Physiotherapy Following Emergency Abdominal Surgery

Physiotherapy following elective abdominal surgery has been well documented, but following emergency abdominal surgery, despite poorer outcomes and increased complication rates, physiotherapy interventions for this patient group remain largely uninvestigated. The most common complication following upper abdominal surgery is the development of a post-operative pulmonary complication (PPC). Risk factors for the development of PPCs include duration of anaesthesia, emergency upper abdominal surgery, current smoker status, respiratory comorbidities, obesity, increased age and multiple surgeries. Physiotherapy interventions aim to prevent or remediate PPCs and post-operative complications associated with the sequelae of immobility such as venothrombotic events and to facilitate recovery from surgery and a return to normal activities of daily living and function. Physiotherapy interventions after major surgery include early mobilisation and respiratory physiotherapy techniques. Respiratory therapies include deep breathing and coughing exercises, positive expiratory pressure devices, incentive spirometry and non-invasive ventilation. Early mobilisation has been demonstrated to be safe and efficacious following elective abdominal surgery and for patients who are critically ill. This chapter reviews the evidence in these populations and propose that, until further studies are available to direct care, this evidence is extrapolated to patients following emergency abdominal surgery. As abdominal surgery impacts on physical recovery and health-related quality of life, post-discharge rehabilitation programmes may improve long-term outcomes; however, rehabilitation following major cavity surgery is in its infancy. This chapter investigates post-operative rehabilitation research to date in this population in an attempt to determine the effectiveness of such programmes and make recommendations for future practice

Preoperative physiotherapy to prevent postoperative pulmonary complications after major abdominal surgery

© 2020 Ianthe Josephine BodenAbdominal surgery is the most common major surgical procedure performed in developed countries. After surgery, postoperative pulmonary complications (PPCs) occur frequently and are a primary cause of morbidity, mortality, and prolonged hospital stay. To minimise PPCs, physiotherapy is ubiquitously provided in the postoperative phase in hospitals throughout developed countries. Physiotherapy clinical trials reporting the largest reductions in PPCs have predominately tested preoperative education and training of patients to perform their own breathing exercises after surgery. These trials were generally of low quality and therefore the results lack certainty. Currently, preoperative physiotherapy is rarely provided in Australian and New Zealand hospitals. A well-designed randomised controlled trial (RCT) investigating the benefit of preoperative physiotherapy to reduce PPC in a modern perioperative context was needed. The aims of this thesis were to: consider the physiological basis for preoperative physiotherapy to minimise PPCs; to conduct a narrative and systematic review of research investigating PPC prevention with breathing exercises; and, to design and conduct an RCT, including quantitative, qualitative, and health economic outcomes, assessing the effectiveness of preoperative physiotherapy to minimise PPC after major abdominal surgery. The Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy (LIPPSMAck-POP) trial was a double-blinded, multicentre, RCT. In pre-admission clinics at three hospitals, 441 patients awaiting major abdominal surgery were randomised to receive an information booklet or an additional education and breathing exercise training session. Education focussed on PPC prevention via self-directed postoperative breathing exercises. A nested mixed-methods study investigated the impact and treatment fidelity of the intervention in 20 consecutive participants. Preventing pneumonia was very important to participants. Intervention participants found preoperative physiotherapy to be interesting and empowering with 94% of remembering the breathing exercises as taught. Following surgery, PPC incidence was halved in the intervention group (adjusted hazard ratio 0.48, 95% confidence interval (CI) 0.35 to 0.75, p=0.001) with a number needed to treat of 7 (95% CI 5 to 14). Intervention participants had significantly reduced pneumonia rates, required fewer antibiotic prescriptions for respiratory infections, less purulent sputum, fewer positive sputum cultures, and were less likely to require oxygen therapy. An integrated health economic analysis found that preoperative physiotherapy had high probability of being cost-effective with an incremental net benefit to hospitals of $4,958 (95$10 to $9,197) for each PPC prevented, given a willingness-to-pay of$45,000 for the service. Quality adjusted life year (QALY) gains were less certain. Improved cost-effectiveness and QALY gains were detected when experienced physiotherapists delivered the intervention. For each PPC prevented, preoperative physiotherapy was likely to cost hospitals less than the costs to treat a PPC. This thesis analysed the evidence for the physiotherapy management of patients having abdominal surgery. A hypothesis for preoperative physiotherapy to minimise PPC after surgery was proposed. This hypothesis was supported with qualitative, primary, secondary, and health economic quantitative outcomes within a multicentre randomised controlled trial, and through a systematic review and meta-analysis. These findings may not be generalisable to all settings and require testing in different surgical populations, cultures, and hospital settings. Effective PPC prophylaxis needs to be investigated for patients unable to attend pre-admission clinics, those having emergency abdominal surgery and in other high-risk populations

Inspiratory muscle training in intensive care unit patients:An international cross-sectional survey of physiotherapist practice

BackgroundInspiratory muscle training is safe and effective in reversing inspiratory muscle weakness and improving outcomes in patients who have experienced prolonged mechanical ventilation in the intensive care unit (ICU). The degree of worldwide implementation of inspiratory muscle training in such patients has not been investigated.ObjectivesThe objectives of this study were to describe the current practice of inspiratory muscle training by intensive care physiotherapists and investigate barriers to implementation in the intensive care context and additionally to determine if any factors are associated with the use of inspiratory muscle training in patients in the ICU and identify preferred methods of future education.MethodOnline cross-sectional surveys of intensive care physiotherapists were conducted using voluntary sampling. Multivariate logistic regression analysis was used to identify factors associated with inspiratory muscle training use in patients in the ICU.Results Of 360 participants, 63% (95% confidence interval [CI] = 58 to 68) reported using inspiratory muscle training in patients in the ICU, with 69% (95% CI = 63 to 75) using a threshold device. Only 64% (95% CI = 58 to 70) of participants who used inspiratory muscle training routinely assessed inspiratory muscle strength. The most common barriers to implementing inspiratory muscle training sessions in eligible patients were sedation and delirium. Participants were 4.8 times more likely to use inspiratory muscle training in patients if they did not consider equipment a barrier and were 4.1 times more likely to use inspiratory muscle training if they aware of the evidence for this training in these patients. For education about inspiratory muscle training, 41% of participants preferred online training modules.ConclusionIn this first study to describe international practice by intensive care therapists, 63% reported using inspiratory muscle training. Improving access to equipment and enhancing knowledge of inspiratory muscle training techniques could improve the translation of evidence into practice

PHYSIO+++: protocol for a pilot randomised controlled trial assessing the feasibility of physiotherapist-led non-invasive ventilation for patients with hypoxaemia following abdominal surgery

Introduction Few clinical trials have investigated physiotherapy interventions to treat hypoxaemia following abdominal surgery. The objective of this study is to determine the feasibility and safety of conducting a clinical trial of physiotherapist-led non-invasive ventilation (NIV).Methods and analysis This single-centre, 50-patient, parallel-group, assessor blinded, pilot feasibility randomised controlled trial with concealed allocation will enrol spontaneously ventilating adults with hypoxaemia within 72 hours of major abdominal surgery. Participants will receive either (1) usual care physiotherapy of a single education session (talk), daily walking of 10–15 min (walk) and four sessions of coached deep breathing and coughing (breathe) or (2) usual care physiotherapy plus four 30 min sessions of physiotherapist-led NIV delivered over 2 postoperative days. Primary feasibility and safety outcome measures are; number of eligible patients recruited per week, total time of NIV treatment delivered, acceptability of treatments to patients and clinicians and incidence of adverse events. Secondary feasibility outcomes include measures of recruitment and treatment adherence. Exploratory outcome measures include change in respiratory parameters, postoperative pulmonary complications, length of hospital stay, health-related quality of life, postoperative activity levels and mortality.Ethics and dissemination Ethics approval has been obtained from the relevant institution. Results will be published to inform future research.Trial registration number ACTRN12622000839707

Additional file 3: of ICEAGE (Incidence of Complications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery

WHODAS. World Health Organisation disability assessment scale. (DOCX 20 kb

Additional file 2: of ICEAGE (Incidence of Complications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery

EQ-5D-5L. EuroQual 5 Domains scoring. (DOCX 90 kb

Additional file 6: of ICEAGE (Incidence of Complications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery

ICEAGE Data Dictionary. Data fields for ICEAGE. (DOCX 18 kb

Physiotherapy management for COVID-19 in the acute hospital setting: Clinical practice recommendations

This document outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It includes: recommendations for physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the selection of physiotherapy treatments and personal protective equipment. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19

Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations

This document outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It includes: recommendations for physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the selection of physiotherapy treatments and personal protective equipment. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.status: publishe