Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: a systematic review

Physiotherapists may influence hospital patient physical activity levels indirectly through workforce training

BACKGROUND

Lower levels of patient physical activity in hospital are associated with poorer functional outcomes. Physiotherapists may influence physical activity outside of therapy time through nursing workforce training.

OBJECTIVE

To estimate physical activity levels in acute inpatients after the Risk Assessment for Moving Individuals SafEly (RAISE) manual handling training intervention for nurses. The secondary aims evaluated nurse experiences of training and the extent to which nurses learnt RAISE skills and incorporated them in clinical practice.

METHODS

Using a pre-post design, nurses from an acute neurological and medical ward participated in a physiotherapy-led, 4-hour training session teaching dynamic risk assessment to safely move patients. Patient physical activity and clinical observation audits of patient transfers were assessed prior to, and 1-week following, training. Surveys evaluated nurse experiences of training.

RESULTS

Among 26 patients, there was a non-significant, moderate positive effect size favoring increased daily steps by 43% (g=.35, MD 208, 95% CI -263 to 679, p = .370). There was no change in sit-to-stand transitions (g=-.02, MD -0.4, 95% CI -16 to 15, p =.963) or daily sedentary hours (g=.05, MD 0.05, 95% CI -0.8 to 0.9, p=.908). Training was well received by all nurse participants, and the physical risk assessment was implemented into practice 89% of the time post training (X2(1) = 5.00, p = .025).

CONCLUSION

A physiotherapy-led manual handling training program involving dynamic risk assessment may help hospital inpatients to increase physical activity outside of therapy time.

Mobilisation of post-ICU patients - a crucial teamwork between physiotherapists and nurses at surgical wards: a qualitative study

PURPOSE

To describe experiences of the ward nurse in relation to extended physiotherapy and mobilising of post-ICU patients.

METHODS

Individual semi-structured interviews were conducted with 17 registered nurses working on surgical wards in a Swedish regional hospital. Qualitative content analysis was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research (COREQ).

RESULTS

The study findings are presented in three categories: challenges to mobilising post-ICU patients, shared responsibility facilitates mobilisation, and extended physiotherapy is beneficial for patients' wellbeing. Nurses stated that they lacked knowledge and skills to perform the safe mobilisation of post-ICU patients due to their complex medical history and needs. Collaboration with physiotherapists was perceived to facilitate mobilisation and to be beneficial for patients' wellbeing outcome.

CONCLUSIONS

The study indicates that post-ICU patients are at risk of remaining immobilised because ward nurses find mobilisation too complex to conduct without support from physiotherapists. Shared responsibility through multi-professional teamwork regarding patient rehabilitation is perceived as contributing the knowledge required to achieve safe mobilisation that enhances autonomy and physical ability in post-ICU patients.

Flexible, adaptable, and supportive systems: qualitative description of factors underpinning an ideal mealtime delivery in rehabilitation care settings

PURPOSE

Whilst evidence about mealtime delivery exists in acute and aged care settings, there is limited understanding of patient and staff preferences for rehabilitation settings. This study aimed to explore patient and staff perceptions about how mealtimes should be delivered to support rehabilitation goals of care. Method: This qualitative descriptive study involved semi-structured interviews with nine patients (previous or current admission) and ten staff from a single metropolitan rehabilitation service. Data were analysed using qualitative content analysis.

RESULTS

Two key categories were identified, including (1) the role of mealtimes in patients' rehabilitation, and (2) factors underpinning ideal mealtime delivery for rehabilitation. Mealtimes help to facilitate recovery, support socialisation, rest, and routine, but were also a time of frustration and challenge for patients. The ideal mealtime was described as creating a therapeutic experience, integrating systems and processes that support rehabilitation, systems that offer flexibility and choice, enhancing mealtime care through interdisciplinary collaboration, and using supportive mealtime care practices.

CONCLUSION

The ideal mealtime in rehabilitation should be underpinned by principles of flexibility, adaptability, and supportive care. Incorporating rehabilitation goals of care can be enabled through mealtime systems that encourage functional therapy activity, optimal nutrition, and time for rest and social engagement.

A self-management program increases the dosage of inpatient rehabilitation by 26 minutes per day: a process evaluation

PURPOSE

To evaluate the implementation of a self-management program, My Therapy, designed to increase inpatient rehabilitation therapy dosage via independent practice.

MATERIALS AND METHODS

A process evaluation of My Therapy for adult patients admitted for rehabilitation for any condition supervised by physiotherapists and occupational therapists across eight rehabilitation wards compared usual care. Outcomes included reach, dosage, fidelity and adaptation.

RESULTS

The mean (SD) age of the process evaluation sample (n = 123) was 73 (11) years with a mean (SD) length of stay of 14.0 (6.6) days. The My Therapy program reached 68% of participants (n = 632/928), and resulted in an average increase in therapy dosage of 26 (95% CI 12 to 40) minutes/day of independent practice. All My Therapy audited programs (n = 28) included body function/structure impairment-based exercises, and half (n = 13/28) included activity/participation-based exercises. On average, participants completed programs 1.8 (SD 1.2) times/day, which were prescribed in accordance with the My Therapy criteria, demonstrating fidelity. There were no between-group differences in daily steps or standing time, however, My Therapy participants spent more time sitting (p ≤ 0.05). Implementation adaptations were minimal.

CONCLUSION

A self-management rehabilitation program was implemented with fidelity for two in three rehabilitation patients, resulting in increased therapy dosage with minimal adaptations.

What factors affect the recruitment and retention of allied health professionals working in hospitals? A systematic literature review

Objective Workforce shortages in hospitals have necessitated a focus on recruitment and retention of health professionals. The aim of this systematic review was to synthesise literature relating to factors that affect recruitment and retention of allied health professionals working in hospital settings. Method PubMed, CINAHL (via EbscoHost), Embase (via Elsevier), and Scopus Advanced Search databases were used to retrieve 1665 studies, of which 16 were included. Herzberg's two-factor theory was used to synthesise study findings and develop key themes. Results Job advancement, company policies, supervision (leadership), working conditions, salary, recognition, and growth opportunities were factors identified as affecting recruitment and retention. Conclusion Identified factors are largely amenable to change and could contribute to a more sustainable allied health workforce in hospitals and enhance the quality of care. This research could significantly impact and enhance the evidence supporting interventions and strategies that are critical for retaining the allied health workforce in hospitals.

Allied health and the frail patient in hospital - a prospective cohort study

Objectives Frailty is associated with significant mortality and morbidity in hospitalised patients. We describe physiotherapy and occupational therapy practices in hospitalised frail patients and examine the role of early intervention. Methods We performed a prospective, observational cohort study in a medical assessment unit in a tertiary care hospital. Patients with COVID-19 infection were excluded. Frailty was measured by the Clinical Frailty Scale (CFS). Early allied health intervention was defined as involvement within 48h of admission. Demographic data, clinical diagnoses, time spent with physiotherapy and occupational therapy, CFS, hospital length of stay and outcomes were recorded and analysed. Results A total of 356 patients were categorised into non-frail (CFS score <5) and frail (CFS score ≥5) groups. The prevalence of frailty was 68% (n =241). Physiotherapy (77.2%) and occupational therapy (75.5%) reviews were more frequent in frail patients than in non-frail patients. Frail patients who had allied health involvement within 48h of admission had a significant reduction in their hospital length of stay (mean reduction of 7.3days, 95% CI: 0.53, 14, P =0.035) and a 2.44% reduction in the relative risk of developing pressure injuries (95% CI: 1.31, 4.53). There was no statistically significant differences in outcomes with allied health intervention for non-frail patients and patients who require residential aged care facility level care. Conclusions Allied health have a key role in the management of frailty. Early allied health intervention was associated with a reduced hospital length of stay as well as a reduced incidence of pressure injury in frail patients.

Real-world environmental enrichment rehabilitation paradigm in people with severe traumatic brain injury: a pilot feasibility study

BACKGROUND

The use of Environmental Enrichment (EE) has been widely studied in animal models. However, the application of the same in humans is limited to rehabilitation settings.

OBJECTIVE

To investigate the feasibility of a community-based EE paradigm in adults with brain injury.

METHODS

Six individuals diagnosed with traumatic brain injury enrolled in the study. The Go Baby Go Café instrumented with a body weight harness system, provided physical and social enrichment as participants performed functional tasks for 2 hours, three times a week, for 2 months. Feasibility and safety outcomes were recorded throughout sessions. Clinical measures including 10-meter walk, timed up and go, jebsen hand function, 6-minute walk, and trail making tests were obtained pre and post intervention.

RESULTS

All participants completed the study. The attendance was 100% and adherence was 87%. Positive changes in clinical measures were statistically significant for the timed up and go (p = 0.0175), TUG-cognitive (p = 0.0064), 10-meter walk (p = 0.0428), six-minute walk (p = 0.0196), TMT-A (p = 0.034). Changes in JHFT were not significant (p = 0.0506), with one subject recording values counter to the trend.

CONCLUSION

The Café was a comprehensive EE-based intervention that was feasible, safe, and has the potential to enhance motor and cognitive function in individuals with brain injury.

Frequent Error Augmentation Training in Physical Therapy Post Stroke

Background

The purpose of this pilot trial was to evaluate the impact of increased frequency of physical therapy sessions with error augmentation on functional mobility and disability outcomes in patients with acute stroke. We hypothesized that participants receiving frequent error augmentation physical therapy interventions (F-EA-PT) would demonstrate a higher degree of improvement on functional mobility and disability measures from admission to three post-intervention time points (treatment day 3, discharge, or 90-day follow-up).

Methods

We allocated 100 individuals to receive either F-EA-PT or standard-of-care physical therapy (SOC-PT). The F-EA-PT group received physical therapy with error augmentation twice daily for 3 out of the first 5 days of hospitalization, and daily treatment sessions thereafter. Error augmentation training emphasizes impairments throughout mobility to challenge the individual, rather than facilitating normal movement patterns. The SOC-PT group received treatment once daily for 3 to 5 days per week. Assessments included National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), Activity Measure for Post-Acute Care (AM-PAC) and Postural Assessment Scale for Stroke (PASS). A repeated measures mixed model approach compared treatment groups for all outcomes.

Results

The F-EA-PT group demonstrated larger magnitudes of reduction of -1.34 on NIHSS (p=0.0426) and -0.81 on mRS (p=0.0037) from admission to 90-day follow-up compared to the SOC-PT group. The F-EA-PT group demonstrated larger magnitudes of change in AM-PAC of 2.12 at treatment day 3 (p=0.0009) and 2.75 at discharge (p<0.0001) compared to SOC-PT. F-EA-PT group experienced greater improvement in PASS over the SOC-PT group with a difference in change of 4.08 at treatment day 3 (p=0.0019) and 4.45 at discharge (p=0.001).

Conclusions

Intervening with a regimen focused on increased frequency and error augmentation from a physical therapy standpoint was safe with only one adverse event. It demonstrated significant improvements in functional outcomes post stroke above those seen with standard-of-care regimen, as evidenced by PASS and AM-PAC scores.

Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT04778475.Medical University of South Carolina IRB II Approved 04/20/2021 PRO00108635.

Relationship Between the Frequency and Duration of Physical Therapy and Hospitalization-associated Disability Among Geriatric Patients with Heart Failure

OBJECTIVE

The aim of this study was to examine the relationship between the frequency and duration of physical therapy (PT) and the development of hospitalization-associated disability (HAD) in hospitalized geriatric patients with heart failure (HF).

METHODS

This single-center, retrospective, observational study included hospitalized patients with HF aged 65 years or older who had received PT. Data regarding demographics, comorbidities, laboratory findings, medications, rehabilitation, and activities of daily living (ADLs) status were collected from electronic medical records. Based on the average frequency and duration of PT, patients were divided into three groups: Group 1, ≥3 days/week and ≥120 minutes/week; Group 2, ≥3 days/week and <120 minutes/week; and Group 3, <3 days/week and <120 minutes/week. Logistic regression analysis was performed to identify the association between the average frequency and duration of weekly PT and the incidence of HAD.

RESULTS

In all, 105 patients (mean age, 84.8 years; proportion of women, 59%) were enrolled in the study, and 43 (41.0%) patients exhibited HAD at discharge. In the multivariate logistic regression analysis, Group 2 (odds ratio [OR], 3.66) and Group 3 (OR, 6.71) had a significantly elevated risk of developing HAD using Group 1 as the reference, even after adjusting for age, ADLs before admission, cognitive function, and severity of HF.

CONCLUSION

This study showed that a lower frequency and shorter duration of PT are associated with developing HAD in hospitalized geriatric patients with HF. However, further prospective studies are required to confirm these findings.

Sarcopenia, malnutrition and cognition affect physiotherapy frequency during geriatric rehabilitation: RESORT cohort

BACKGROUND

Physiotherapy (PT) is important to optimize functional recovery in geriatric rehabilitation. The dose of PT received by inpatients during geriatric rehabilitation and the determinants of dose are unknown.

OBJECTIVES

Describe PT dose in terms of total number of sessions, frequency, duration and type of sessions, and inpatient characteristics determining the frequency of PT in geriatric rehabilitation.

METHODS

The observational, longitudinal REStORing health of acutely unwell adulTs (RESORT) cohort consists of geriatric inpatients undergoing rehabilitation including PT (Melbourne, Australia). Ordinal regression was used to assess the determinants of PT frequency (total number of sessions divided by length of stay in weeks). Malnutrition, frailty and sarcopenia were diagnosed according to the Global Leadership Initiative on Malnutrition criteria, Clinical Frailty Scale and revised definition of the European Working Group on Sarcopenia in Older People respectively.

RESULTS

Of the 1890 participants, 1799, median (quartile 1; quartile 3) age 83.4 (77.6; 88.4) years, 56% females received PT and were admitted for at least 5 days. Median total number of PT sessions was 15 (8; 24); median frequency was 5.2 sessions per week (3.0; 7.7); and duration was 27 (22; 34) minutes per session. Higher disease burden, cognitive impairment, delirium, higher anxiety and depression scores, malnutrition, frailty and sarcopenia were associated with a lower PT frequency. Older age, female sex, musculoskeletal reason for admission, greater independence in (instrumental) activities of daily living and handgrip strength were associated with a higher PT frequency.

CONCLUSIONS

PT frequency varied widely with a median of 1 session per working day. PT frequency was lowest in participants with poorest health characteristics.

Effects of an electronic health record-based mobility assessment and automated referral for inpatient physical therapy on patient outcomes: A quasi-experimental study

OBJECTIVE

To assess the effectiveness of a hospital physical therapy (PT) referral triggered by scores on a mobility assessment embedded in the electronic health record (EHR) and completed by nursing staff on hospital admission.

DATA SOURCES

EHR and billing data from 12 acute care hospitals in a western Pennsylvania health system (January 2017-February 2018) and 11 acute care hospitals in a northeastern Ohio health system (August 2019-July 2021).

STUDY DESIGN

We utilized a regression discontinuity design to compare patients admitted to PA hospitals with stroke who reached the mobility score threshold for an EHR-PT referral (treatment) to those who did not (control). Outcomes were hospital length of stay (LOS) and 30-day readmission or mortality. Control variables included demographics, insurance, income, and comorbidities. Hospital systems with EHR-PT referrals were also compared to those without (OH hospitals as alternative control). Subgroup analyses based on age were also conducted.

DATA EXTRACTION

We identified adult patients with a primary or secondary diagnosis of stroke and mobility assessments completed by nursing (n = 4859 in PA hospitals, n = 1749 in OH hospitals) who completed their inpatient stay.

PRINCIPAL FINDINGS

In the PA hospitals, patients with EHR-PT referrals had an 11.4 percentage-point decrease in their 30-day readmission or mortality rates (95% CI -0.57, -0.01) relative to the control. This effect was not observed in the OH hospitals for 30-day readmission (β = 0.01; 95% CI -0.25, 0.26). Adults over 60 years old with EHR-PT referrals in PA had a 26.2 percentage-point (95% CI -0.88, -0.19) decreased risk of readmission or mortality compared to those without. Unclear relationships exist between EHR-PT referrals and hospital LOS in PA.

CONCLUSIONS

Health systems should consider methodologies to facilitate early acute care hospital PT referrals informed by mobility assessments.

Relationship between time of referral for physiotherapy and length of stay after stroke in a Nigerian tertiary hospital: a retrospective study

Background

Despite the known benefits of physiotherapy, the relationship between its time of referral and the length of stay (LOS) of stroke patients in developing countries has been understudied. This relationship was investigated in this study as we determined the relationships between LOS and time of referral and LOS and the number of physiotherapy sessions received.

Methods

Medical records of stroke patients admitted at Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife between January 2007 and December 2016 were retrieved. Descriptive statistics were used to summarize the data, independent samples t test, and one-way analysis of variance were used to determine differences, and Pearson correlation was used to determine relationships.

Results

A total of 585 medical records were retrieved. With an inpatient mortality rate of 40.7%, only 243 case records were included in the study. The mean LOS was 17 ± 13 days, and 63.4% received inpatient physiotherapy. Patients who were referred for physiotherapy (p = 0.019) and those who utilized physiotherapy (p = 0.001) had higher LOS. Also, there were significant correlations between LOS and the time of referral for physiotherapy (r = 0.575, p = 0.001) and LOS and the number of physiotherapy sessions received (r = 0.293, p = 0.001).

Conclusions

Stroke patients who utilized physiotherapy had longer LOS. The longer the time of referral and the higher the number of physiotherapy sessions, the longer the LOS. Early referral and commencement of physiotherapy optimize physiotherapy utilization, which may reduce the LOS of stroke patients.

Examining the effectiveness of virtual, augmented, and mixed reality (VAMR) therapy for upper limb recovery and activities of daily living in stroke patients: a systematic review and meta-analysis

INTRODUCTION

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) are emerging technologies in the field of stroke rehabilitation that have the potential to overcome the limitations of conventional treatment. Enhancing upper limb (UL) function is critical in stroke impairments because the upper limb is involved in the majority of activities of daily living (ADL).

METHODS

This study reviewed the use of virtual, augmented and mixed reality (VAMR) methods for improving UL recovery and ADL, and compared the effectiveness of VAMR treatment to conventional rehabilitation therapy. The databases ScienceDirect, PubMed, IEEE Xplore, and Web of Science were examined, and 50 randomized control trials comparing VAMR treatment to standard therapy were determined. The random effect model and fixed effect model are applied based on heterogeneity.

RESULTS

The most often used outcomes of UL recovery and ADL in stroke rehabilitation were the Fugl-Meyer Assessment for Upper Extremities (FMA-UE), followed by the Box and Block Test (BBT), the Wolf Motor Function Test (WMFT), and the Functional Independence Measure (FIM). According to the meta-analysis, VR, AR, and MR all have a significant positive effect on improving FMA-UE for UL impairment (36 studies, MD = 3.91, 95 percent CI = 1.70-6.12, P = 0.0005) and FIM for ADL (10 studies, MD = 4.25, 95 percent CI = 1.47-7.03, P = 0.003), but not on BBT and WMFT for the UL function tests (16 studies, MD = 2.07, 95 percent CI = - 0.58-4.72, P = 0.13), CONCLUSIONS: VAMR therapy was superior to conventional treatment in UL impairment and daily function outcomes, but not UL function measures. Future studies might include further high-quality trials examining the effect of VR, AR, and MR on UL function measures, with an emphasis on subgroup meta-analysis by stroke type and recovery stage.

The Effectiveness of Adapted Personalized Motor Activity (AMPA) to Improve Health in Individuals with Mental Disorders and Physical Comorbidities: A Randomized Controlled Trial

Mental disorders are highly prevalent worldwide and have a high impact on daily functioning. Exercise therapy was found to improve health of individuals with physical and mental disorders. This study aims to investigate the effectiveness of an Adapted Personalized Motor Activity (AMPA) in improving health in individuals with physical and mental disorders. Forty-three patients affected by both mental and chronic nontransmissible conditions were randomly assigned to intervention group (AMPA intervention) and control group (no intervention). Perceived physical and mental health were assessed using the Short Form 12 (SF-12) questionaries. Moreover, subjects underwent an accurate medical screening process, complete clinical evaluation, body composition evaluation, and cardiopulmonary assessment. Repeated Measurement Analysis of the Variance (RM-ANOVA) was used to compare any changes in health and physiological parameters in-between groups. AMPA group showed a statistically significant improvement in both perceived mental and physical health. Moreover, Body Mass Index (BMI), glycolipid profile, aerobic functional capacity and cardiopulmonary parameters improved significantly among individuals from the intervention group compared with the individuals from the control group. AMPA may be considered a possible intervention to improve health in individuals suffering from multiple physical and mental disorders. Future studies should examine the effectiveness in larger and heterogeneous sample of chronically ill patients and the long-term effect of AMPA.

Higher Frequency of Acute Occupational Therapy Services Is Associated With Reduced Hospital Readmissions

IMPORTANCE

Hospital readmissions are associated with poor patient outcomes, including higher risk for mortality, nutritional concerns, deconditioning, and higher costs.

OBJECTIVE

To evaluate how acute occupational therapy service delivery factors affect readmission risk.

DESIGN

Cross-sectional, retrospective study.

SETTING

Single academic medical center.

PARTICIPANTS

Medicare inpatients with a diagnosis included in the Hospital Readmissions Reduction Program (HRRP; N = 17,618). Data were collected from medical records at a large urban hospital in southeastern Wisconsin. Outcomes and Measures: Logistic regression models were estimated to examine the association between acute occupational therapy service delivery factors and odds of readmission. In addition, the types of acute occupational therapy services for readmitted versus not-readmitted patients were compared.

RESULTS

Patients had significantly higher odds of readmission if they received occupational therapy services while hospitalized (odds ratio [OR] = 1.18, 95% confidence interval [CI] [1.07, 1.31]). However, patshients who received acute occupational therapy services had significantly lower odds of readmission if they received a higher frequency (OR = 0.99, 95% CI [0.99,1.00]) of acute occupational therapy services. A significantly higher proportion of patients who were not readmitted, compared with patients who were readmitted, received activities of daily living (ADL) or self-care training (p < .01).

CONCLUSIONS AND RELEVANCE

For patients with HRRP-qualifying diagnoses who received acute occupational therapy services, higher frequency of acute occupational therapy services was linked with lower odds of readmission. Readmitted patients were less likely to have received ADL or self-care training while hospitalized. What This Article Adds: Identifying factors of acute occupational therapy services that reduce the odds of readmission for Medicare patients may help to improve patient outcomes and further define occupational therapy's role in the U.S. quality-focused health care system.

Effectiveness of Weekend Physiotherapy on Geriatric In-Patients' Physical Function

Purpose

Hospital-associated disability (HAD) is significant among geriatric patients admitted to acute care hospitals. The objective of the study is to evaluate the effectiveness of additional weekend physiotherapy on mobility impairments of high-risk older patients admitted to the acute medical unit.

Methods

A prospective, non-randomized controlled trial was conducted in one of the medical units in a northern Ontario hospital. A total of 41 patients were recruited using a consecutive sampling method and assigned to a control group (n = 19) and an experimental group (n = 22). The de Morton Mobility Index (DEMMI) and the Barthel Index (BI) were the outcome measures.

Results

A Mann-Whitney U test was used to analyze the group differences, and it showed that there was a statistically significant difference (p < .05) between the experimental and control groups on the DEMMI and the BI.

Conclusion

Additional weekend physiotherapy significantly improves elderly patients’ physical function and gets them physically ready for discharge when medically stable. This may significantly reduce the alternate level of care for patients.

Does additional weekend and holiday physiotherapy benefit geriatric patients with hip fracture? - A case-historical control study

OBJECTIVE

To evaluate the new service model of additional weekend and holiday physiotherapy (PT) by comparing functional outcomes and hospital length of stay between a group of geriatric patients with hip fracture receiving daily PT training and a group of geriatric patients with hip fracture receiving weekdays PT training.

METHODS

A retrospective case-historical control chart review was conducted and a total of 355 patients were identified. Between-group comparisons were done on functional outcomes including Modified Functional Ambulation Classification (MFAC), Elderly Mobility Scale (EMS), Modified Barthel Index (MBI) and process outcome in terms of length of stay (LOS) in hospitals.

RESULTS

With similar characteristics, patients who received weekend and holiday PT training had a significant higher percentage of MFAC Category III and a significant lower percentage of MFAC Category II ( p = 0 . 015 ) and significant higher MBI scores ( mean ± standard deviation, median; Study group: 47 . 4 ± 19 . 6 points, 51 points; Control group: 43 . 0 ± 20 . 0 points, 43 points; p = 0 . 042 ) upon admission to rehabilitation hospital. A similar trend in EMS scores (Study group: 8 . 2 ± 5 . 5 points, 7 points; Control group: 8 . 4 ± 6 . 1 points, 6 points; p = 0 . 998 ) and MBI scores (Study group: 63 . 0 ± 23 . 4 points, 68 points; Control group: 61 . 2 ± 26 . 1 points, 64 points; p = 0 . 743 ) were observed upon discharge from the rehabilitation hospital. The average LOS in acute hospitals remained static (Study group: 7 . 7 ± 3 . 9 days, 7 days; Control group: 7 . 4 ± 5 . 0 days, 6 days; p = 0 . 192 ). The average LOS in rehabilitation hospital (Study group: 20 . 0 ± 5 . 5 days, 20 days; Control group: 24 . 3 ± 9 . 9 days, 23 days; p < 0 . 001 ) and total in-patient LOS (Study group: 26 . 7 ± 6 . 4 days, 26 days; Control group: 30 . 7 ± 11 . 2 days, 28 days; p < 0 . 001 ) were significantly reduced. A higher percentage of days having PT training during hospitalization in rehabilitation hospital was shown with the implementation of new service (Study group: 89.1%; Control group: 65.9%, p < 0 . 001 ).

CONCLUSION

Additional weekend and holiday PT training in post-operative acute and rehabilitation hospitalization benefits geriatric patients with hip fracture in terms of improved training efficiency, where hospital LOS was shortened with more PT sessions, without any significant impacts on functional outcome.

Decreasing pressure injuries and acute care length of stay in patients with acute traumatic spinal cord injury

OBJECTIVES

Identifying factors associated with the occurrence of pressure injuries (PI) during acute care and with longer length of stay (LOS), focusing on modifiable factors that can be addressed and optimized by the acute rehabilitation team.

DESIGN

Prospective cohort study.

SETTING

A single Level-1 trauma center specialized in SCI care.

PARTICIPANTS

A cohort of 301 patients with acute TSCI was studied.

OUTCOME MEASURES

The primary outcome was the occurrence of PI during acute care stay. The secondary outcome was acute care LOS. Bivariate and multivariate logistic or linear regression analyses were performed to determine the association between non-modifiable factors and outcomes (PI of any stage and acute LOS), whereas bivariate and hierarchical multivariate logistic or linear regression analyses were used for modifiable factors.

RESULTS

When controlling for the level and severity of the TSCI, the occurrence of pneumonia (OR = 2.1, CI = 1.1-4.1) was significantly associated with the occurrence of PI. When controlling for the level and severity of the TSCI, the occurrence of medical complications (PI, urinary tract infection and pneumonia) and lesser daily therapy resulted in significantly longer acute care LOS (P < .001).

CONCLUSIONS

Prevention of PI occurrence and the optimization of the acute care LOS represent crucial challenges of the acute rehabilitation team, as they are significantly associated with higher functional outcomes. Patients who develop pneumonia may benefit from more aggressive prevention strategies to reduce PI occurrence. Systematic protocols for the prevention of complications as well as greater volume of therapy interventions should be considered to optimize the acute care LOS.

Physical activity and moving more for health

Non-communicable diseases are a leading cause of death and levels are rising. Lifestyle changes, including physical activity, have benefits in all-cause mortality, cardiovascular and metabolic disease, respiratory conditions and cognitive and mental health. In some cancers, particularly colon, prostate and breast, physical activity improves quality of life and outcomes before, during and after treatment. Sedentary time is an independent risk factor with adverse effects in hospitalised patients. Mechanisms include anti-inflammatory effects and augmentation of physiological and neuroendocrine responses to stressors. Engaging patients is affected by barriers: for clinicians, awareness of guidelines and personal physical activity levels are important factors; for patients, barriers are influenced by life events, socioeconomic and cultural factors. Interventions to increase activity levels are effective in the short- and medium-term, including brief interventions. Face-to-face is more effective than remote advice and behavioural interventions are more effective than cognitive. There are no published guidelines for physical activity in hospitalised patients.

Effect of early intensive rehabilitation on the clinical outcomes of patients with acute stroke

AIM

Intensive rehabilitation effectively improves physical functions in patients with acute stroke, but the frequency of intervention and its cost-effectiveness are poorly studied. This study aimed to examine the effect of early high-frequency rehabilitation intervention on inpatient outcomes and medical expenses of patients with stroke.

METHODS

The study retrospectively included 1759 patients with acute stroke admitted to the Kobe City Medical Center General Hospital between 2013 and 2016. Patients with a transient ischemic attack, subarachnoid hemorrhage, and those who underwent urgent surgery were excluded. Patients were divided into two groups according to the frequency of rehabilitation intervention: the high-frequency intervention group (>2 times/day, n = 1105) and normal-frequency intervention group (<2 times/day, n = 654). A modified Rankin scale score ≤2 at discharge, immobility-related complications and medical expenses were compared between the groups.

RESULTS

The high-frequency intervention group had a significantly shorter time to first rehabilitation (median [interquartile range], 19.0 h [13.1-38.4] vs. 24.7 h [16.1-49.4], P < 0.001) and time to first mobilization (23.3 h [8.7-47.2] vs. 22.8 h [5.7-62.3], P = 0.65) than the normal-frequency intervention group. Despite higher disease severity, the high-frequency intervention group exhibited favorable outcomes at discharge (modified Rankin scale, ≤2; adjusted odds ratio, 1.89; 95% confidence interval, 1.25-2.85; P = 0.002). No significant differences were observed between the two groups concerning the rate of immobility-related complications and total medical expenses during hospitalization.

CONCLUSIONS

High-frequency intervention was associated with improved outcomes and decreased medical expenses in patients with stroke. Our results may contribute to reducing medical expenses by increasing the efficiency of care delivery. Geriatr Gerontol Int 2021; 21: 623-628.

Retrospective study demonstrating therapy time impact on inpatient rehabilitation functional gains

PURPOSE

The purpose of this retrospective study is to evaluate the association of total therapy time during inpatient rehabilitation and gain in functional independence for patients admitted to an inpatient rehabilitation facility (IRF).

MATERIALS AND METHODS

The study utilized a retrospective design that included all IRF patients from three IRFs in California from January 1, 2012 to December 31, 2013. Patient data collected as part of usual, routine medical, and rehabilitation care were used and includes demographics, medical variables, and functional outcomes data.

RESULTS

There were 3212 patients discharged from the three IRFs, with 2,777 patients having received speech language pathology (SLP) therapy along with occupational therapy and physical therapy. Speech language pathology services were not provided for 435 patients in the database. Our results support that among all types of patients, increased therapy hours were associated with increased functional gains. For total functional independence measure (FIM) gain, an additional hour of PT therapy per day was associated with an increase of 7.55 FIM gain points (p < 0.001) and an additional hour of OT therapy per day was associated with an increase of 1.16 FIM gain points (p = 0.045), when adjusted for other variables in the model. SLP hours per day did not remain in the FIM gain model.

CONCLUSIONS

The findings of this study add to the understanding of therapy time and functional gain in an inpatient rehabilitation program. There is a positive relationship between total therapy time and functional gain. In the future determining the intensity and the related therapy activities provided will be needed to impact functional change. This has implications for shaping rehabilitation practice in the future.Implications for rehabilitationIncreased number of therapy hours were associated with functional gains in an inpatient rehabilitation program for all types of patients.An additional hour of physical therapy per day was associated with an increase of 7.55 functional independence measure (FIM) point gain.An additional hour of occupational therapy per day was associated with an increase of 1.16 FIM point gain.Determining the intensity and related activities are needed to impact functional change which has implications for shaping rehabilitation practice.

Virtual reality games for rehabilitation of upper extremities in stroke patients

INTRODUCTION

Stroke is one of the main causes of physical disability in which doing frequent and early exercise is imperative for rehabilitation. Virtual reality gaming has a high potential in rehabilitation leading to increased performance of patients. This study aimed to develop, validate and examine virtual reality games in chronic stroke patients.

METHODS

This was a single before-after study. To determine the movements and content of games, 9 physiotherapists and 11 game designers were asked to participate in a questionnaire-based survey. Then, to evaluate the impact of games on rehabilitation, patients (N = 10; mean age = 52 ± 4.38) with chronic stroke were asked to play the games three times a week for four weeks. Outcomes included measurement of the ability to perform shoulder, elbow and wrist movements was performed using goniometric instrument, Modified Motor Assessment Scale (MMAS) was used to assess the functional ability of patients and muscle spasticity, and brunnstrom's stages of recovery test was also used to assess spastic and involuntary muscle movement.

RESULTS

Games have positive effects on the horizontal abduction of shoulder (16.26 ± 23.94, P = 0.02), horizontal adduction of shoulder (59.24 ± 74.76, P = 0.00), supination of wrist (10.68 ± 53.52, P = 0.02), elbow flexion (0.1 ± 1.5, P = 0.00), and wrist flexion (0.06 ± 1.34, P = 0.03). However, they had no effects on the flexion of shoulder, flexion of elbow, extension of elbow, and extension of wrist (p-value> 0.05).

CONCLUSIONS

The results showed that games improve the range of motion of the participants in terms of horizontal abduction and abduction of the shoulder, elbow flexion, and supination and flexion of the wrist. Due to the small sample size in this study, we recommend more studies with larger samples and a control group.

Pre-operative physiotherapy following unilateral ankle fractures at a tertiary hospital in South Africa: Perceptions of patients and nurses

BACKGROUND

Ankle fractures are a common injury because of an increase in levels of physical activity, as well as senescence worldwide. Ankle fractures often require surgical management for optimal stabilisation. Pre-operative physiotherapy is necessary to prepare patients for early mobilisation and home discharge. There is a lack of information on the influence of pre-operative physiotherapy on post-operative rehabilitation success, as well as timeous discharge, in patients with ankle fractures.

OBJECTIVES

To explore the perceptions of patients receiving pre-operative physiotherapy care following a unilateral ankle fracture and the perceptions of nursing staff managing these patients at a tertiary hospital in South Africa.

METHOD

A descriptive qualitative design, using semi-structured interviews, including both patients with unilateral ankle fractures and nurses caring for these patients, was adopted. Interviews were recorded and verbatim transcriptions were analysed utilising thematic analysis.

RESULTS

Four overarching themes emerged: the perceived benefits of pre-operative physiotherapy; inhibitors to physiotherapy rehabilitation; hidden enablers to pre-operative physiotherapy and future initiatives for rehabilitation.

CONCLUSION

The perceived benefits included improved functional independence and safety of patients, as well as reduced burden of care for nurses. Patients also believed that pain and fear were two inhibitors to physiotherapy. Furthermore, nurses identified that organisational limitations, such as short-staffing and inadequately trained staff, inhibited pre-operative physiotherapy and continuity of care. Early post-operative discharge was a crucial hidden enabler to the pre-operative physiotherapy protocol. Recommendations included improved health education; the potential role of nursing staff as facilitators in pre-operative rehabilitation and regular, pre-operative in-patient monitoring of physiotherapy intervention.

CLINICAL IMPLICATIONS

Health education was perceived to have improved patient safety and compliance which subsequently reduced patient safety incidences as well as served as a risk mitigation measure. Furthermore, gait training and muscle strengthening exercises was perceived to have resulted in safe, independent mobility to ensure prompt discharge home. Consequently, a reduced post-operative length of in hospital stay results in major cost savings per patient as well as improved access and bed availability. Future studies may need to explore the effects of pre-operative physiotherapy on post-operative success and return to pre-injury activity.

Potential Efficacy of Pragmatic Exercise Program (SPRINT) during Hospitalization in Older Adults on Health Care and Physical Performance: A Pilot Study

OBJECTIVES

Immobilization contribute to iatrogenic decline in hospitalized older adult. Implementing physical activity (PA) seems to be one of the best and easy solution. However, PA interventions are poorly integrated into usual care and those available are either non-specific, need supervision or requested human/material resources. Thus, we aimed to assess the effect of a pragmatic, unsupervised, and specific PA program (SPRINT) on health care practice and functional capacities in hospitalized older patients.

DESIGN

Single arm interventional pragmatic pilot study.

SETTING

Geriatric Assessment Unit (GAU).

PARTICIPANTS

Of the 39 patients (> 65 years) hospitalized in a GAU and eligible, 19 agreed to participate (AP) and 20 declined (N-AP).

INTERVENTION

One of the 4 PA programs, developed by our team, was allocated according to mobility profile. Individual functional capacities (i.e. balance, walking speed, functional mobility profile (PFMP)), active time (METS> 1.5: min), length of hospitalization (LOS), discharge orientation were assessed at admission and discharge of GAU.

RESULTS

Baseline characteristics of the 2 groups were comparable. At discharge, the AP group improved more on walking speed (0.57 ± 0.21 vs. 0.64 ± 0.19; p = 0.013), Berg balance scale (41.8 ± 13.7 vs. 45.1 ± 9.7; p = 0.017) and PFMP (54.0 ± 7.1 vs 55.1 ± 5.5; p = 0.042) than the N-AP group. The LOS was significantly shorter in AP group compared to the N-AP group (5 vs. 36 days; p = 0.026) and more subjects in the AP group were oriented at home without health or social services (89.5 vs. 60%; p=0.065).

CONCLUSION

SPRINT appears effective to counteract iatrogenic decline and decreased the LOS. Moreover, this simple pragmatic PA tool seems to improve the life trajectory and healthcare practice in aging population. Further researches are needed to confirm these promising pragmatic results.

Can in-hospital or post discharge caregiver involvement increase functional performance of older patients? A systematic review

BACKGROUND

Regaining pre-hospitalization activity levels is only achieved in 30-50% of older patients. Extra physiotherapy time has been proven to improve functional outcome and shorten length of stay, but is costly. Considering their key role in caring for older people, involving informal caregivers in rehabilitation might further improve functional performance.

AIM

To determine if in-hospital or post discharge caregiver involvement can increase functional performance in older adults. The secondary aim was to determine if caregiver involvement can influence, quality of life of patient and caregiver, medical costs, readmission rate, discharge location, and mortality.

DESIGN

Systematic review with narrative synthesis.

METHODS

The electronic bibliographic databases MEDLINE, Embase, CINAHL, Cochrane and Web of Science were searched for (quasi) experimental and observational studies, with the following inclusion criteria; caregiver involvement regarding functional performance, mean age over 65 years, admitted to a hospital unit and subsequently discharged to their home setting. Risk of bias was assessed with the Rob 2 (randomized trials) and the ROBINS-1 tool (non-randomized studies).

RESULTS

Eight studies of an initial 4683 were included: four randomized controlled trials, one prospective cohort study, one non-randomized controlled trial, one subgroup analysis of an RCT and one prospective pre-post study. All but one study included patients with stroke. Three types of caregiver interventions could be distinguished: a care pathway (inclusion of caregivers in the process of care), education on stroke and teaching of bed-side handling-skills, and caregiver-mediated exercises. The one study evaluating the care pathway reported 24.9% more returns home in the intervention group. Studies evaluating the effect of education and bed-side handling-skills reported higher effect sizes for several outcomes with increasing session frequency. All studies with caregiver-mediated exercises showed beneficial effects on functional performance, immediately after the intervention and within 3 months follow-up.

CONCLUSION

The findings of this review suggest that involvement of caregivers in the rehabilitation of older adults leads to better functional performance up to 3 months after initiation. However, evidence is low and mainly focusing on stroke.

A novel early mobility bundle improves length of stay and rates of readmission among hospitalized general medicine patients

Inpatient early mobility initiatives are effective therapeutic interventions for improving patient outcomes and decreasing use of hospital resources among adult ICU and general medicine patients. To establish and demonstrate guidelines for early patient ambulation, we developed and implemented a novel multidisciplinary mobility bundle utilizing the JH-HLM (Johns Hopkins Highest Level of Mobility) scale for mobility classification, on a single adult general medicine unit of a community hospital. Our results show that patients admitted to the unit after implementation of the mobility bundle had improved mobility scores, reduced rates of 30-day hospital readmission, and a shortened length of hospital stay. This study emphasizes the importance of measuring mobility using a systematic method, easing workflow among unit practitioners, and allowing mobility initiatives to be jointly driven by nursing, physical therapy, and physicians.

The Effect of Caregiver-Mediated Mobility Interventions in Hospitalized Patients on Patient, Caregiver, and Health System Outcomes: A Systematic Review

OBJECTIVE

To synthesize the evidence examining caregiver-mediated mobility interventions in a hospital setting and whether they improve patient, caregiver, or health system outcomes.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus databases from inception to September 7, 2018.

STUDY SELECTION

Two reviewers independently selected original research in inpatient settings that reported on an intervention delivered by a caregiver (eg, family, friend, paid worker) and directed to the patient's mobility. Mobility interventions were categorized based on the level of caregiver engagement using a 3-category framework: inform (provision of education on patient's condition and management), activate (prompting caregivers to take action in patient care), and collaborate (encouraging interaction with providers or other caregivers).

DATA EXTRACTION

One reviewer extracted data, and another checked the data. Quality was assessed using the Cochrane Collaboration's risk of bias tool and Grading of Recommendations, Assessment, Development and Evaluation approach.

DATA SYNTHESIS

Forty studies met the inclusion criteria; most were randomized controlled trials (n=16/40, 40.0%) and investigated older adults (n=18/40, 45.0%) with stroke (n=20/40, 50.0%). Inform (n=2) and activate (n=4) interventions and combined inform-activate (n=5/6, 83.3%) and inform-activate-collaborate (n=6/10, 60.0%) interventions were reported to improve patient mobility. Inform-activate and inform-collaborate interventions were reported to improve caregiver outcomes (eg, burden) (n=13/19, 68.4%). Studies that engaged caregivers in all 3 strategies (inform-activate-collaborate) were reported to improve health system outcomes (eg, hospital readmission) (n=4/6, 66.7%). Most studies were of unclear (n=22/40, 55.0%) or low risk of bias (n=11/40, 27.5%) for most domains.

CONCLUSIONS

Engaging caregivers in mobility of hospitalized patients may improve patient mobility as well as caregiver and health system outcomes.

Using co-production to increase activity in acute stroke units: the CREATE mixed-methods study

Background

Stroke is the most common neurological disability in the UK. Any activity contributes to recovery, but stroke patients can be inactive for > 60% of their waking hours. This problem remains, despite organisational changes and targeted interventions. A new approach to addressing post-stroke inactivity is needed. Experience-based co-design has successfully initiated improvements for patients and staff in other acute settings. Experience-based co-design uses observational fieldwork and filmed narratives with patients to trigger different conversations and interactions between patients and staff to improve health-care services.

Objectives

To complete a rapid evidence synthesis of the efficacy and effectiveness of co-production as an approach to quality improvement in acute health-care settings; to evaluate the feasibility and impact of patients, carers and staff co-producing and implementing interventions to increase supervised and independent therapeutic patient activity in acute stroke units; and to understand the experience of participating in experience-based co-design and whether or not interventions developed and implemented in two units could transfer to two additional units using an accelerated experience-based co-design cycle.

Design

A mixed-methods case comparison using interviews, observations, behavioural mapping and self-report surveys (patient-reported outcome measure/patient-reported experience measure) pre and post implementation of experience-based co-design cycles, and a process evaluation informed by normalisation process theory.

Setting

The setting was two stroke units (acute and rehabilitation) in London and two in Yorkshire.

Participants

In total, 130 staff, 76 stroke patients and 47 carers took part.

Findings

The rapid evidence synthesis showed a lack of rigorous evaluation of co-produced interventions in acute health care, and the need for a robust critique of co-production approaches. Interviews and observations (365 hours) identified that it was feasible to co-produce and implement interventions to increase activity in priority areas including ‘space’ (environment), ‘activity’ and, to a lesser extent, ‘communication’. Patients and families reported benefits from participating in co-design and perceived that they were equal and valued members. Staff perceived that experience-based co-design provided a positive experience, was a valuable improvement approach and led to increased activity opportunities. Observations and interviews confirmed the use of new social spaces and increased activity opportunities. However, staff interactions remained largely task focused, with limited focus on enabling patient activity. Behavioural mapping indicated a mixed pattern of activity pre and post implementation of co-designed changes. Patient-reported outcome measure/patient-reported experience measure response rates were low, at 12–38%; pre- and post-experience-based co-design cohorts reported dependency, emotional and social limitations consistent with national statistics. Post-experience-based co-design patient-reported experience measure data indicated that more respondents reported that they had ‘enough things to do in their free time’. The use of experience-based co-design – full and accelerated – legitimised and supported co-production activity. Staff, patients and families played a pivotal role in intervention co-design. All participants recognised that increased activity should be embedded in everyday routines and in work on stroke units.

Limitations

Communication by staff that enabled patient activity was challenging to initiate and sustain.

Conclusions

It was feasible to implement experience-based co-design in stroke units. This resulted in some positive changes in unit environments and increased activity opportunities for patients. There was no discernible difference in experiences or outcomes between full and accelerated experience-based co-design. Future work should consider multiple ways to embed increased patient activity into everyday routines in stroke units.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 35. See the NIHR Journals Library website for further project information.

Real-World Goal Setting and Use of Outcome Measures According to the International Classification of Functioning, Disability and Health: A European Survey of Physical Therapy Practice in Multiple Sclerosis

Goal setting is a core component of physical therapy in multiple sclerosis (MS). It is unknown whether and to what extent goals are set at different levels of the International Classification of Functioning, Disability and Health (ICF), and whether, and to which, standardized outcome measures are used in real life for evaluation at the different ICF levels. Our aim was to describe the real-world use of goal setting and outcome measures in Europe. An online cross-sectional survey, completed by 212 physical therapists (PTs) specialized in MS from 26 European countries, was conducted. Differences between European regions and relationships between goals and assessments were analyzed. PTs regularly set goals, but did not always apply the Specific, Measurable, Achievable, Realistic, Timed (SMART) criteria. Regions did not differ in the range of activities assessed, but in goals set (e.g., Western and Northern regions set significantly more goals regarding leisure and work) and outcome measures used (e.g., the Berg Balance Scale was more frequently used in Northern regions). Quality of life was not routinely assessed, despite being viewed as an important therapy goal. Discrepancies existed both in goal setting and assessment across European regions. ICF assists in understanding these discrepancies and in guiding improved health-care for the future.

Staff knowledge, attitudes and behaviours related to mobilisation in a rehabilitation setting: Short report of a multidisciplinary survey

OBJECTIVES

Regular mobilising is important in inpatient rehabilitation, but objective measurements show low patient mobility. We sought to understand multidisciplinary staff perspectives on barriers and enablers to mobility in a rehabilitation setting.

METHODS

A validated barriers survey (standardised score 0-100, higher representing greater barriers) was distributed to 99 clinical staff on two wards at a single rehabilitation facility.

RESULTS

The survey was completed by 83 staff (52 nurses, 25 allied health professionals, 4 therapy assistants and 2 medical officers) and identified barriers in behaviour (mean 39, SD 11), attitudes (mean 34, SD 12) and knowledge (mean 23, SD 18). Prominent perceived barriers were nursing workload, unclear responsibility for mobilising, risk of staff injury, patient motivation and family participation; perceived enablers were good knowledge, positive outcome expectations and team communication.

CONCLUSIONS

These barriers can inform locally tailored strategies to improve rehabilitation patient mobility.

An observational study of physical, cognitive and social activities in rehabilitation inpatients

OBJECTIVES

To describe patient behaviour related to mobility in a rehabilitation inpatient setting and compare intensive and Transition Care Program (TCP, slow-stream rehabilitation) models.

METHODS

Prospective cross-sectional design including weekday and weekend sampling in two rehabilitation wards (one intensive and one TCP) in a publicly funded facility. A single trained observer undertook behavioural mapping, observing patient location, mobility, activity and company on all inpatients 8 am-4 pm using a structured 2-minute observation protocol. Observations were summarised and compared between wards.

RESULTS

We observed 74 inpatients on a Tuesday and 77 on a Sunday. Participants spent 7% (median) of daytime standing or walking. They spent 62%-87% in their room, 22%-40% sleeping or resting and 74%-86% alone. The only significant difference between wards was time spent off ward on Tuesday. Activity was lower on Sunday.

CONCLUSIONS

Time spent in physical, cognitive and social activities is low in inpatient rehabilitation and TCP wards.

How Effective Are Interventions to Increase Physical Activity Levels among Older Inpatients Receiving Rehabilitation, without Increasing the Amount of Therapy? A Systematic Review

Purpose: We systematically reviewed the effectiveness of interventions to increase physical activity in older adults (aged ≥ 60 y), admitted for inpatient rehabilitation, without increasing the amount of therapy. Method: Five electronic databases were systematically searched to identify English-language articles reporting controlled trials of interventions to increase the physical activity (through participation or behavioural change) of older adults receiving inpatient rehabilitation. Trials were excluded if an intervention increased the intensity of usual care, either during the week or on the weekend. Two reviewers independently completed trial selection, quality assessment, and data extraction. Data were synthesized descriptively, and effect sizes with 95% CIs were calculated. Results: Of the 316 articles identified, 3 were included. Two were activity-based, and 1 was a behavioural change intervention. Physical activity was significantly improved in the behavioural change intervention trial that occurred during therapy (d = 0.27; 95% CI: 0.02, 0.52) and non-therapy time (d = 0.43; 95% CI: 0.19, 0.68). Participants in all trials were sedentary for the vast majority of the day. Conclusions: Older adults in inpatient rehabilitation have a high level of inactivity. Evidence is lacking that interventions increase physical activity in older adults admitted to inpatient rehabilitation without increasing the amount of time in therapy. Evidence from one trial indicates that behaviour-based strategies are effective for increasing physical activity levels in the inpatient rehabilitation setting.

'It's . . . forward-focused': Experiences of a mobility clinic for people with limb loss

BACKGROUND

Mobility clinics are designed to extend gait and mobility training beyond rehabilitation programmes. No research has been undertaken into participants' experiences of attending these multidisciplinary, experience-based clinics. Research in this area is needed to ensure clinics meet intended goals, including understanding the motivation and experience of attendees. Insights may improve mobility clinics and inform strategies to encourage greater participation.

OBJECTIVES

To explore the motivation of people with limb loss to attend a mobility clinic, the experience of participation and their perception of the clinic's benefits.

STUDY DESIGN

Qualitative methodology, naturalistic enquiry.

METHODS

Semi-structured interviews were conducted with nine clinic attendees during the clinic. Interviews were transcribed verbatim, data thematically analysed and emergent themes underwent member checking.

RESULTS

Three themes emerged from the data: facing the challenge captured how participants' have adapted to amputation, valuing peers highlights the important role of peers in learning and support and improving mobility described the ongoing quest to improve mobility.

CONCLUSION

The mobility clinic was attractive to those who liked challenges and was an invaluable source of learning for those wishing to improve their mobility. Future clinics should ensure that peer education is supported, and activities cater for a range of skills and fitness levels.

CLINICAL RELEVANCE

Findings of this study indicate that those who attended the mobility clinic liked to challenge themselves. Participation with peers was an important source of learning and support. Those participants who had previously attended a mobility clinic reported improvements in their overall daily function.

Patients With Greater Stroke Severity and Premorbid Disability Are Less Likely to Receive Therapist Consultations and Intervention During Acute Care Hospitalization

BACKGROUND

A substantial number of patients with stroke never receive acute care therapy services, despite the fact that therapy after stroke reduces the odds of death and disability and improves patients' functioning.

OBJECTIVE

The aim of this study was to estimate the proportion of and factors associated with receipt of therapist consultations and interventions during acute care hospitalization following ischemic and hemorrhagic stroke.

DESIGN

This was a single-center longitudinal observational study.

METHODS

Adults with a diagnosis of ischemic or hemorrhagic stroke (N = 1366) were enrolled during their hospitalization in an acute stroke center in a large metropolitan area. The main outcomes were receipt of therapist consultations, interventions, or both.

RESULTS

Participants with acute hemorrhagic stroke (intracerebral: odds ratio [OR] = 0.34 [95% CI = 0.19-0.60]; subarachnoid: OR = 0.52 [95% CI = 0.28-0.99]) and with greater stroke severity by National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score of > 15: OR = 0.34 [95% CI = 0.23-0.51]) were less likely to receive therapist consultations. Participants with moderate stroke severity (NIHSS score of 6-15: OR = 1.43 [95% CI = 1.01-2.33]) were more likely to receive therapy interventions. Those who were able to ambulate before admission were more than 5 times as likely to receive therapy interventions (OR = 5.08 [95% CI = 1.91-13.52]). Also, participants with longer lengths of stay (ie, more intensive care unit and non-intensive care unit days) were more likely to receive therapist consultations and interventions. Tests or procedures were the most common reasons for unsuccessful attempts to complete therapist consultations.

LIMITATIONS

Lack of operational and qualitative data prohibited detailed explorations of barriers to delivery of therapist consultations and interventions.

CONCLUSIONS

Approximately 1 in 4 participants with acute stroke received neither a consultation nor an intervention. Efforts to improve the delivery of acute care therapy services are needed to optimize care for these people.

Increased allied health services to general and acute medical units decreases length of stay: comparison with a historical cohort

Objective The present study evaluated the effect of an initiative to fund increased allied health (AH) services, enabling increased days and both volume and scope of AH services, for general medical in-patients in the Central Adelaide Local Health Network for a 6-month trial period. Methods A quasi-experimental mixed-methods study was undertaken involving general medical in-patients at two acute tertiary-referral public hospitals with a prospective (December 2015-May 2016) and historical comparison (December 2014-May 2015) cohort. Outcome measures compared between the two cohorts included hospital length of stay (LOS), occupied bed-days, adverse events and AH service data. Results After implementation of increased AH services, there were significant decreases in the median (interquartile range) of both hospital LOS (from 7.2 (7.0-8.0) to 6.5 (6.1-6.7) days; P=0.006) and occupied bed-days (from 5295.0 (5200.0-5622.3) to 4662.5 (4335.8-4744.3) bed-days per month; P=0.004). There was no significant change in weekend discharges or adverse events. AH services increased, with the median number of referrals seen by AH professionals per month, occasions of AH service and AH intervention time per month increasing by 17%, 45% and 43% respectively after implementation, along with a faster response time to referrals. Conclusions Increased levels of AH staffing to general medical in-patients were associated with a significant reduction in hospital LOS and occupied bed-days. What is known about the topic? AH services are an important component in the delivery of safe, effective and efficient health care to hospitalised patients. There is little evidence specifically investigating the effect of increased AH services for general medical patients in an acute hospital setting. What does this paper add? This study provides new evidence demonstrating that increasing AH services to general medical in-patients within two acute tertiary-referral public hospitals decreased hospital LOS and occupied bed-days, without an increase in adverse events. What are the implications for practitioners? A funding initiative to enable increased AH services to general medical in-patients significantly reduced hospital LOS and occupied bed-days. These findings will be of considerable interest to other healthcare centres, particularly those where AH levels are below benchmark figures.

Feasibility of increasing the dosage of inpatient occupational therapy and physiotherapy rehabilitation via independent tasks and exercises: 'My Therapy'

INTRODUCTION

The dosage of occupational therapy and physiotherapy positively correlates with rehabilitation patient and health service outcomes. Nevertheless, increasing the dosage during inpatient rehabilitation without additional resources can be challenging. This study aimed to determine feasibility of increasing the dosage of inpatient occupational therapy and physiotherapy rehabilitation with independent tasks and exercises outside of supervised sessions, the 'My Therapy' programme.

METHODS

A two-group, quasi-experimental, pre-post-design examined feasibility of delivering My Therapy in addition to usual care, compared to usual care alone, for hospitalised musculoskeletal and frail older rehabilitation patients. My Therapy was prescribed by the occupational therapist and physiotherapist. A booklet was provided with an individually tailored set of tasks and exercises that were a sub-set of routine therapy, to be practised safely, effectively and independently outside of supervised sessions. The primary outcome was feasibility of My Therapy implementation to achieve at least 70% adherence. Secondary outcomes were self-reported daily My Therapy participation (minutes), total daily rehabilitation participation (minutes), adverse events, length of stay, 10-metre walk speed, FIM scores and discharge destination.

RESULTS

Participation in My Therapy was achieved by 72% (83/116) of the My Therapy group, who averaged 14 min (SD 14) of daily practice outside of supervised sessions. Total daily rehabilitation participation was 177 min (SD 47) for My Therapy participants (n = 116) and 148 min (SD 88) for usual care participants (n = 89); mean difference 30 min (p = .00). A minimal clinically important difference in FIM was achieved for a significantly higher portion of the My Therapy group (22%, n = 26) compared to usual care (10%, n = 9; p = .02). There were no adverse events, safety concerns or group differences for other secondary outcomes.

CONCLUSION

My Therapy was a feasible and safe way to increase the dosage of inpatient occupational therapy and physiotherapy rehabilitation via independent practice. Clinical Trial Registry: ACTRN12616000691448.

An augmented prescribed exercise program (APEP) to improve mobility of older acute medical patients - a randomized, controlled pilot and feasibility trial

BACKGROUND

There is inconclusive evidence for the effectiveness of additional exercise in older hospital patients. The aims of this study were (1) to assess the feasibility of an augmented prescribed exercise program (APEP) in older acute medical patients and (2) to measure the potential effects of APEP on mobility capacity in order to assess the feasibility of a large full-scale study.

METHODS

We conducted a single-center, prospective, parallel-group, single-blinded, randomized (1:1) controlled pilot and feasibility trial. Participants were recruited from acute geriatric wards of a general hospital. Key inclusion criteria were: age ≥ 65 years and walking ability. Key exclusion criteria were severe cognitive impairment and medical restriction for physical exercise interventions. Both groups received usual care, including physiotherapy. Intervention group participants were scheduled for additional exercise sessions (20-30 min, 4-5x/week). Feasibility of the trial design was assessed along pre-defined criteria for process, resources and management. Feasibility of the APEP intervention was analyzed by means of adherence, compliance and safety. Outcomes were measured at baseline and prior to hospital discharge. The primary outcome was mobility capacity (de Morton Mobility Index; DEMMI). Secondary outcomes were walking ability, physical endurance, fear of falling, frailty and length of stay.

RESULTS

Thirty-five participants were recruited (recruitment rate 20.3%). We lost 7 participants to follow-up (retention rate: 80%). Intervention group participants (n = 17) each participated in 5.3 ± 2.2 additional exercise sessions (mean duration: 23.2 ± 4.0 min; mean adherence rate 78% ± 26%). No severe adverse events occurred during study assessments or APEP sessions. There were no statistically significant differences in mean change scores in any outcome measure. A sample of 124 participants would be required to detect a difference of 4 DEMMI points (ES = 0.45) with a power of 80%.

CONCLUSIONS

This small feasibility RCT indicates that an APEP intervention may be safe and feasible in older acute medical patients. APEP may possibly induce small to moderate effects on mobility, but the clinical relevance of these effects may be limited. These results inform the planning of a larger-scale phase III study.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00011262 ). Registered 27 October 2016.

Factors affecting exercise program adherence in patients with acute hip fracture and impact on one-year survival

OBJECTIVE

To study the adherence of an Early Inpatient Exercise Program in patients with acute hip fracture, identify variables associated with its performance, and its association to one-year survival.

METHODS

Observational longitudinal study of a cohort of 509 patients, admitted consecutively with a hip fracture in La Paz University Hospital (Madrid, Spain). Data included sociodemographic variables, pre-fracture physical functioning, cognitive impairment, comorbidities, measure of exercise adherence (pre-surgery exercise, post-surgery exercise, and rehabilitation sessions) and vital status at follow-up. One year after the fracture, either patients or relatives were contacted by telephone to ascertain their vital status. Data were analyzed using logistic regressions and multivariate Cox proportional hazards regression.

RESULTS

Three quarters of patients (76.0%) were able to comply with the Early Inpatient Exercise Program. Factors associated with adherence were: living at home (Odds Ratio (OR)=3.39; 95% Confidence Interval (CI): 2.03, 5.64), absence of pre-fracture disability (OR=3.78; 95% CI: 2.21, 6.47), absence of pre-fracture cognitive impairment (OR=2.36; 95% CI: 1.36, 4.07) and comorbidities (OR=1.66; 95% CI: 1.03, 2.67). Early Inpatient Exercise Program adherence was associated with one-year survival (HR=1.62; 95% CI: 1.06, 2.49).

CONCLUSIONS

The adherence with an Early Inpatient Exercise Program is high and is associated with 1-year survival. It is important to make a stronger effort to encourage participation in Early Inpatient Exercise Program in the 24% currently non-compliant, and in those with cognitive and physical impairments.

How soon do allied health professionals lose confidence to perform EBP activities? A cross-sectional study

OBJECTIVE

To explore if there is a relationship between allied health professionals' confidence to perform a range of evidence-based practice (EBP) activities and the time since they graduated from their entry-level degree and the presence of postgraduate qualifications.

DESIGN

Cross-sectional survey.

SETTING

Allied health professionals from two Australian public metropolitan health services, including acute, subacute, and community settings.

PARTICIPANTS

Sample of 288 (n = 288) allied health professionals from the disciplines of physiotherapy, occupational therapy, speech pathology, social work, dietetics/nutrition, and other.

MAIN OUTCOME MEASURE

Cross-sectional survey including 12 questions measuring respondents' confidence to conduct a range of EBP activities.

RESULTS

Allied health professionals begin to lose confidence related to EBP activities within the first 5 years of clinical practice, particularly for those activities involving critical analysis of published studies. Respondents with postgraduate qualifications were more likely to report greater confidence with EBP activities, suggesting that higher level qualifications protect against the effect of degradation of EBP skills and confidence over time.

CONCLUSIONS

Allied health professionals' confidence to perform EBP activities degrades over time, particularly for those individuals with no postgraduate qualifications. Registration and accreditation bodies along with allied health professional employers should explore potential strategies to preserve and enhance EBP skills, confidence, and behaviours.

The risk of conclusion change in systematic review updates can be estimated by learning from a database of published examples

OBJECTIVES

To determine which systematic review characteristics are needed to estimate the risk of conclusion change in systematic review updates.

STUDY DESIGN AND SETTING

We applied classification trees (a machine learning method) to model the risk of conclusion change in systematic review updates, using pairs of systematic reviews and their updates as samples. The classifiers were constructed using a set of features extracted from systematic reviews and the relevant trials added in published updates. Model performance was measured by recall, precision, and area under the receiver operating characteristic curve (AUC).

RESULTS

We identified 63 pairs of systematic reviews and updates, of which 20 (32%) exhibited a change in conclusion in their updates. A classifier using information about new trials exhibited the highest performance (AUC: 0.71; recall: 0.75; precision: 0.43) compared to a classifier that used fewer features (AUC: 0.65; recall: 0.75; precision: 0.39).

CONCLUSION

When estimating the risk of conclusion change in systematic review updates, information about the sizes of trials that will be added in an update are most useful. Future tools aimed at signaling conclusion change risks would benefit from complementary tools that automate screening of relevant trials.

Can the effects of the mobilization of vulnerable elders in Ontario (MOVE ON) implementation be replicated in new settings: an interrupted time series design

BACKGROUND

Bed rest for older hospitalized patients places them at risk for hospital-acquired morbidity. We previously evaluated an early mobilization intervention and found it to be effective at improving mobilization rates and decreasing length of stay on internal medicine units. The aim of this study was to conduct a replication study evaluating the impact of the evidence-informed mobilization intervention on surgery, psychiatry, medicine, and cardiology inpatient units.

METHODS

A multi-component early mobilization intervention was tailored to the local context at seven hospitals in Ontario, Canada. The primary outcome was patient mobilization measured by conducting visual audits twice a week, three times a day. Secondary outcomes were hospital length of stay and discharge destination, which were obtained from hospital decision support data. The study population was patients aged 65 years and older who were admitted to surgery, psychiatry, medicine, and cardiology inpatient units between March and August 2014. Using an interrupted time series design, the intervention was evaluated over three time periods-pre-intervention, during, and post-intervention.

RESULTS

A total of 3098 patients [mean age 78.46 years (SD 8.38)] were included in the overall analysis. There was a significant increase in mobility immediately after the intervention period compared to pre-intervention with a slope change of 1.91 (95% confidence interval [CI] 0.74-3.08, P-value = 0.0014). A decreasing trend in median length of stay was observed in the majority of the participating sites. Overall, a median length of stay of 26.24 days (95% CI 23.67-28.80) was observed pre-intervention compared to 23.81 days (95% CI 20.13-27.49) during the intervention and 24.69 days (95% CI 22.43-26.95) post-intervention. The overall decrease in median length of stay was associated with the increase in mobility across the sites.

CONCLUSIONS

MOVE increased mobilization and these results were replicated across surgery, psychiatry, medicine, and cardiology inpatient units.

In inpatient rehabilitation, large amounts of practice can occur safely without direct therapist supervision: an observational study

QUESTIONS

When a hospital gymnasium used for inpatient rehabilitation is set up to allow semi-supervised practice: what percentage of practice is performed as semi-supervised practice, what percentage of patients in the gym are actively engaged in practice at one time, and is the semi-supervised practice that occurs safe?

DESIGN

An observational study using periodic behaviour mapping.

PARTICIPANTS

Patients in general and stroke rehabilitation units of a metropolitan hospital.

OUTCOME MEASURES

Observations in the rehabilitation gym quantified the number of patients in the gym and the numbers of patients practising and resting. In observations of patients practising, the condition of practice was recorded as being with a therapist, with a family member, or with no direct supervision. The number of adverse events during the data collection period was collected from the hospital Incident Information Management System.

RESULTS

The rehabilitation gym was observed on 113 occasions, resulting in 1319 individual patient observations. An average of 12 patients were in the gym during the observations. Practice was being performed with family supervision in 15% of observations and with no direct supervision in 26% of observations, resulting in semi-supervised practice accounting for 41% of all observations of practice. The percentage of observations that were of patients taking part in active practice was 78%. There were no adverse events in the gym.

CONCLUSION

In an inpatient setting, a large percentage of practice can be performed as semi-supervised practice. This does not appear to compromise the time spent in active practice or patient safety.

Effect of physical interventions on physical performance and physical activity in older patients during hospitalization: a systematic review

Background

To counteract decline in physical performance and physical activity in older patients during hospitalization, multiple physical interventions were developed. However, it is unknown whether these are effective in this particular population. This systematic review aimed to identify the effect of physical interventions on physical performance and physical activity in older patients during hospitalization.

Methods

The systematic search included PubMed, EMBASE, Cinahl, the Trials database of The Cochrane Library and SPORTdiscus from inception to 22 November 2017. Studies were included if the mean age of the patient cohort was 65 years and older and the effect of physical interventions on physical performance or physical activity was evaluated during hospitalization.

Results

Fifteen randomized controlled trials met the inclusion criteria. Overall, the effect of physical interventions on physical performance was inconsistent. Patient tailored interventions, i.e. continuously adapted to the capabilities of the patient were not found to be superior over interventions that were not. Physical activity as outcome measure was not addressed. Reporting of intensity of the interventions and adherence were frequently lacking.

Conclusions

Evidence for the effect of physical interventions on physical performance in older patients during hospitalization was found uncertain. Further research on the efficacy of the intervention is needed, comparing types of intervention with detailed reporting of frequency, intensity and duration.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0965-2) contains supplementary material, which is available to authorized users.

Academic Geriatric Orthopaedics: A New paradigm for Inpatient Care

Purpose of review

Healthcare systems are embarking on innovative, technologically savvy approaches to caring for our most rapidly growing population worldwide- the elderly. As healthcare systems respond, adapt and strategically plan for this rapidly growing population, it is paramount that we develop new paradigms of care for older patients. This review highlights some of the approaches academic medical centers are taking to improve the musculoskeletal and orthopaedic health of older adults.

Recent Findings

Academic health centers are posed to set and lead the standard of care for the next generation of orthopaedic care for older adults by leveraging innovative informatics platforms, quality improvement methodologies, game-changing research initiatives, education to the next generation of providers and helping change policies to help patients receive the best quality of life possible across the aging spectrum.

Summary

Academic geriatric orthopaedics can help society embrace a new paradigm in care for older adults by leveraging rapidly developing technologically and innovative approaches to care, advanced research, and education.

Additional structured physical activity does not improve walking in older people (>60years) undergoing inpatient rehabilitation: a randomised trial

QUESTIONS

Among older people receiving inpatient rehabilitation, does additional supervised physical activity lead to faster self-selected gait speed at discharge? Does additional supervised physical activity lead to better mobility, function and quality of life at discharge and 6 months following discharge?

DESIGN

Multi-centre, parallel-group, randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Older people (age>60years) from two Australian hospitals undergoing rehabilitation to improve mobility.

INTERVENTION

Participants received multidisciplinary care, including physiotherapy. During hospital rehabilitation, the experimental group (n=99) spent additional time daily performing physical activities that emphasised upright mobility tasks; the control group (n=99) spent equal time participating in social activities.

OUTCOME MEASURES

Self-selected gait speed was the primary outcome at discharge and a secondary outcome at the 6-month follow-up. Timed Up and Go, De Morton Mobility Index, Functional Independence Measure and quality of life were secondary outcomes at discharge and tertiary outcomes at the 6-month follow-up.

RESULTS

The experimental group received a median of 20 additional minutes per day (IQR 15.0 to 22.5) of upright activities for a median of 16.5days (IQR 10.0 to 25.0). Gait speed did not differ between groups at discharge. Mean gait speed was 0.51m/s (SD 0.29) in the experimental group and 0.56m/s (SD 0.28) in the control group (effect size -0.06m/s, 95% CI -0.12 to 0.01, p=0.096). No significant differences were detected in other secondary measures.

CONCLUSION

While substantial gains in mobility were achieved by older people receiving inpatient rehabilitation, additional physical activity sessions did not lead to better walking outcomes at discharge or 6 months.

TRIAL REGISTRATION

ACTRN12613000884707. [Said CM, Morris ME, McGinley JL, Szoeke C, Workman B, Liew D, Hill KD, Woodward M, Wittwer JE, Churilov L, Danoudis M, Bernhardt J (2018) Additional structured physical activity does not improve walking in older people (> 60 years) undergoing inpatient rehabilitation: a randomised trial. Journal of Physiotherapy 64: 237-244].