The feasibility of using mouthpiece ventilation in the intensive care unit for post-extubation breathing support after acute tetraplegia.

STUDY DESIGN: A prospective cohort of patients with acute tetraplegia. OBJECTIVES: This study aimed to determine the feasibility of using mouthpiece ventilation (MPV) in the intensive care unit (ICU) for patients who are extubated after suffering an acute cervical spinal cord injury (CSCI). SETTING: ICU, Princess Alexandra Hospital, Brisbane Australia. METHODS: New admissions to ICU in the 14 months between April 2017 and June 2018 with a CSCI who underwent intubation were assessed for inclusion. MPV was provided to consenting participants (who were deemed likely to be able to maintain ventilation on their own) at the time of extubation and was utilised in addition to standard care while participants were awake. MPV settings, usage, and support hours to educate and facilitate MPV were collected. Feedback from participants and clinical staff was gathered throughout the study. Pre- and post-extubation measures of forced vital capacity (FVC), the frequency of endotracheal suction of sputum, and gas exchange using ventilation-perfusion ratios were recorded along with the incidence of reintubation. RESULTS: Fourteen participated in utilising MPV with 16 episodes of extubation. The average time per participant to have MPV titrated and bedside data collected was 178 minutes. Data from 16 episodes of extubation have been included. Three of the 14 participants failed initial extubation. Feedback from participants and clinicians has been positive and constructive, enabling MPV settings to be adapted to the person with acute CSCI during this pilot study. CONCLUSION: MPV is feasible to use post-extubation for people with CSCI in ICU. Pressure control mode MPV was deemed the most suitable for newly extubated acute CSCI patients. Intensive clinical support is required initially to provide education prior to MPV, and at the time of extubation for both patient and treating clinicians. Both report it to be a useful adjunct to ICU treatment.

Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study.

BACKGROUND: Critical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward. OBJECTIVES: The objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach-style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation. METHODS: A new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions. RESULTS: The service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care. CONCLUSIONS: Critical care outreach-style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.

Improving physical activity after stroke via treadmill training and self management (IMPACT): a protocol for a randomised controlled trial.

BACKGROUND: The level of physical activity undertaken by stroke survivors living in the community is generally low. The main objectives of the IMPACT trial are to determine, in individuals undergoing rehabilitation after stroke, if 8 weeks of high-intensity treadmill training embedded in self-management education (i) results in more physical activity than usual physiotherapy gait training and (ii) is more effective at increasing walking ability, cardiorespiratory fitness, self-efficacy, perception of physical activity, participation, and health-related quality of life as well as decreasing cardiovascular risk, and depression, at 8 and 26 weeks. METHODS: A prospective, two-arm, parallel-group, randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis, will be conducted. 128 stroke survivors undergoing rehabilitation who are able to walk independently will be recruited and randomly allocated to either the experimental or control group, who will both undergo gait training for 30 min, three times a week for 8 weeks under the supervision of a physiotherapist. Outcomes will be measured at baseline (Week 0), on completion of the intervention (Week 8) and beyond the intervention (Week 26). This study has obtained ethical approval from the relevant Human Research Ethics Committees. DISCUSSION: Improving stroke survivors' walking ability and cardiorespiratory fitness is likely to increase their levels of physical activity. Furthermore, if education in self-management results in sustained high levels of physical activity, this should result in improved participation and quality of life. TRIAL REGISTRATION: This trial was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000744752 ) on 4th July, 2013.

Exercise training for improving outcomes post-burns: a systematic review and meta-analysis.

OBJECTIVES: To determine the effectiveness of different modalities of exercise and to evaluate the safety of exercise-based interventions post-burns. DATA SOURCES: Six databases were searched from inception to October 2017 using "burn," "exercise" and synonyms as keywords. Relevant authors, key journals and reference lists of included studies were hand-searched. REVIEW METHODS: Articles reporting on exercise interventions in patients post-burn and considering physical, physiological or psychological outcomes were considered. Two authors independently screened 2253 records and selected 19 articles for inclusion. The quality of the evidence was assessed at the study level and at the outcome level. RESULTS: Unbiased effect size estimators (pooled Hedges' g) with 95% confidence intervals (CIs) were calculated if there were two or more trials with homogeneous outcomes. There were no significant differences post-exercise training in VO2peak ( g = 0.99; 95% CI: -0.4 to 2.4: P = 0.18), resting energy expenditure ( g = -0.51; 95% CI: -1.99 to 0.97: P = 0.5) and muscle strength ( g = 0.51; 95% CI: -0.03 to 1.05: P = 0.07) between groups. Evidence suggested exercise had a beneficial effect on body composition ( g = 0.59; 95% CI: 0.05 to 1.14: P = 0.03), need of surgical release of contractures (risk ratio = 0.34; 95% CI: 0.2 to 0.7; P = 0.004) and health-related quality of life. However, a lack of evidence existed regarding the safety of exercise training post-burns. CONCLUSION: Limited evidence suggests that exercise has a beneficial effect on physical and physiological outcomes in patients post-burn. Further trials using high-quality methodology are required, with focus on reporting of adverse events, health-related quality of life and psychological outcomes.

Secretion clearance strategies in Australian and New Zealand Intensive Care Units.

INTRODUCTION/AIMS: To describe the processes of care for secretion clearance in adult, intubated and mechanically ventilated patients in Australian and New Zealand Intensive Care Units (ICUs). METHODS/RESULTS: A prospective, cross-sectional study was conducted through the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG) Point Prevalence Program. Forty-seven ICUs collected data from 230 patients intubated and ventilated on the study day. Secretion clearance techniques beyond standard suctioning were used in 84/230 (37%) of patients during the study period. Chest wall vibration 34/84 (40%), manual lung hyperinflation 24/84 (29%), chest wall percussion 20/84 (24%), postural drainage/patient positioning 17/84 (20%) and other techniques including mobilisation 15/84 (18%), were the most common secretion clearance techniques employed. On average (SD), patients received airway suctioning 8.8 (5.0) times during the 24-h study period. Mucus plugging events were infrequent (2.7%). The additional secretion clearance techniques were provided by physiotherapy staff in 24/47 (51%) ICUs and by both nursing and physiotherapy staff in the remaining 23/47 (49%) ICUs. CONCLUSION: One-third of intubated and ventilated patients received additional secretion clearance techniques. Mucus plugging events were infrequent with these additional secretion clearance approaches. Prospective studies must examine additional secretion clearance practices, prevalence of mucus plugging episodes and impact on patient outcomes.

A new marker of sepsis post burn injury?*.

OBJECTIVES: Accurate diagnosis of sepsis is difficult in patients post burn due to the large inflammatory response produced by the major insult. We aimed to estimate the values of serum N-terminal pro-B-type natriuretic peptide and procalcitonin and the changes in hemodynamic variables as markers of sepsis in critically ill burn patients. DESIGN: Prospective, observational study. SETTING: A quaternary-level university-affiliated ICU. PATIENTS: Fifty-four patients with burns to total body surface area of greater than or equal to 15%, intubated with no previous cardiovascular comorbidities, were enrolled. INTERVENTIONS: At admission, a FloTrac/Vigileo system was attached and daily blood samples taken from the arterial catheter. Infection surveillance was carried out daily with patients classified as septic/nonseptic according to American Burns Consensus criteria. MEASUREMENTS AND MAIN RESULTS: N-terminal pro-B-type natriuretic peptide, procalcitonin, and waveform analysis of changes in stroke volume index and systemic vascular resistance index were measured within the first 24 hours after burn and daily thereafter for the length of the ICU stay or until their first episode of sepsis. Prevalences of stroke volume variation less than 12% (normovolemia) with hypotension (systolic blood pressure < 90 mm Hg) were recorded. Patients with sepsis differed significantly from "no sepsis" for N-terminal pro-B-type natriuretic peptide, systemic vascular resistance index, and stroke volume index on days 3-7. Procalcitonin did not differ between sepsis and "no sepsis" except for day 3. Area under the receiver operating characteristic curves showed excellent discriminative power for B-type natriuretic peptide (p = 0.001; 95% CI, 0.99-1.00), systemic vascular resistance index (p < 0.001; 95% CI, 0.97-0.99), and stroke volume index (p < 0.01; 95% CI, 0.96-0.99) in predicting sepsis but not for procalcitonin (not significant; 95% CI, 0.29-0.46). A chi-square crosstab found that there was no relationship between hypotension with normovolemia (stroke volume variation < 12%) and sepsis. CONCLUSIONS: Serum N-terminal pro-B-type natriuretic peptide levels and certain hemodynamic changes can be used as an early indicator of sepsis in patients with burn injury. Procalcitonin did not assist in the early diagnosis of sepsis.

Cardiovascular mortality post burn injury.

BACKGROUND: Burn injury is responsible for both acute and ongoing inflammation, resulting in systematic changes impacting the cardiovascular, hepatobiliary, endocrine, and metabolic systems, but there is minimal investigation into long-term clinical outcomes. This study aimed to investigate mortality due to cardiovascular related long-term postburn injury. METHODS: This was a retrospective cohort study linking a burns unit database with mortality outcomes from a Registry of Births, Deaths and Marriages. Data were extracted from the Australian Institute of Health and Welfare and stratified into three age groups: 15 to 44 years, 45 to 64 years, and 65+ years. Mortality rate ratios (MRRs) and 95% confidence interval (CI) were calculated to compare the burns cohort mortality incidence rates with the national mortality incidence rates for each of the three age groups. Logistic regression was used to identify demographic and clinical factors associated with cardiovascular mortality. RESULTS: A total of 4,134 individuals in the database were analyzed according to demographic and clinical variables. The 20-year age-standardized cardiovascular mortality rate for the burns cohort was significantly higher compared with the Australian population (250.6 per 100,000 person-years vs. 207.9 per 100,000 person-years) (MRR, 1.21; 95% CI, 1.001-1.45). Cardiovascular mortality was significantly higher in males aged 15-44 and 45-64 years had a cardiovascular mortality rate significantly higher than the Australian population (MRR = 10.06, 95% CI 3.49-16.63), and (MRR = 2.40, 95% CI 1.42-3.38) respectively. Those who died of cardiovascular disease were more frequently intubated postburn injury ( p = 0.01), admitted to intensive care ( p < 0.0001), and had preexisting comorbid physical conditions (60.9% vs. 15.0%, p < 0.0001). CONCLUSION: Survivors from burn injury, especially young males, are at increased long-term risk of death from cardiovascular disease. Increased screening and counseling pertaining to lifestyle factors should be standard management postburn injury. Longitudinal observation of physiological changes, investigation of mechanistic factors, and investigation of interventional strategies should be instituted. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Abdominal binder improves lung volumes and voice in people with tetraplegic spinal cord injury.

OBJECTIVE: To investigate the effect of an elasticated abdominal binder on respiratory, voice, and blood pressure outcomes for people with a motor complete acute tetraplegia during the first year after injury. DESIGN: Randomized crossover study. SETTING: Large university-affiliated referral hospital. PARTICIPANTS: Consenting participants (N=14, 13 men and 1 woman) with recent, motor complete, C3-T1 spinal cord injury. INTERVENTIONS: Abdominal binder on/off with participant seated in upright wheelchair, with 3 repeated measures at 6 weeks, 3 months, and 6 months after commencing daily use of an upright wheelchair. MAIN OUTCOME MEASURES: Forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximal expiratory pressure were measured. Mean arterial pressure, maximum sustained vowel time, and sound pressure level were also measured. RESULTS: Overall, an abdominal binder resulted in a statistically significant improvement in forced vital capacity (weighted mean difference .34 L [95% confidence interval (CI) .10-.58], P=.005), forced expiratory volume in 1 second (.25 L [95% CI -.01 to .51], P=.05), peak expiratory flow (.81 L/s [95% CI .13-1.48], P=.02), maximal inspiratory pressure (7.40 cm H(2)O [95% CI 1.64-13.14], P=.01), and maximum sustained vowel time (3.75 s [95% CI .90-6.60], P=.01). There was no statistically significant improvement in maximal expiratory pressure (5.37 cm H(2)O [95% CI -1.15 to 11.90], P=.11), mean arterial pressure (4.41 mmHg [95% CI -6.15 to 14.97], P=.41), or sound pressure level (1.14 dB [95% CI -1.31 to 3.58], P=.36). CONCLUSIONS: An individually fitted abdominal binder significantly improved forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximum sustained vowel time in people with newly acquired tetraplegia. Further study is needed into the effect of the long-term use of the abdominal binder on breathing mechanics, functional residual capacity, total lung capacity, and respiratory health.

IMproving Physical ACtivity after stroke via Treadmill training (IMPACT) and self-management: A randomized trial.

AIM: To determine if treadmill training embedded in self-management education commencing during stroke inpatient rehabilitation results in more physical activity than usual gait training. METHOD: A prospective, parallel-group, randomized trial with concealed allocation, blinded measurement, and intention-to-treat analysis involving 119 stroke survivors undergoing rehabilitation who were able to walk independently was undertaken. The experimental group undertook treadmill training (40-60% heart rate reserve) and self-management education for 30 min, three times a week for 8 weeks, and the control group undertook the same amount of usual gait training. Outcomes were measured at baseline (Week 0), on completion of the intervention (Week 8), and beyond the intervention (Week 26). The primary outcome was physical activity measured as steps/day using an activity monitor. Secondary outcomes were walking ability, cardiorespiratory fitness, cardiovascular risk, depression, self-efficacy, perception of physical activity, participation, and quality of life. RESULTS: After 8 weeks, the experimental group took 1436 more steps/day (95% confidence interval (CI) = 229 to 2643) than the control group. By 6 months, they took 871 more steps/day (95% CI -385 to 2129) than the control group. There was no difference between groups in any other outcome. CONCLUSION: In individuals undergoing rehabilitation after stroke, 8 weeks of treadmill training embedded in self-management resulted in more physical activity than usual gait training and this was largely maintained at 6 months, despite little effect on walking or cardiorespiratory fitness, suggesting the self-management was responsible.

Physical activity and cancer prevention: a systematic review of clinical trials.

BACKGROUND: Physically active individuals have lower rates of many cancers and improved cancer outcomes. Controlled exercise trials measuring putative biomarkers of cancer risk are being conducted to further understand the role of exercise in cancer etiology and progression. We aimed to systematically review the effect of exercise on various biomarkers. METHODS: A comprehensive search strategy identified 353 publications from January 1980 to August 2010. We included those clinical trials of exercise measuring biomarkers following minimum 4-week intervention among cancer survivors or people with one or more cancer risk factors. Two reviewers abstracted data and assessed quality independently. Effect sizes and 95% confidence intervals were estimated. RESULTS: Four primary prevention and five tertiary prevention trials were included. Exercise had a small to moderate effect on improving concentrations of several blood biomarkers implicated in breast and colon cancer pathways including insulin, leptin, estrogens, and apoptosis regulation. In breast cancer survivors, exercise had a small to moderate effect on improving some biomarkers associated with prognosis including various insulin-like growth factor axis proteins, insulin, and inflammation; and a large effect on enhancing immune function. CONCLUSION: Data are few, but there is some evidence to support the role of exercise in modulating various cancer pathways.

Diaphragm and peripheral muscle thickness on ultrasound: intra-rater reliability and variability of a methodology using non-standard recumbent positions.

BACKGROUND AND OBJECTIVE: Reliable measurement of diaphragm and peripheral muscle thickness, using diagnostic ultrasound, has only been validated in the erect posture. However, in many clinical populations, including critically ill patients, the erect posture presents logistic difficulties. This study aimed to validate ultrasound measurement of diaphragm and peripheral muscle thickness in the recumbent position. METHODS: An observational methodology of repeated but blind ultrasound and anthropometric measurements was applied, to assess inta-rater reliability. Thirteen healthy volunteers (aged 20-73years) participated. A pneumotachograph was used to target lung volume, as diaphragm thickness was measured from ultrasound at end-expiration, and both 25% and 50% of inspiratory capacity, while semi-recumbent. The thicknesses of the mid-upper arm, mid-forearm and mid-thigh musculature were also measured bilaterally while supine. RESULTS: Diaphragm thickness could be reliably measured at end-expiration (intra-class correlation coefficient (ICC)=0.990, 95% confidence interval: 0.918-0.998), 25% of inspiratory capacity (ICC=0.959 (0.870-0.988)) and 50% of inspiratory capacity (ICC=0.994 (0.980-0.998)). Peripheral muscle thickness measurements were also reliable (ICC=0.998-1.0). Supine anthropometric measurements of limb segment lengths and girths were highly reproducible. CONCLUSIONS: This ultrasound technique has good reliability in recumbent positions, making it useful for application to clinical populations when the erect posture is not practical.

Early rehabilitation in sepsis: a prospective randomised controlled trial investigating functional and physiological outcomes The i-PERFORM Trial (Protocol Article).

BACKGROUND: Patients with sepsis syndromes in comparison to general intensive care patients can have worse outcomes for physical function, quality of life and survival. Early intensive care rehabilitation can improve the outcome in general Intensive Care Unit (ICU) patients, however no investigations have specifically looked at patients with sepsis syndromes. The 'i-PERFORM Trial' will investigate if early targeted rehabilitation is both safe and effective in patients with sepsis syndromes admitted to ICU. METHODS/DESIGN: A single-centred blinded randomized controlled trial will be conducted in Brisbane, Australia. Participants (n = 252) will include those ≥ 18 years, mechanically ventilated for ≥ 48 hours and diagnosed with a sepsis syndrome. Participants will be randomised to an intervention arm which will undergo an early targeted rehabilitation program according to the level of arousal, strength and cardiovascular stability and a control group which will receive normal care.The primary outcome measures will be physical function tests on discharge from ICU (The Acute Care Index of Function and The Physical Function ICU Test). Health-related quality of life will be measured using the Short Form-36 and the psychological component will be tested using The Hospital Anxiety and Depression Scale. Secondary measures will include inflammatory biomarkers; Interleukin-6, Interleukin-10 and Tumour Necrosis Factor-α, peripheral blood mitochondrial DNA content and lactate, fat free muscle mass, tissue oxygenation and microcirculatory flow. DISCUSSION: The 'i-PERFORM Trial' will determine whether early rehabilitation for patients with sepsis is effective at improving patient outcomes with functional and physiological parameters reflecting long and short-term effects of early exercise and the safety in its application in critical illness. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000808044.

High-intensity treadmill training and self-management for stroke patients undergoing rehabilitation: a feasibility study.

BACKGROUND: Physical activity undertaken by stroke survivors is generally low. This trial investigated the feasibility of delivering a high-intensity treadmill and self-management program to people with stroke undergoing inpatient rehabilitation and determine whether physical activity, walking ability and cardiorespiratory fitness could be increased. METHOD: A phase I, single-group, pre-post intervention study was conducted with stroke survivors undergoing inpatient rehabilitation who could walk. Participants undertook a high-intensity treadmill and self-management program for up to 30 min, three times a week for 8 weeks under the supervision of their usual physiotherapist. Feasibility was determined by examining compliance, satisfaction and adverse events. Clinical outcomes were amount of physical activity, walking ability, and cardiorespiratory fitness collected pre-training (week 0), post-training (week 8), and at follow-up (week 26). RESULTS: Forty stroke survivors participated, completing 10 (SD 6) sessions, 94% at the specified training intensity, with high satisfaction and no adverse events related to the intervention. At week 8, participants completed 2749 steps/day (95% CI 933 to 4564) more physical activity than at week 0. Walking distance increased by 110 m (95% CI 23 to 196), walking speed by 0.24 m/s (95% CI 0.05 to 0.42), and VO2 peak by 0.29 ml/kg/min (95% CI 0.03 to 0.56). At week 26, increases in physical activity, walking distance and speed, and cardiorespiratory fitness were maintained. CONCLUSIONS: A high-intensity treadmill training program embedded within a self-management approach during inpatient rehabilitation appears feasible and potentially may offer sustained improvements in physical activity, walking ability, fitness, and quality of life. A randomised trial is warranted. TRIAL REGISTRATION: This feasibility study was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000764730 ).

Exercise and the Prevention of Oesophageal Cancer (EPOC) study protocol: a randomized controlled trial of exercise versus stretching in males with Barrett's oesophagus.

BACKGROUND: Chronic gastro-oesophageal reflux disease and excessive body fat are considered principal causes of Barrett's oesophagus (a metaplastic change in the cells lining the oesophagus) and its neoplastic progression, oesophageal adenocarcinoma. Metabolic disturbances including altered levels of obesity-related cytokines, chronic inflammation and insulin resistance have also been associated with oesophageal cancer development, especially in males. Physical activity may have the potential to abrogate metabolic disturbances in males with Barrett's oesophagus and elicit beneficial reductions in body fat and gastro-oesophageal reflux symptoms. Thus, exercise may be an effective intervention in reducing oesophageal adenocarcinoma risk. However, to date this hypothesis remains untested.The 'Exercise and the Prevention of Oesophageal Cancer Study' will determine whether 24 weeks of exercise training will lead to alterations in risk factors or biomarkers for oesophageal adenocarcinoma in males with Barrett's oesophagus. Our primary outcomes are serum concentrations of leptin, adiponectin, tumour necrosis factor-alpha, C-reactive protein and interleukin-6 as well as insulin resistance. Body composition, gastro-oesophageal reflux disease symptoms, cardiovascular fitness and muscular strength will also be assessed as secondary outcomes. METHODS/DESIGN: A randomized controlled trial of 80 overweight or obese, inactive males with Barrett's oesophagus will be conducted in Brisbane, Australia. Participants will be randomized to an intervention arm (60 minutes of moderate-intensity aerobic and resistance training, five days per week) or a control arm (45 minutes of stretching, five days per week) for 24 weeks. Primary and secondary endpoints will be measured at baseline (week 0), midpoint (week 12) and at the end of the intervention (week 24). DISCUSSION: Due to the increasing incidence and very high mortality associated with oesophageal adenocarcinoma, interventions effective in preventing the progression of Barrett's oesophagus are urgently needed. We propose that exercise may be successful in reducing oesophageal adenocarcinoma risk. This primary prevention trial will also provide information on whether the protective association between physical activity and cancer is causal. TRIAL REGISTRATION: ACTRN12609000401257.

The use of exercise in burns rehabilitation: A worldwide survey of practice.

INTRODUCTION: Exercise-based interventions have been used to enhance the recovery of burn patients affected by hypermetabolism, muscle wasting and contractures. Although the benefits of exercise in burn population have been previously reported, the extent of exercise prescription in burn patients worldwide remains unknown. Therefore, the purpose of this study is to identify the extent and characteristics of exercise use in specialised and non-specialised burn centres worldwide. METHODS: A web-based survey was developed in English and translated into Spanish and Chinese languages. Distribution of the surveys was made via email using personal contacts of the authors and through six scientific societies related to burn care in 2018. Data were analysed using descriptive statistics and comparisons between frequency distribution on variables of interest using the Chi-Square test and contingency tables. RESULTS: One hundred and fifty-six surveys were completed (103 from the English version, 20 from the Chinese version, and 33 from the Spanish version). The response rate varied from 36.2% (English version) to 9.3% (Chinese version). Fifty eight percent of the surveyed clinicians worked in cities of 1 million inhabitants or more, and 92.3% worked in hospital-based burn centres. Exercise was used by 64.1% of the participants at the intensive care unit level, 75% in burn wards prior to complete wound healing, and 80.1% in rehabilitation units after wound healing. The type of exercise offered, parameters assessed, and characteristics of exercise programs varied notably among burn centres and clinicians consulted. CONCLUSION: The majority of the surveyed clinicians used exercise for rehabilitation of patients following burn injuries. Further investigation is required to elucidate the access to exercise interventions prescribed by health professionals in remote areas, in less developed countries, and the extent of home-based exercise performed by patients.

Quadriceps Muscle Strength and Body Mass Index Are Associated With Estimates of Physical Activity Postheart Transplantation.

BACKGROUND: Although exercise capacity improves postheart transplantation (HTx), it remains unclear if the level of physical activity (PA) shows similar improvement. The purpose of this study was to (1) describe PA levels and (2) identify factors which may be associated with levels of PA post-HTx. METHODS: A prospective observational cross-sectional study was conducted at a single center HTx outpatient clinic. Medically stable adult recipients 6 months or longer post-HTx were recruited. Physical activity level (PAL) and average daily time spent at least moderately active (≥3 metabolic equivalents) were estimated using a multisensor device. Factors investigated were demographic (age, sex, body mass index [BMI], time post-HTx, and reason for HTx), corticosteroid use, exercise capacity (6-min walk distance), and quadriceps muscle strength corrected for body weight (QS%). RESULTS: The mean post-HTx time of the 75 participants was 9.2 ± 7.0 years (0.5-26 y). Twenty-seven (36%) participants were classified as extremely inactive (PAL, <1.40), 26 (34.6%) sedentary (1.40 ≤ PAL ≤ 1.69), and 22 (29.3%) active (PAL, ≥1.70). Multivariable analysis showed greater QS% (ß = 0.004 (0.002-0.006) P = 0.001) to be independently associated with increased PAL. For increased time, 3 or more metabolic equivalents both greater QS% (ß = 0.0164 [0.003-0.029]; P = 0.014) and lower BMI (ß = -0.0626 [-0.115 to -0.0099]; P = 0.021) were independently associated. CONCLUSIONS: The degree of observed sedentary behavior post-HTx is surprising, with the majority of participants not reaching levels of PA recommended for health benefits. QS% and BMI were the only factors found to be independently associated with estimates of PA. Further quality trials are required to demonstrate the long-term benefits of regular PA and investigate ways of increasing adherence to PA post-HTx.

Motivators and barriers for participation in aquatic and land-based exercise training programs for people with stable heart failure: A mixed methods approach.

BACKGROUND: Aquatic exercise training may be suitable for people with stable heart failure (HF) to engage in physical activity. OBJECTIVES: Acceptability, experiences and preferences regarding aquatic and traditional land-based exercise training, were explored in people with HF. METHODS: As part of a comparative intervention study, participants completed a questionnaire assessing acceptability, benefits and challenges of aquatic compared to land-based programs. Semi-structured interviews explored participant experiences in greater depth. RESULTS: Forty-eight participants, (mean age 70 + /- 11 years), completed the questionnaire and 14 participated in semi structured interviews. Aquatic exercise was regarded as acceptable and beneficial. Motivators were similar for both programs and included: a skilled and compassionate workforce, tailored care, perceived health benefit, sense of safety and an inclusive and enjoyable environment. Few barriers were identified for either program. CONCLUSIONS: Aquatic and land-based exercise training are equally acceptable for people with stable HF and motivators are similar for both programs.

Muscle stretching technique increases vital capacity and range of motion in patients with chronic obstructive pulmonary disease.

OBJECTIVES: To determine if a specific hold and relax stretching technique was capable of (1) reversing the effect of tight chest wall muscles by increasing chest expansion, vital capacity, and shoulder range of motion and (2) decreasing perceived dyspnea and respiratory rate in persons with chronic obstructive pulmonary disease (COPD). DESIGN: Double-blind crossover trial. SETTING: A physiotherapy department at a major metropolitan hospital. PARTICIPANTS: Fourteen stable patients with COPD who had recently completed a pulmonary rehabilitation program were enrolled, with 10 patients completing the study. INTERVENTION: A hold and relax stretching technique of the pectoralis major and a sham technique each for 2 days. MAIN OUTCOME MEASURES: The primary outcome measure was vital capacity (VC), with secondary outcome measures being perceived dyspnea, axillary (ACE) and xiphisternal chest expansion (XCE), right and left shoulder horizontal extension, and respiratory rate. RESULTS: The hold and relax technique to the pectoralis major compared with the sham technique produced significant effects on VC (P<.01), and right (P<.01) and left (P<.05) upper-limb range of motion. There was no significant effect on ACE, XCE, perceived dyspnea, or respiratory rate. There was no order effect for either technique. CONCLUSIONS: The hold and relax technique produces short-term benefits in patients with COPD and should be investigated further.

Lateral positioning of ventilated intensive care patients: a study of oxygenation, respiratory mechanics, hemodynamics, and adverse events.

OBJECTIVES: To investigate the effect of 90 degrees lateral positioning on oxygenation, respiratory mechanics, and hemodynamics in ventilated intensive care patients. METHODS: Thirty-four subjects (mean age = 46.1 +/- 17.3 years) with no, unilateral, or bilateral pulmonary infiltrates on chest radiograph participated. Arterial blood gas, respiratory mechanic, and hemodynamic data were analyzed at the supine starting position (T0), then 30 minutes and 2 hours into the lateral turn (T30 and T120, respectively) and 30 minutes post return to the supine position (T150). RESULTS: No difference was found in PaO(2)/FiO(2) due to positioning patients from supine to lateral (P = .15) regardless of the underlying lung pathology. Dynamic compliance decreased during lateral positioning, particularly in the subjects with no lung pathology (T0 = 56 +/- 18.6 > (T30 = 49.9 +/- 18; T120 = 49.2 +/- 17) L/cmH(2)0, P < .01) or unilateral lung pathology (T0 = 41.4 +/- 11.2 > (T30 = 36.6 +/- 8.8; T120 = 37.3 +/- 9.5) L/cmH(2)0, P < .01). Blood pressure and heart rate were unaffected, but cardiac index significantly increased at T30 (T0 = 3.7 +/- 1.2, T30 = 4.8 +/- 1.3 L/min/m(2), P < .01). While the incidence of adverse events was high (21%), they were primarily minor and transient. CONCLUSIONS: In this heterogeneous population, lateral positioning had no beneficial effect on gas exchange. However, in ventilated patients who were hemodynamically stable, it was well tolerated and not associated with significant serious adverse events.