Response to physical rehabilitation and recovery trajectories following critical illness: individual participant data meta-analysis protocol.

INTRODUCTION: The number of inconclusive physical rehabilitation randomised controlled trials for patients with critical illness is increasing. Evidence suggests critical illness patient subgroups may exist that benefit from targeted physical rehabilitation interventions that could improve their recovery trajectory. We aim to identify critical illness patient subgroups that respond to physical rehabilitation and map recovery trajectories according to physical function and quality of life outcomes. Additionally, the utilisation of healthcare resources will be examined for subgroups identified. METHODS AND ANALYSIS: This is an individual participant data meta-analysis protocol. A systematic literature review was conducted for randomised controlled trials that delivered additional physical rehabilitation for patients with critical illness during their acute hospital stay, assessed chronic disease burden, with a minimum follow-up period of 3 months measuring performance-based physical function and health-related quality of life outcomes. From 2178 records retrieved in the systematic literature review, four eligible trials were identified by two independent reviewers. Principal investigators of eligible trials were invited to contribute their data to this individual participant data meta-analysis. Risk of bias will be assessed (Cochrane risk of bias tool for randomised trials). Participant and trial characteristics, interventions and outcomes data of included studies will be summarised. Meta-analyses will entail a one-stage model, which will account for the heterogeneity across and the clustering between studies. Multiple imputation using chained equations will be used to account for the missing data. ETHICS AND DISSEMINATION: This individual participant data meta-analysis does not require ethical review as anonymised participant data will be used and no new data collected. Additionally, eligible trials were granted approval by institutional review boards or research ethics committees and informed consent was provided for participants. Data sharing agreements are in place permitting contribution of data. The study findings will be disseminated at conferences and through peer-reviewed publications. PROSPERO REGISTRATION NUMBER: CRD42019152526

Early mobilisation in mechanically ventilated patients:A systematic integrative review of definitions and activities

From PubMed via Jisc Publications RouterHistory: received 2018-10-23, accepted 2018-12-11Publication status: epublishMechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature. Whittemore and Knafl's framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies. Seventy-six studies were included from which four major themes were inferred: (1) , (2) , (3) and (4) . The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients' characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation. This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite

Enhanced Learning Using Digital Recordings with Integrated Standardized Patient Examinations (ISPEs) in Physical Therapy Education: A Qualitative Pilot Study

(1) Background: Integrated standardized patient examinations (ISPEs) allow students to demonstrate competence with curricular learning and communication. Digital recordings of these experiences provide an objective permanent record, allowing students to review and improve their performance. Although recordings have been utilized as a tool in physical therapy education, no studies have described the impact of reviewing recordings of ISPE. This qualitative pilot study aimed to investigate student perceptions and learning after reviewing their recordings of ISPE. (2) Methods: Second-year Doctor of Physical Therapy students (n= 23) participated in the study by completing an anonymous online survey after reviewing their recordings from three ISPEs. Thematic analysis was used to identify codes and central themes from the survey data. (3) Results: The results showed that 95.6% of students found the video review process beneficial. Five themes emerged: (i) digital recordings provide an objective performance assessment, (ii) approaches to self-review vary, (iii) it provides an opportunity for growth, (iv) a holistic review is possible, and (v) students need structure and guidance in the process. (4) Conclusions: Study findings indicate that a review of the recordings of ISPEs facilitates the development of clinical skills for physical therapy students. Implementing an explicit framework for reviewing the recordings may enhance the process and facilitate further promotion of reflection-on-action

Prolonged acute care and post-acute care admission and recovery of physical function in survivors of acute respiratory failure: a secondary analysis of a randomized controlled trial

Abstract Background The proportion of survivors of acute respiratory failure is growing; yet, many do not regain full function and require prolonged admission in an acute or post-acute care facility. Little is known about their trajectory of functional recovery. We sought to determine whether prolonged admission influenced the trajectory of physical function recovery and whether patient age modified the recuperation rate. Methods We performed a secondary analysis of a randomized clinical trial of intensive physical therapy for patients with acute respiratory failure requiring mechanical ventilation for ≥4 days. The primary outcome was Continuous Scale Physical Functional Performance, short form (CS-PFP-10), score. Predictor variables included prolonged admission in an acute or post-acute care facility at 1 month, time, and patient age. To determine whether the association between admission and functional outcome varied over time, a multivariable mixed effects linear regression model was fit using an interaction between prolonged admission and time with a primary outcome of total CS-PFP-10 score. Results Of the 89 patients included, 56% (50 of 89) required prolonged admission. At 1 month, patients who remained admitted had CS-PFP-10 scores that were 20.1 (CI 10.4–29.8) points lower (p < 0.0001) than patients who were discharged to home. However, there was no difference in the rate at which physical function improved from 3 to 6 months for patients who required prolonged admission compared with those who returned home (p = 0.24 for interaction between prolonged admission and time). Adjusted for age, Acute Physiology and Chronic Health Evaluation II score, and sex, both groups had CS-PFP-10 scores that were 8.2 (CI 4.5–12.0) points higher at 6 months than at 3 months (p < 0.0001). For each additional year in patient age, CS-PFP-10 recovered 0.36 points slower (95% CI 0.12–0.61; p = 0.004). Conclusions Patients who require prolonged admission after acute respiratory failure have significantly lower physical functional performance than patients who return home. However, the rates of physical functional recovery between the two groups do not differ. The majority of survivors do not recover sufficiently to achieve functional independence by 6 months. Older age negatively influences the trajectory of functional recovery. Trial registration ClinicalTrials.gov, NCT01058421 . Registered on 26 January 2010

The Physical Function Intensive Care Test: Implementation in Survivors of Critical Illness

BACKGROUND: Recent studies have demonstrated safety, feasibility, and decreased hospital length of stay for patients with weakness acquired in the intensive care unit (ICU) who receive early physical rehabilitation. The scored Physical Function in Intensive Care Test (PFIT-s) was specifically designed for this population and demonstrated excellent psychometrics in an Australian ICU population. OBJECTIVE: The purpose of this study was to determine the responsiveness and predictive capabilities of the PFIT-s in patients in the United States admitted to the ICU who required mechanical ventilation (MV) for 4 days or longer. METHODS: This nested study within a randomized trial administered the PFIT-s, Medical Research Council (MRC) sum score, and grip strength test at ICU recruitment and then weekly until hospital discharge, including at ICU discharge. Spearman rho was used to determine validity. The effect size index was used to calculate measurement responsiveness for the PFIT-s. The receiver operating characteristic curve was used in predicting participants' ability to perform functional components of the PFIT-s. RESULTS: From August 2009 to July 2012, 51 patients were recruited from 4 ICUs in the Denver, Colorado, metro area. At ICU discharge, PFIT-s scores were highly correlated to MRC sum scores (rho=.923) and grip strength (rho=.763) (P<.0005). Using baseline test with ICU discharge (26 pairs), test responsiveness was large (1.14). At ICU discharge, an MRC sum score cut-point of 41.5 predicted participants' ability to perform the standing components of the PFIT-s. LIMITATIONS: The small sample size was a limitation. However, the findings are consistent with those in a larger sample from Australia. CONCLUSIONS: The PFIT-s is a feasible and valid measure of function for individuals who require MV for 4 days or longer and who are alert, able to follow commands, and have sufficient strength to participate

ISCHEMIA-INDUCED REDUCTION OF SOMATOSENSORY INPUT DECREASES BALANCE; ADDED VIBRATORY NOISE PARTIALLY RESTORES FUNCTION

In this project we mimicked loss of sensation in the feet, commonly seen in diabetic patients, through an ischemic protocol, a reduction of circulation in young healthy adults. This loss of sensation resulted in changes in balance like those seen in diabetic patients that are prone to falls. We then tested the effectiveness of a vibratory device to improve balance. Purpose (a): We investigated the feasibility of using vibrotactile biofeedback to improve balance in healthy young adults in which the somatosensory information from their feet has been temporarily decreased. We hypothesized that though stochastic resonance, vibratory noise applied just proximal to a region of reduced somatosensation will improve ability to maintain balance. Methods (b): Ten healthy young individuals aged 18 to 25 years old gave informed consent and participated in this study. We experimentally induced “somatosensory loss” in non-diabetic young healthy subjects using pressure cuffs wrapped around the ankles, kept inflated at 220-250mmHg for 35 min. A vibrotactile biofeedback system was positioned just above the pressure cuffs. An array of vibrotactile actuators, under a Texas Instruments MSP430 microcontroller, produced vibration at two frequencies: a barely perceptible low frequency and a high vibration frequency. Data was collected at baseline before the pressure cuffs were inflated and during the last 15 minutes of the ischemic protocol under three conditions: no vibration, low frequency and high frequency vibrations. Outcome measures included: centre of pressure (COP) variability with subjects standing with feet side by side/ one foot, with eyes open/closed; plantar surface pressure sensation and vibratory threshold evaluated with Siemens Monofilaments and Rydel-Seiffer tuning fork, respectively. Results (c): In single limb support with eyes closed, ischemia increases the COP variability (p=.01) and the addition of vibrotactile feedback at both frequencies decreases it baseline values. Plantar surface pressure sensation threshold increased after ischemia (p=.03) and was decreased with the added vibrotactile feedback. The vibratory extension threshold measured at the hallux IP joint was decreased by ischemia (p. Conclusions (d): The ischemic protocol produced balance changes in healthy young adults. The vibratory biofeedback was able to partially compensate for the experimental induced sensory loss and improve balance function. Most diabetic patients become “visually dependent” due to peripheral neuropathy, and may experience falls at night or when they turn their head or talk to someone while walking. The next step of this research is to test the effectiveness of a vibrotactile biofeedback to decrease the risk for falls in diabetic adults with peripheral neuropathies

Service-Learning Enhances Physical Therapy Students\u27 Ability to Examine Fall Risk in Older Adults

Service-learning (SL) is one educational methodology that provides students opportunities to practice and refine affective, cognitive and psychomotor skills in a community-based setting. PURPOSE: The aims of this study were: 1) to investigate the impact of SL on physical therapy (PT) students\u27 attitudes and perceived clinical competence when working with older adults, and 2) to evaluate the difference between perceptions of students who developed and implemented the SL activity vs those who implemented only. METHODS: Eighty PT students, (from two consecutive cohorts) enrolled in a first-year geriatrics course, participated in this study. The first cohort designed and implemented the SL activities, while the second cohort only implemented these activities. Student self-perceived anxiety, confidence, knowledge and skills were assessed by pre-And post-SL surveys using a 5- point Likert-like scale. RESULTS: Both cohorts reported similar anxiety and confidence levels pre-SL. For both cohorts, with the exception of one item, all responses to anxiety items significantly decreased from pre-To post-SL. All students\u27 confidence levels for assessing and mitigating fall risk in older adults increased post-SL (p ‹ 0.01). Moreover, students in cohort 1, who designed and delivered SL activities, expressed self-perceived improvement in their ability to interpret results of evaluations, to determine type and severity of balance impairments, and to serve a geriatric population (p ‹ 0.05) compared to students in cohort 2 who only implemented the activities. CONCLUSION: Embedding SL into a geriatrics course decreased self-perceived anxiety and improved student confidence regarding working with older adults. Also, empowering students to be actively involved in the design and implementation of SL increased self-perceived ability in interpreting results from assessments. J Allied Health 2017; 46(3):e51-e58