A postoperative shoulder exercise program improves function and decreases pain following open thoracotomy: a randomised trial

Physiotherapy provided for patients undergoing thoracic surgery in Sweden - a national survey of practice

INTRODUCTION

Patients undergoing thoracic surgery commonly receive perioperative physio-therapy, typically consisting of education, mobilization, breathing exercises, and mobility exercises. To date, no study has described physiotherapy practice for patients undergoing thoracic surgery in Sweden.

PURPOSE

To investigate physiotherapy interventions for patients undergoing thoracic surgery in Sweden.

METHODS

All physiotherapists currently working in thoracic surgery units in Sweden (n = 8) were eligible to participate. A survey was e-mailed to the physiotherapists, to determine physiotherapy interventions offered to patients undergoing thoracoscopy or open thoracic surgery. Of 21 physiotherapists, 13 (62%) responded, representing seven hospitals.

RESULTS

Physiotherapists reported routinely providing preoperative education and postoperative treatment for all patients undergoing thoracic surgery. Breathing exercises and mobilization were usually initiated on the day of surgery or the first postoperative day. Common treatments were deep breathing exercises, with or without positive expiratory pressure, and airway clearance techniques. Upper limb and shoulder exercises were typically initiated on the first or second day after surgery. The most important factor reported to influence treatment choice was personal experience of the attending physiotherapist. No routine post-discharge rehabilitation was provided.

CONCLUSION

Physiotherapists in Sweden reported routinely treating patients scheduled for thoracic surgery, both pre and postoperatively. Prehabilitation or post-discharge rehabilitation was not routinely provided.

The Impact of Post-Thyroidectomy Neck Stretching Exercises on Neck Discomfort, Pressure Symptoms, Voice and Quality of Life: A Randomized Controlled Trial

Background

Methods

Results

Conclusions

Home-based pulmonary rehabilitation in patients undergoing (chemo)radiation therapy for unresectable lung cancer: a prospective explorative study

AIMS

The prevention of pulmonary toxicity is an important goal for patient candidate to radiation therapy for lung cancer. There is a lack of evidence on the role of exercise training for patients with unresectable stage III lung cancer candidated to radical treatment. The aim of this study was to evaluate the feasibility of a home-based pulmonary rehabilitation (PR) program and to identify reliable tools in terms of respiratory function, exercise capacity and quality of life.

METHODS

Patients' recruitment lasted from April 2020 till February 2022. The PR program was proposed concomitantly to radiation therapy to the first 20 patients (interventional group, IG), and the other 20 patients were identified as an observational group (OG). All patients were assessed at baseline (T0) and after 8 weeks (T2) with 6 minute walking test (6MWT), modified Borg Scale (mBORG), SF-36 questionnaire (SF-36) and pulmonary function test (PFT); after 4 weeks (T1), only SF-36 was administered.

RESULTS

A decrease of 13.8 m in the walked-distance was registered in the OG between T0 and T2 (p = 0.083). Instead, an increase of 56.6 m in the distance walked was recorded in the IG between T0 and T2 (p ≤ 0.001). In the OG, the mBORG scores showed a negative trend. On the contrary, in the IG, these scores showed a slight improvement. In the OG, all the items of SF-36 scores decreased between T0 and T1. In the IG, an increased trend from T0 to T2 was observed for all the items of SF-36. No clinically significant variations were detected from baseline to T2 in both groups regarding PFT.

CONCLUSION

The 6MWT, mBORG and SF-36 resulted as useful tools to assess the role of a PR program. A significant gain in functional exercise capacity and a prevention of the physiological impairment of QoL during radio(chemo)therapy was registered.

Standardizing Discharge Opioid Prescriptions in Kidney Transplant Patients Decreases Opioid Usage

BACKGROUND

Kidney transplant recipients are frequently prescribed excess opioids at discharge relative to their inpatient requirements. Recipients who fill prescriptions after transplant have an increased risk of death and graft loss. This study examined the impact of standardized prescriptions on discharge amount and number of outpatient refills.

MATERIALS AND METHODS

A historical cohort (Group 1) was compared to a cohort without patient-controlled analgesia (Group 2) and a cohort in which providers prescribed no opioids to patients who required none on the day prior to discharge, and 10 pills to those who required opioids on the day prior (Group 3). Demographics, oral morphine equivalents (OMEs) prescribed on the day prior to and at discharge, and outpatient refills were collected.

RESULTS

270 recipients were included. There was a nonsignificant trend towards lower OMEs on the day prior to discharge in Groups 2 and 3. Nonopioid adjunct use increased (P < 0.001). Discharge OMEs significantly decreased (mean 87.2 in Group 1, 62.8 in Group 2, 26.6 in Group 3, P< 0.001). The number of patients discharged without opioids increased (23.8% of Group 1, 37.5% of Group 2, 60.6% of Group 3, P < 0.001). Group 3, Asian descent, and lower OMEs on the day prior were factors significantly associated with decreased discharge OMEs on multivariable linear regression. Twelve percent of Group 2 and 2% of Group 3 patients received an outpatient refill (P = 0.02).

CONCLUSIONS

A protocol targeting discharge opioids significantly reduced the amount of opioids prescribed in kidney transplant recipients; most patients subsequently received no opioids at discharge.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Effect of Muscle Energy Techniques V/S Active Range of Motion Exercises on Shoulder Function Post Modified Radical Neck Dissection in patients with Head and Neck Cancer - A Randomized Clinical Trial

Purpose:

Shoulder and cervical pain, reduced mobility and disability are some of the major complications associated with surgeries of head and neck cancers affecting several domains of quality of life. In the present study we aimed to compare the effectiveness of Muscle Ener-gy Techniques (METS) and Active Range of Motion Exercises in reducing pain, improving shoulder mobility and function in patients post Modified Radical Neck Dissection (MRND).

Methods:

Forty eight subjects were randomly assigned to two groups. Group A received active range of motion (AROM) exercises and group B received Muscle energy techniques (METS). Both the groups were treated for a period of 10 consecutive days starting from the 3rd to 5th postoperative day. Data was collected on the 1st and 10th day of intervention.

Results:

Both groups showed highly significant improvements in shoulder range of motion , decrease in pain and better Global Rating Change cores(GRCS) (p=0.005). GRCS and shoul-der abduction showed significant improvement in group B when compared to group A, sug-gesting better clinical outcomes in those treated with Muscle Energy Techniques.

Conclusion:

This study showed that both METs and AROM exercises were effective in im-proving shoulder range of motion, function and reducing pain in patients post MRND but-Muscle Energy Techniques were more effective when compared to AROM exercises.

Exercise training as part of lung cancer therapy

Exercise training is playing an increasing role in lung cancer care. Lung cancer is associated with significant burden to the individual and healthcare system. There is now substantial evidence that exercise training is safe, feasible and effective at improving several outcomes in people with lung cancer, especially in those with NSCLC. Exercise is beneficial across the lung cancer disease and treatment pathway, including in patients with early stage disease before and after surgery, and in patients with advanced disease. This review describes the impact of lung cancer and lung cancer treatment on patient health outcomes and summarizes the aims, safety, feasibility and effects of exercise training in the context of both early stage and advanced stage lung cancer. The paper also includes a discussion of current topical discussion areas including the use of exercise in people with bone metastases and the potential effect of exercise on suppression of tumour growth. Finally, seven clinical questions are included, which are a priority to be addressed by future research over the next decade as we strive to progress the field of lung cancer and improve patient outcomes.

Physiotherapy management of patients with major chest trauma: Results from a global survey

Aim

Major chest trauma is associated with significant morbidity and mortality. Management of patients with major chest trauma includes pain relief, ventilatory management, surgical fixation and early rehabilitation to improve both short- and long-term outcomes. Physiotherapy is widely considered an integral component of the multidisciplinary trauma team and aims to improve respiratory status and reduce the sequelae associated with immobility and reduced physical function. Despite this there is scarce evidence describing or investigating physiotherapy interventions and how these practices vary worldwide. The aim of this study was to ascertain the current physiotherapy management of patients having sustained major chest trauma and to investigate how such practices varied internationally.

Methods

A purpose designed online survey was administered to a group of experienced physiotherapists who work in the field of trauma.

Results

Response rate was 51% ( n = 49) and respondents represented all five continents. Respondents reported focussing on active coughing ( n = 46, 96%, r = 0.5, p = 0.98), body positioning ( n = 43, 94%, r = 0.7, p = 0.41), deep breathing exercises ( n = 44, 94%, r = 0.8, p = 0.66) and early mobilisation ( n = 47, 98%, r = 1, p = 0.64). Ambulation in hospital was reported to be common ( n = 46, 98%, r = 0.2, p = 0.99) but rehabilitation to address longer term sequelae following hospital discharge was reported to be rare ( n = 4, 8%).

Conclusion

This survey has highlighted those practices used by physiotherapists worldwide which aim to address the complications associated with major chest trauma. Having established global practice, the study provides a platform for future research investigating the efficacy of such interventions in improving both short- and long-term outcomes for patients following major chest injury.

In-Hospital Physiotherapy and Physical Recovery 3 Months After Lung Cancer Surgery: A Randomized Controlled Trial

Background. Lung cancer is the most frequently diagnosed cancer and one of the leading causes of cancer deaths. Surgery is the primary approach for curative treatment. Postoperative complications are common, and physiotherapy is often routinely provided for their prevention and treatment, even though the evidence is limited. The aim of this study was to examine the effect of in-hospital physiotherapy on postoperative physical capacity, physical activity, and lung function among patients undergoing lung cancer surgery. Methods. A total of 107 patients undergoing elective thoracic surgery were included in a single-blinded randomized controlled trial, and randomized to a study group, receiving in-hospital physiotherapy treatment, or a control group, not receiving in-hospital physiotherapy treatment. The patients were assessed preoperatively and 3 months after surgery. The in-hospital physiotherapy treatment consisted of early mobilization, ambulation, breathing exercises, and thoracic range of motion exercises. Physical capacity was assessed with the 6-minute walk test. Level of physical activity was objectively assessed with an accelerometer and subjectively assessed with the International Physical Activity Questionnaire Modified for the Elderly. Results. Physical capacity for the whole sample was significantly decreased 3 months postoperatively compared with preoperative values (P = .047). There were no statistically significant differences between the groups regarding physical capacity, physical activity, spirometric values, or dyspnea. However, patients in the study group increased their level of self-reported physical activity from preoperatively to 3 months postoperatively, while the patients in the control group did not. Conclusions. No difference in physical capacity, physical activity, or lung function was found 3 months postoperatively in lung cancer surgery patients receiving in-hospital physiotherapy compared with control patients.

An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy

Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contribute to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8 weeks. This perspective paper proposes that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. A clinical paradigm shift is encouraged, one that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.

A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video-assisted thoracoscopic surgery lobectomy

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy has recently been adopted as the gold standard surgical option for the treatment of early stage non-small cell lung cancer. Enhanced recovery after surgery (ERAS) is being progressively adopted in thoracic surgery to improve the postoperative outcomes. Even if the benefits of ERAS are universally accepted, to date a standardized and uniform approach has not been described in the medical literature. The Italian VATS group has recently proposed to include in the VATS lobectomy database a structured protocol for ERAS.

Methods

The ERAS section of the Italian VATS group is proposing a comprehensive ERAS protocol within the VATS lobectomy database, allowing the prospective collection of a dedicated set of data. Separate sections of the protocol are dedicated to different topics of ERAS. This study is specifically dedicated to the section of physiokinesis therapy. The medical literature will be extensively reviewed and a physiotherapy (PT) protocol of ERAS will be presented and discussed. A seta of structured clinical pathways will also be suggested for adoption in the VATS Group database.

Discussion

Pre- and post-operative adoption of an ERAS protocol in patients undergoing VATS lobectomy may promote an improved post-operative course, a shorter hospital stay and an overall more comfortable patients' experience. The mainstays of a physiokinesis therapy ERAS protocol are patients' education, constant physical and respiratory therapy sessions, and adoption of adequate devices. Although many studies have investigated the usefulness of physical and respiratory physiokinesis therapy, a comprehensive ERAS protocol for VATS lobectomy patients has not yet been described. The proposed ERAS platform, adopted by the VATS Group database, will contribute to a prospective data collection and allow a scientific analysis of the results.

Advances in cardiorespiratory physiotherapy and their clinical impact

INTRODUCTION

Cardiorespiratory physiotherapy is an evidence-based practice that has evolved alongside changes in medical and surgical management, analgesia, the ageing society and increasing comorbidities of our patient populations. Continued research provides the profession with the ability to adapt to meet the changing patient and community needs. Areas covered: This review focuses on surgical, respiratory and critical care settings discussing the most significant changes over the past decade with an increased focus on rehabilitation across the care continuum and a shift away from providing predominately airway clearance in established disease populations but also providing this in emerging groups. Further important changes are identification and emphases on patient self-management including changing their behaviour to more positively embrace wellness, particularly increasing physical activity levels. This paper outlines these changes and offers speculation on factors that may impact the profession in the future. Expert commentary: The increasing focus on new technologies, physical activity levels, changes to the health systems in different countries and an increasingly comorbid and ageing society will shape the next steps in the evolution of cardiorespiratory physiotherapy. Continued research is vital to keep pace with these changes so that physiotherapists can provide the most effective treatments to improve patient outcomes.

Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial

OBJECTIVE

To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx).

DESIGN

Randomized controlled trial.

SETTING

Physiotherapy gym.

PARTICIPANTS

Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx.

INTERVENTIONS

All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment.

MAIN OUTCOME MEASURES

Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors.

RESULTS

After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P<.001) as well as greater UL strength than did participants in the NULP (mean peak force, 8.4±4.0Nm vs 6.7±2.8Nm; P=.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P=.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported.

CONCLUSIONS

UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.

Physiotherapy management of patients undergoing thoracotomy procedure: A survey of current practice in Gauteng

BACKGROUND

Physiotherapy is included in the management of patients undergoing thoracic surgery. The aim of this study was to describe physiotherapy practice in the management of patients who undergo an open thoracotomy.

METHODS

A cross-sectional study using convenience sampling was undertaken. An electronic self-administered questionnaire was distributed via SurveyMonkey to 1389 physiotherapists registered with the South African Society of Physiotherapy in Gauteng. The data collection period was August and September 2014 and data were analysed descriptively.

RESULTS

A total of 323 physiotherapists (23.3%) responded to the survey and 141 (10.2%) indicated that they treated patients with open thoracotomies. Preoperative treatment was done by 65 (41.6%) and consisted of teaching supported coughing (92.3%; n = 60), sustained maximal inspiration (70.8%; n = 46) and the active cycle of breathing technique (69.2%; n = 45). One hundred and sixteen (82.3%) respondents treated patients during their hospital stay. Deep breathing exercises (97.6%; n = 83), coughing (95.3%; n = 81), early mobilisation (95.3%; n = 81), upper limb mobility exercises (91.8%; n = 78), chest wall vibrations (88.2%; n = 75) and trunk mobility exercises (85.9%; n = 73) were done frequently. Pain management modalities were less common, for example transcutaneous electrical nerve stimulation (12.9%; n = 11). Post hospital physiotherapy management was uncommon (32.6%; n = 46).

CONCLUSION

Physiotherapy related to early mobilisation in hospital is in line with evidence-based practice, but further education is needed regarding the need for physiotherapy post hospital discharge and pain management.

The role of physiotherapy in patients undergoing pulmonary surgery for lung cancer. A literature review

This review aims to appraise the role of physiotherapy care in patients submitted to pulmonary surgery, in preoperative, perioperative, and postoperative phases. Pulmonary surgery is the gold standard treatment for patients with lung cancer if it is completely resectable. However, the major impairments and complications induced by surgery are well known. Physiotherapy has been regularly used both in the preparation of the surgical candidates; in their functional recovery in the immediate postoperative period, and in the medium/long term but there is a lack of concise evidence-based recommendations. Therefore, the aim of this review is to appraise the literature about the role of physiotherapy interventions in patients undergoing lung surgery for lung cancer, in preoperative, perioperative, postoperative and maintenance stages, to the recovery and well-being, regardless of the extent of surgical approach. In conclusion, physiotherapy programs should be individually designed, and the goals established according to surgery timings, and according to each subject's needs. It can also be concluded that in the preoperative phase, the main goals are to avoid postoperative pulmonary complications and reduce the length of hospital stay, and the therapeutic targets are respiratory muscle training, bronchial hygiene and exercise training. For the perioperative period, breathing exercises for pulmonary expansion and bronchial hygiene, as well as early mobilization and deambulation, postural correction and shoulder range of motion activities, should be added. Finally, it can be concluded that in the postoperative phase exercise training should be maintained, and adoption of healthy life-style behaviours must be encouraged.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.

Physiotherapy Practice Patterns for Management of Patients Undergoing Thoracic Surgeries in India: A Survey

Aim. The aim of the current study is to determine the practice patterns of physiotherapists for patients undergoing thoracic surgeries in India. Materials and Methodology. A cross-sectional survey was conducted across India in which 600 questionnaires were sent in emails to physiotherapists. The questionnaire addressed assessment and treatment techniques of thoracic surgery. Results. A total of 234 completed questionnaires were returned with a response rate of 39%, with the majority of responses received from Telangana, Karnataka, and Andhra Pradesh. More than 90% of the responders practiced physical examination, chest expansion, chest X-ray, ABG analysis, pulmonary function test, and SpO₂ (oxygen saturation) as the assessment measures in both the pre- and the postoperative phase. Breathing exercises, incentive spirometry, thoracic expansion exercises, coughing and huffing, positioning, and modified postural drainage are found to be commonly used physiotherapy interventions, both pre- and postoperatively, with a response rate of more than 90%. A response rate of more than 84.6% indicated that patients are made to dangle their lower limbs over the edge of the bed on the 1st postoperative day. Mobilization, such as walking up to a chair, sit to stand exercises, and perambulation within the patient's room, was started on the 2nd postoperative day, as stated by more than 65% of the physiotherapists. Staircase climbing was started on the 5th postoperative day. The most commonly used functional evaluation prior to discharge was 6-minute walk test. This was, in fact, practiced by 77.4% of the physiotherapists in their clinical settings. Conclusion. The most predominantly employed assessment measures included were physical examination, chest expansion, ABG analysis, pulmonary function test, chest X-ray, SpO₂ (oxygen saturation), peripheral muscle strength, and cardiopulmonary exercise. The physiotherapy interventions most commonly used were breathing exercises, thoracic expansion exercises, incentive spirometry, and coughing and huffing techniques, in both the pre- and the postoperative phase.

Exercise Training for Patients Pre- and Postsurgically Treated for Non-Small Cell Lung Cancer: A Systematic Review and Meta-analysis

BACKGROUND

This meta-analysis examined the effects of exercise training on length of hospital stay, postoperative complications, exercise capacity, 6-minute walking distance (6MWD), and health-related quality of life (HRQoL) in patients following resection of non-small cell lung cancer (NSCLC).

METHODS

This review searched PubMed, EMBASE, and the Cochrane Collaboration data base up to August 16, 2015. It includes 15 studies comparing exercise endurance and quality of life before versus after exercise training in patients undergoing lung resection for NSCLC.

RESULTS

This review identified 15 studies, 8 of which are randomized controlled trials including 350 patients. Preoperative exercise training shortened length of hospital stay; mean difference (MD): -4.98 days (95% CI = -6.22 to -3.74, P < .00001) and also decreased postoperative complications for which the odds ratio was 0.33 (95% CI = 0.15 to 0.74, P = .007). Four weeks of preoperative exercise training improved exercise capacity; 6MWD was increased to 39.95 m (95% CI = 5.31 to 74.6, P = .02) .While postoperative exercise training can also effectively improve exercise capacity, it required a longer training period; 6MWD was increased to 62.83 m (95% CI = 57.94 to 67.72) after 12 weeks of training ( P < .00001). For HRQoL, on the EORTC-QLQ-30, there were no differences in patients' global health after exercise, but dyspnea score was decreased -14.31 points (95% CI = -20.03 to -8.58, P < .00001). On the SF-36 score, physical health was better after exercise training (MD = 3 points, 95% CI = 0.81 to 5.2, P = .007) while there was no difference with regard to mental health. The I² statistics of all statistically pooled data were lower than 30%. There was a low amount of heterogeneity among these studies.

CONCLUSIONS

Evidence from this review suggests that preoperative exercise training may shorten length of hospital stay, decrease postoperative complications and increase 6MWD. Postoperative exercise training can also effectively improve both the 6MWD and quality of life in surgical patients with NSCLC, but requiring a longer training period.

Bilateral Shoulder Dysfunction Related to the Lung Resection Area After Thoracotomy

This study aimed to investigate the mobility, pain, and disability of the shoulders after different pulmonary surgical procedures.It is a cross-sectional prospective study. A total of 38 patients who underwent lung surgery via thoracotomy (mean age = 57 ± 10 years) were evaluated in the preoperative period, and first and second postoperative days were assessed for range of motion of shoulder; pain intensity; and application of the Shoulder Pain and Disability Index questionnaire. This study compared the 3 days of evaluation, and the subgroups according to the resection area (biopsy/nodulectomy, lung segmentectomy and lobectomy).There was a decrease of flexion (153° ± 16°-98° ± 23°), abduction (151° ± 20°-126° ± 38°), and increased Shoulder Pain and Disability Index (2.4-44.3) in the shoulder ipsilateral to surgery from the preoperative to the first postoperative day (P < 0.05). There was a greater loss of ipsilateral flexion and abduction in the lobectomy subgroup (P < 0.05), and decreased abduction of the contralateral shoulder in the lung segmentectomy and lobectomy subgroups (P < 0.05).After pulmonary surgery, there is bilateral impairment in shoulder range of motion, with greater limitation on ipsilateral shoulder, and larger resections.

Improving the management of post-operative acute pain: priorities for change

Poor management of post-operative acute pain can contribute to medical complications including pneumonia, deep vein thrombosis, infection and delayed healing, as well as the development of chronic pain. It is therefore important that all patients undergoing surgery should receive adequate pain management. However, evidence suggests this is not currently the case; between 10% and 50% of patients develop chronic pain after various common operations, and one recent US study recorded >80% of patients experiencing post-operative pain. At the first meeting of the acute chapter of the Change Pain Advisory Board, key priorities for improving post-operative pain management were identified in four different areas. Firstly, patients should be more involved in decisions regarding their own treatment, particularly when fateful alternatives are being considered. For this to be meaningful, relevant information should be provided so they are well informed about the various options available. Good physician/patient communication is also essential. Secondly, better professional education and training of the various members of the multidisciplinary pain management team would enhance their skills and knowledge, and thereby improve patient care. Thirdly, there is scope for optimizing treatment. Examples include the use of synergistic analgesia to target pain at different points along pain pathways, more widespread adoption of patient-controlled analgesia, and the use of minimally invasive rather than open surgery. Fourthly, organizational change could provide similar benefits; introducing acute pain services and increasing their availability towards the 24 hours/day ideal, greater adherence to protocols, increased use of patient-reported outcomes, and greater receptivity to technological advances would all help to enhance performance and increase patient satisfaction. It must be acknowledged that implementing these recommendations would incur a considerable cost that purchasers of healthcare may be unwilling or unable to finance. Nevertheless, change is under way and the political will exists for it to continue.

Transcutaneous Electrical Nerve Stimulation Reduces Post-Thoractomy Ipsilateral Shoulder Pain. A Prospective Randomized Study

OBJECTIVES

The patient's position during an axillary thoracotomy can cause postoperative pain and decrease mobility of the ipsilateral shoulder. In this study, we assessed whether the implementation of a standardized analgesia program using transcutaneous electrical nerve stimulation (TENS) decreases local pain and improves ipsilateral shoulder mobility.

METHOD

Randomized, single-blind, single-center clinical trial of 50 patients who had undergone anatomical lung resection via axillary muscle-sparing thoracotomy. Patients were treated with TENS devices for 30 minutes every 8 hours, beginning on postoperative day 1. Pain and mobility of the affected limb were recorded at the same time on postoperative days 1 through 3. A visual analogue scale was used for pain assessment and shoulder mobility was assessed with a goniometer. Results were compared using a non-parametric test.

RESULTS

Twenty-five patients were randomized to each group. Mean age of the control group was 62.7±9.3 years and 63.4±10.2 years in the experimental group. Shoulder mobility parameters were similar in both groups on all postoperative days. However, pain during flexion significantly decreased on day 2 (P=.03) and day 3 (P=.04) in the experimental group.

CONCLUSION

The use of TENS decreases pain from shoulder flexion in patients undergoing axillary thoracotomy for pulmonary resection.

The use of a modified, oscillating positive expiratory pressure device reduced fever and length of hospital stay in patients after thoracic and upper abdominal surgery: a randomised trial

QUESTION

Does the use of an oscillating positive expiratory pressure (PEP) device reduce postoperative pulmonary complications in thoracic and upper abdominal surgical patients?

DESIGN

A multi-centre, parallel-group, randomised controlled trial with intention-to-treat analysis, blinding of some outcomes, and concealed allocation.

PARTICIPANTS

A total of 203 adults after thoracic or upper abdominal surgery with general anaesthesia.

INTERVENTION

Participants in the experimental group used an oscillating PEP device, thrice daily for 5 postoperative days. Both the experimental and control groups received standard medical postoperative management and early mobilisation.

OUTCOME MEASURES

Fever, days of antibiotic therapy, length of hospital stay, white blood cell count, and possible adverse events were recorded for 28 days or until hospital discharge.

RESULTS

The 99 participants in the experimental group and 104 in the control group were well matched at baseline and there was no loss to follow-up. Fever affected a significantly lower percentage of the experimental group (22%) than the control group (42%), with a RR of 0.56 (95% CI 0.36 to 0.87, NNT 6). Similarly, length of hospital stay was significantly shorter in the experimental group, at 10.7 days (SD 8.1), than in the control group, at 13.3 days (SD 11.1); the mean difference was 2.6 days (95% CI 0.4 to 4.8). The groups did not differ significantly in the need for antibiotic therapy, white blood cell count or total expense of treatment.

CONCLUSION

In adults undergoing thoracic and upper abdominal surgery, postoperative use of an oscillating PEP device resulted in fewer cases of fever and shorter hospital stay. However, antibiotic therapy and total hospital expenses were not significantly reduced by this intervention.

TRIAL REGISTRATION

NCT00816881.

Forced treadmill running suppresses postincisional pain and inhibits upregulation of substance P and cytokines in rat dorsal root ganglion

Exercise causes a variety of psychophysical effects (eg, alterations in pain sensation). Tissue injury induces mediator releases in the spinal cord resulting in pain hypersensitivity; however, the contribution of the dorsal root ganglion (DRG) is poorly understood. In this study, we tested if forced treadmill running can attenuate postoperative pain and alter substance P (SP) or proinflammatory cytokine level in the DRG by using a rat model of skin/muscle incision and retraction (SMIR). We evaluated mechanical sensitivity to von Frey stimuli (6 and 15 g) and expression of SP, interleukin-1β, and interleukin-6 in the DRG of sham-operated sedentary rats, SMIR sedentary rats, sham-operated rats with forced treadmill running, and SMIR rats with forced treadmill running. At postoperative day 8, trained rats ran for 5 days per week for 4 weeks on a treadmill 70 minutes/d with an intensity of 18 m/min. On postoperative day 6, SMIR sedentary rats displayed a significant mechanical hypersensitivity that persisted until postoperative day 35. By comparison, SMIR-operated rats, which received forced treadmill running, exhibited a quick recovery from mechanical hypersensitivity. SMIR sedentary rats showed an upregulation of SP, interleukin-1β, and interleukin-6 in the DRG at postoperative days 14 and 28, whereas SMIR-operated rats receiving forced treadmill running reversed this upregulation at postoperative day 28. We concluded that forced treadmill running alleviated persistent postincisional pain caused by SMIR surgery. This appears to be protective against postoperative pain, which probably relates to the downturn in excess SP, interleukin-1β, and interleukin-6 in the DRG.

PERSPECTIVE

Controlling the expression of SP, interleukin-6, and interleukin-1β in the DRG can help manage postoperative pain. This finding could potentially help clinicians and physical therapists who seek to examine how exercise may attenuate postsurgical pain and its mechanism.

Physiotherapy practice patterns for patients undergoing surgery for lung cancer: a survey of hospitals in Australia and New Zealand

BACKGROUND

There has been a recent increase in the research available to guide physiotherapy management of patients who require surgical resection for lung cancer. It is unclear whether this evidence has influenced clinical practice.

AIM

To describe physiotherapy practice patterns in the preoperative and postoperative management of patients who undergo surgical resection for lung cancer.

METHODS

Physiotherapists involved in the management of patients who require surgical resection for lung cancer at hospitals across Australia and New Zealand were mailed a purpose-designed questionnaire.

RESULTS

The response rate was 91% (43/47). Prior to surgery, 40% (n = 17) of the respondents indicated that patients were not assessed by a physiotherapist. In most hospitals (n = 39; 91%), patients did not participate in supervised exercise training before surgery. Most commonly, physiotherapy was commenced on the day following surgery (n = 39; 91%), with walking-based exercise being the treatment that was most frequently implemented in all patients (n = 40; 93%). Seventy-two per cent of respondents referred less than 25% of patients to pulmonary rehabilitation on discharge from hospital. Physiotherapy assessment and treatment choices were influenced predominantly by established practice in the hospital and personal experience rather than research findings.

CONCLUSION

In people who undergo surgical resection for lung cancer, physiotherapy services focused on reducing or preventing postoperative pulmonary complications. Despite recent data suggesting that exercise training is beneficial in this population, our data indicate that referral to pulmonary rehabilitation was uncommon.

Safety and Feasibility of an Exercise Intervention for Patients Following Lung Resection

Purpose. Following surgical lung resection, patients frequently suffer functional decline and reduced activity levels. Despite this exercise interventions are not routinely provided. This study aimed to establish the safety and feasibility of exercise administered following lung resection in an Australian setting. Method. Pilot randomized controlled trial. Fifteen individuals (53% male), mean ± standard deviation age 65.5 ± 16.1 years, undergoing surgery for suspected lung cancer. Randomization occurred postoperatively. Control arm received protocolized inpatient respiratory physiotherapy. Intervention arm additionally received twice daily exercise until discharge home and twice weekly as outpatient for 8 weeks. Outcome measures (safety, feasibility, functional capacity, functional mobility, and health-related quality of life [HRQoL]) were assessed preoperatively and 2 and 12 weeks postoperatively. Results. Fifteen participants (lung cancer n = 10) were assigned to control (n = 8) and intervention (n = 7) groups. Inpatient exercise was delivered on 71% of occasions (35 out of 49 planned sessions). Four participants attended outpatient exercise sessions and these participants attended sessions on 81% of occasions (52 out of 64 planned sessions). No adverse events occurred. There was a significant between group difference in 6-Minute Walk Test (6MWT; P = .024). In both groups the 6MWT declined from baseline to 2 weeks postoperative and then improved up to 12 weeks; improvements were greater in the intervention group. Intervention was associated with positive trends of improvement in some HRQoL domains. Conclusions. Exercise intervention performed in the inpatient and outpatient settings for individuals following lung resection was safe and feasible. The uptake rate for outpatient exercise was 57%, similar to previous trials; however, adherence was excellent within the subgroup of participants who attended. Further research is required to investigate the best setting of exercise delivery and explore ways to improve the uptake rate.

Questioning the role of targeted respiratory physiotherapy over and above a standard clinical pathway in the postoperative management of patients following open thoracotomy

Summary of: Reeve JC et al (2010) Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial. Eur J Cardiothorac Surg 37: 1158-1166. [Prepared by Kylie Hill, CAP Editor.]

QUESTION

Does routine prophylactic targeted respiratory physiotherapy after elective pulmonary resection via open thoracotomy decrease the incidence of postoperative pulmonary complications and reduce length of hospital stay?

DESIGN

Randomised, controlled trial with concealed allocation in which those who collected outcome measures were blinded to group allocation.

SETTING

Hospital ward of a tertiary referral centre in Auckland, New Zealand.

PARTICIPANTS

Adults scheduled for pulmonary resection via open thoracotomy.

EXCLUSION CRITERIA

(i) unable to understand written and spoken English, (ii) tumour invasion of the chest wall or brachial plexus, (iii) physiotherapy for a respiratory or shoulder problem within 2 weeks prior to admission, (iv) development of a postoperative pulmonary complication prior to randomisation on Day 1 postoperatively, or (v) intubation and mechanical ventilation ≥ 24 hours following surgery. Randomisation of 76 patients allocated 42 to the intervention group and 34 to the control group.

INTERVENTIONS

Both groups received usual medical and nursing care via a standardised clinical pathway, which included early and frequent position changes, sitting out of bed on the first postoperative day, early ambulation and frequent pain assessment. In addition, the intervention group received daily targeted respiratory physiotherapy, which comprised deep breathing and coughing exercises, assistance with ambulation, and progressive shoulder and thoracic cage exercises.

OUTCOME MEASURES

The primary outcome was incidence of postoperative pulmonary complications, defined using a standardised diagnostic tool. The secondary outcome was the length of hospital stay.

RESULTS

The primary and secondary outcomes were available for all enrolled patients. Neither the incidence of postoperative pulmonary complications [mean difference intervention-control 1.8% (95% CI -10.6 to 13.1%)] nor the hospital length of stay [intervention group median 6.0 days, control group median 6.0 days; p=0.87) differed significantly between groups. The overall incidence of postoperative pulmonary complications (3.9%) was lower than expected.

CONCLUSION

In adults following open thoracotomy, the addition of targeted respiratory physiotherapy to a standardised clinical pathway that included early mobilisation did not reduce the incidence of postoperative pulmonary complications or change length of hospital stay.