Use of activity tracking in major visceral surgery-the Enhanced Perioperative Mobilization (EPM) trial: study protocol for a randomized controlled trial

The feasibility of patient-reported outcomes, physical function, and mobilization in the care pathway for head and neck cancer surgical patients

BACKGROUND

Head and neck cancer (HNC) patients are an understudied population whose treatment often includes surgery, causing a wide range of side effects. Exercise prehabilitation is a promising tool to optimize patient outcomes and may confer additional benefits as a prehabilitation tool. The primary objective of this study was to assess the feasibility of measuring patient-reported outcomes (PROs), physical function, and in-hospital mobilization across the HNC surgical timeline in advance of a future prehabilitation trial. The secondary objective was to examine potential changes in these outcomes across the surgical timeline.

METHODS

HNC patients scheduled to undergo oncologic resection with free-flap reconstruction completed assessments of PROs and physical function at three timepoints across the surgical timeline (baseline, in-hospital, and postsurgical/outpatient). Mobilization was measured during the in-hospital period. The feasibility of recruitment and measurement completion was tracked, as were changes in both PROs and physical function.

RESULTS

Of 48 eligible patients, 16 enrolled (recruitment rate of 33%). The baseline and in-hospital PROs were completed by 88% of participants, while the outpatient assessments were completed by 81% of participants. The baseline and in-hospital assessment of physical function were completed by 56% of participants, and 38% completed the outpatient assessment. Measuring in-hospital mobilization was completed for 63% of participants.

CONCLUSION

Measuring PROs and in-hospital mobilization is feasible across the surgical timeline in HNC; however, the in-person assessment of physical function prior to surgery was not feasible. A multidisciplinary collaboration between exercise specialists and clinicians supported the development of new clinical workflows in HNC surgical care that will aid in the implementation of a future prehabilitation trial for this patient population.

Use of a Multi-Sensor Monitoring Device in an Early Post-operative Mobilization Program

BACKGROUND

The current study aimed to evaluate the validity and feasibility of using a multi-sensor device to monitor patient mobility in a large postoperative population.

METHODS

In this IRB-approved study, postoperative patient posture was recorded using a multi-sensor monitoring device (ViSi Mobile®) and compared with direct observations of patient physical activity. Retrospective cohort analysis of postoperative patient posture data from January to December 2019 was then performed. Patterns of postoperative mobilization were evaluated.

RESULTS

Multi-sensor real-time posture monitoring with the ViSi Mobile® system consistently differentiate between rest and upright posture (sensitivity and specificity, both 100%). During observation of ambulatory events, ViSi Mobile® system correctly recorded a patient's position as upright at each validation time point in 72.7% (8 of 11) of walks. Clinical data from 562 postoperative patients were linked with posture monitoring data. Median duration of posture monitoring was 64 hours (IQR 52.5) and median number of posture positions recorded per patient was 15,370 (IQR 12,685). Median duration of upright position per day was 148.6 minutes (IQR 192.8). Duration in active upright position per day was not associated with risk of readmission (P > .05).

CONCLUSION

Real-time posture data from a multi-sensor monitoring device (ViSi Mobile®) was shown to consistently differentiate rest and active upright position. This novel technology can provide useful insight into adherence and clinical benefit of early mobilization programs.

Postoperative mobilisation as an indicator for the quality of surgical nursing care

BACKGROUND

Postoperative mobilisation is an important part of fundamental care. Increased mobilisation has positive effect on recovery, but immobilisation is still a challenge in postoperative care.

AIMS

To report how the establishment of a national nursing database was used to measure postoperative mobilisation in patients undergoing surgery for ovarian cancer.

METHODS

'Mobilisation' was defined as at least 3 hours out of bed on postoperative day 1, with the goal set at achieving this in 60% of patients. Data entry was performed by clinical nurses on 4400 patients with ovarian cancer.

FINDINGS

46.7% of patients met the goal for mobilisation on the first postoperative day, but variations in duration and type of mobilisation were observed. Of those mobilised, 51.8% had been walking in the hallway.

CONCLUSIONS

A national nursing database creates opportunities to optimise fundamental care. By comparing nursing data with oncological, surgical and pathology data it became possible to study mobilisation in relation to cancer stage, comorbidity, treatment and extent of surgery.

Improving postoperative mobilisation rates in patients undergoing elective major hepatopancreatobiliary surgery

BACKGROUND

Early mobilisation reduces postoperative complications such as pneumonia, deep vein thrombosis and hospital length of stay. Many authors have reported poor compliance with early mobilisation within Enhanced Recovery After Surgery initiatives.

OBJECTIVES

The primary objective was to increase postoperative day (POD) 2 mobilisation rate from 23% to 75% in patients undergoing elective major hepatopancreatobiliary (HPB) surgery within 6 months.

METHODS

We report a multidisciplinary team clinical practice improvement project (CPIP) to improve postoperative mobilisation of patients undergoing elective major HPB surgery. We identified the common barriers to mobilisation and analysed using the fishbone or cause-and-effect diagram and Pareto chart. A series of Plan-Do-Study-Act cycles followed this. We tracked the rate of early mobilisation and mean distance walked. In the post hoc analysis, we examined the potential cost savings based on reduced hospital length of stay.

RESULTS

Mobilisation rate on POD 2 following elective major HPB surgery improved from 23% to 78.9%, and this sustained at 6 months after the CPIP. Wound pain was the most common reason for failure to ambulate on POD 2. Hospital length of stay reduced from a median of 8 days to 6 days with an estimated cost saving of S$2228 per hospital stay.

CONCLUSION

Multidisciplinary quality improvement intervention effort resulted in an improved POD 2 mobilisation rate for patients who underwent elective major HPB surgery. This observed outcome was sustained at 6 months after completion of the CPIP with potential cost savings.

Activity Tracking After Surgery: Does It Correlate With Postoperative Complications?

BACKGROUND

Postoperative ambulation is an important tenet in enhanced recovery programs. We quantitatively assessed the correlation of decreased postoperative ambulation with postoperative complications and delays in gastrointestinal function.

METHODS

Patients undergoing major abdominal surgery were fitted with digital ankle pedometers yielding continuous measurements of their ambulation. Primary endpoints were the overall and system-specific complication rates, with secondary endpoints being the time to first passage of flatus and stool, the length of hospital stay, and the rate of readmission.

RESULTS

100 patients were enrolled. We found a significant, independent inverse correlation between the number of steps on the first and second postoperative days (POD1/2) and the incidence of complications as well as the recovery of GI function and the likelihood of readmission (P < .05). POD2 step count was an independent risk factor for severe complications (P = .026).

DISCUSSION

Digitally quantified ambulation data may be a prognostic biomarker for the likelihood of severe postoperative complications.

Smartband Use During Enhanced Recovery After Surgery Facilitates Inpatient Recuperation Following Minimally Invasive Colorectal Surgery

Background: Enhanced recovery after surgery (ERAS) is valuable in perioperative care for its ability to improve short-term surgical outcomes and facilitate patient recuperation after major surgery. Early postoperative mobilization is a vital component of the integrated care pathway and is a factor strongly associated with successful outcomes. However, early mobilization still has various definitions and lacks specific strategies. Methods: Patients who underwent minimally invasive surgery for colorectal cancer followed our perioperative ERAS program, including mobilization from the first postoperative day. After perioperative care skills were improved in our well-established program, compliance, inpatient surgical outcomes, and complications associated with adding smartband use were evaluated and compared with the outcomes for standard protocol. Quality of recovery was evaluated using patient-rated QoR-40 questionnaires the day before surgery, on postoperative days 1 and 3, and on the day of discharge. Results: Smartband use after minimally invasive colorectal surgery failed to increase compliance with early mobilization or reduce the occurrence of postoperative complications significantly compared with standard ERAS protocol. However, when smartbands were utilized, quality of recovery was optimized and patients returned to their preoperative status earlier, at postoperative day 3. The length of hospital stay, as defined by discharge criteria, and hospital stay of patients without complications was reduced by 1.1 and 0.9 days, respectively (P = 0.009 and 0.049, respectively). Conclusions: Smartbands enable enhanced communication between patients and surgical teams and strengthen self-management in patients undergoing minimally invasive colorectal resection surgery. Accelerated recovery to preoperative functional status can be facilitated by integrating smartbands into the process of early mobilization during ERAS.

Factors influencing post-surgical variability in StepWatch data in youth with cerebral palsy

BACKGROUND

Over the past several years, activity monitors have become very popular in the general population, and due to their low cost and ease of use, are starting to be seen as clinical tools for the assessment of interventions. This presents researchers with the opportunity to better understand how activity, or lack thereof, is related to the recovery of patients. However, even in individuals without disabilities, there is a high degree of variability in activity monitor data which must be better understood in order to produce clinically meaningful interpretation of such data.

RESEARCH QUESTION

What sources of variability contribute the most to the daily scatter in activity data as measured by StepWatches in youth with Cerebral Palsy (CP)? In particular, do non-clinical factors such as weather and location contribute to this variability significantly?

METHODS

This was a retrospective study making use of data from our activity monitoring protocol of youths with CP who obtain single event multi-level surgeries. Before and after these surgeries, 57 such youths aged 4.2-21.3 years were issued StepWatches to monitor daily activity for 8 day periods over 24 months duration. Weather data and walk scores for the patients' home locations were collected from online databases. Steps per hour were predicted from clinical and environmental data using bootstrapped regression to determine the stability of regression coefficients and the percent variability explained by each variable.

RESULTS

Time since surgery, age, season, GMFCS level, and surgical burden were significant variables in the model. Of them, GMFCS level was most important and explained nearly 16% of the variability in the data. Temperature, precipitation, and walk score had small effects on step count variance.

SIGNIFICANCE

Understanding sources of variability in step-counts is important if such a measure is to be used as a clinical measure of recovery, and may be important in the consideration of future surgical planning.

Use of Activity Tracking in Major Visceral Surgery-the Enhanced Perioperative Mobilization Trial: a Randomized Controlled Trial

BACKGROUND

Early mobilization is one essential item within the enhanced recovery after surgery (ERAS) concept, but lacks solid evidence and a standardized assessment. The aim was to monitor and increase the postoperative mobilization of patients after major visceral surgery by providing a continuous step count feedback using activity tracking wristbands.

METHODS

The study was designed as a randomized controlled single-center trial (NCT02834338) with two arms (open and laparoscopic surgery). Participants were randomized to either receive feedback of their step counts using an activity tracker wristband or not. The primary study endpoint was the mean step count during the first 5 postoperative days (PODs).

RESULTS

A total of 132 patients were randomized. After laparoscopic operations, the average step count during PODs 1-5 was significantly increased by the feedback compared with the control group (P < 0.001); the cumulative step count (9867 versus 6103, P = 0.037) and activity time were also significantly increased. These results could not be confirmed in the open surgery arm. Possible reasons were a higher age and significantly more comorbidities in the open intervention group. Patients who achieved more than the median cumulative step count had a significantly shorter hospital stay and lower morbidity in both arms. The average step count also correlated with the length of hospital stay (R = - 0.341, P < 0.001).

CONCLUSION

This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative mobilization in abdominal surgery. Our results demonstrate that activity tracking can enhance perioperative mobilization after laparoscopic surgery.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02834338.

Consumer-Based Wearable Activity Trackers Increase Physical Activity Participation: Systematic Review and Meta-Analysis

BACKGROUND

The range of benefits associated with regular physical activity participation is irrefutable. Despite the well-known benefits, physical inactivity remains one of the major contributing factors to ill-health throughout industrialized countries. Traditional lifestyle interventions such as group education or telephone counseling are effective at increasing physical activity participation; however, physical activity levels tend to decline over time. Consumer-based wearable activity trackers that allow users to objectively monitor activity levels are now widely available and may offer an alternative method for assisting individuals to remain physically active.

OBJECTIVE

This review aimed to determine the effects of interventions utilizing consumer-based wearable activity trackers on physical activity participation and sedentary behavior when compared with interventions that do not utilize activity tracker feedback.

METHODS

A systematic review was performed searching the following databases for studies that included the use of a consumer-based wearable activity tracker to improve physical activity participation: Cochrane Controlled Register of Trials, MEDLINE, PubMed, Scopus, Web of Science, Cumulative Index of Nursing and Allied Health Literature, SPORTDiscus, and Health Technology Assessments. Controlled trials of adults comparing the use of a consumer-based wearable activity tracker with other nonactivity tracker-based interventions were included. The main outcome measures were physical activity participation and sedentary behavior. All studies were assessed for risk of bias, and the Grades of Recommendation, Assessment, Development, and Evaluation system was used to rank the quality of evidence. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement were followed. A random-effects meta-analysis was completed on the included outcome measures to estimate the treatment effect of interventions that included an activity tracker compared with a control group.

RESULTS

There was a significant increase in daily step count (standardized mean difference [SMD] 0.24; 95% CI 0.16 to 0.33; P<.001), moderate and vigorous physical activity (SMD 0.27; 95% CI 0.15 to 0.39; P<.001), and energy expenditure (SMD 0.28; 95% CI 0.03 to 0.54; P=.03) and a nonsignificant decrease in sedentary behavior (SMD -0.20; 95% CI -0.43 to 0.03; P=.08) following the intervention versus control comparator across all studies in the meta-analyses. In general, included studies were at low risk of bias, except for performance bias. Heterogeneity varied across the included meta-analyses ranging from low (I²=3%) for daily step count through to high (I²=67%) for sedentary behavior.

CONCLUSIONS

Utilizing a consumer-based wearable activity tracker as either the primary component of an intervention or as part of a broader physical activity intervention has the potential to increase physical activity participation. As the effects of physical activity interventions are often short term, the inclusion of a consumer-based wearable activity tracker may provide an effective tool to assist health professionals to provide ongoing monitoring and support.

Consumer-Based Wearable Activity Trackers Increase Physical Activity Participation: Systematic Review and Meta-Analysis

BACKGROUND

The range of benefits associated with regular physical activity participation is irrefutable. Despite the well-known benefits, physical inactivity remains one of the major contributing factors to ill-health throughout industrialized countries. Traditional lifestyle interventions such as group education or telephone counseling are effective at increasing physical activity participation; however, physical activity levels tend to decline over time. Consumer-based wearable activity trackers that allow users to objectively monitor activity levels are now widely available and may offer an alternative method for assisting individuals to remain physically active.

OBJECTIVE

This review aimed to determine the effects of interventions utilizing consumer-based wearable activity trackers on physical activity participation and sedentary behavior when compared with interventions that do not utilize activity tracker feedback.

METHODS

A systematic review was performed searching the following databases for studies that included the use of a consumer-based wearable activity tracker to improve physical activity participation: Cochrane Controlled Register of Trials, MEDLINE, PubMed, Scopus, Web of Science, Cumulative Index of Nursing and Allied Health Literature, SPORTDiscus, and Health Technology Assessments. Controlled trials of adults comparing the use of a consumer-based wearable activity tracker with other nonactivity tracker-based interventions were included. The main outcome measures were physical activity participation and sedentary behavior. All studies were assessed for risk of bias, and the Grades of Recommendation, Assessment, Development, and Evaluation system was used to rank the quality of evidence. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement were followed. A random-effects meta-analysis was completed on the included outcome measures to estimate the treatment effect of interventions that included an activity tracker compared with a control group.

RESULTS

There was a significant increase in daily step count (standardized mean difference [SMD] 0.24; 95% CI 0.16 to 0.33; P<.001), moderate and vigorous physical activity (SMD 0.27; 95% CI 0.15 to 0.39; P<.001), and energy expenditure (SMD 0.28; 95% CI 0.03 to 0.54; P=.03) and a nonsignificant decrease in sedentary behavior (SMD -0.20; 95% CI -0.43 to 0.03; P=.08) following the intervention versus control comparator across all studies in the meta-analyses. In general, included studies were at low risk of bias, except for performance bias. Heterogeneity varied across the included meta-analyses ranging from low (I2=3%) for daily step count through to high (I2=67%) for sedentary behavior.

CONCLUSIONS

Utilizing a consumer-based wearable activity tracker as either the primary component of an intervention or as part of a broader physical activity intervention has the potential to increase physical activity participation. As the effects of physical activity interventions are often short term, the inclusion of a consumer-based wearable activity tracker may provide an effective tool to assist health professionals to provide ongoing monitoring and support.

Improved early outcome after TKA through an app-based active muscle training programme-a randomized-controlled trial

PURPOSE

The purpose of this prospective randomized-controlled trial (RCT) was to evaluate if an app-based feedback-controlled active muscle training programme can be used to improve the outcome in the immediate postoperative period after total knee arthroplasty (TKA).

METHODS

Sixty patients, with a median age of 65.9 years (range 45-84), awaiting primary TKA were randomized into a control and training group. Both groups followed an identical postoperative protocol. In addition, the training group postoperatively performed an app-based feedback-controlled active muscle training programme multiple times daily. Outcome measures were active and passive range of motion (ROM), pain at rest and in motion, knee extension strength, the timed "Up and Go", 10-m Walk Test, 30-s Chair Stand Test, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), and clinical data.

RESULTS

The training group performed an average of 18.4 training sessions, which led to significantly higher ROM, less pain at rest and in motion, higher strength, and significantly higher functional scores. More training correlated with a better outcome.

CONCLUSIONS

The use of an app-based feedback-controlled active muscle training programme can improve the clinical outcome after TKA, especially ROM and reduce pain. Clinically relevant is that the training programme could be considered an alternative to continuous passive motion after total knee arthroplasty.

LEVEL OF EVIDENCE

II.

Evaluating the Impact of Physical Activity Apps and Wearables: Interdisciplinary Review

Background

Although many smartphone apps and wearables have been designed to improve physical activity, their rapidly evolving nature and complexity present challenges for evaluating their impact. Traditional methodologies, such as randomized controlled trials (RCTs), can be slow. To keep pace with rapid technological development, evaluations of mobile health technologies must be efficient. Rapid alternative research designs have been proposed, and efficient in-app data collection methods, including in-device sensors and device-generated logs, are available. Along with effectiveness, it is important to measure engagement (ie, users’ interaction and usage behavior) and acceptability (ie, users’ subjective perceptions and experiences) to help explain how and why apps and wearables work.

Objectives

This study aimed to (1) explore the extent to which evaluations of physical activity apps and wearables: employ rapid research designs; assess engagement, acceptability, as well as effectiveness; use efficient data collection methods; and (2) describe which dimensions of engagement and acceptability are assessed.

Method

An interdisciplinary scoping review using 8 databases from health and computing sciences. Included studies measured physical activity, and evaluated physical activity apps or wearables that provided sensor-based feedback. Results were analyzed using descriptive numerical summaries, chi-square testing, and qualitative thematic analysis.

Results

A total of 1829 abstracts were screened, and 858 articles read in full. Of 111 included studies, 61 (55.0%) were published between 2015 and 2017. Most (55.0%, 61/111) were RCTs, and only 2 studies (1.8%) used rapid research designs: 1 single-case design and 1 multiphase optimization strategy. Other research designs included 23 (22.5%) repeated measures designs, 11 (9.9%) nonrandomized group designs, 10 (9.0%) case studies, and 4 (3.6%) observational studies. Less than one-third of the studies (32.0%, 35/111) investigated effectiveness, engagement, and acceptability together. To measure physical activity, most studies (90.1%, 101/111) employed sensors (either in-device [67.6%, 75/111] or external [23.4%, 26/111]). RCTs were more likely to employ external sensors (accelerometers: P=.005). Studies that assessed engagement (52.3%, 58/111) mostly used device-generated logs (91%, 53/58) to measure the frequency, depth, and length of engagement. Studies that assessed acceptability (57.7%, 64/111) most often used questionnaires (64%, 42/64) and/or qualitative methods (53%, 34/64) to explore appreciation, perceived effectiveness and usefulness, satisfaction, intention to continue use, and social acceptability. Some studies (14.4%, 16/111) assessed dimensions more closely related to usability (ie, burden of sensor wear and use, interface complexity, and perceived technical performance).

Conclusions

The rapid increase of research into the impact of physical activity apps and wearables means that evaluation guidelines are urgently needed to promote efficiency through the use of rapid research designs, in-device sensors and user-logs to assess effectiveness, engagement, and acceptability. Screening articles was time-consuming because reporting across health and computing sciences lacked standardization. Reporting guidelines are therefore needed to facilitate the synthesis of evidence across disciplines.