der Hoeven JG, Heunks LM. The differential diagnosis for failure to wean from mechanical ventilation. Curr Opin Anaesthesiol. 2016; 29: 150-7. doi:

Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med. 2010; 182(4): 446-54. doi: 10.1164/rccm.201002-0210CI.

Ali NA, O'Brien JM, Jr., Hoffmann SP, Phillips G, Garland A, Finley JC, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008; 178(3): 261-8. doi: 10.1164/rccm.200712-1829OC.

Weijs PJM, Looijaard WGPM, Dekker IM, Stapel SN, Girbes AR, Oudemans-van Straaten HM, et al. Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients. Criti Care. 2014; 18(2): R12-R. doi: 10.1186/cc13189.

Dres M, Goligher EC, Heunks LMA, Brochard LJ. Critical illness-associated diaphragm weakness. Intensive Care Med. 2017; 43: 1441-52. doi:

Powers SK, Kavazis AN, DeRuisseau KC. Mechanisms of disuse muscle atrophy: role of oxidative stress. Am J Physiol Regul Integr Comp Physiol. 2005; 288: R337-44. doi: 00469.2004.

van Gassel RJJ, Baggerman MR, van de Poll MCG. Metabolic aspects of muscle wasting during critical illness. Curr Opin Clin Nutr Metab Care. 2020; 23(2): 96-101. doi: 10.1097/MCO.0000000000000628.

Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, et al. Acute skeletal muscle wasting in critical illness. Jama. 2013; 310(15): 1591-600. doi:

Nakanishi N, Tsutsumi R, Okayama Y, Takashima T, Ueno Y, Itagaki T, et al. Monitoring of muscle mass in critically ill patients: comparison of ultrasound and two bioelectrical impedance analysis devices. Journal of intensive care. 2019; 7: 61-. doi: 10.1186/s40560-019-0416-y.

Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008; 358: 1327-35. doi:

Goligher EC, Fan E, Herridge MS, Murray A, Vorona S, Brace D, et al. Evolution of diaphragm thickness during mechanical ventilation. Impact of inspiratory effort. Am J Respir Crit Care Med. 2015; 192(9): 1080-8. doi:

Sprague SS, Hopkins PD. Use of inspiratory strength training to wean six patients who were ventilator-dependent. Phys Ther. 2003; 83: 171-81. doi:

Elkins M, Dentice R. Inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unit: a systematic review. J Physiother. 2015; 61: 125-34. doi:

Magalhaes PAF, Camillo CA, Langer D, Andrade LB, Duarte M, Gosselink R. Weaning failure and respiratory muscle function: what has been done and what can be improved? Respir Med. 2018; 134: 54-61. doi:

Vorona S, Sabatini U, Al-Maqbali S, Bertoni M, Dres M, Bissett B, et al. Inspiratory muscle rehabilitation in critically ill adults. a systematic review and meta-analysis. Ann Am Thorac Soc. 2018; 15: 735-44. doi:

Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. Jama. 2008; 300(14): 1685-90. doi: 10.1001/jama.300.14.1685.

Winkelman C. Inactivity and inflammation in the critically ill patient. Crit Care Clin. 2007; 23(1): 21-34. doi: 10.1016/j.ccc.2006.11.002.

Zang K, Chen B, Wang M, Chen D, Hui L, Guo S, et al. The effect of early mobilization in critically ill patients: A meta-analysis. Nurs Crit Care. 2019;n/a(n/a). doi: 10.1111/nicc.12455.

Tipping CJ, Harrold M, Holland A, Romero L, Nisbet T, Hodgson CL. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med. 2017; 43: 171-83. doi:

Constantin D, Menon MK, Houchen-Wolloff L, Morgan MD, Singh SJ, Greenhaff P, et al. Skeletal muscle molecular responses to resistance training and dietary supplementation in COPD. Thorax. 2013; 68(7): 625. doi: 10.1136/thoraxjnl-2012-202764.

Tanner RE, Brunker LB, Agergaard J, Barrows KM, Briggs RA, Kwon OS, et al. Age-related differences in lean mass, protein synthesis and skeletal muscle markers of proteolysis after bed rest and exercise rehabilitation. The Journal of physiology. 2015; 593(18): 4259-73. doi: 10.1113/JP270699.

Jones SW, Hill RJ, Krasney PA, O'Conner B, Peirce N, Greenhaff PL. Disuse atrophy and exercise rehabilitation in humans profoundly affects the expression of genes associated with the regulation of skeletal muscle mass. Faseb j. 2004; 18(9): 1025-7. doi: 10.1096/fj.03-1228fje.

Franca EE, Ferrari F, Fernandes P, Cavalcanti R, Duarte A, Martinez BP, et al. Physical therapy in critically ill adult patients: recommendations from the Brazilian Association of Intensive Care Medicine Department of Physical Therapy. Rev Bras Ter Intensiva. 2012; 24: 6-22. doi:

Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physical therapy utilization in intensive care units: results from a national survey. Crit Care Med. 2009; 37: 561-6; quiz 6-8. doi:

Jang MH, Shin M-J, Shin YB. Pulmonary and Physical Rehabilitation in Critically Ill Patients. Acute and critical care. 2019; 34(1): 1-13. doi: 10.4266/acc.2019.00444.

Nydahl P, Ewers A, Brodda D. Complications related to early mobilization of mechanically ventilated patients on intensive care units. Nurs Crit Care. 2014. doi:

Ambrosino N, Venturelli E, Vagheggini G, Clini E. Rehabilitation, weaning and physical therapy strategies in chronic critically ill patients. European Respiratory Journal. 2012; 39(2): 487. doi: 10.1183/09031936.00094411.

Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009; 373: 1874-82. doi:

Chittawatanarat K, Thongchai C. Spontaneous breathing trial with low pressure support protocol for weaning respirator in surgical ICU. J Med Assoc Thai. 2009;92:1306-12. doi:

Beduneau G, Pham T, Schortgen F, Piquilloud L, Zogheib E, Jonas M, et al. Epidemiology of weaning outcome according to a new definition. The WIND study. Am J Respir Crit Care Med. 2017; 195: 772-83. doi:

Langer D, Charususin N, Jacome C, Hoffman M, McConnell A, Decramer M, et al. Efficacy of a novel method for inspiratory muscle training in people with chronic obstructive pulmonary disease. Phys Ther. 2015; 95: 1264-73. doi:

Caruso P, Denari SD, Ruiz SA, Bernal KG, Manfrin GM, Friedrich C, et al. Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients. Clinics (Sao Paulo). 2005; 60: 479-84. doi:

Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008; 36: 2238-43. doi:

Medical Research Council. MRC Muscle Scale London1976 [cited 2018 May 9]. Available from:

Kim D, Sun JS, Lee YH, Lee JH, Hong J, Lee JM. Comparative assessment of skeletal muscle mass using computerized tomography and bioelectrical impedance analysis in critically ill patients. Clin Nutr. 2018. doi:

Looijaard WGPM, Molinger J, Weijs PJM. Measuring and monitoring lean body mass in critical illness. Curr Opin Crit Care. 2018;24:241-7. doi:

InBody UK. InBody S10 user’s manual 2017 [updated 18 October 2017; cited 2019 26 August]. Available from:

Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007; 39(8): 1435-45. doi: 10.1249/mss.0b013e3180616aa2.

Battaglini C, Bottaro M, Dennehy C, Rae L, Shields E, Kirk D, et al. The effects of an individualized exercise intervention on body composition in breast cancer patients undergoing treatment. Sao Paulo Med J. 2007; 125(1): 22-8. doi: 10.1590/s1516-31802007000100005.

Menon MK, Houchen L, Harrison S, Singh SJ, Morgan MD, Steiner MC. Ultrasound assessment of lower limb muscle mass in response to resistance training in COPD. Respiratory research. 2012; 13(1): 119-. doi: 10.1186/1465-9921-13-119.

Chiappa GR, Roseguini BT, Vieira PJ, Alves CN, Tavares A, Winkelmann ER, et al. Inspiratory muscle training improves blood flow to resting and exercising limbs in patients with chronic heart failure. J Am Coll Cardiol. 2008; 51(17): 1663-71. doi: 10.1016/j.jacc.2007.12.045.

Downey AE, Chenoweth LM, Townsend DK, Ranum JD, Ferguson CS, Harms CA. Effects of inspiratory muscle training on exercise responses in normoxia and hypoxia. Respir Physiol Neurobiol. 2007; 156(2): 137-46. doi: 10.1016/j.resp.2006.08.006.

Souza H, Rocha T, Pessoa M, Rattes C, Brandão D, Fregonezi G, et al. Effects of inspiratory muscle training in elderly women on respiratory muscle strength, diaphragm thickness and mobility. J Gerontol A Biol Sci Med Sci. 2014; 69(12): 1545-53. doi: 10.1093/gerona/glu182.

Kyle UG, Gremion G, Genton L, Slosman DO, Golay A, Pichard C. Physical activity and fat-free and fat mass by bioelectrical impedance in 3853 adults. Med Sci Sports Exerc. 2001; 33(4): 576-84. doi: 10.1097/00005768-200104000-00011.

Rossi FE, Lecca AR, Martins LGP, Takahashi LSO, Christofaro DGD, Gobbo LA, et al. Physical exercise programs at Basic Healthcare Units decrease body fat and improve the functional capacity of women over 50 years old. Journal of exercise rehabilitation. 2017; 13(3): 315-21. doi: 10.12965/jer.1734986.493.

Liao CD, Tsauo JY, Lin LF, Huang SW, Ku JW, Chou LC, et al. Effects of elastic resistance exercise on body composition and physical capacity in older women with sarcopenic obesity: A CONSORT-compliant prospective randomized controlled trial. Medicine (Baltimore). 2017; 96(23): e7115. doi: 10.1097/md.0000000000007115.

Noites A, Pinto J, Freitas CP, Melo C, Albuquerque A, Teixeira M, et al. Effects of microcurrents and physical exercise on the abdominal fat in patients with coronary artery disease. Eur J Integr Med. 2015; 7(5): 499-507. doi:

Shoar S, Esmaeili S, Safari S. Pain management after surgery: a brief review. Anesthesiology and pain medicine. 2012; 1(3): 184-6. doi: 10.5812/kowsar.22287523.3443.

Bear DE, Wandrag L, Merriweather JL, Connolly B, Hart N, Grocott MPW, et al. The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review. Critical care (London, England). 2017; 21(1): 226-. doi: 10.1186/s13054-017-1810-2.