The Association Between Preoperative Inspiratory Muscle Training Variables and Postoperative Pulmonary Complications in Subjects With Esophageal Cancer

BACKGROUND

Preoperative inspiratory muscle training (IMT) is frequently used in patients waiting for major surgery to improve respiratory muscle function and to reduce the risk of postoperative pulmonary complications (PPCs). Currently, the mechanism of action of IMT in reducing PPCs is still unclear. Therefore, we investigated the associations between preoperative IMT variables and the occurrence of PPCs in patients with esophageal cancer.

METHODS

A multi-center cohort study was conducted in subjects scheduled for esophagectomy, who followed IMT as part of a prehabilitation program. IMT variables included maximum inspiratory pressure (PImax) before and after IMT and IMT intensity variables including training load, frequency, and duration. Associations between PImax and IMT intensity variables and PPCs were analyzed using independent samples t tests and logistic regression analyses, corrected for age and pulmonary comorbidities and stratified for the occurrence of anastomotic leakages.

RESULTS

Eighty-seven subjects were included (69 males; mean age 66.7 ± 7.3 y). A higher PImax (odds ratio 1.016, P = .07) or increase in PImax during IMT (odds ratio 1.020, P = .066) was not associated with a reduced risk of PPCs after esophagectomy. Intensity variables of IMT were also not associated (P ranging from .16 to .95) with PPCs after esophagectomy. Analyses stratified for the occurrence of anastomotic leakages showed no associations between IMT variables and PPCs.

CONCLUSIONS

This study shows that an improvement in preoperative inspiratory muscle strength during IMT and training intensity of IMT were not associated with a reduced risk on PPCs after esophagectomy. Further research is needed to investigate other possible factors explaining the mechanism of action of preoperative IMT in patients undergoing major surgery, such as the awareness of patients related to respiratory muscle function and a diaphragmatic breathing pattern.

Development of a goal-directed movement intervention (GOAL) using a movement sensor for hospitalized patients: An intervention mapping approach

OBJECTIVE

To describe the development of a goal-directed movement intervention in two medical wards, including recommendations for implementation and evaluation.

DESIGN

Implementation Research.

SETTING

Pulmonology and nephrology/gastroenterology wards of the University Medical Centre Utrecht, The Netherlands.

PARTICIPANTS

Seven focus groups were executed including 28 nurses, 7 physical therapists and 15 medical specialists. Patients' perceptions were repeatedly assessed during the iterative steps of the intervention development.

INTERVENTION

Interventions were targeted to each ward's specific character, following an Intervention Mapping approach using literature and research meetings. Main measures: Intervention components were linked to Behavior Change Techniques and implementation strategies will be selected using the Expert Recommendation Implementing Change tool. Evaluation outcomes like number of patients using the movement intervention will be measured, based on the taxonomy of Proctor.

RESULTS

The developed intervention consists of: insight in patients movement behavior (monitoring & feedback), goal setting (goals & planning) and adjustments to the environment (associations & antecedents). The following implementation strategies are recommended: to conduct educational meetings, prepare & identify champions and audit & provide feedback. To measure service and client outcomes, the mean level of physical activity per ward can be evaluated and the Net Promoter Score can be used.

CONCLUSION(S)

This study shows the development of a goal-directed movement intervention aligned with the needs of healthcare professionals. This resulted in an intervention consisting of feedback & monitoring of movement behavior, goal setting and adjustments in the environment. Using a step-by-step iterative implementation model to guide development and implementation is recommended.

Inpatient physical activity across a large university city hospital: a behavioral mapping study

BACKGROUND

Physical inactivity is common during hospitalization. Physical activity has been described in different inpatient populations but never across a hospital.

PURPOSE

To describe inpatient movement behavior and associated factors throughout a single university hospital.

METHODS

A prospective observational study was performed. Patients admitted to clinical wards were included. Behavioral mapping was undertaken for each participant between 9AM and 4PM. The location, physical activity, daily activity, and company of participants were described. Barriers to physical activity were examined using linear regression analyses.

RESULTS

In total, 345 participants from 19 different wards were included. The mean (SD) age was 61 (16) years and 57% of participants were male. In total, 65% of participants were able to walk independently. On average participants spent 86% of observed time in their room and 10% of their time moving. A physiotherapist or occupational therapist was present during 1% of the time, nursing staff and family were present 11% and 13%, respectively. Multivariate regression analysis showed the presence of an intravenous line (p = .039), urinary catheter (p = .031), being female (p = .034), or being dependent on others for walking (p = .016) to be positively associated with the time spent in bed. Age > 65, undergoing surgery, receiving encouragement by a nurse or physician, reporting a physical complaint or pain were not associated with the time spent in bed (P > .05).

CONCLUSION

As family members and nursing staff spend more time with patients than physiotherapists or occupational therapists, increasing their involvement might be an important next step in the promotion of physical activity.

Improving physical activity in hospitalized patients: The preliminary effectiveness of a goal-directed movement intervention

OBJECTIVE

To evaluate the preliminary effectiveness of a goal-directed movement intervention using a movement sensor on physical activity of hospitalized patients.

DESIGN

Prospective, pre-post study.

SETTING

A university medical center.

PARTICIPANTS

Patients admitted to the pulmonology and nephrology/gastro-enterology wards.

INTERVENTION

The movement intervention consisted of (1) self-monitoring of patients' physical activity, (2) setting daily movement goals and (3) posters with exercises and walking routes. Physical activity was measured with a movement sensor (PAM AM400) which measures active minutes per day.

MAIN MEASURES

Primary outcome was the mean difference in active minutes per day pre- and post-implementation. Secondary outcomes were length of stay, discharge destination, immobility-related complications, physical functioning, perceived difficulty to move, 30-day readmission, 30-day mortality and the adoption of the intervention.

RESULTS

A total of 61 patients was included pre-implementation, and a total of 56 patients was included post-implementation. Pre-implementation, patients were active 38 ± 21 minutes (mean ± SD) per day, and post-implementation 50 ± 31 minutes per day (Δ12, P = 0.031). Perceived difficulty to move decreased from 3.4 to 1.7 (0-10) (Δ1.7, P = 0.008). No significant differences were found in other secondary outcomes.

CONCLUSIONS

The goal-directed movement intervention seems to increase physical activity levels during hospitalization. Therefore, this intervention might be useful for other hospitals to stimulate inpatient physical activity.

Effects of Exercise during Chemo- or Radiotherapy on Immune Markers: A Systematic Review

INTRODUCTION

Patients with cancer receiving radio- or chemotherapy undergo many immunological stressors. Chronic regular exercise has been shown to positively influence the immune system in several populations, while exercise overload may have negative effects. Exercise is currently recommended for all patients with cancer. However, knowledge regarding the effects of exercise on immune markers in patients undergoing chemo- or radiotherapy is limited. The aim of this study is to systematically review the effects of moderate- and high-intensity exercise interventions in patients with cancer during chemotherapy or radiotherapy on immune markers.

METHODS

For this review, a search was performed in PubMed and EMBASE, until March 2023. Methodological quality was assessed with the PEDro tool and best-evidence syntheses were performed both per immune marker and for the inflammatory profile.

RESULTS

Methodological quality of the 15 included articles was rated fair to good. The majority of markers were unaltered, but observed effects included a suppressive effect of exercise during radiotherapy on some pro-inflammatory markers, a preserving effect of exercise during chemotherapy on NK cell degranulation and cytotoxicity, a protective effect on the decrease in thrombocytes during chemotherapy, and a positive effect of exercise during chemotherapy on IgA.

CONCLUSION

Although exercise only influenced a few markers, the results are promising. Exercise did not negatively influence immune markers, and some were positively affected since suppressed inflammation might have positive clinical implications. For future research, consensus is needed regarding a set of markers that are most responsive to exercise. Next, differential effects of training types and intensities on these markers should be further investigated, as well as their clinical implications.

Mental, cognitive and physical outcomes after intensive care unit treatment during the COVID-19 pandemic: a comparison between COVID-19 and non-COVID-19 patients

To compare mental, cognitive and physical outcomes between COVID-19 and non-COVID-19 patients, 3-6 months after Intensive Care Unit (ICU) treatment during the COVID-19 pandemic and to compare mental outcomes between relatives of these patients. This retrospective cohort study included 209 ICU survivors (141 COVID-19 patients and 68 non-COVID-19 patients) and 168 of their relatives (maximum one per patient) during the COVID-19 pandemic. Primary outcomes were self-reported occurrence of mental, cognitive and/or physical symptoms 3-6 months after ICU discharge. The occurrence of mental symptoms did not differ between former COVID-19 patients (34.7% [43/124]) and non-COVID-19 patients (43.5% [27/62]) (p = 0.309), neither between relatives of COVID-19 patients (37.6% [38/101]) and relatives of non-COVID-19 patients (39.6% [21/53]) (p = 0.946). Depression scores on the Hospital Anxiety and Depression Scale were lower in former COVID-19 patients, compared to non-COVID-19 patients (p = 0.025). We found no differences between COVID-19 and non-COVID-19 patients in cognitive and physical outcomes. Mental, cognitive and physical outcomes in COVID-19 ICU survivors were similar to non-COVID-19 ICU survivors. Mental symptoms in relatives of COVID-19 ICU survivors did not differ from relatives of non-COVID-19 ICU survivors, within the same time frame.

Patients With and Without COVID-19 in the Intensive Care Unit: Physical Status Outcome Comparisons 3 Months After Discharge

OBJECTIVE

Many patients with coronavirus disease 2019 (COVID-19) infections were admitted to an intensive care unit (ICU). Physical impairments are common after ICU stays and are associated with clinical and patient characteristics. To date, it is unknown if physical functioning and health status are comparable between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 3 months after ICU discharge. The primary objective of this study was to compare handgrip strength, physical functioning, and health status between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 3 months after ICU discharge. The second objective was to identify factors associated with physical functioning and health status in patients in the ICU with COVID-19.

METHODS

In this observational, retrospective chart review study, handgrip strength (handheld dynamometer), physical functioning (Patient-Reported Outcomes Measurement Information System Physical Function), and health status (EuroQol 5 Dimension 5 Level) were compared between patients in the ICU with COVID-19 and patients in the ICU without COVID-19 using linear regression. Multilinear regression analyses were used to investigate whether age, sex, body mass index, comorbidities in medical history (Charlson Comorbidity Index), and premorbid function illness (Identification of Seniors At Risk-Hospitalized Patients) were associated with these parameters in patients in the ICU with COVID-19.

RESULTS

In total, 183 patients (N = 92 with COVID-19) were included. No significant between-group differences were found in handgrip strength, physical functioning, and health status 3 months after ICU discharge. The multilinear regression analyses showed a significant association between sex and physical functioning in the COVID-19 group, with better physical functioning in men compared with women.

CONCLUSION

Current findings suggest that handgrip strength, physical functioning, and health status are comparable for patients who were in the ICU with COVID-19 and patients who were in the ICU without COVID-19 3 months after ICU discharge.

IMPACT

Aftercare in primary or secondary care in the physical domain of postintensive care syndrome after ICU discharge in patients with COVID-19 and in patients without COVID-19 who had an ICU length of stay >48 hours is recommended.

LAY SUMMARY

Patients who were in the ICU with and without COVID-19 had a lower physical status and health status than healthy people, thus requiring personalized physical rehabilitation. Outpatient aftercare is recommended for patients with an ICU length of stay >48 hours, and functional assessment is recommended 3 months after hospital discharge.

What moves patients to participate in prehabilitation before major surgery? A mixed methods systematic review

BACKGROUND

Prehabilitation offers patients the opportunity to actively participate in their perioperative care by preparing themselves for their upcoming surgery. Experiencing barriers may lead to non-participation, which can result in a reduced functional capacity, delayed post-operative recovery and higher healthcare costs. Insight in the barriers and facilitators to participation in prehabilitation can inform further development and implementation of prehabilitation. The aim of this review was to identify patient-experienced barriers and facilitators for participation in prehabilitation.

METHODS

For this mixed methods systematic review, articles were searched in PubMed, EMBASE and CINAHL. Articles were eligible for inclusion if they contained data on patient-reported barriers and facilitators to participation in prehabilitation in adults undergoing major surgery. Following database search, and title and abstract screening, full text articles were screened for eligibility and quality was assessed using the Mixed Method Appraisal Tool. Relevant data from the included studies were extracted, coded and categorized into themes, using an inductive approach. Based on these themes, the Capability, Opportunity, Motivation, Behaviour (COM-B) model was chosen to classify the identified themes.

RESULTS

Three quantitative, 14 qualitative and 6 mixed methods studies, published between 2007 and 2022, were included in this review. A multitude of factors were identified across the different COM-B components. Barriers included lack of knowledge of the benefits of prehabilitation and not prioritizing prehabilitation over other commitments (psychological capability), physical symptoms and comorbidities (physical capability), lack of time and limited financial capacity (physical opportunity), lack of social support (social opportunity), anxiety and stress (automatic motivation) and previous experiences and feeling too fit for prehabilitation (reflective motivation). Facilitators included knowledge of the benefits of prehabilitation (psychological capability), having access to resources (physical opportunity), social support and encouragement by a health care professional (social support), feeling a sense of control (automatic motivation) and beliefs in own abilities (reflective motivation).

CONCLUSIONS

A large number of barriers and facilitators, influencing participation in prehabilitation, were found across all six COM-B components. To reach all patients and to tailor prehabilitation to the patient's needs and preferences, it is important to take into account patients' capability, opportunity and motivation.

TRIAL REGISTRATION

Registered in PROSPERO (CRD42021250273) on May 18th, 2021.

Physical activity monitoring during hospital stay: a validation study

PURPOSE

The primary aim of this study was to investigate the concurrent validity of the PAM AM400 accelerometer for measuring physical activity in usual care in hospitalized patients by comparing it with the ActiGraph wGT3X-BT accelerometer.

MATERIALS AND METHODS

This was a prospective single centre observational study performed at the University Medical Centre Utrecht in The Netherlands. Patients admitted to different clinical wards were included. Intraclass Correlation Coefficients (ICCs) were computed using a two-way mixed model with random subjects. Additionally, Bland-Altman plots were made to visualize the level of agreement of the PAM with the ActiGraph. To test for proportional bias, a regression analysis was performed.

RESULTS

In total 17 patients from different clinical wards were included in the analyses. The level of agreement between the PAM and ActiGraph was found strong with an ICC of 0.955. The Bland-Altman analyses showed a mean difference of 1.12 min between the two accelerometers and no proportional bias (p = 0.511).

CONCLUSIONS

The PAM is a suitable movement sensor to validly measure the active minutes of hospitalized patients. Implementation of this device in daily care might be helpful to change the immobility culture in hospitals.IMPLICATIONS FOR REHABILITATIONPhysical inactivity is common during hospital admission and the main cause of loss of muscle mass and physical fitness.The PAM AM400 is a suitable movement sensor to validly measure the active minutes of hospitalized patients.Implementation of this device in daily care might be helpful to change the immobility culture in hospitals.

Physical functioning and physical activity after gastrointestinal or bladder oncological surgery: An observational cohort study

OBJECTIVE

The aim of this study was to investigate the recovery of physical functioning and objective physical activity levels up to 3 months after oncological surgery and to determine the association between physical activity levels and the recovery of physical functioning.

METHODS

A longditudinal observational cohort study was conducted in patients who underwent gastrointestinal or bladder oncological surgery. Recovery of physical functioning was measured preoperatively, and 1 and 3 months after discharge. Physical activity was objectively measured with an accelerometer during hospitalisation, and 1 and 3 months after discharge.

RESULTS

Between February and November 2019, 68 patients were included. Half of the patients (49%) were not recovered in physical functioning 3 months after surgery. During hospitalisation, physical activity increased from 13 to 46 median active minutes per day. At 1 and 3 months after discharge, patients were physically active for 138 and 159 median minutes per day, respectively. Patients with higher levels of physical activity 1 month after discharge showed to have higher levels of physical functioning up to 3 months after discharge.

CONCLUSION

At 3 months after surgery, physical functioning is still diminished in half of the patients. It is important to evaluate both physical activity levels and physical functioning levels after surgery to enable tailored postoperative mobility care.

Perceived Factors of Influence on the Implementation of a Multidimensional Project to Improve Patients' Movement Behavior During Hospitalization: A Qualitative Study

OBJECTIVE

The aim of this study was to explore perceived factors of influence on the implementation of Hospital in Motion, a multidimensional and multidisciplinary implementation project to improve inpatients' movement behavior.

METHODS

This qualitative study was conducted on 4 wards. Per ward, a tailored action plan was implemented consisting of multiple tools and interventions to stimulate the integration of inpatient physical activity in usual care processes. After implementation, semi-structured interviews were performed with health care professionals and patients to explore perceived factors of influence on the implementation of the Hospital in Motion project. A content analysis was performed using the framework of the Medical Research Council for complex interventions as guidance for the identification of categories and themes.

RESULTS

In total, 16 interviews were conducted with health care professionals and 12 with patients. The results were categorized into the 3 key components of the Medical Research Council framework: implementation, mechanisms of impact, and context. An important factor of influence within the theme "implementation" was the iterative and multidisciplinary approach. Within the theme "mechanisms of impact," continuous attention and the interaction of multiple interventions, tailored to the target group and targeting multiple dimensions (individual, inter-professional, community and society), were perceived as important. Within the theme "context," the intrinsic motivation and inter-professional, community and societal culture towards physical activity was perceived to be of influence.

CONCLUSION

Impact can be achieved and maintained by creating continuous attention to inpatient physical activity and by the interaction between different interventions and dimensions during implementation. To maintain enough focus, the amount of activities at one time should be limited.

IMPACT

To improve inpatients' movement behavior, implementation project teams should be multidisciplinary and should implement a small set of tailored interventions that target multiple dimensions. Intermediate evaluation of the implementation process, strategies, and interventions is recommended.

Decrease of physical fitness during neoadjuvant chemoradiotherapy predicts the risk of pneumonia after esophagectomy

Although neoadjuvant chemoradiotherapy (nCRT) is frequently used in esophageal cancer patients undergoing treatment with curative intent, it can negatively impact patients' physical fitness. A decline in physical fitness during chemoradiotherapy may be an indication of vulnerability. The aim of this study was to evaluate whether changes in physical fitness, weight, and fat-free mass index (FFMI) during nCRT can predict the risk of postoperative pneumonia. A retrospective longitudinal observational cohort study was performed in patients who received curative treatment for esophageal cancer between September 2016 and September 2018 in a high-volume center for esophageal cancer surgery. Physical fitness (handgrip strength, leg extension strength, and exercise capacity), weight, and FFMI were measured before and after chemoradiotherapy. To be included in the data analyses, pre- and post-nCRT data had to be available of at least one of the outcome measures. Logistic regression analyses were performed to evaluate the predictive value of changes in physical fitness, weight, and FFMI during nCRT on postoperative pneumonia, as defined by the Uniform Pneumonia Scale. In total, 91 patients were included in the data analyses. Significant associations were found between the changes in handgrip strength (odds ratio [OR] 0.880, 95% confidence interval [CI]: 0.813-0.952) and exercise capacity (OR 0.939, 95%CI: 0.887-0.993) and the occurrence of postoperative pneumonia. All pneumonias occurred in patients with declines in handgrip strength and exercise capacity after nCRT. A decrease of handgrip strength and exercise capacity during nCRT predicts the risk of pneumonia after esophagectomy for cancer. Measuring physical fitness before and after chemoradiotherapy seems an adequate method to identify patients at risk of postoperative pneumonia.

Perceptions and ideas of critically ill patients, their family and staff members regarding family participation in the physiotherapy-related care of critically ill patients: a qualitative study

BACKGROUND

Involvement of families in physiotherapy-related tasks of critically ill patients could be beneficial for both patients and their family. Before designing an intervention regarding family participation in the physiotherapy-related care of critically ill patients, there is a need to investigate the opinions of critically ill patients, their family and staff members in detail.

OBJECTIVE

Exploring the perceptions of critically ill patients, their family and staff members regarding family participation in physiotherapy-related tasks of critically ill patients and the future intervention.

METHODS

A multicenter study with a qualitative design is presented. Semistructured interviews were conducted with critically ill patients, family and intensive care staff members, until theoretical saturation was reached. The conventional content method was used for data analyses.

RESULTS

Altogether 18 interviews were conducted between May 2019 and February 2020. In total, 22 participants were interviewed: four patients, five family members, and 13 ICU staff members. Six themes emerged: 1) prerequisites for family participation (e.g., permission and capability); 2) timing and interactive aspects of engaging family (e.g., communication); 3) eligibility of patients and family (e.g., first-degree relatives and spouses, and long stay patients); 4) suitability of physiotherapy-related tasks for family (e.g., passive, active and breathing exercises); 5) expected effects (e.g., physical recovery and psychological wellbeing); and 6) barriers and facilitators, which may affect the feasibility (e.g., safety, privacy, and responsibility).

CONCLUSION

Patients, family members and staff members supported the idea of increased family participation in physiotherapy-related tasks and suggested components of an intervention. These findings are necessary to further design and investigate family participation in physiotherapy-related tasks.

Usability and Preliminary Effectiveness of a Preoperative mHealth App for People Undergoing Major Surgery: Pilot Randomized Controlled Trial

BACKGROUND

Major surgery is associated with negative postoperative outcomes such as complications and delayed or poor recovery. Multimodal prehabilitation can help to reduce the negative effects of major surgery. Offering prehabilitation by means of mobile health (mHealth) could be an effective new approach.

OBJECTIVE

The objectives of this pilot study were to (1) evaluate the usability of the Be Prepared mHealth app prototype for people undergoing major surgery, (2) explore whether the app was capable of bringing about a change in risk behaviors, and (3) estimate a preliminary effect of the app on functional recovery after major surgery.

METHODS

A mixed-methods pilot randomized controlled trial was conducted in two Dutch academic hospitals. In total, 86 people undergoing major surgery participated. Participants in the intervention group received access to the Be Prepared app, a smartphone app using behavior change techniques to address risk behavior prior to surgery. Both groups received care as usual. Usability (System Usability Scale), change in risk behaviors 3 days prior to surgery, and functional recovery 30 days after discharge from hospital (Patient-Reported Outcomes Measurement Information System physical functioning 8-item short form) were assessed using online questionnaires. Quantitative data were analyzed using descriptive statistics, chi-square tests, and multivariable linear regression. Semistructured interviews about the usability of the app were conducted with 12 participants in the intervention group. Thematic analysis was used to analyze qualitative data.

RESULTS

Seventy-nine people-40 in the intervention group and 39 in the control group-were available for further analysis. Participants had a median age of 61 (interquartile range 51.0-68.0) years. The System Usability Scale showed that patients considered the Be Prepared app to have acceptable usability (mean 68.2 [SD 18.4]). Interviews supported the usability of the app. The major point of improvement identified was further personalization of the app. Compared with the control group, the intervention group showed an increase in self-reported physical activity and muscle strengthening activities prior to surgery. Also, 2 of 2 frequent alcohol users in the intervention group versus 1 of 9 in the control group drank less alcohol in the run-up to surgery. No difference was found in change of smoking cessation. Between-group analysis showed no meaningful differences in functional recovery after correction for baseline values (β=-2.4 [95% CI -5.9 to 1.1]).

CONCLUSIONS

The Be Prepared app prototype shows potential in terms of usability and changing risk behavior prior to major surgery. No preliminary effect of the app on functional recovery was found. Points of improvement have been identified with which the app and future research can be optimized.

TRIAL REGISTRATION

Netherlands Trial Registry NL8623; https://www.trialregister.nl/trial/8623.

Family participation in physiotherapy-related tasks of critically ill patients: A mixed methods systematic review

PURPOSE

Providing an overview of studies on family participation in physiotherapy-related tasks of critically ill patients, addressing two research questions (RQ): 1) What are the perceptions of patients, relatives, and staff about family participation in physiotherapy-related tasks? and 2) What are the effects of interventions of family participation in physiotherapy-related tasks?

MATERIAL AND METHODS

Qualitative, quantitative and mixed-methods articles were identified using PubMed, Embase and CINAHL. Studies reporting on family participation in physiotherapy-related tasks of adult critically ill patients were included. A convergent segregated approach for mixed-methods reviews was used.

RESULTS

Eighteen articles were included; 13 for RQ1, and 5 for RQ2. The included studies were quantitative, qualitative and mixed-method, including between 8 and 452 participants. The descriptive studies exhibit a general appreciation for involvement of relatives in physiotherapy-related tasks, although most of the studies reported on family involvement in general care and incorporated diverse physiotherapy-related tasks. One study explored the effectiveness of family participation on a rehabilitation outcome and showed that the percentage of patients mobilizing three times a day increased.

CONCLUSION

Positive attitudes were observed among patients, their relatives and staff towards family participation in physiotherapy-related tasks of critically ill patients. However, limited research has been done into the effect of interventions containing family participation in physiotherapy-related tasks.

The Effectiveness of Hospital in Motion, a Multidimensional Implementation Project to Improve Patients' Movement Behavior During Hospitalization

OBJECTIVE

Hospital in Motion is a multidimensional implementation project aiming to improve movement behavior during hospitalization. The purpose of this study was to investigate the effectiveness of Hospital in Motion on movement behavior.

METHODS

This prospective study used a pre-implementation and post-implementation design. Hospital in Motion was conducted at 4 wards of an academic hospital in the Netherlands. In each ward, multidisciplinary teams followed a 10-month step-by-step approach, including the development and implementation of a ward-specific action plan with multiple interventions to improve movement behavior. Inpatient movement behavior was assessed before the start of the project and 1 year later using a behavioral mapping method in which patients were observed between 9:00 am and 4:00 pm. The primary outcome was the percentage of time spent lying down. In addition, sitting and moving, immobility-related complications, length of stay, discharge destination home, discharge destination rehabilitation setting, mortality, and 30-day readmissions were investigated. Differences between pre-implementation and post-implementation conditions were analyzed using the chi-square test for dichotomized variables, the Mann Whitney test for non-normal distributed data, or independent samples t test for normally distributed data.

RESULTS

Patient observations demonstrated that the primary outcome, the time spent lying down, changed from 60.1% to 52.2%. For secondary outcomes, the time spent sitting increased from 31.6% to 38.3%, and discharges to a rehabilitation setting reduced from 6 (4.4%) to 1 (0.7%). No statistical differences were found in the other secondary outcome measures.

CONCLUSION

The implementation of the multidimensional project Hospital in Motion was associated with patients who were hospitalized spending less time lying in bed and with a reduced number of discharges to a rehabilitation setting.

IMPACT

Inpatient movement behavior can be influenced by multidimensional interventions. Programs implementing interventions that specifically focus on improving time spent moving, in addition to decreasing time spent lying, are recommended.

General lifestyle interventions on their own seem insufficient to improve the level of physical activity after stroke or TIA: a systematic review

Background

Insufficient amounts of physical activity is a risk factor for (recurrent) stroke. People with a stroke or transient ischemic attack (TIA) have a high risk of recurrent stroke and have lower levels of physical activity than their healthy peers. Though several reviews have looked at the effects of lifestyle interventions on a number of risk factors of recurrent stroke, the effectiveness of these interventions to increase the amounts of physical activity performed by people with stroke or TIA are still unclear. Therefore, the research question of this study was: what is the effect of lifestyle interventions on the level of physical activity performed by people with stroke or TIA?

Method

A systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Pubmed, Embase and Cumulative Index for Nursing and Allied Health Literature (CINAHL), were searched up to August 2018. Randomised controlled trials that compared lifestyle interventions, aimed to increase the amount of physical activity completed by participants with a stroke or TIA, with controls were included. The Physiotherapy Evidence Database (PEDro) score was used to assess the quality of the articles, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method for the best evidence synthesis.

Results

Eleven trials (n = 2403) met the inclusion criteria. The quality of the trials was mostly high, with 8 (73%) of trials scoring ≥6 on the PEDro scale. The overall best evidence syntheses showed moderate quality evidence that lifestyle interventions do not lead to significant improvements in the physical activity level of people with stroke or TIA. There is low quality evidence that lifestyle interventions that specifically target physical activity are effective at improving the levels of physical activity of people with stroke or TIA.

Conclusion

Based on the results of this review, general lifestyle interventions on their own seem insufficient in improving physical activity levels after stroke or TIA. Lifestyle interventions that specifically encourage increasing physical activity may be more effective. Further properly powered trials using objective physical activity measures are needed to determine the effectiveness of such interventions.

Trial registration

PROSPERO, CRD42018094437.

Perspectives of patients and health-care professionals on physical activity of hospitalized patients

Background: A lack of physical activity during hospitalization can lead to adverse outcomes like complications and loss of physical function. More insight into factors that influence physical activity during a hospital stay is needed to develop strategies to change the mobility culture in hospitals. Objective: To give an overview of factors that influence physical activity of patients by exploring the perspectives of both patients and health-care professionals regarding physical activity during hospital stay. Method: Semi-structured interviews with patients and health-care professionals were conducted at a university hospital in the Netherlands. Patients were interviewed about their daily activities during their hospital stay and the factors that were of influence. Health-care professionals were asked about their perceptions regarding their responsibilities in promoting physical activity during hospitalization. Results: In total eight patients and nine health-care professionals participated. Patients and health-care professionals stated that low physical activity levels were mostly caused by a poor physical status, patients' expectations to lie in bed during hospitalization, and the lack of knowledge on the importance of physical activity. Lack of time was the main barrier for health-care professionals to promote physical activity. Conclusion: Physical activity is not yet seen as a structural part of hospital care by both patients and health-care professionals, and does not have priority within current daily routines. To increase physical activity levels of hospitalized patients, more knowledge and tools should be available for both patients and health-care professionals.

Validity of three accelerometers to investigate lying, sitting, standing and walking

Background

Hospital stays are associated with high levels of sedentary behavior and physical inactivity. To objectively investigate physical behavior of hospitalized patients, these is a need for valid measurement instruments. The aim of this study was to assess the criterion validity of three accelerometers to measure lying, sitting, standing and walking.

Methods

This cross-sectional study was performed in a university hospital. Participants carried out several mobility tasks according to a structured protocol while wearing three accelerometers (ActiGraph GT9X Link, Activ8 Professional and Dynaport MoveMonitor). The participants were guided through the protocol by a test leader and were recorded on video to serve as reference. Sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) were determined for the categories lying, sitting, standing and walking.

Results

In total 12 subjects were included with a mean age of 49.5 (SD 21.5) years and a mean body mass index of 23.8 kg/m² (SD 2.4). The ActiGraph GT9X Link showed an excellent sensitivity (90%) and PPV (98%) for walking, but a poor sensitivity for sitting and standing (57% and 53%), and a poor PPV (43%) for sitting. The Activ8 Professional showed an excellent sensitivity for sitting and walking (95% and 93%), excellent PPV (98%) for walking, but no sensitivity (0%) and PPV (0%) for lying. The Dynaport MoveMonitor showed an excellent sensitivity for sitting (94%), excellent PPV for lying and walking (100% and 99%), but a poor sensitivity (13%) and PPV (19%) for standing.

Conclusions

The validity outcomes for the categories lying, sitting, standing and walking vary between the investigated accelerometers. All three accelerometers scored good to excellent in identifying walking. None of the accelerometers were able to identify all categories validly.

Hospital in Motion, a Multidimensional Implementation Project to Improve Patients' Physical Behavior During Hospitalization: Protocol for a Mixed-Methods Study

Background

Despite the evidence of the adverse consequences of immobility during hospitalization, patients spend most of the time in bed. Although physical activity is a modifiable factor that can prevent in-hospital functional decline, bed rest is deeply rooted in the hospital culture. To attack this, a multidimensional approach is needed. Therefore, Hospital in Motion, a multidimensional implementation project, was designed to improve physical behavior during hospitalization.

Objective

The primary objective of this study is to investigate the effectiveness of Hospital in Motion on inpatient physical behavior. Secondary objectives are to investigate the effectiveness on length of hospital stay and immobility-related complications of patients during hospitalization and to monitor the implementation process.

Methods

For this study, Hospital in Motion will be implemented within 4 wards (cardiology, cardiothoracic surgery, medical oncology, and hematology) in a Dutch University Medical Center. Per ward, multidisciplinary teams will be composed who follow a step-by-step multidimensional implementation approach including the development and implementation of tailored action plans with multiple interventions to stimulate physical activity in daily care. A prepost observational study design will be used to evaluate the difference in physical behavior before and 1 year after the start of the project, including 40 patients per time point per ward (160 patients in total). The primary outcome measure is the percentage of time spent lying, measured with the behavioral mapping method. In addition, a process evaluation will be performed per ward using caregivers’ and patient surveys and semistructured interviews with patients and caregivers.

Results

This study is ongoing. The first participant was enrolled in October 2017 for the premeasurement. The postmeasurements are planned for the end of 2018. The first results are expected to be submitted for publication in autumn 2019.

Conclusions

This study will provide information about the effectiveness of the Hospital in Motion project on physical behavior and about the procedures of the followed implementation process aimed to incorporate physical activity in usual care. These insights will be useful for others interested in changing physical behavior during hospitalization.

Trial Registration

Netherlands Trial Register NTR7109; https://www.trialregister.nl/trial/6914 (Archived by WebCite at http://www.webcitation.org/76dyhdjdd)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11341

Measuring physical activity levels in hospitalized patients: a comparison between behavioural mapping and data from an accelerometer

Objective:

To investigate the level of agreement of the behavioural mapping method with an accelerometer to measure physical activity of hospitalized patients.

Design:

A prospective single-centre observational study.

Setting:

A university medical centre in the Netherlands.

Subjects:

Patients admitted to the hospital.

Main measures:

Physical activity of participants was measured for one day from 9 AM to 4 PM with the behavioural mapping method and an accelerometer simultaneously. The level of agreement between the percentages spent lying, sitting and moving from both measures was evaluated using the Bland–Altman method and by calculating Intraclass Correlation Coefficients.

Results:

In total, 30 patients were included. Mean (±SD) age was 63.0 (16.8) years and the majority of patients were men (n = 18). The mean percentage of time (SD) spent lying was 47.2 (23.3) and 49.7 (29.8); sitting 42.6 (20.5) and 40.0 (26.2); and active 10.2 (6.1) and 10.3 (8.3) according to the accelerometer and observations, respectively. The Intraclass Correlation Coefficient and mean difference (SD) between the two measures were 0.852 and –2.56 (19.33) for lying; 0.836 and 2.60 (17.72) for sitting; and 0.782 and −0.065 (6.23) for moving. The mean difference between the two measures is small (⩽2.6%) for all three physical activity levels. On patient level, the variation between both measures is large with differences above and below the mean of ⩾20% being common.

Conclusion:

The overall level of agreement between the behavioural mapping method and an accelerometer to identify the physical activity levels ‘lying’, ‘sitting’ and ‘moving’ of hospitalized patients is reasonable.

Effect of preoperative inspiratory muscle training on physical functioning following esophagectomy

This study aims to examine the effect of preoperative inspiratory muscle training (IMT) on pre- and postoperative functional exercise performance in patients undergoing esophagectomy. A subcohort of patients recruited to the PREPARE randomized control trial were studied. Following evaluation of respiratory muscle function (spirometry, maximum inspiratory pressure (MIP), and inspiratory muscle endurance), postoperative mobilization (accelerometry) and postoperative physical functioning (6-minute walk test (6MWT)), participants scheduled for esophagectomy were randomly assigned to either 2 weeks of preoperative IMT or a control group. Measures were repeated on the day before surgery and postoperatively. Sixty participants (mean (standard deviation) age 64.13 (7.8) years; n = 42 male; n = 43 transthoracic esophagectomy; n = 17 transhiatial esophagectomy) were included in the final analysis (n = 28 IMT; n = 32 control). There was a significant improvement in preoperative MIP (P = 0.03) and inspiratory muscle endurance (P = 0.04); however preoperative 6MWT distance did not change. Postoperatively, control participants were more active on postoperative day (POD)1, and from POD1-POD5 (P = 0.04). Predischarge, 6MWT distance was significantly lower in the IMT group (305.61 (116.3) m) compared to controls (380.2 (47.1) m, P = 0.03). Despite an increase in preoperative respiratory muscle function, preoperative IMT does not improve pre- or postoperative physical functioning or postoperative mobilization following esophagectomy.

Construct validity and inter-rater reliability of the Dutch activity measure for post-acute care "6-clicks" basic mobility form to assess the mobility of hospitalized patients

To evaluate the construct validity and the inter-rater reliability of the Dutch Activity Measure for Post-Acute Care "6-clicks" Basic Mobility short form measuring the patient's mobility in Dutch hospital care. First, the "6-clicks" was translated by using a forward-backward translation protocol. Next, 64 patients were assessed by the physiotherapist to determine the validity while being admitted to the Internal Medicine wards of a university medical center. Six hypotheses were tested regarding the construct "mobility" which showed that: Better "6-clicks" scores were related to less restrictive pre-admission living situations (p = 0.011), less restrictive discharge locations (p = 0.001), more independence in activities of daily living (p = 0.001) and less physiotherapy visits (p < 0.001). A correlation was found between the "6-clicks" and length of stay (r= -0.408, p = 0.001), but not between the "6-clicks" and age (r= -0.180, p = 0.528). To determine the inter-rater reliability, an additional 50 patients were assessed by pairs of physiotherapists who independently scored the patients. Intraclass Correlation Coefficients of 0.920 (95%CI: 0.828-0.964) were found. The Kappa Coefficients for the individual items ranged from 0.649 (walking stairs) to 0.841 (sit-to-stand). The Dutch "6-clicks" shows a good construct validity and moderate-to-excellent inter-rater reliability when used to assess the mobility of hospitalized patients. Implications for Rehabilitation Even though various measurement tools have been developed, it appears the majority of physiotherapists working in a hospital currently do not use these tools as a standard part of their care. The Activity Measure for Post-Acute Care "6-clicks" Basic Mobility is the only tool which is designed to be short, easy to use within usual care and has been validated in the entire hospital population. This study shows that the Dutch version of the Activity Measure for Post-Acute Care "6-clicks" Basic Mobility form is a valid, easy to use, quick tool to assess the basic mobility of Dutch hospitalized patients.

Multicentre randomized clinical trial of inspiratory muscle training versus usual care before surgery for oesophageal cancer

Background

Up to 40 per cent of patients undergoing oesophagectomy develop pneumonia. The aim of this study was to assess whether preoperative inspiratory muscle training (IMT) reduces the rate of pneumonia after oesophagectomy.

Methods

Patients with oesophageal cancer were randomized to a home-based IMT programme before surgery or usual care. IMT included the use of a flow-resistive inspiratory loading device, and patients were instructed to train twice a day at high intensity (more than 60 per cent of maximum inspiratory muscle strength) for 2 weeks or longer until surgery. The primary outcome was postoperative pneumonia; secondary outcomes were inspiratory muscle function, lung function, postoperative complications, duration of mechanical ventilation, length of hospital stay and physical functioning.

Results

Postoperative pneumonia was diagnosed in 47 (39·2 per cent) of 120 patients in the IMT group and in 43 (35·5 per cent) of 121 patients in the control group (relative risk 1·10, 95 per cent c.i. 0·79 to 1·53; P = 0·561). There was no statistically significant difference in postoperative outcomes between the groups. Mean(s.d.) maximal inspiratory muscle strength increased from 76·2(26·4) to 89·0(29·4) cmH2O (P &lt; 0·001) in the intervention group and from 74·0(30·2) to 80·0(30·1) cmH2O in the control group (P &lt; 0·001). Preoperative inspiratory muscle endurance increased from 4 min 14 s to 7 min 17 s in the intervention group (P &lt; 0·001) and from 4 min 20 s to 5 min 5 s in the control group (P = 0·007). The increases were highest in the intervention group (P &lt; 0·050).

Conclusion

Despite an increase in preoperative inspiratory muscle function, home-based preoperative IMT did not lead to a decreased rate of pneumonia after oesophagectomy. Registration number: NCT01893008 (https://www.clinicaltrials.gov).

Feasibility of Exercise Training in Cancer Patients Scheduled for Elective Gastrointestinal Surgery

BACKGROUND/AIMS

This study examines the feasibility of a preoperative exercise program to improve the physical fitness of a patient before gastrointestinal surgery.

METHODS

An outpatient exercise program was developed to increase preoperative aerobic capacity, peripheral muscle endurance and respiratory muscle function in patients with pancreatic, liver, intestinal, gastric or esophageal cancer. During a consult at the outpatient clinic, patients were invited to participate in the exercise program when their surgery was not scheduled within 2 weeks.

RESULTS

The 115 participants followed on average 5.7 (3.5) training sessions. Adherence to the exercise program was high: 82% of the planned training sessions were attended, and no adverse events occurred. Mixed model analyses showed a significant increase of maximal inspiratory muscle strength (84.1-104.7 cm H2O; p = 0.00) and inspiratory muscle endurance (35.0-39.5 cm H2O; p = 0.00). No significant changes were found in aerobic capacity and peripheral muscle strength.

CONCLUSION

This exercise program in patients awaiting oncological surgery is feasible in terms of participation and adherence. Inspiratory muscle function improved significantly as a result of inspiratory muscle training. The exercise program however failed to result in improved aerobic capacity and peripheral muscle strength, probably due to the limited number of training sessions as a result of the restricted time interval between screening and surgery.

Preoperative inspiratory muscle training to prevent postoperative pulmonary complications in patients undergoing esophageal resection (PREPARE study): study protocol for a randomized controlled trial

BACKGROUND

Esophageal resection is associated with a high incidence of postoperative pneumonia. Respiratory complications account for almost half of the readmissions to the critical care unit. Postoperative complications can result in prolonged hospital stay and consequently increase healthcare costs. In cardiac surgery a preoperative inspiratory muscle training program has shown to prevent postoperative pneumonia and reduce length of hospital stay. While in some surgical centers inspiratory muscle training is already used in the preoperative phase in patients undergoing esophageal resection, the added value of this intervention on the reduction of pulmonary complications has not yet been investigated in large surgical populations other than cardiac surgery in a randomized and controlled study design.

METHODS/DESIGN

The effect of a preoperative inspiratory muscle training program on the incidence of postoperative pneumonia in patients undergoing esophageal resection will be studied in a single blind multicenter randomized controlled trial (the PREPARE study). In total 248 patients (age >18 years) undergoing esophageal resection for esophageal cancer will be included in this study. They are randomized to either usual care or usual care with an additional inspiratory muscle training intervention according to a high-intensity protocol which is performed with a tapered flow resistive inspiratory loading device. Patients have to complete 30 dynamic inspiratory efforts twice daily for 7 days a week until surgery with a minimum of 2 weeks. The starting training load will be aimed to be 60% of maximal inspiratory pressure and will be increased based on the rate of perceived exertion.The main study endpoint is the incidence of postoperative pneumonia. Secondary objectives are to evaluate the effect of preoperative inspiratory muscle training on length of hospital stay, duration of mechanical ventilation, incidence of other postoperative (pulmonary) complications, quality of life, and on postoperative respiratory muscle function and lung function.

DISCUSSION

The PREPARE study is the first multicenter randomized controlled trial to evaluate the hypothesis that preoperative inspiratory muscle training leads to decreased pulmonary complications in patients undergoing esophageal resection.

TRIAL REGISTRATION

NCT01893008.

How to increase activity level in the acute phase after stroke

AIMS AND OBJECTIVES

To study how patients with acute stroke spend their day and to determine whether activity levels of patients with acute stroke in a Dutch university hospital increase after the implementation of interventions to stimulate activity.

BACKGROUND

Previous studies suggest that patients with acute stroke are prone to inactivity. Early mobilisation and increasing levels of activities are part of several guidelines for patients with stroke. However, implementing interventions to increase activity levels is difficult owing to time and money constrains.

DESIGN

This study used a descriptive pre/postdesign.

METHODS

Outcomes is assessed on three levels: location, other people involved and activity, and it is determined by direct non-participant observation. An intervention was implemented to stimulate activity levels of the patients. This intervention consisted of (1) increasing the group therapy session and (2) providing a therapy guide that includes exercises patients can do by themselves or together with nurses, therapists or their family to stimulate the patients to be more active.

RESULTS

In total, 66 patients have been observed: 35 during the first and 31 during the second observation periods. Compared with the first observation period, patients in the second observation period spent less time in their room and spent less time lying in bed (49 vs. 29%). They did spend more time sitting in bed (13% vs. 20%) and sitting supported (14% vs. 24%).

CONCLUSION

Simple interventions can lead to less inactivity in patients with acute stroke. Nurses should be highly involved in implementing and stimulating these interventions. Also, family can play an important role in reducing inactivity in patients after stroke.

RELEVANCE TO CLINICAL PRACTICE

Nurses can play an important role in increasing activity levels of patients by using simple interventions.

The effects of preoperative exercise therapy on postoperative outcome: a systematic review

OBJECTIVE

To summarize the current evidence on the effects of preoperative exercise therapy in patients awaiting invasive surgery on postoperative complication rate and length of hospital stay.

DATA SOURCES

A primary search of relevant key terms was conducted in the electronic databases of PubMed, EMBASE, PEDro and CINAHL.

REVIEW METHODS

Studies were included if they were controlled trials evaluating the effects of preoperative exercise therapy on postoperative complication rate and length of hospital stay. The methodological quality of included studies was independently assessed by two reviewers using the PEDro scale. Statistical pooling was performed when studies were comparable in terms of patient population and outcome measures. Results were separately described if pooling was not possible.

RESULTS

Twelve studies of patients undergoing joint replacement, cardiac or abdominal surgery were included. The PEDro scores ranged from 4 to 8 points. Preoperative exercise therapy consisting of inspiratory muscle training or exercise training prior to cardiac or abdominal surgery led to a shorter hospital stay and reduced postoperative complication rates. By contrast, length of hospital stay and complication rates of patients after joint replacement surgery were not significantly affected by preoperative exercise therapy consisting of strength and/or mobility training.

CONCLUSION

Preoperative exercise therapy can be effective for reducing postoperative complication rates and length of hospital stay after cardiac or abdominal surgery. More research on the utility of preoperative exercise therapy and its long-term effects is needed as well as insight in the benefits of using risk models.