Prehabilitation in radiation therapy: a scoping review.

PURPOSE/OBJECTIVES: Radiation therapy (RT) is a central component of cancer treatment with survival and long-term quality-of-life benefits across a spectrum of oncologic diagnoses. However, RT has been associated with varying levels of fatigue, pain, weight loss, and changes in mental health both during and post-treatment. Prehabilitation aims to optimize health prior to anti-neoplastic therapy in order to reduce side effects, increase adherence to treatment, expedite post-treatment recovery, and improve long-term outcomes. Though prehabilitation has been studied in those undergoing cancer-related surgery, literature on prehabilitation in individuals undergoing RT has not been comprehensively explored. Thus, this scoping review aims to summarize the existing literature focused on prehabilitation interventions for patients receiving RT. MATERIALS/METHODS: The PRISMA-ScR checklist for conducting scoping reviews was adopted to identify and evaluate studies investigating the efficacy of prehabilitation before and during RT for cancer over the past 21 years (10/2002-10/2022). A search of prehabilitation and RT was performed to identify studies investigating prehabilitation interventions in adult cancer patients undergoing RT. RESULTS: A total of 30 articles met inclusion criteria, yielding 3657 total participants. Eighteen (60%) studies were randomized controlled trials (RCTs) with sample sizes ranging from 21 to 221. The most commonly studied populations were patients with head and neck cancer, followed by rectal, breast, and lung cancer. A majority (80%) of studies evaluated one prehabilitation intervention (i.e., unimodal). Targeted physical exercises were the most common intervention, followed by general physical exercises and technology/apps. Adherence/feasibility was the most common primary outcome, representing 30% of studies. All studies reported data on sex, and 5 (17%) reported data on race and/or ethnicity. CONCLUSIONS: Prehabilitation interventions have been successfully implemented in patients with cancer undergoing surgical treatment. Based on limited current literature, prehabilitation appears to have a promising effect in reducing morbidity in adult cancer patients requiring RT. Though our review identified many RCTs, they were frequently small sample trials with primary outcomes focused on feasibility, rather than functional status or quality of life. Thus, there is a need for adequately powered, randomized controlled intervention trials to investigate the efficacy of prehabilitation and maximize the treatment outcomes for patients undergoing RT.

Diversity, Equity, and Inclusion Curriculum Embedded in a Physical Medicine and Rehabilitation Residency Program.

ABSTRACT: Diversity, equity, and inclusion initiatives are continuing to have increased importance in medical training, including rehabilitation medicine. Although resident-led curricula have been integrated into medical education in other training programs, to our knowledge, this the first report focusing on integrating these topics into resident education for a physical medicine and rehabilitation program. We created a didactic curriculum for our rehabilitation residents that included: quarterly lectures on diversity, equity, and inclusion topics followed by small group discussions. Each session also included an article that was included in the discussion. The sessions used both anonymous presurvey and postsurvey data to assess the efficacy of our initiative. Our initial data showed that our quarterly sessions created a safe and comfortable environment for discussing diversity, equity, and inclusion topics. In addition, our session specific data supported that increased awareness of diversity, equity, and inclusion disparities with rehabilitation and medicine was achieved. Our committee used the data and feedback to create further iterations of this initiative within our program, and we believe that this is a model that can be adopted by other physical medicine and rehabilitation residencies.

The Role of Surgical Prehabilitation During the COVID-19 Pandemic and Beyond.

The challenging circumstances of the COVID-19 pandemic caused a regression in baseline health of disadvantaged populations, including individuals with frail syndrome, older age, disability, and racial-ethnic minority status. These patients often have more comorbidities and are associated with increased risk of poor postoperative complications, hospital readmissions, longer length of stay, nonhome discharges, poor patient satisfaction, and mortality. There is critical need to advance frailty assessments to improve preoperative health in older populations. Establishing a gold standard for measuring frailty will improve identification of vulnerable, older patients, and subsequently direct designs for population-specific, multimodal prehabilitation to reduce postoperative morbidity and mortality.

Addressing Rehabilitation Health Care Disparities During the Coronavirus Disease-2019 Pandemic and Beyond.

The coronavirus disease-2019 pandemic exposed and expanded upon preexisting health care disparities. Individuals with disabilities and those who identify with racial/ethnic minority groups have been disproportionately adversely impacted. These inequities are likely present in the proportions of individuals impacted by post-acute sequelae of severe acute respiratory syndrome coronavirus 2 infection requiring specialized rehabilitation. Specific populations including, but not limited to pregnant, pediatric, and older individuals, may also necessitate tailored medical care during acute infection and beyond. Telemedicine may reduce the care gap. Further research and clinical guidance are needed to provide equitable, culturally competent, and individualized care to these historically or socially marginalized and underrepresented populations.

Informed consent in episiotomy: Co-analysis with midwives and distillation of best practice.

BACKGROUND: Performing an episiotomy where clinically indicated is a key intervention in the Obstetric Anal Sphincter Injury Care Bundle (OASI-CB) implemented across England and Wales to reduce the risk and increase the detection of severe perineal trauma after birth. Standards of consent provided to people in maternity care generally and for episiotomy specifically have been reported as suboptimal. Compromising birthing people's personal autonomy or sense of control has been linked to a dissatisfying birth experience, negative psychological sequelae, and litigation. METHODS: This study explored experienced midwives' practice of informed consent for episiotomy during a midwife-led birth. We sampled 43 midwives across eight NHS Trusts in England and Wales using online focus groups and telephone interviews about their experience of consent in episiotomy. Using qualitative content analysis and art-based co-analysis methods with eight midwives from across the research sites, we co-analyzed and co-constructed three themes and four practice recommendations from the data. RESULTS: Three themes were constructed from the data: Assent rather than consent, Change in culture to support best practice, and Standardized information. These themes informed the shaping of four recommendations for best practice in episiotomy informed consent. CONCLUSION: This study has shown how variations in midwifery practice and culture may impact birthing people's experience of informed consent in episiotomy. Midwives may not have the knowledge or skills to conduct a detailed consent conversation, leading to variation in practice and messages for birthing people. The use of antenatal discussion aids can offer women the opportunity to become informed and fully participate in the decision-making process.

Red flags for episiotomy in a midwife-led birth: Using co-production with midwives to capture clinical experience.

BACKGROUND: One of four key points in the Obstetric Anal Sphincter Injury Care Bundle, first piloted in the UK in 2016, was the directive to perform episiotomy when clinically indicated. Midwives are the primary health care professional for straightforward births in the UK and there is very little published literature that relates to their practice in this area. AIM: The aim of the study was to explore experienced midwives' decision-making processes in their assessments for episiotomy during birth. METHODS: 43 midwives self-identifying as confident in performing episiotomy were sampled across 8 NHS Trusts in England and Wales. Data collection was via online focus groups and 1:1 interviews. Primary thematic analysis was undertaken by the research team. Preliminary themes were used to structure a co-production analysis workshop where eight experienced midwives undertook a secondary analysis of the data resulting in four overall themes. FINDINGS: Four themes were identified, 'Optimising Perineal Function', 'Red Flags to Stimulate Decision-Making', 'The Midwives' Episiotomy' and 'Infiltration as a Catalyst for Birth'. DISCUSSION: Midwives use a number of visual, auditory and touch cues to inform their assessments for episiotomy during birth. CONCLUSION: This study provides valuable insight into the cues that guide experienced midwives' decision-making in relation to episiotomy and contributes evidence related to performing episiotomy when clinically indicated in spontaneous vaginal birth.

Cancer Prehabilitation in Practice: the Current Evidence.

PURPOSE OF REVIEW: This article serves to describe recent controversies in cancer prehabilitation including efficacy, dose, cost effectiveness, stakeholder input, and international implementation. RECENT FINDINGS: Appropriate frequency, type, and timing have yet to be determined, but high intensity exercise is recommended. Costs are favorable when modeled and information on costs of real-world application are forthcoming. Patients are interested in and willing to attend cancer prehabilitation. Cancer prehabilitation research is spreading throughout the world. Cancer prehabilitation includes assessment of a newly diagnosed cancer patient's baseline fitness and targeted interventions to improve their health before surgery, chemotherapy, or radiation. Cancer prehabilitation improves fitness as measured preoperatively and improves outcomes postoperatively.

Physical and Psychological Health Behavior Changes During the COVID-19 Pandemic that May Inform Surgical Prehabilitation: a Narrative Review.

Purpose of Review: Multimodal prehabilitation aims to improve preoperative health in ways that reduce surgical complications and expedite post-operative recovery. However, the extent to which preoperative health has been affected by the COVID-19 pandemic is unclear and evidence for the mitigating effects of prehabilitation in this context has not been elucidated. The COVID-19 pandemic has forced a rapid reorganization of perioperative pathways. Delayed diagnosis and surgery have caused a backlog of cases awaiting surgery increasing the risk of more complex procedures due to disease progression. Poor fitness and preoperative deconditioning are predictive of surgical complications and may be compounded by pandemic-related restrictions to accessing supportive services. The COVID-19 pandemic has forced a rapid reorganization of perioperative pathways. This narrative review aims to summarize the understanding of the effects of the COVID-19 pandemic on preoperative health and related behaviors and their implication for the need and delivery for prehabilitation to engender improved surgical outcomes. A literature search of Medline was conducted for articles related to preoperative health, prehabilitation, and surgical outcomes published between December 1, 2020 and January 31, 2021. Additional hand searches for relevant publications within the included literature were also conducted through October 15, 2021. Recent Findings: The COVID-19 pandemic, and measures designed to reduce the spread of the virus, have resulted in physical deconditioning, deleterious dietary changes, substance misuse, and heightened anxiety prior to surgery. Due to the adverse health changes prior to surgery, and often protracted waiting time for surgery, there is likely an elevated risk of peri- and post-operative complications. A small number of prehabilitation services and research programmes have been rapidly adapted or implemented to address these needs. Summary: During the COVID-19 pandemic to date, people undergoing surgery have faced a triple threat posed by extended wait times for surgery, reduced access to supportive services, and an elevated risk of poor outcomes. It is imperative that healthcare providers find ways to employ evidence-based prehabilitation strategies that are accessible and safe to mitigate the negative impact of the pandemic on surgical outcomes. Attention should be paid to cohorts most affected by established health inequities and further exacerbated by the pandemic.

Author Diversity on Clinical Practice Guideline Committees.

ABSTRACT: Reports have demonstrated that women overall and women physicians, in particular, are underrepresented as authors of clinical practice guidelines. This analysis used publicly available information to explore the diversity of rehabilitation-related clinical practice guideline authors by gender, race, and ethnicity. Primary analysis identified authors' gender, race, ethnicity, and visible minority status. Two sets were analyzed: (1) clinical practice guidelines by Department of Veterans Affairs (VA) categorized as "Rehabilitation" or "Pain" (n = 7; VA clinical practice guidelines) and (2) a set (n = 10) published in the United States (US) from 2019 to 2021 that were selected because of low numbers of inclusion at less than 20% women authors. Key findings include that among physician authors, both the VA and US clinical practice guidelines underrepresented women (15 [24.2%] and 27 [16.7%], respectively) and those coded as a racial or ethnic minority were particularly underrepresented. Notably, women authors overall were equally represented (92 [50.0%]) in the VA clinical practice guidelines. The US clinical practice guidelines had women authors who were underrepresented (36 [19.0%]). Secondary analysis of the entire set of VA clinical practice guidelines (n = 21) found gaps in diversity-related content. Clinical practice guidelines have far-reaching health and economic impacts, and addressing disparities in the diversity of author teams and/or gaps in diversity-related content is of paramount importance.

A Randomized, Double-Blind, Placebo-Controlled Study of Neuromuscular Electrical Stimulation (NMES) use for Recovery after Elective Total Hip Replacement Surgery.

Early physical activity has been proven to accelerate functional recovery after total hip replacement (THR). Weightbearing intolerance secondary to postoperative pain inhibits participation in physical therapy and limits the achievement of functional independence. Neuromuscular electrical stimulation (NMES) has been shown to improve pain and accelerate recovery. This study focused on the effects of NMES on weightbearing pain. The primary objective of this study was to compare the efficacy of NMES versus placebo in the reduction of pain and the use of opiate medications in the treatment of patients during weightbearing exercises after THR. A secondary objective was to assess the use of NMES during weightbearing exercise and its effects on function, hospital length of stay, and disposition planning. This was a randomized, doubleblinded, placebo-controlled study performed with subjects obtained from an outpatient orthopaedic service. Subject underwent elective THR. The NMES device was provided to all subjects; active and a control group were assigned different intensity levels of stimulation. Twenty-nine subjects participated in the study: 15 in the active and 14 in the control group. Data, including pain assessment, opiates use, function, hospital length of stay in days, and disposition was recorded and analyzed. Both control and active groups showed no significant difference on the pain visual analog scale at various postoperative time intervals, length of inpatient hospital stay, and days on opiate medications.

No evidence for race and socioeconomic status as independent predictors of 30-day readmission rates following orthopedic surgery.

The Centers for Medicare & Medicaid Services considers readmissions within 30 days of discharge to be a quality indicator. Hospitals' and eventually physicians' readmission rates will be used to determine payment for services. It is imperative that health care providers understand which patients are at risk for readmission so that they can apply the appropriate preventive interventions. The research team analyzed all orthopedic admissions and readmissions at their institution from September 2008 to April 2011 in this study. Preparing for the next stage in health care reform, identifying any preoperative factors that may place certain patients into a "high-risk" category for readmission following an orthopedic procedure is of paramount importance. This data analysis of more than 13 000 patients noted that race-based and income-based risk factors did not translate into significant risk factors or predictors of 30-day readmission following orthopedic admission.

Rapid mobilization decreases length-of-stay in joint replacement patients.

BACKGROUND: Physiotherapy after total joint replacement enhances postoperative recovery. Implementing a pathway to include earlier postoperative mobilization can reduce the hospital length-of-stay as well as cost. QUESTIONS: Does a rapid rehabilitation program con- sisting of physical therapy on the day of surgery affect the hospital length-of-stay on patients undergoing either total hip or total knee replacements? Is there a difference in the effectiveness of rapid rehabilitation between patients under- going Total Hip and Total Knee Replacements? Can these patients tolerate day of surgery physical therapy sessions? PATIENTS AND METHODS: Nine-hundred hip and knee arthro- plasty patients were divided into two groups for analysis. Group 1 participated in a rapid rehabilitation physical therapy program that began with physical therapists in the recovery room. Group 2 received a standard physical therapy protocol starting the day after surgery. Progression with rehabilitation was followed, and length of hospital stay between the two groups was compared. RESULTS: Total length-of-stay was 3.9 days for the rapid rehabilitation group and was 4.4 days (p < 0.001) for the standard therapy group. We found the rapid rehabilitation group had a significantly shorter length-of-stay than patients who began therapy on postoperative day one. In addition to decreased length-of-stay, rapid rehabilitation also resulted in direct savings considering fewer hospital resources were utilized over the decreased time in-house. CONCLUSIONS: Rapid mobilization of total joint replacement patients in the recovery room can be accomplished safely and reduces the overall length of hospital stay for over 70 % of patients.

Fourier transform infrared spectroscopic imaging parameters describing acid phosphate substitution in biologic hydroxyapatite.

Acid phosphate substitution into mineralized tissues is an important determinant of their mechanical properties and their response to treatment. This study identifies and validates Fourier transform infrared spectroscopic imaging (FTIRI) spectral parameters that provide information on the acid phosphate (HPO4) substitution into hydroxyapatite in developing mineralized tissues. Curve fitting and Fourier self-deconvolution were used to identify subband positions in model compounds (with and without HPO4). The intensity of subbands at 1127 and 1110 cm(-1) correlated with the acid phosphate content in these models. Peak height ratios of these subbands to the ν3 vibration at 1096 cm(-1) found in stoichiometric apatite were evaluated in the model compounds and mixtures thereof. FTIRI spectra of bones and teeth at different developmental ages were analyzed using these spectral parameters. Factor analysis (a chemometric technique) was also conducted on the tissue samples and resulted in factor loadings with spectral features corresponding to the HPO4 vibrations described above. Images of both factor correlation coefficients and the peak height ratios 1127/1096 and 1112/1096 cm(-1) demonstrated higher acid phosphate content in younger vs. more mature regions in the same specimen. Maps of the distribution of acid phosphate content will be useful for characterizing the extent of new bone formation, the areas of potential decreased strength, and the effects of therapies such as those used in metabolic bone diseases (osteoporosis, chronic kidney disease) on mineral composition. Because of the wider range of values obtained with the 1127/1096 cm(-1) parameter compared to the 1110/1096 cm(-1) parameter and the smaller scatter in the slope, it is suggested that this ratio should be the parameter of choice.

An analysis of causes of readmission after spine surgery.

STUDY DESIGN: Retrospective review of medical records. OBJECTIVE: We reviewed all early readmissions after elective spine surgery at a single orthopedic specialty hospital to analyze the causes of unplanned readmissions. SUMMARY OF BACKGROUND DATA: Recent advances in techniques and instrumentation have made more complex spinal surgeries possible, although sometimes with more complications. Early readmission rate is being used as a marker to evaluate quality of care. There is little data available regarding the causes of early readmissions after spine surgery. METHODS: Using the hospital's administrative database of patient records from 2007 to 2009, all patients who underwent spine surgery and were readmitted to the hospital within 30 days were identified and broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Analysis was focused on 12 common spine procedures based on the principle procedure International Classification of Diseases, Ninth Revision, Clinical Modification code for the patient's initial admission. The readmission rate was calculated for each procedure. RESULTS: A total of 156 early readmissions were identified, of which 141 were unplanned. Of the unplanned readmissions, the most common causes were infection or a concern for an infection (45 patients, 32% of unplanned readmissions), nonsurgical complications (31 patients, 22% of readmissions), complications requiring surgical revision (21 patients, 15% of readmissions), and wound drainage (12 patients, 9% of readmissions). Fifty-seven percent of unplanned readmissions required a return to the operating room (76% of infections or concern for infection). The average length of stay for the unplanned readmissions was 6.5 days. When using the 12 most common procedures based on the International Classification of Diseases, Ninth Revision, Clinical Modification, the early readmission rate was 3.8% (141 early readmissions in 3673 procedures). CONCLUSION: Infection, medical complications after surgery, and surgical complications requiring revision of implants are the primary causes of unplanned early readmissions and spine surgery. Further studies are necessary to identify patients and procedures most associated with readmission.

Depression as a longitudinal outcome and antecedent of preadolescents' peer relationships and peer-relevant cognition.

Using longitudinal data and structural modeling, we investigated bidirectional associations among preadolescents' peer relationships, peer-relevant cognition, and depressive symptoms. Depression was expected to be an outcome and precursor of peer-relevant cognition, and cognition was expected to be an outcome and precursor of being more or less liked by classmates (peer likeability). We also examined whether cognition mediated the association between peer likeability and depression. Participants were 308 students (mean age = 11.0, SD = 0.9) who participated twice during a school year. A third assessment was completed with Grade 5 to 6 students 1 year after the second assessment. The model with bidirectional paths had a good fit to the data, but the most parsimonious model was an "effects" model showing that preadolescents with more depressive symptoms had less positive peer-relevant cognition at later assessments, and that those with more positive peer-relevant cognition were more liked by their peers over time. There were no age differences, some gender differences, and no support for cognition as a moderator of the association between depression and peer likeability.