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Heredia-Ciuró A, Quero-Valenzuela F, Martín-Núñez J, Calvache-Mateo A, Valenza-Peña G, López-López L, Valenza MC. Physical Deconditioning in Lung Cancer Patients Who Underwent Lung Resection Surgery in Spain: A Prospective Observational Study. Cancers (Basel) 2024; 16:2790. [PMID: 39199563 PMCID: PMC11353127 DOI: 10.3390/cancers16162790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 07/24/2024] [Accepted: 08/06/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Lung resection represents the main curative treatment modality for lung cancer. These patients present with physical deterioration that has been studied previously using objective variables; however, no previous studies have evaluated the self-perceived physical fitness of these patients. For these reasons, to increase the current knowledge on lung cancer patients' impairment, the aim of this study was to characterize the self-perceived physical deconditioning of lung cancer patients undergoing lung resection in the short and medium term after surgery. METHODS A longitudinal, observational, prospective cohort study was performed in the Thoracic Surgery Service of the Hospital Virgen de las Nieves (Granada). Symptoms (pain, fatigue, cough and dyspnea) and physical fitness (upper and lower limbs) were assessed before surgery, at discharge and at one month after discharge. RESULTS Among the total of 88 patients that we included in our study, significant differences were found at discharge in symptoms (p < 0.05) and physical fitness (p < 0.05). One month after surgery, higher levels of pain (p = 0,002) and dyspnea (p = 0.007) were observed, as well as poorer results in the upper (p = 0.023) and lower limbs' physical fitness, with regard to the initial values. CONCLUSIONS Patients undergoing lung resection present an increase in symptoms and physical fitness deterioration at discharge, which is maintained one month after surgery.
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Affiliation(s)
- Alejandro Heredia-Ciuró
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (A.H.-C.); (J.M.-N.); (A.C.-M.); (G.V.-P.); (M.C.V.)
| | | | - Javier Martín-Núñez
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (A.H.-C.); (J.M.-N.); (A.C.-M.); (G.V.-P.); (M.C.V.)
| | - Andrés Calvache-Mateo
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (A.H.-C.); (J.M.-N.); (A.C.-M.); (G.V.-P.); (M.C.V.)
| | - Geraldine Valenza-Peña
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (A.H.-C.); (J.M.-N.); (A.C.-M.); (G.V.-P.); (M.C.V.)
| | - Laura López-López
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (A.H.-C.); (J.M.-N.); (A.C.-M.); (G.V.-P.); (M.C.V.)
| | - Marie Carmen Valenza
- Department of Physiotherapy, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (A.H.-C.); (J.M.-N.); (A.C.-M.); (G.V.-P.); (M.C.V.)
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Yanagita Y, Arizono S, Tawara Y, Oomagari M, Machiguchi H, Tanahashi M, Katagiri N, Iida Y, Kozu R. Physical activity in patients with non-small cell lung cancer after lung resection. Clin Biomech (Bristol, Avon) 2024; 115:106249. [PMID: 38615547 DOI: 10.1016/j.clinbiomech.2024.106249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/31/2024] [Accepted: 04/10/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Lung resection is the standard of care for patients with clinical stage I/II non-small cell lung cancer. This surgery reduces both the duration and quality of patients' daily ambulatory activities 1 month after surgery. However, little is known about physical activity after lung resection in patients with lung cancer. To evaluate the recovery process of physical activity with pulmonary rehabilitation in patients after lung resection and examine whether physical activity is affected by age. METHODS In this prospective, observational study, we measured and analysed participants' postoperative physical activity using a uniaxial accelerometer daily from postoperative day 1 to 30. FINDINGS We analysed 99 patients who underwent thoracic surgery. The number of walking steps significantly increased until day 4 and then reached a plateau thereafter. The duration of exercise at <3 metabolic equivalents significantly increased until day 3, and no significant difference was observed thereafter. Exercise at >3 metabolic equivalents significantly increased until day 4 and reached a plateau thereafter. A significant correlation was observed between age and number of steps after day 4. Compared with video-assisted thoracoscopic surgery, thoracotomy significantly decreased the number of steps from day 3 to 4. INTERPRETATION We found that the level of physical activity varied by index in patients with non-small cell lung cancer who underwent lung resection. Age and surgical procedure affect different periods with the increase in post-operative walking steps.
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Affiliation(s)
- Yorihide Yanagita
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki City, Nagasaki Prefecture 852-8520, Japan
| | - Shinichi Arizono
- Department of Physical Therapy, School of Rehabilitation Sciences, Seirei Christopher University, 3453 Mikatahara-cho, Hamamatsu City, Shizuoka Prefecture 433-8558, Japan.
| | - Yuichi Tawara
- Department of Physical Therapy, School of Rehabilitation Sciences, Seirei Christopher University, 3453 Mikatahara-cho, Hamamatsu City, Shizuoka Prefecture 433-8558, Japan
| | - Masaki Oomagari
- Department of Rehabilitation, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Hamamatsu City, Shizuoka Prefecture 433-8558, Japan
| | - Hikaru Machiguchi
- Department of Rehabilitation, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-ku, Yokohama, Kanagawa 236-0051, Japan
| | - Masayuki Tanahashi
- Division of Thoracic Surgery, Respiratory Disease Centre, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Hamamatsu City, Shizuoka Prefecture 433-8558, Japan
| | - Norimasa Katagiri
- Department of Rehabilitation Medicine, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Hamamatsu City, Shizuoka Prefecture 433-8558, Japan
| | - Yuki Iida
- Department of Physical Therapy, School of Health Science, Toyohashi Sozo University, 20-1 Matsushita, Ushikawa-cho, Toyohashi City, Aichi Prefecture 440-8511, Japan
| | - Ryo Kozu
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki City, Nagasaki Prefecture 852-8520, Japan
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Nakanishi K, Goto H. A New Index for the Quantitative Evaluation of Surgical Invasiveness Based on Perioperative Patients' Behavior Patterns: Machine Learning Approach Using Triaxial Acceleration. JMIR Perioper Med 2023; 6:e50188. [PMID: 37962919 PMCID: PMC10685283 DOI: 10.2196/50188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/12/2023] [Accepted: 10/11/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The minimally invasive nature of thoracoscopic surgery is well recognized; however, the absence of a reliable evaluation method remains challenging. We hypothesized that the postoperative recovery speed is closely linked to surgical invasiveness, where recovery signifies the patient's behavior transition back to their preoperative state during the perioperative period. OBJECTIVE This study aims to determine whether machine learning using triaxial acceleration data can effectively capture perioperative behavior changes and establish a quantitative index for quantifying variations in surgical invasiveness. METHODS We trained 7 distinct machine learning models using a publicly available human acceleration data set as supervised data. The 3 top-performing models were selected to predict patient actions, as determined by the Matthews correlation coefficient scores. Two patients who underwent different levels of invasive thoracoscopic surgery were selected as participants. Acceleration data were collected via chest sensors for 8 hours during the preoperative and postoperative hospitalization days. These data were categorized into 4 actions (walking, standing, sitting, and lying down) using the selected models. The actions predicted by the model with intermediate results were adopted as the actions of the participants. The daily appearance probability was calculated for each action. The 2 differences between 2 appearance probabilities (sitting vs standing and lying down vs walking) were calculated using 2 coordinates on the x- and y-axes. A 2D vector composed of coordinate values was defined as the index of behavior pattern (iBP) for the day. All daily iBPs were graphed, and the enclosed area and distance between points were calculated and compared between participants to assess the relationship between changes in the indices and invasiveness. RESULTS Patients 1 and 2 underwent lung lobectomy and incisional tumor biopsy, respectively. The selected predictive model was a light-gradient boosting model (mean Matthews correlation coefficient 0.98, SD 0.0027; accuracy: 0.98). The acceleration data yielded 548,466 points for patient 1 and 466,407 points for patient 2. The iBPs of patient 1 were [(0.32, 0.19), (-0.098, 0.46), (-0.15, 0.13), (-0.049, 0.22)] and those of patient 2 were [(0.55, 0.30), (0.77, 0.21), (0.60, 0.25), (0.61, 0.31)]. The enclosed areas were 0.077 and 0.0036 for patients 1 and 2, respectively. Notably, the distances for patient 1 were greater than those for patient 2 ({0.44, 0.46, 0.37, 0.26} vs {0.23, 0.0065, 0.059}; P=.03 [Mann-Whitney U test]). CONCLUSIONS The selected machine learning model effectively predicted the actions of the surgical patients with high accuracy. The temporal distribution of action times revealed changes in behavior patterns during the perioperative phase. The proposed index may facilitate the recognition and visualization of perioperative changes in patients and differences in surgical invasiveness.
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Affiliation(s)
- Kozo Nakanishi
- Department of General Thoracic Surgery, National Hospital Organization Saitama Hospital, Wako Saitama, Japan
| | - Hidenori Goto
- Department of General Thoracic Surgery, National Hospital Organization Saitama Hospital, Wako Saitama, Japan
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Raz DJ, Kim JY, Erhunwmunesee L, Hite S, Varatkar G, Sun V. The value of perioperative physical activity in older patients undergoing surgery for lung cancer. Expert Rev Respir Med 2023; 17:691-700. [PMID: 37668168 DOI: 10.1080/17476348.2023.2255133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/24/2023] [Accepted: 08/31/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION With a median age at diagnosis of 70, lung cancer represents an enormous public health problem among older Americans. An estimated 19,000 people age 65 and older undergo lung cancer surgery annually in the US. Older adults undergoing lung cancer surgery are often frail with limited physiologic reserves, multi-morbidities, and functional impairments. Physical function, dyspnea, and quality of life return to baseline slower in older adults compared with younger adults after lung surgery. AREAS COVERED In this review, we summarize available data about perioperative physical activity interventions that may improve outcomes for older adults undergoing lung cancer surgery. We also review the limitations of existing studies and discuss emerging data on the roles of telehealth and family caregiver inclusion in peri-operative physical activity interventions. EXPERT OPINION We propose that future perioperative physical activity interventions in older adults undergoing lung cancer surgery should include a comprehensive geriatric assessment to guide personalized interventions. Interventions should be conceptually based, with a focus on enhancing self-efficacy, motivation, and adherence through classic behavior change strategies that are proven to impact outcomes. Finally, interventions should be designed with attention to feasibility and scalability. Exercise programs delivered via telehealth (telephone or tele-video) may improve access and convenience for patients.
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Affiliation(s)
- Dan J Raz
- Department of Surgery, City of Hope, CA, USA
| | - Jae Y Kim
- Department of Surgery, City of Hope, CA, USA
| | - Loretta Erhunwmunesee
- Department of Surgery, City of Hope, CA, USA
- Department of Population Sciences, City of Hope, CA, USA
| | - Sherry Hite
- Department of Rehabilitation, City of Hope, CA, USA
| | | | - Virginia Sun
- Department of Surgery, City of Hope, CA, USA
- Department of Population Sciences, City of Hope, CA, USA
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Comprehensive assessment of postoperative mobility during the first days after mini-invasive lung surgery: A prospective observational study. J Clin Anesth 2023; 86:111048. [PMID: 36716650 DOI: 10.1016/j.jclinane.2022.111048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/29/2022] [Accepted: 12/28/2022] [Indexed: 01/30/2023]
Abstract
STUDY OBJECTIVE Postoperative physical therapy and early mobilization are major elements for enhanced recovery after surgery. In contrast with supervised physical therapy sessions that can be monitored, self-mobilization is not easily quantifiable and has so far been estimated mainly through patient auto-reports. This study aimed to perform a comprehensive and objective evaluation of postoperative mobility. DESIGN Prospective observational study. SETTING Postoperative setting. PATIENTS Patients undergoing mini-invasive lung surgery. INTERVENTIONS Measurement of postoperative mobility during the first five postoperative days using an accelerometer (ActiGraph GT3X). MEASUREMENTS The primary outcome was the number of daily steps. Secondary outcomes included physical activity duration and intensity, sedentary time, number of breaks in sedentary time, sedentary patterns, daily evaluation by physiotherapists, postoperative complications, and acceptability of wearing the accelerometer. MAIN RESULTS Sixty patients were included in the study, of whom 56 provided at least one day of valid accelerometry data. There was no significant change during the first four PODs concerning the number of daily steps nor the mean cadence. One-minute cadence peak, total activity counts, and duration of light-intensity physical activity increased over time (p = 0.032, p = 0.001 and p = 0.001, respectively). Sedentary patterns changed favorably over time, with a decrease in prolonged sedentary bouts (≥ 60 consecutive min) (p < 0.001), and an increase in shorter bouts (< 10 min) (p = 0.001). Similar results were observed when analysis was adjusted for the day of the week when the surgery took place. The median acceptability of wearing the accelerometer was excellent (median 10 [9-10] on a 10-point Likert scale). Three patients had major complications. CONCLUSIONS Our findings suggest that daily steps may not be the only relevant indicator of early mobility following thoracic surgery and that accelerometry is suitable to follow patients' early postoperative activity.
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van den Eijnden MAC, van der Stam JA, Bouwman RA, Mestrom EHJ, Verhaegh WFJ, van Riel NAW, Cox LGE. Machine Learning for Postoperative Continuous Recovery Scores of Oncology Patients in Perioperative Care with Data from Wearables. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23094455. [PMID: 37177659 PMCID: PMC10181524 DOI: 10.3390/s23094455] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
Assessing post-operative recovery is a significant component of perioperative care, since this assessment might facilitate detecting complications and determining an appropriate discharge date. However, recovery is difficult to assess and challenging to predict, as no universally accepted definition exists. Current solutions often contain a high level of subjectivity, measure recovery only at one moment in time, and only investigate recovery until the discharge moment. For these reasons, this research aims to create a model that predicts continuous recovery scores in perioperative care in the hospital and at home for objective decision making. This regression model utilized vital signs and activity metrics measured using wearable sensors and the XGBoost algorithm for training. The proposed model described continuous recovery profiles, obtained a high predictive performance, and provided outcomes that are interpretable due to the low number of features in the final model. Moreover, activity features, the circadian rhythm of the heart, and heart rate recovery showed the highest feature importance in the recovery model. Patients could be identified with fast and slow recovery trajectories by comparing patient-specific predicted profiles to the average fast- and slow-recovering populations. This identification may facilitate determining appropriate discharge dates, detecting complications, preventing readmission, and planning physical therapy. Hence, the model can provide an automatic and objective decision support tool.
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Affiliation(s)
- Meike A C van den Eijnden
- Philips Research, 5656 AE Eindhoven, The Netherlands
- Department Biomedical Engineering, Eindhoven University of Technology, 5612 AE Eindhoven, The Netherlands
| | - Jonna A van der Stam
- Department Biomedical Engineering, Eindhoven University of Technology, 5612 AE Eindhoven, The Netherlands
- Department of Clinical Chemistry, Catharina Hospital, 5602 ZA Eindhoven, The Netherlands
| | - R Arthur Bouwman
- Department of Anaesthesiology, Catharina Hospital, 5602 ZA Eindhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AE Eindhoven, The Netherlands
| | - Eveline H J Mestrom
- Department of Anaesthesiology, Catharina Hospital, 5602 ZA Eindhoven, The Netherlands
| | | | - Natal A W van Riel
- Department Biomedical Engineering, Eindhoven University of Technology, 5612 AE Eindhoven, The Netherlands
| | - Lieke G E Cox
- Philips Research, 5656 AE Eindhoven, The Netherlands
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Chen S, Li X, Wu Y, Li Y, Cao P, Yin Y, Chen Z. Preoperative respiratory muscle training combined with aerobic exercise improves respiratory vital capacity and daily life activity following surgical treatment for myasthenia gravis. J Cardiothorac Surg 2023; 18:160. [PMID: 37095505 PMCID: PMC10127428 DOI: 10.1186/s13019-023-02283-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/08/2023] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE The effects of preoperative respiratory muscle training (RMT) on postoperative complications in patients surgically treated for myasthenia gravis (MG) remain unclear. The present study therefore evaluated the effects of preoperative moderate-to-intense RMT and aerobic exercise, when added to respiratory physiotherapy, on respiratory vital capacity, exercise capacity, and duration of hospital stay in patients with MG. METHODS Eighty patients with MG scheduled for extended thymectomy were randomly divided into two groups. The 40 subjects in the study group (SG) received preoperative moderate-to-intense RMT and aerobic exercise in addition to respiratory physiotherapy, whereas the 40 subjects in the control group (CG) received only chest physiotherapy. Respiratory vital capacity (as determined by VC, FVC, FEV1, FEV1/FVC, and PEF) and exercise capacity (as determined by the 6-min walk test [6 MWT]) were measured pre- and postoperatively and before discharge. The duration of hospital stay and activity of daily living (ADL) were also determined. RESULTS Demographic and surgical characteristics, along with preoperative vital capacity and exercise capacity, were similar in the two groups. In the CG, VC (p = 0.001), FVC (p = 0.001), FEV1 (p = 0.002), PEF (p = 0.004), and 6MWT (p = 0.041) were significantly lower postoperatively than preoperatively, whereas the FEV1/FVC ratio did not differ significantly. Postoperative VC (p = 0.012), FVC (p = 0.030), FEV1 (p = 0.014), and PEF (p = 0.035) were significantly higher in the SG than in the CG, although 6MWT results did not differ. ADL on postoperative day 5 was significantly higher in the SG than in the CG (p = 0.001). CONCLUSION RMT and aerobic exercise can have positive effects on postoperative respiratory vital capacity and daily life activity, and would enhance recovery after surgery in MG patients.
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Affiliation(s)
- Sai Chen
- Center for Private Medical Service and Healthcare, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Xin Li
- Department of Rehabilitation, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yunshan Wu
- Department of Cardiothoracic Surgery of East Division, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510700, Guangdong, People's Republic of China
| | - Yana Li
- Department of Cardiothoracic Surgery of East Division, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510700, Guangdong, People's Republic of China
| | - Peili Cao
- Department of Cardiothoracic Surgery of East Division, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510700, Guangdong, People's Republic of China
| | - Yuchun Yin
- Center for Private Medical Service and Healthcare, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Zhenguang Chen
- Department of Cardiothoracic Surgery of East Division, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510700, Guangdong, People's Republic of China.
- Department of Thoracic Surgery, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan Road II, Guangzhou, 510080, Guangdong, People's Republic of China.
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Halfwerk FR, Wielens N, Hulskotte S, Brusse-Keizer M, Grandjean JG. A mobilization poster stimulates early in-hospital rehabilitation after cardiac surgery: a prospective sequential-group study. J Cardiothorac Surg 2023; 18:83. [PMID: 36895040 PMCID: PMC9999498 DOI: 10.1186/s13019-023-02173-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/28/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Patients infrequently mobilize at the surgical ward after cardiac surgery. Inactivity results in prolonged hospital stay, readmissions and increased cardiovascular mortality. Next, the course of in-hospital mobilization activities for patients is unclear. The aim was to evaluate early mobilization after heart surgery with a mobilization poster on the Activity Classification Guide for Inpatient Activities score from the American College for Sports Medicine (ACSM). Second, to develop a Thorax Centrum Twente (TCT) score to assess distinctive activities performed. METHODS A poster was developed for the Moving is Improving! study to stimulate hospital mobilization after heart surgery. In this sequential-group study at a cardiothoracic surgery ward, 32 patients were included in the usual care group and 209 patients in the poster mobilization group. Change of ACSM and TCT scores over time were both defined as primary endpoints. Secondary endpoints included length of stay and survival. A subgroup analysis for coronary artery bypass grafting (CABG) was performed. RESULTS ACSM score increased during hospital stay (p < 0.001). No significant increase of ACSM score was observed with a mobilization poster (p = 0.27), nor in the CABG subgroup (p = 0.15). The poster increased mobility to chair, toilet, corridor (all p < 0.01) and cycle ergometer (p = 0.02) as measured by the activity-specific TCT scores, without differences in length of stay or survival. CONCLUSIONS ACSM score measured day-to-day functional changes, without significant differences between the poster mobilization and usual care group. Actual activities measured with the TCT score did improve. The mobilization poster is now new standard care, and effects in other centers and other departments should be assessed. TRIAL REGISTRATION This study does not fall under the ICMJE trial definition and was not registered.
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Affiliation(s)
- Frank R Halfwerk
- Department of Cardio-Thoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands. .,Department of Biomechanical Engineering, TechMed Centre, University of Twente, PO Box 217, 7500 AE, Enschede, The Netherlands.
| | - Nicole Wielens
- Department of Cardio-Thoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands
| | - Stephanie Hulskotte
- Department of Cardio-Thoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands
| | | | - Jan G Grandjean
- Department of Cardio-Thoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands.,Department of Biomechanical Engineering, TechMed Centre, University of Twente, PO Box 217, 7500 AE, Enschede, The Netherlands
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Brown CH, Yanek L, Healy R, Tsay T, Di J, Goeddel L, Young D, Zipunnikov V, Schrack J. Comparing three wearable accelerometers to measure early activity after cardiac surgery. JTCVS OPEN 2022; 11:176-191. [PMID: 36172447 PMCID: PMC9510817 DOI: 10.1016/j.xjon.2022.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 03/30/2022] [Accepted: 05/23/2022] [Indexed: 11/24/2022]
Abstract
Objective Wearable activity monitors can provide detailed data on activity after cardiac surgery and discriminate a patient's risk for hospital-based outcomes. However, comparative data for different monitoring approaches, as well as predictive ability over clinical characteristics, are lacking. In addition, data on specific thresholds of activity are needed. The objective of this study was to compare 3 wearable activity monitors and 1 observational mobility scale in discriminating risk for 3 hospital-based outcomes, and to establish clinically relevant step thresholds. Methods Cardiac surgery patients were enrolled between June 2016 and August 2017 in a cohort study. Postoperative activity was measured by 3 accelerometry monitors (StepWatch Ambulation Monitor, Fitbit Charge HR, and ActiGraph GT9X) and 1 nurse-based observation scale. Monitors represent a spectrum of characteristics, including wear location (ankle/wrist), output (activity counts/steps), consumer accessibility, and cost. Primary outcomes were duration of hospitalization >7 days, discharge to a nonhome location, and 30-day readmission. Results Data were available from 193 patients (median age 67 years [interquartile range, 58-72]). All postoperative day 2 activity metrics (ie, from StepWatch, Fitbit, ActiGraph, and the observation scale) were independently associated with prolonged hospitalization and discharge to a nonhome location. Only steps as measured by StepWatch was independently associated with 30-day readmission. Overall, StepWatch provided the greatest discrimination (C-statistics 0.71-0.76 for all outcomes). Step thresholds between 250 and 500 steps/day identified between 74% and 96% of patients with any primary outcome. Conclusions Data from wearable accelerometers provide additive value in early postoperative risk-stratification for hospital-based outcomes. These results both support and provide guidance for activity-monitoring programs after cardiac surgery.
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Affiliation(s)
- Charles H. Brown
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
- Address for reprints: Charles H. Brown, IV, MD, MHS, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21210.
| | - Lisa Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Ryan Healy
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Tiffany Tsay
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Junrui Di
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Lee Goeddel
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Daniel Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, Nev
| | - Vadim Zipunnikov
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Jennifer Schrack
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - the Cardiac Surgery Mobility Working GroupWhitmanGlennMDaMandalKaushikMDaMadeiraTimCRNPaGrantMichael C.MD, MSEbHoyerErik H.MDcDepartment of Surgery, Johns Hopkins University School of Medicine, Baltimore, MdDepartment of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MdDepartment of Physical Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
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Early Postoperative Pain Trajectories after Posterolateral and Axillary Approaches to Thoracic Surgery: A Prospective Monocentric Observational Study. J Clin Med 2022; 11:jcm11175152. [PMID: 36079080 PMCID: PMC9457305 DOI: 10.3390/jcm11175152] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/23/2022] [Accepted: 08/29/2022] [Indexed: 12/25/2022] Open
Abstract
Less-invasive thoracotomies may reduce early postoperative pain. The aims of this study were to identify pain trajectories from postoperative days 0–5 after posterolateral and axillary thoracotomies and to identify potential factors related to the worst trajectory. Patients undergoing a posterolateral (92 patients) or axillary (89 patients) thoracotomy between July 2014 and November 2015 were analyzed in this prospective monocentric cohort study. The best-fitting model resulted in four pain trajectory groups: trajectory 1, the “worst”, with 29.8% of the patients with permanent significant pain; trajectory 2 with patients with low pain (32.6%); trajectory 3 with patients with a steep decrease in pain (22.7%); and trajectory 4 with patients with a steep increase (14.9%). According to a multinomial logistic model multivariable analysis, some predictive factors allow for differentiation between trajectory groups 1 and 2. Risk factors for permanent pain are the existence of preoperative pain (OR = 6.94, CI 95% (1.54–31.27)) and scar length (OR = 1.20 (1.05–1.38)). In contrast, ASA class III is a protective factor in group 1 (OR = 0.02 (0.001–0.52)). In conclusion, early postoperative pain can be characterized by four trajectories and preoperative pain is a major factor for the worst trajectory of early postoperative pain.
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Dijkstra F, van der Sluis G, Jager-Wittenaar H, Hempenius L, Hobbelen JSM, Finnema E. Facilitators and barriers to enhancing physical activity in older patients during acute hospital stay: a systematic review. Int J Behav Nutr Phys Act 2022; 19:99. [PMID: 35908056 PMCID: PMC9338465 DOI: 10.1186/s12966-022-01330-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/06/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To improve older patients' physical activity (PA) behavior, it is important to identify facilitators and barriers to enhancing PA in older patients (≥ 65 years) during hospitalization from the perspectives of patients, caregivers, and healthcare professionals (HCPs). METHODS In this systematic review, a search of PubMed, CINAHL, PsycINFO, EMBASE, and Web of Science (January 2000-May 2021) was performed, and quantitative, qualitative, and mixed-methods studies were included. The methodological quality of included studies was assessed using the Mixed Methods Appraisal Tool. Identified facilitators and barriers were categorized using the social ecological model at the intrapersonal, interpersonal, and institutional levels. RESULTS The 48 included articles identified 230 facilitators and 342 barriers. The main facilitators at the intrapersonal level included: knowledge, awareness, and attitudes; interpersonal level: social support, including encouragement and interdisciplinary collaboration; and institutional level: stimulating physical environment, patient activities and schedules, and PA protocols. The main barriers at the intrapersonal level included: physical health status, having lines or drains, patients' fear, and HCPs' safety concerns; interpersonal level: patient-HCP relation and HCPs' unclear roles; and institutional level: lack of space and resources, including time and equipment. Best evidence synthesis provided moderate level of evidence for three barriers: patients' unwillingness or refusal to move, patients having symptoms, and patients having lines or drains. No moderate level of evidence was found for facilitators. CONCLUSION The PA behavior of older adults during hospitalization is multidimensional. Our overview highlights facilitators and barriers on multilevel scale (intrapersonal, interpersonal, and institutional levels) that guides patients, caregivers, HCPs, and researchers in future clinical practice, and intervention development and implementation.
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Affiliation(s)
- F Dijkstra
- Research Group Living, Wellbeing and Care for Older People, NHL Stenden University of Applied Sciences, Rengerslaan 8-10, P.O. Box 1080, 8900, CB, Leeuwarden, The Netherlands.
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands.
- Department of Health Science, Section of Nursing Research & Education, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
- FAITH research, Groningen/Leeuwarden, The Netherlands.
| | - G van der Sluis
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands
- FAITH research, Groningen/Leeuwarden, The Netherlands
- Department of Health Strategy and Innovation, Nij Smellinghe Hospital Drachten, Drachten, The Netherlands
| | - H Jager-Wittenaar
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands
- FAITH research, Groningen/Leeuwarden, The Netherlands
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - L Hempenius
- Geriatric Center, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - J S M Hobbelen
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands
- FAITH research, Groningen/Leeuwarden, The Netherlands
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - E Finnema
- Research Group Living, Wellbeing and Care for Older People, NHL Stenden University of Applied Sciences, Rengerslaan 8-10, P.O. Box 1080, 8900, CB, Leeuwarden, The Netherlands
- Department of Health Science, Section of Nursing Research & Education, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- FAITH research, Groningen/Leeuwarden, The Netherlands
- Research Group Nursing Diagnostics, Hanze University of Applied Sciences, Groningen, The Netherlands
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Kuroyama Y, Geshi E. Preoperative Physical Inactivity Affects the Postoperative Course of Surgical Patients with Lung Cancer. Phys Ther Res 2022; 24:256-263. [PMID: 35036260 DOI: 10.1298/ptr.e10127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/13/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Preoperative performance status is an important factor in thoracic surgery, but little is known about the effect of preoperative physical activity (PA) on the postoperative course. This study investigated the associations between preoperative PA and postoperative complications and clinical outcomes of lung cancer surgery. METHODS This prospective observational study included patients who underwent surgery for lung cancer at a single institution. PA was measured before hospitalization for 5 consecutive days and then after surgery until hospital discharge. The daily step count and time spent performing moderate intensity activity (> 3 metabolic equivalents) were measured with an accelerometer. We examined the correlations between PA and preoperative pulmonary function and physical fitness, and examined the relationship between postoperative complication and PA. Finally, a multivariate analysis was performed with pre-hospital PA as the dependent variable. RESULTS Forty-two patients were analyzed. Univariate analysis found no correlation between pre-hospital PA and preoperative pulmonary function, but found significant positive correlations between pre-hospital PA and time spent performing moderate intensity activity, in-hospital PA, preoperative 6-minute walk distance, and maximum gait speed (r > 0.5, p < 0.01). The nine patients who developed postoperative complications had significantly lower pre-hospital and postoperative step count than the patients with no complication (p = 0.04). Multiple regression analysis showed that pre-hospital PA was significantly associated with time spent performing moderate intensity activity, maximum gait speed, and postoperative complication. CONCLUSIONS Evaluation of pre-hospital PA is useful in predicting the postoperative course after lung cancer surgery.
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Affiliation(s)
- Yuki Kuroyama
- School of Nursing and Rehabilitation Sciences, Showa University, Japan.,Department of Rehabilitation, Showa General Hospital, Japan
| | - Eiichi Geshi
- School of Nursing and Rehabilitation Sciences, Showa University, Japan
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Strother M, Koepsell K, Song L, Faerber J, Bernard J, Malkowicz SB, Guzzo T, Tasian G. Financial incentives and wearable activity monitors to increase ambulation after cystectomy: A randomized controlled trial. Urol Oncol 2021; 39:434.e31-434.e38. [PMID: 33308975 PMCID: PMC8184881 DOI: 10.1016/j.urolonc.2020.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/05/2020] [Accepted: 11/22/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Financial incentive programs are effective in increasing physical activity for overweight, ambulatory adults. We sought to determine the potential effect size and direction of financial incentives on ambulation after radical cystectomy. MATERIALS AND METHODS We performed a pilot randomized controlled trial of daily financial incentives to meet postoperative step goals among adults with Eastern Cooperative Oncology Group performance status ≤2 who underwent radical cystectomy for bladder cancer at a single center. Step counts were measured over a 3- to 14-day preoperative period and 30-day postoperative period using a wearable activity monitor. Postoperative daily step goals of 10%, 25%, 40%, and 55% of mean preoperative daily step counts were set for postoperative weeks 1 through 4, respectively. The primary outcome was the number of postoperative days on which the step goals were met. Secondary outcomes included the number of daily postoperative steps taken and the length of stay. Participants randomized to the intervention arm received $1.50 for every day the goal was met with a 20% chance of a $100 reward if the step goal was met on >75% of the first 30 postoperative days. Questionnaires assessing self-reported physical activity, disability, and social support were administered preoperatively at 30 days postoperatively. RESULTS Thirty-three patients were analyzed, 11 in the control and 22 in the intervention arms. There were no statistically significant differences between incentive and control arms for the primary outcome (4.5/30 days vs. 9/30 days, P = 0.53). Results after adjusting for differences in baseline characteristics were similar (RR 1.00, 95% CI 0.24-4.19, P = 1.00). There were also no differences in average daily postoperative steps (median 979 vs. 1191, 95% CI -810 to 1,400, P = 0.59), length of stay (7.5 vs. 7, 95% CI -2.7 to 5.1, P = 0.56), or self-reported measures of disability, activity, and social support. CONCLUSIONS While this trial was a pilot study and not powered to detect a difference between groups, there was no suggestion of any clinically important impact of this financial incentive on postoperative ambulation. While a fully-powered trial is feasible, given the small range of plausible benefit, such a trial would be unlikely to influence clinical practice.
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Affiliation(s)
- Marshall Strother
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA.
| | - Kristen Koepsell
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lihai Song
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer Faerber
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joshua Bernard
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - S Bruce Malkowicz
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Thomas Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Gregory Tasian
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
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Bellas-Cot.ín S, Casans-Franc..s R, Ib.í..ez C, Muguruza I, Mu..oz-Alameda LE. Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital: an ambispective cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021; 73:16-24. [PMID: 33930342 PMCID: PMC9801216 DOI: 10.1016/j.bjane.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 03/16/2021] [Accepted: 04/14/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To analyze the effects of an ERAS program on complication rates, readmission, and length of stay in patients undergoing pulmonary resection in a tertiary university hospital. METHODS Ambispective cohort study with a prospective arm of 50 patients undergoing thoracic surgery within an ERAS program (ERAS group) versus a retrospective arm of 50 patients undergoing surgery before the protocol was implemented (Standard group). The primary outcome was the number of patients with 30-day surgical complications. Secondary outcomes included ERAS adherence, non-surgical complications, mortality, readmission, reintervention rate, pain, and hospital length of stay. We performed a multivariate logistic analysis to study the correlation between outcomes and ERAS adherence. RESULTS In the univariate analysis, we found no difference between the two groups in terms of surgical complications (Standard 18 [36%] vs. ERAS 12 [24%], p=0.19). In the ERAS group, only the readmission rate was significantly lower (Standard 15 [30%] vs. ERAS 6 [12%], p=0.03). In the multivariate analysis, ERAS adherence was the only factor associated with a reduction in surgical complications (OR [95% CI]=0.02 [0.00, 0.59], p=0.03) and length of stay (HR [95% CI]=18.5 [4.39, 78.4], p<0.001). CONCLUSIONS The ERAS program significantly reduced the readmission rate at our hospital. Adherence to the ERAS protocol reduced surgical complications and length of stay.
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Affiliation(s)
- Soledad Bellas-Cot.ín
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain,Corresponding author.
| | - Rub..n Casans-Franc..s
- Hospital Universitario Infanta Elena, Department of Anaesthesiology, Valdemoro, Madrid, Spain
| | - Cristina Ib.í..ez
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain
| | - Ignacio Muguruza
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Thoracic Surgery, Madrid, Spain
| | - Luis E. Mu..oz-Alameda
- Hospital Universitario Fundaci..n Jim..nez D.¡az, Department of Anaesthesiology, Madrid, Spain
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Memon A, Lec P, Lenis A, Sharma V, Wood E, Schade G, Brisbane W. Relationship Between Mobile Digital Sensor Monitoring and Perioperative Outcomes: Systematic Review. JMIR Perioper Med 2021; 4:e21571. [PMID: 33629966 PMCID: PMC7952235 DOI: 10.2196/21571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 01/07/2021] [Accepted: 01/29/2021] [Indexed: 12/26/2022] Open
Abstract
Background Monitoring surgical recovery has traditionally been confined to metrics measurable within the hospital and clinic setting. However, commercially available mobile sensors are now capable of extending measurements into a patient’s home. As these sensors were developed for nonmedical applications, their clinical role has yet to be established. The aim of this systematic review is to evaluate the relationship between data generated by mobile sensors and postoperative outcomes. Objective The objective of this study is to describe the current use of mobile sensors in the perioperative setting and the correlation between their data and clinical outcomes. Methods A systematic search of EMBASE, MEDLINE, and Cochrane Library from inception until April 2019 was performed to identify studies of surgical patients monitored with mobile sensors. Sensors were considered if they collected patient metrics such as step count, temperature, or heart rate. Studies were included if patients underwent major surgery (≥1 inpatient postoperative day), patients were monitored using mobile sensors in the perioperative period, and the study reported postoperative outcomes (ie, complications and hospital readmission). For studies including step count, a pooled analysis of the step count per postoperative day was calculated for the complication and noncomplication cohorts using mean and a random-effects linear model. The Grading of Recommendations, Assessment, Development, and Evaluation tool was used to assess study quality. Results From 2209 abstracts, we identified 11 studies for review. Reviewed studies consisted of either prospective observational cohorts (n=10) or randomized controlled trials (n=1). Activity monitors were the most widely used sensors (n=10), with an additional study measuring temperature, respiratory rate, and heart rate (n=1). Low step count was associated with worse postoperative outcomes. A median step count of around 1000 steps per postoperative day was associated with adverse surgical outcomes. Within the studies, there was heterogeneity between the type of surgery and type of reported postoperative outcome. Conclusions Despite significant heterogeneity in the type of surgery and sensors, low step count was associated with worse postoperative outcomes across surgical specialties. Further studies and standardization are needed to assess the role of mobile sensors in postoperative care, but a threshold of approximately 1000 steps per postoperative day warrants further investigation.
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Affiliation(s)
- Ali Memon
- Department of Urology, University of Washington, Seattle, WA, United States
| | - Patrick Lec
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Andrew Lenis
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Vidit Sharma
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Erika Wood
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
| | - George Schade
- Department of Urology, University of Washington, Seattle, WA, United States
| | - Wayne Brisbane
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, United States
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Pulle MV, Tiwari N, Asaf BB, Puri HV, Bishnoi S, Gopinath SK, Kumar A. Does an enhanced recovery after surgery protocol affect perioperative surgical outcomes in stage III tubercular empyema? A comparative analysis of 243 patients. Asian Cardiovasc Thorac Ann 2020; 29:218492320966435. [PMID: 33131291 DOI: 10.1177/0218492320966435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Enhanced recovery after surgery protocols in tuberculous empyema surgery have the potential for improved outcomes, but have not been studied widely. This study aimed to analyze the outcomes after implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tubercular empyema. METHODS A retrospective analysis of patients who underwent surgery for tuberculous empyema in a dedicated thoracic surgery center from March 2012 to March 2019 was performed. The control group included patients operated on between March 2012 and March 2016. The enhanced recovery after surgery protocol was strictly introduced into our practice from April 2016. The study group included patients operated on between April 2016 and March 2019. All perioperative outcomes were measured, documented, analyzed, and compared between the two groups. There were 166 patients in the control group and 77 in the study group. RESULTS Intraoperative blood loss (p = 0.0001), prolonged air leak (p = 0.04), chest tube duration (p = 0.005), and length of stay (p = 0.003) were significantly reduced in the study group. Overall rates of postoperative complications (p = 0.04) including wound infection (p = 0.01) were also significantly lower in the study group. CONCLUSIONS Implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tuberculous empyema is feasible and effective. Application of such a protocol leads to less intraoperative blood loss, shorter hospital stay and duration of chest drainage, and fewer complications. Application of enhanced recovery after surgery protocols are strongly recommended in tubercular empyema surgery.
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Affiliation(s)
| | - Neha Tiwari
- Centre for Chest Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Belal Bin Asaf
- Centre for Chest Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Sukhram Bishnoi
- Centre for Chest Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Arvind Kumar
- Centre for Chest Surgery, Sir Ganga Ram Hospital, New Delhi, India
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17
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Wu S, Liu J, Liang H, Ma Y, Zhang Y, Liu H, Yang H, Xin T, Liang W, He J. Factors influencing the length of stay after mediastinal tumor resection in the setting of an enhanced recovery after surgery (ERAS)-TUBELESS protocol. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:740. [PMID: 32647665 PMCID: PMC7333128 DOI: 10.21037/atm-20-287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Prolonged length of stay after surgery is considered to increase cost and hospital-acquired complications. Therefore, we aimed to identify the risk factors that were associated with an increased length of stay after mediastinal tumor resection in the setting of an enhanced recovery after surgery (ERAS)-TUBELESS protocol. Methods This prospective cohort study collected data on consecutive patients undergoing video-assisted thoracoscopic surgery (VATS) resection for mediastinal tumor between December 2015 and November 2018 at a single center in China. All patients followed the ERAS-TUBELESS protocol. A length of stay after VATS tumor resection (LOS) greater than 3 days was considered an increased LOS. Univariable and multivariable logistic regression models were used to identify potential factors associated with increased LOS. Factors were divided into patient-related risk factors and procedure-related risk factors. Results A total of 204 patients were included, of which 85 (41.67%) patients had a LOS of more than 3 days. The median LOS for the entire cohort was 3 days. All the patient-related risk factors had no significantly associated with a prolonged LOS. Procedure-related risk factors that were significantly associated with a prolonged LOS were surgeon, operation time, intraoperative blood loss, drainage tube, analgesic drugs, and complications. Anesthesia with spontaneous ventilation was correlated with early discharge (LOS ≤1 day). Conclusions In the setting of an ERAS-TUBELESS protocol, the main drivers of LOS were procedure-related factors. Anesthesia with spontaneous ventilation was associated with early discharge (LOS ≤1 day) and thus promoted thoracic day surgery.
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Affiliation(s)
- Shilong Wu
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Jun Liu
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Hengrui Liang
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Yanzhi Ma
- Department of Anesthesia, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | | | - Hui Liu
- Guangzhou Medical University, Guangzhou, China
| | - Hanyu Yang
- Guangzhou Medical University, Guangzhou, China
| | - Tuo Xin
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Wenhua Liang
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery and Oncology, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China
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18
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Jonsson M, Ahlsson A, Hurtig-Wennlöf A, Vidlund M, Cao Y, Westerdahl E. In-Hospital Physiotherapy and Physical Recovery 3 Months After Lung Cancer Surgery: A Randomized Controlled Trial. Integr Cancer Ther 2020; 18:1534735419876346. [PMID: 31530046 PMCID: PMC6751530 DOI: 10.1177/1534735419876346] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Yang Cao
- Örebro University, Örebro, Sweden.,Karolinska Institutet, Stockholm, Sweden
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Jonsson M, Hurtig-Wennlöf A, Ahlsson A, Vidlund M, Cao Y, Westerdahl E. In-hospital physiotherapy improves physical activity level after lung cancer surgery: a randomized controlled trial. Physiotherapy 2019; 105:434-441. [DOI: 10.1016/j.physio.2018.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/04/2018] [Indexed: 02/07/2023]
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Fazio S, Stocking J, Kuhn B, Doroy A, Blackmon E, Young HM, Adams JY. How much do hospitalized adults move? A systematic review and meta-analysis. Appl Nurs Res 2019; 51:151189. [PMID: 31672262 DOI: 10.1016/j.apnr.2019.151189] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/22/2019] [Accepted: 09/02/2019] [Indexed: 01/04/2023]
Abstract
AIM To quantify the type and duration of physical activity performed by hospitalized adults. BACKGROUND Inactivity is pervasive among hospitalized patients and is associated with increased mortality, functional decline, and cognitive impairment. Objective measurement of activity is necessary to examine associations with clinical outcomes and quantify optimal inpatient mobility interventions. METHODS We used PRISMA guidelines to search three databases in December 2017 to retrieve original research evaluating activity type and duration among adult acute-care inpatients. We abstracted data on inpatient population, measurement method, monitoring time, activity duration, and study quality. RESULTS Thirty-eight articles were included in the review and 7 articles were included in the meta-analysis. Study populations included geriatric (n = 5), surgical (n = 5), medical (n = 12), post-stroke (n = 10), psychiatric (n = 2), and critical care inpatients (n = 4). To measure activity, 29% of studies used human observation and 71% used activity monitors. Among inpatient populations, 87-100% of time was spent sitting or lying in-bed. Among medical inpatients monitored over a continuous 24-hour period (n = 7), 70 min per day was spent standing/walking (95% CI 57-83 min). CONCLUSIONS This review provides a baseline assessment and benchmark of inpatient activity, which can be used to compare inpatient mobility practices. While there is substantial heterogeneity in how researchers measure and define how much inpatients move, there is consistent evidence that patients are mostly inactive and in-bed during hospitalization. Future research is needed to establish standardized methods to accurately and consistently measure inpatient mobility over time.
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Affiliation(s)
- Sarina Fazio
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, 2570 48th Street, CA 95817, United States of America; UC Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, 4150 V Street, Suite 3400, CA 95817, United States of America.
| | - Jacqueline Stocking
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, 4150 V Street, Suite 3400, CA 95817, United States of America
| | - Brooks Kuhn
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, 4150 V Street, Suite 3400, CA 95817, United States of America
| | - Amy Doroy
- UC Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817, United States of America
| | - Emma Blackmon
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, 2570 48th Street, CA 95817, United States of America; UC Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817, United States of America
| | - Heather M Young
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, 2570 48th Street, CA 95817, United States of America
| | - Jason Y Adams
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, 4150 V Street, Suite 3400, CA 95817, United States of America
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Sun V, Raz DJ, Erhunmwunsee L, Ruel N, Carranza J, Prieto R, Ferrell B, Krouse RS, McCorkle R, Kim JY. Improving family caregiver and patient outcomes in lung cancer surgery: Study protocol for a randomized trial of the multimedia self-management (MSM) intervention. Contemp Clin Trials 2019; 83:88-96. [PMID: 31279090 PMCID: PMC6661176 DOI: 10.1016/j.cct.2019.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/27/2019] [Accepted: 07/02/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe the study protocol of the Multimedia Self-Management (MSM) intervention to prepare patients and family caregivers (FCGs) for lung cancer surgery. DESIGN The study is a five-year, single site, randomized controlled trial of 160 lung cancer surgery FCG and patient dyads (320 total participants), comparing intervention and attention control arms. SETTING One National Cancer-Institute (NCI) designated comprehensive cancer center in Southern California. PARTICIPANTS Patients who are scheduled to undergo lung cancer surgery and their FCGs are enrolled as dyads only. INTERVENTION Based on the Chronic Care Self-Management Model (CCM), the intervention is a nurse-led, caregiver-based, multimedia care program for lung cancer surgery. Its primary focus is to help FCGs develop self-management skills related to their caregiving role through goal setting, proactive planning, building problem-solving skills, and accessing family support services. The intervention also supports dyads to prepare for surgery and post-operative recovery at home. It includes videos, print, web-based, and post-discharge telephone support. MAIN OUTCOME MEASURES FCG and patient psychological distress and QOL; FCG burden and preparedness for caregiving; FCG and patient healthcare resource use (in-home nursing care, urgent care/ER visits, readmissions). ANALYSIS Repeated measures ANCOVA statistical design will be used, removing variances prior to examining mean squares for the group by occasion interactions, and co-varying the baseline scores. In addition, structured equation modeling (SEM) will assess whether mediating and moderating factors are associated with outcomes. ClinicalTrials.gov Identifier: NCT03686007.
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Affiliation(s)
- Virginia Sun
- Division of Nursing Research and Education, Department of Population Sciences, United States of America.
| | - Dan J Raz
- Division of Thoracic Surgery, Department of Surgery, United States of America
| | | | - Nora Ruel
- Biostatistics and Mathematical Modeling Core City of Hope, Duarte, CA, United States of America
| | - Jacqueline Carranza
- Division of Nursing Research and Education, Department of Population Sciences, United States of America
| | - Rosemary Prieto
- Division of Nursing Research and Education, Department of Population Sciences, United States of America
| | - Betty Ferrell
- Division of Nursing Research and Education, Department of Population Sciences, United States of America
| | - Robert S Krouse
- Surgical Services, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States of America; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Ruth McCorkle
- School of Nursing, Yale University, New Haven, CT, United States of America
| | - Jae Y Kim
- Division of Thoracic Surgery, Department of Surgery, United States of America
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22
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Gilmore SJ, Hahne AJ, Davidson M, McClelland JA. Physical activity patterns of patients immediately after lumbar surgery. Disabil Rehabil 2019; 42:3793-3799. [DOI: 10.1080/09638288.2019.1610512] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Sarah J. Gilmore
- St Vincent’s Private Hospital Melbourne, Fitzroy, Australia
- Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, School of Allied Health, La Trobe University, Bundoora, Australia
| | - Andrew J. Hahne
- Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, School of Allied Health, La Trobe University, Bundoora, Australia
| | - Megan Davidson
- Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, School of Allied Health, La Trobe University, Bundoora, Australia
| | - Jodie A. McClelland
- Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, School of Allied Health, La Trobe University, Bundoora, Australia
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23
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Video-assisted thoracoscopic lobectomy: which patients require postoperative physiotherapy? Physiotherapy 2019; 106:87-93. [PMID: 31000366 DOI: 10.1016/j.physio.2019.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 01/04/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Following major thoracic surgery physiotherapy is recommended to improve reduced lung volume, aid secretion clearance, and improve mobility, however, in many centres physiotherapy provision is variable following minimally invasive video-assisted thoracoscopic surgery (VATS). The objective of this study was to observe frequency of problems potentially amenable to physiotherapy following VATS lobectomy, and to identify associated baseline factors of patients in whom physiotherapy may be beneficial. METHODS A prospective observational study was performed including all consecutive cancer patients undergoing VATS lobectomy in a regional centre over 4years (2012-2016). Standard postoperative care included early mobilisation by nursing staff from postoperative day one (POD1). Physiotherapy assessment of all patients on POD1 determined presence of issues potentially amenable to physiotherapy intervention, and treatment was commenced. Outcome measures included postoperative pulmonary complication (PPC) development, hospital and high dependency unit (HDU) length of stay (LOS). RESULTS Of 285 patients, 209 (73%) received physiotherapy to assist/improve reduced mobility, of these 23 (8%) also received sputum clearance therapies and 65 (23%) specific therapy for lung volume loss. The remaining 76 (27%) patients had significantly lower hospital/HDU LOS (P<0.001) reflecting uncomplicated recovery. Chronic obstructive pulmonary disease (COPD), body mass index (BMI), preoperative mobility and age were independently associated with issues potentially amenable to physiotherapy (P=0.013). CONCLUSION Following VATS lobectomy a large proportion of patients demonstrated issues potentially amenable to physiotherapy. The authors recommend that patients receive routine physiotherapy assessment following this type of surgery to ensure that all issues are identified early. Screening of COPD, BMI, preoperative mobility and age will allow early identification of patients who may benefit most from postoperative physiotherapy and preoperative optimisation, however, these factors cannot predict the need for physiotherapy.
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24
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Brocki BC, Andreasen JJ, Westerdahl E. Inspiratory Muscle Training in High-Risk Patients Following Lung Resection May Prevent a Postoperative Decline in Physical Activity Level. Integr Cancer Ther 2018; 17:1095-1102. [PMID: 30136589 PMCID: PMC6247561 DOI: 10.1177/1534735418796286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objectives. To describe postoperative self-reported physical activity (PA) level and assess the effects of 2 weeks of postoperative inspiratory muscle training (IMT) in patients at high risk for postoperative pulmonary complications following lung resection. Methods. This is a descriptive study reporting supplementary data from a randomized controlled trial that included 68 patients (mean age = 70 ± 8 years), randomized to an intervention group (IG; n = 34) or a control group (CG; n = 34). The IG underwent 2 weeks of postoperative IMT added to a standard postoperative physiotherapy given to both groups. The standard physiotherapy consisted of breathing exercises, coughing techniques, and early mobilization. We evaluated self-reported physical activity (Physical Activity Scale 2.1 questionnaire) and health status (EuroQol EQ-5D-5L questionnaire), assessed the day before surgery and 2 weeks postoperatively. Results. A significant percentage of the patients in the IG reported less sedentary activity 2 weeks postoperatively when compared with the CG (sedentary 6% vs 22%, low activity 56% vs 66%, moderate activity 38% vs 12%, respectively; P = .006). The mean difference in EQ-5D-5L between the IG and CG 2 weeks postoperatively was nonsignificant (P = .80). The overall preoperative EQ-5D-5L index score for the study population was comparable to a reference population. Conclusion. Postoperative IMT seems to prevent a decline in PA level 2 weeks postoperatively in high-risk patients undergoing lung resection. More research is needed to confirm these findings.
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25
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Hussey JM, Yang T, Dowds J, O'Connor L, Reynolds JV, Guinan EM. Quantifying postoperative mobilisation following oesophagectomy. Physiotherapy 2018; 105:126-133. [PMID: 30343873 DOI: 10.1016/j.physio.2018.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/08/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Early mobilisation is in integral component of postoperative recovery following complex surgical procedures such as oesophageal cancer resections, however evidence to guide early mobilisation protocols in critical care settings is limited. Furthermore, little is known about actual mobilisation levels postoperatively. This study quantified postoperative mobilisation post- oesophagectomy and investigated barriers to mobility. DESIGN Prospective observational study. SETTING Postoperative critical care setting in a tertiary care referral centre for oesophagectomy. PARTICIPANTS Thirty participants (mean age 65 (SD 7) years, n=19 males) scheduled for oesophagectomy. MAIN OUTCOME MEASURES The primary outcome, postoperative physical activity, was measured objectively using the Actigraph GT3X+. Medical records were examined for a range of outcomes including medical status, pain scores and physiotherapy comments to identify factors which may have influenced mobility. RESULTS During postoperative day (POD) 1-5, participants spent the majority of time (>96%) sedentary. Participation in light intensity activity was low but did increase daily from a median of 12 (IQR 19) minutes/day on POD1 to a median of 53 (IQR 73.25) minutes/day on POD5 p<0.001), with a corresponding increase in daily step count. Haemodynamic instability was the most common reason reported by physiotherapists for either not attempting mobility or limiting postoperative mobilisation levels. CONCLUSIONS These data demonstrate that despite daily physiotherapy, there are multiple challenges to postoperative mobilisation. Haemodynamic instability, likely related to thoracic epidurals, was the key limitation to early mobilisation. Goal-directed mobilisation in collaboration with the multidisciplinary team may play a considerable role in overcoming modifiable barriers to postoperative mobilisation.
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Affiliation(s)
- J M Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Ireland
| | - T Yang
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Ireland
| | - J Dowds
- Department of Physiotherapy, St James's Hospital, Dublin, Ireland
| | - L O'Connor
- Department of Physiotherapy, St James's Hospital, Dublin, Ireland
| | - J V Reynolds
- Department of Surgery, Trinity College and St James's Hospital Dublin, Ireland
| | - E M Guinan
- School of Medicine, Trinity College Dublin, Ireland.
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26
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The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg 2018; 155:1843-1852. [DOI: 10.1016/j.jtcvs.2017.10.151] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/12/2017] [Accepted: 10/24/2017] [Indexed: 02/07/2023]
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27
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Edbrooke L, Denehy L, Parry SM, Astin R, Jack S, Granger CL. How is physical activity measured in lung cancer?A systematic review of outcome measures and their psychometric properties. Respirology 2017; 22:263-277. [PMID: 28102971 DOI: 10.1111/resp.12975] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/02/2016] [Accepted: 11/10/2016] [Indexed: 12/18/2022]
Abstract
Physical activity (PA) levels are low in patients with lung cancer. Emerging evidence supports the use of interventions to increase PA in this population. We aimed to (1) identify and synthesize outcome measures which assess PA levels in patients with lung cancer and (2) to evaluate, synthesize and compare the psychometric properties of these measures. A systematic review of articles from searches was conducted of five electronic databases and personal records. Eligible studies were those which assessed PA using either performance-based or patient-reported measures. For aim 2, studies identified in aim 1 reporting on at least one psychometric property (validity, reliability, responsiveness or measurement error) were included. Two independent reviewers assessed eligibility and risk of bias with the COnsensus-based Standards for the selection of health status Measurement INstruments. Thirty-four studies using 21 different measures of PA were identified. Seventeen studies used performance-based measures. The Godin Leisure Time Exercise Questionnaire (GLTEQ) was the most frequently used patient-reported measure. Psychometric properties were reported for 13 of these measures and most frequently for movement sensors. Two studies reported on properties of the GLTEQ. Quality ratings for risk of bias were low. There is significant heterogeneity amongst studies regarding method of PA measurement along the lung cancer continuum. Greater consensus could be achieved by using a consensus approach such as a Delphi process. Future studies should include assessment of psychometric properties of the measurement tool being used. Currently, it is recommended where feasible, both performance-based and patient-reported measurements of PA should be undertaken.
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Affiliation(s)
- Lara Edbrooke
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Linda Denehy
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ronan Astin
- Institute for Human Health and Performance, University College London, London, UK
| | - Sandy Jack
- University Hospital Southampton, Southampton, UK
| | - Catherine L Granger
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Department of Physiotherapy, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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28
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Sacevich C, Semakuba B, McKay WP, Thakore S, Twagirumugabe T, Nyiligira J. Subcutaneous ketamine for postoperative pain relief in Rwanda: a randomized clinical trial. Can J Anaesth 2017; 65:170-177. [PMID: 29134517 DOI: 10.1007/s12630-017-1009-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Postoperative pain control is often inadequate in low-income countries such as Rwanda, prompting the search for an inexpensive improvement. A randomized controlled trial was conducted to study the use of subcutaneous ketamine for the management of postoperative pain in patients undergoing major surgery in Kigali, Rwanda. METHODS Fifty-nine patients undergoing major abdominal, head and neck, plastic, or gynecological surgeries were studied. In addition to standard care, patients received five subcutaneous injections of ketamine 1 mg·kg-1 (ketamine group, n = 30) or normal saline (placebo group, n = 29) during the postoperative period. The first injection was administered in the postanesthesia care unit and then every 12 hr thereafter starting at 20:00 on the day of surgery. Pain was assessed three times per day using an 11-point verbal response scale. Patients were also assessed for side effects, including nausea and vomiting, hallucinations, nightmares, sedation, hypertension, and seizures. RESULTS The mean (SD) overall postoperative pain scale score was higher in the control group than in the ketamine group [4.8 (1.7) vs 3.7 (1.5), respectively; difference of means, 1.1; 95% confidence interval [CI], 0.3 to 1.9; P = 0.009]. Brief hallucinations (ketamine group, 11 patients; placebo group, 0 patients; risk difference, 0.37; 95% CI, 0.18 to 0.54; P < 0.001) were associated with ketamine administration. CONCLUSIONS Results of this study in Kigali, Rwanda showed that subcutaneous administration of ketamine 1 mg·kg-1 twice daily, in addition to standard postoperative care, produced a small improvement in postoperative pain but resulted in more minor side effects TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02514122). Registered 31 July 2015.
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Affiliation(s)
- Calen Sacevich
- Department of Anesthesia, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - William P McKay
- Department of Anesthesia, University of Saskatchewan, Saskatoon, SK, Canada.
| | - Shefali Thakore
- Department of Anesthesia, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - John Nyiligira
- Department of Pharmacy, University Teaching Hospital of Kigali, Kigali, Rwanda
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29
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Baldwin C, van Kessel G, Phillips A, Johnston K. Accelerometry Shows Inpatients With Acute Medical or Surgical Conditions Spend Little Time Upright and Are Highly Sedentary: Systematic Review. Phys Ther 2017; 97:1044-1065. [PMID: 29077906 DOI: 10.1093/ptj/pzx076] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/21/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND Physical inactivity and sedentary behaviors have significant and independent effects on health. The use of wearable monitors to measure these constructs in people who are hospitalized with an acute illness is rapidly expanding, but has not been systematically described. PURPOSE The purpose of this study was to review the use of accelerometer monitoring with inpatients who are acutely ill, including what activity and sedentary behaviors have been measured and how active or sedentary inpatients are. DATA SOURCES Databases used were MEDLINE, EMBASE, CINAHL, and Scopus. STUDY SELECTION Quantitative studies of adults with an acute medical or surgical hospital admission, on whom an accelerometer was used to measure a physical activity or sedentary behavior, were selected. DATA EXTRACTION AND DATA SYNTHESIS Procedures were completed independently by 2 reviewers, with differences resolved and cross-checked by a third reviewer. Forty-two studies were identified that recruited people who had medical diagnoses (n = 10), stroke (n = 5), critical illness (n = 3), acute exacerbations of lung disease (n = 7), cardiac conditions (n = 7), or who were postsurgery (n = 10). Physical activities or sedentary behaviors were reported in terms of time spent in a particular posture (lying/sitting, standing/stepping), active/inactive, or at a particular activity intensity. Physical activity was also reported as step count, number of episodes or postural transitions, and bouts. Inpatients spent 93% to 98.8% (range) of their hospital stay sedentary, and in most studies completed <1,000 steps/day despite up to 50 postural transitions/day. No study reported sedentary bouts. Many studies controlled for preadmission function as part of the recruitment strategy or analysis or both. LIMITATIONS Heterogeneity in monitoring devices (17 models), protocols, and variable definitions limited comparability between studies and clinical groups to descriptive synthesis without meta-analysis. CONCLUSIONS Hospitalized patients were highly inactive, especially those with medical admissions, based on time and step parameters. Accelerometer monitoring of sedentary behavior patterns was less reported and warrants further research.
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Affiliation(s)
- Claire Baldwin
- Sansom Institute of Health Research, School of Health Sciences, Division of Health Sciences, University of South Australia, City East Campus, Centenary Building, Adelaide, South Australia 5000, Australia
| | - Gisela van Kessel
- Sansom Institute of Health Research, School of Health Sciences, Division of Health Sciences, University of South Australia
| | - Anna Phillips
- Sansom Institute of Health Research, School of Health Sciences, Division of Health Sciences, University of South Australia
| | - Kylie Johnston
- Sansom Institute of Health Research, School of Health Sciences, Division of Health Sciences, University of South Australia
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30
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Schwellnus L, Roos R, Naidoo V. Physiotherapy management of patients undergoing thoracotomy procedure: A survey of current practice in Gauteng. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2017; 73:344. [PMID: 30135901 PMCID: PMC6093126 DOI: 10.4102/sajp.v73i1.344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 05/30/2017] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Liezel Schwellnus
- Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Ronel Roos
- Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Vaneshveri Naidoo
- Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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31
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Abeles A, Kwasnicki RM, Pettengell C, Murphy J, Darzi A. The relationship between physical activity and post-operative length of hospital stay: A systematic review. Int J Surg 2017; 44:295-302. [PMID: 28689861 DOI: 10.1016/j.ijsu.2017.06.085] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/14/2017] [Accepted: 06/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recovery from surgery has traditionally been measured using specific outcome measures, such as length of hospital stay. However, advances in technology have enabled the measurement of continuous, objective physical activity data in the perioperative period. The aim of this systematic review was to determine the relationship between length of hospital stay and physical activity data for patients undergoing surgery. METHODS A systematic search of EMBASE, Medline and the Cochrane Library, from inception until January 2017, was performed to identify all study designs that evaluated physical activity after surgery. Studies were included if a wearable sensor measured patient activity as an in-patient and the length of hospital stay was reported. Only English articles were included. RESULTS Six studies with a total of 343 participants were included in this review. All the studies were prospective observational studies. Each study used a different sensor, with the commonest being a tri-axial accelerometer, and multiple different physical activity outcome measures were used, thereby prohibiting meta-analysis. Four of the studies demonstrated a relationship between physical activity levels and length of hospital stay, while two studies did not show any significant relationship. CONCLUSION The amount of physical activity performed post-operatively negatively correlates with the length of hospital stay. This suggests that objective physical activity data collected by body worn sensors may be capable of predicting functional recovery post-operatively.
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Affiliation(s)
- Aliza Abeles
- Department of Surgery and Cancer, St Mary's Hospital, 10th Floor QEQM Building, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom.
| | - Richard M Kwasnicki
- Department of Surgery and Cancer, St Mary's Hospital, 10th Floor QEQM Building, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom
| | - Chris Pettengell
- Department of Surgery and Cancer, St Mary's Hospital, 10th Floor QEQM Building, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom
| | - Jamie Murphy
- Department of Surgery and Cancer, St Mary's Hospital, 10th Floor QEQM Building, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom
| | - Ara Darzi
- Department of Surgery and Cancer, St Mary's Hospital, 10th Floor QEQM Building, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom
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32
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Esteban PA, Hernández N, Novoa NM, Varela G. Evaluating patients’ walking capacity during hospitalization for lung cancer resection†. Interact Cardiovasc Thorac Surg 2017; 25:268-271. [DOI: 10.1093/icvts/ivx100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/31/2017] [Indexed: 11/14/2022] Open
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33
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Guinan EM, Dowds J, Donohoe C, Reynolds JV, Hussey J. The physiotherapist and the esophageal cancer patient: from prehabilitation to rehabilitation. Dis Esophagus 2017; 30:1-12. [PMID: 27862675 DOI: 10.1111/dote.12514] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Esophageal cancer is a serious malignancy often treated with multimodal interventions and complex surgical resection. As treatment moves to centers of excellence with emphasis on enhanced recovery approaches, the role of the physiotherapist has expanded. The aim of this review is to discuss the rationale behind both the evolving prehabilitative role of the physiotherapist and more established postoperative interventions for patients with esophageal cancer. While a weak association between preoperative cardiopulmonary fitness and post-esophagectomy outcome is reported, cardiotoxicity during neoadjuvant chemotherapy and/or radiotherapy may heighten postoperative risk. Preliminary studies suggest that prehabilitative inspiratory muscle training may improve postoperative outcome. Weight and muscle loss are a recognized sequelae of esophageal cancer and the functional consequences of this should be assessed. Postoperative physiotherapy priorities include effective airway clearance and early mobilization. The benefits of respiratory physiotherapy post-esophagectomy are described by a small number of studies, however, practice increasingly recognizes the importance of early mobilization as a key component of postoperative recovery. The benefits of exercise training in patients with contraindications to mobilization remain to be explored. While there is a strong basis for tailored physiotherapy interventions in the management of patients with esophageal cancer, this review highlights the need for studies to inform prehabilitative and postoperative interventions.
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Affiliation(s)
- E M Guinan
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - J Dowds
- Department of Physiotherapy, St James's Hospital, Dublin, Ireland
| | - C Donohoe
- Department of Surgery, St James's Hospital Dublin, Dublin, Ireland
| | - J V Reynolds
- Department of Surgery, St James's Hospital Dublin, Dublin, Ireland.,Trinity Translational Medicine Institute, Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - J Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
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34
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Affiliation(s)
- Catherine L Granger
- Department of Physiotherapy, University of Melbourne; Department of Physiotherapy, Royal Melbourne Hospital; Institute for Breathing and Sleep, Melbourne, Australia
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35
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The role of a video-assisted thoracic approach for rib fixation. Eur J Trauma Emerg Surg 2016; 43:185-190. [PMID: 26850079 DOI: 10.1007/s00068-016-0641-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Rib fixation remains a contentious issue in the current practice of orthopaedic, trauma and thoracic surgeons. Whilst rib fractures are undoubtedly associated with high levels of morbidity and mortality, the optimal surgical approach has not yet been fully elucidated in prospective trials and the volume of procedures performed remains low. METHODS We evaluated 21 consecutive patients who underwent surgical rib fixation either via a standard thoracotomy approach or following the introduction of a video-assisted technique with minimal thoracic incisions. RESULTS The average age of patients undergoing rib fixation was 47 and the median length of post-operative stay was 4 days. More than 70 % of patients were found to have concurrent haemothoraces, and 19 % had significant injuries to underlying intra-thoracic structures requiring repair. One patient returned to theatre for persistent blood loss; however, there were no other immediate complications or mortalities. CONCLUSIONS We discuss the involvement of thoracic surgeons, early assessment of the thoracic cavity with video assistance and optimal peri-operative management with particular reference to cases which demonstrate recent changes in our practice.
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36
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Madansein R, Parida S, Padayatchi N, Singh N, Master I, Naidu K, Zumla A, Maeurer M. Surgical treatment of complications of pulmonary tuberculosis, including drug-resistant tuberculosis. Int J Infect Dis 2016; 32:61-7. [PMID: 25809758 DOI: 10.1016/j.ijid.2015.01.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/16/2015] [Accepted: 01/19/2015] [Indexed: 11/28/2022] Open
Abstract
Surgery for drug-resistant tuberculosis has been shown to be safe and effective, with similar level of mortalities associated with surgical intervention observed with that for lung cancer. While surgery has been an option to treat TB in the pre-antibiotic era, it is now increasingly used to treat complications of pulmonary TB, particularly in patients with drug-resistant TB who do not respond to medical treatment. The two most frequent indications for lung resection in drug- resistant TB, are i) failed medical treatment with persistent sputum positivity or ii) patients who have had medical treatment and are sputum negative, but with persistent localized cavitary disease or bronchiectasis. Massive hemoptysis is a potentially life-threatening complication of TB. Lung resection is potentially curative in patients with massive hemoptysis and cavitary or bronchiectatic disease. Bronchial artery embolization in these patients has a high success rate but bears also the risk of recurrence. Lung resection can be safely undertaken in selected patients with HIV co-infection and pulmonary complications of TB. Ambulatory drainage is a novel, safe, affordable and effective method of draining a chronic TB associated empyema thoracis. We review here the current surgical treatment of the complications of pulmonary TB and discuss the experience from the Durban Cardiothoracic Surgery Unit for the surgical treatment of patients with complicated pulmonary TB.
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Affiliation(s)
- Rajhmun Madansein
- Department of Cardiothoracic Surgery, University of KwaZulu-Natal, Inkosi Albert Luthuli Central Hospital, King Dinuzulu Hospital, Dept of Health, KwaZulu-Natal Province, Durban, South Africa; DR-TB Department, King Dinuzulu Hospital, Dept of Health, KwaZulu-Natal Province, Durban, South Africa; MSC_Durban Team.
| | - Shreemanta Parida
- Division of Therapeutic Immunology, TIM, Dept of Laboratory Medicine, Karolinska Institutet.
| | - Nesri Padayatchi
- MSC_Durban Team; Centre for AIDS Prevention Research in South Africa (CAPRISA), University of KwaZulu-Natal, SAMRC CAPRISA HIV - TB Pathogenesis and Treatment Research Unit, Durban, South Africa.
| | - Nalini Singh
- DR-TB Department, King Dinuzulu Hospital, Dept of Health, KwaZulu-Natal Province, Durban, South Africa; MSC_Durban Team.
| | - Iqbal Master
- DR-TB Department, King Dinuzulu Hospital, Dept of Health, KwaZulu-Natal Province, Durban, South Africa; MSC_Durban Team.
| | - Kantharuben Naidu
- DR-TB Department, King Dinuzulu Hospital, Dept of Health, KwaZulu-Natal Province, Durban, South Africa; MSC_Durban Team.
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London Medical School, London, UK.
| | - Markus Maeurer
- Division of Therapeutic Immunology, TIM, Dept of Laboratory Medicine, Karolinska Institutet; Center for allogeneic stem cell transplantation (CAST), Karolinska Hospital, Stockholm, Sweden.
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Granger CL, Parry SM, Edbrooke L, Denehy L. Deterioration in physical activity and function differs according to treatment type in non-small cell lung cancer - future directions for physiotherapy management. Physiotherapy 2015; 102:256-63. [PMID: 26597694 DOI: 10.1016/j.physio.2015.10.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/16/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To investigate in non-surgically and surgically treated non-small cell lung cancer (NSCLC): (1) changes in physical activity, function, health-related quality of life (HRQoL) and symptoms after diagnosis; and (2) the association between physical activity and outcomes. DESIGN Prospective observational study. SETTING Three acute tertiary hospitals. PARTICIPANTS Sixty-nine individuals (43 male, median [IQR] age 68 [61 to 74] years) with stage I-IV NSCLC. MAIN OUTCOME MEASURES The primary outcome (Physical Activity Scale for the Elderly) and secondary outcome (six-minute walk test and questionnaires assessing HRQoL, function, symptoms, mood) were measured at diagnosis (pre-treatment), and eight to ten weeks post-diagnosis (post-operative and/or during chemotherapy/radiotherapy). RESULTS Individuals treated surgically (n=27) experienced a deterioration in physical activity levels (baseline median [IQR]=74 [51 to 135]; follow-up median [IQR]=29 [24 to 73]; median difference=45, effect size=0.3). At follow-up physical activity was inversely related to depression, pain and appetite loss (rho>0.5, p<0.05). In contrast non-surgical individuals (n=42) did not experience a change in physical activity, however did experience deterioration in function, functional capacity, global HRQoL, fatigue and dyspnoea. Physical activity levels were low in this group and at follow-up the strongest relationships with physical activity levels were global HRQoL, function, fatigue and mood (inverse, rho>0.5, p<0.05). CONCLUSIONS Surgically treated individuals experienced a reduction in physical activity levels after diagnosis, which was not seen in the non-surgical group. Lower physical activity levels were associated with poorer outcomes, particularly in non-surgically treated individuals. Further research is required to establish the optimal intervention to improve physical activity levels in these cohorts.
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Affiliation(s)
- C L Granger
- Department of Physiotherapy, The University of Melbourne, 161 Barry Street, Parkville 3010, Victoria, Australia; Department of Physiotherapy, Royal Melbourne Hospital, Grattan Street, Parkville 3010, Victoria, Australia; Institute for Breathing and Sleep, Heidelberg Road, Heidelberg 3084, Victoria, Australia.
| | - S M Parry
- Department of Physiotherapy, The University of Melbourne, 161 Barry Street, Parkville 3010, Victoria, Australia.
| | - L Edbrooke
- Department of Physiotherapy, The University of Melbourne, 161 Barry Street, Parkville 3010, Victoria, Australia.
| | - L Denehy
- Department of Physiotherapy, The University of Melbourne, 161 Barry Street, Parkville 3010, Victoria, Australia; Institute for Breathing and Sleep, Heidelberg Road, Heidelberg 3084, Victoria, Australia.
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