Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge.

BACKGROUND: The study objective was to obtain consensus on physical therapy (PT) in the rehabilitation of critical illness survivors after hospital discharge. Research questions were: what are PT goals, what are recommended measurement tools, and what constitutes an optimal PT intervention for survivors of critical illness? METHODS: A Delphi consensus study was conducted. Panelists were included based on relevant fields of expertise, years of clinical experience, and publication record. A literature review determined five themes, forming the basis for Delphi round one, which was aimed at generating ideas. Statements were drafted and ranked on a 5-point Likert scale in two additional rounds with the objective to reach consensus. Results were expressed as median and semi-interquartile range, with the consensus threshold set at ≤0.5. RESULTS: Ten internationally established researchers and clinicians participated in this Delphi panel, with a response rate of 80 %, 100 %, and 100 % across three rounds. Consensus was reached on 88.5 % of the statements, resulting in a framework for PT after hospital discharge. Essential handover information should include information on 15 parameters. A core set of outcomes should test exercise capacity, skeletal muscle strength, function in activities of daily living, mobility, quality of life, and pain. PT interventions should include functional exercises, circuit and endurance training, strengthening exercises for limb and respiratory muscles, education on recovery, and a nutritional component. Screening tools to identify impairments in other health domains and referral to specialists are proposed. CONCLUSIONS: A consensus-based framework for optimal PT after hospital discharge is proposed. Future research should focus on feasibility testing of this framework, developing risk stratification tools and validating core outcome measures for ICU survivors.

Patient perceptions of ICU physiotherapy: 'Your body needs to go somewhere to be recharged '.

Background: Patient satisfaction is an essential concept to consider for the improvement of quality care in healthcare centres and hospitals and has been linked to increased patient compliance with treatment plans, better patient safety and improved clinical outcomes. Objectives: As part of a before-and-after clinical trial aimed to investigate the implementation of an evidence-based and -validated physiotherapy protocol within a surgical intensive care unit (ICU), we decided to include the patient perception of physiotherapy received in the intervention unit. Methods: A nested, exploratory, descriptive, qualitative study design was adopted. Purposively selected adult patients discharged from ICU during the implementation phase of the trial were interviewed. Results: Eighteen patients (10 male) with a median age of 44 years and median ICU length of stay (LOS) of six days were included. Three themes and nine categories emerged: (i) linking therapy to clinical outcome (patient expectations and understanding; physiotherapy activities and the implication of mobilisation; physiotherapy benefits and progression); (ii) the importance of developing a trusting relationship (physiotherapy value; safety; continuity of care); and (iii) communication (satisfaction; interactions and patient perception and experience of physiotherapy). Conclusion: While confirming barriers to early mobility, patients perceived participation in mobility activities as a marked jolt in their journey to recovery following a critical incident. Effective communication and preservation of trust between physiotherapist and patient are essential for understanding expectations and can facilitate improved outcomes. Clinicians can use the information when managing critically ill patients. Including patient-reported outcomes to measure physiotherapy interventions used in the ICU is feasible and can inform the development of such outcomes. Contribution of the study: The study highlights the feasibility and importance of the use of patient-reported outcomes to measure physiotherapy interventions and informs the development of patient reported outcomes and the importance of patient centred physiotherapy care in the ICU setting.

Substitution of high monounsaturated fatty acid avocado for mixed dietary fats during an energy-restricted diet: effects on weight loss, serum lipids, fibrinogen, and vascular function.

OBJECTIVE: First, we wanted to dispel the myth that avocados are fattening and therefore should be avoided in energy-restricted diets. Second, we examined the effects of avocados, a rich source of monounsaturated fatty acids, as part of an energy-restricted diet on weight loss, serum lipids, fibrinogen, and vascular function in overweight and obese subjects. METHODS: Sixty-one free-living volunteers (13 men and 48 women), with body mass index of 32 +/- 3.9 kg/m(2) (mean +/- standard deviation) participated in this randomized, controlled, parallel study. Subjects were paired and randomly assigned to one of two groups. The experimental group consumed 200 g/d of avocado (30.6 g of fat), which substituted for 30 g of other mixed dietary fats such as margarine or oil, and the control group excluded avocado from their energy-restricted diet for 6 wk. Seven-day isoenergetic menus were planned according to mean energy requirements of both sexes to provide total energy intakes consisting of 30% fat, 55% carbohydrates, and 15% protein. Anthropometric measurements, physical activity, blood pressure, and arterial compliance were measured with standard methods at the beginning and end of the intervention. Fasting blood samples were drawn at the beginning and end of the intervention. RESULTS: Fifty-five subjects completed the study. The compliance rate to avocado intake in the experimental group was 94.6%. The percentage of plasma oleic acid increased significantly with the consumption of avocado in the experimental group, whereas a decrease was seen in the percentage of myristic acid from baseline to the end of the intervention in both groups but was significant only in the experimental group. Anthropometric measurements (body mass, body mass index, and percentage of body fat) decreased significantly in both groups during the study (P < 0.001), and the change was similar in both groups. Serum lipid concentrations (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triacylglycerols), fibrinogen, blood pressure, and arterial compliance did not change significantly within or between groups. CONCLUSION: The consumption of 200 g/d of avocado within an energy-restricted diet does not compromise weight loss when substituted for 30 g of mixed dietary fat. Serum lipid concentrations, plasma fibrinogen, arterial compliance, and systolic and diastolic blood pressures were not affected by weight loss or avocado intake.

Implementation of a protocol facilitates evidence-based physiotherapy practice in intensive care units.

OBJECTIVES: To compare the physiotherapy service provided when therapists' decisions are guided by an evidence-based protocol with usual care (i.e. patient management based on therapists' clinical decisions). DESIGN: Exploratory, controlled, pragmatic sequential time block clinical trial. SETTING: Level 3 surgical unit in a tertiary hospital in South Africa. PARTICIPANTS: All patients admitted consecutively to the surgical unit over a 3-month period were allocated to usual or protocol care based on date of admission. INTERVENTIONS: Usual care was provided by clinicians from the hospital department, and non-specialised physiotherapists were appointed as locum tenens to provide evidence-based protocol care. MAIN OUTCOME MEASURES: Patient waiting time, frequency of treatment sessions, tasks performed and adverse events. RESULTS: During protocol-care periods, treatment sessions were provided more frequently (P<0.001) and with a shorter waiting period (P<0.001). It was more likely for a rehabilitation management option to be included in a treatment session during protocol-care periods (odds ratio 2.34, 95% confidence interval 1.66 to 3.43; P<0.001). No difference in the risk of an adverse event was found between protocol-care and usual-care periods (P=0.34). CONCLUSIONS: Physiotherapy services provided in intensive care units (ICUs) when the decisions of non-specialised therapists are guided by an evidence-based protocol are safe, differ from usual care, and reflect international consensus on current best evidence for physiotherapy in ICUs. Non-specialised therapists can use this protocol to provide evidence-based physiotherapy services to their patients. Future trials are needed to establish whether or not this will improve patient outcome.

Dietary intakes assessed by 24-h recalls in peri-urban African adolescents: validity of energy intake compared with estimated energy expenditure.

BACKGROUND/OBJECTIVE: The objective of this study is to determine the relative validity of reported energy intake (EI) derived from multiple 24-h recalls against estimated energy expenditure (EE(est)). Basal metabolic rate (BMR) equations and physical activity factors were incorporated to calculate EE(est). SUBJECTS/METHODS: This analysis was nested in the multidisciplinary PhysicaL Activity in the Young study with a prospective study design. Peri-urban black South African adolescents were investigated in a subsample of 131 learners (87 girls and 44 boys) from the parent study sample of 369 (211 girls and 158 boys) who had all measurements taken. Pearson correlation coefficients and Bland-Altman plots were calculated to identify the most accurate published equations to estimate BMR (P<0.05 statistically significant). EE(est) was estimated using BMR equations and estimated physical activity factors derived from Previous Day Physical Activity Recall questionnaires. After calculation of EE(est), the relative validity of reported energy intake (EI(rep)) derived from multiple 24-h recalls was tested for three data subsets using Pearson correlation coefficients. Goldberg's formula identified cut points (CPs) for under and over reporting of EI. RESULTS: Pearson correlation coefficients between calculated BMRs ranged from 0.97 to 0.99. Bland-Altman analyses showed acceptable agreement (two equations for each gender). One equation for each gender was used to calculate EE(est). Pearson correlation coefficients between EI(rep) and EE(est) for three data sets were weak, indicating poor agreement. CPs for physical activity groups showed under reporting in 87% boys and 95% girls. CONCLUSION: The 24-h recalls measured at five measurements over 2 years offered poor validity between EI(rep) and EE(est).