Exercise and Airway Clearance Techniques in Cystic Fibrosis.

Exercise and airway clearance techniques (ACTs) have been a cornerstone of treatment for people with cystic fibrosis (pwCF) for many decades. Exercise may confer both respiratory and nonrespiratory benefits for pwCF, with greater exercise capacity associated with improved survival. A wide variety of exercise interventions for pwCF have been investigated. ACTs may assist in reducing respiratory symptoms for pwCF and are currently recommended to be performed daily, with the types of ACTs used varying globally. While recommended components of care, both exercise and ACTs are time-intensive and maintaining adherence to the recommendations over the longer term can be challenging. It has been proposed that with advances in the therapeutic options for pwCF, a rationalization of the therapeutic regimen may be possible. We summarize the current evidence for the use of exercise and ACTs by pwCF, discuss the implications of the introduction of cystic fibrosis transmembrane conductance regulator modulators on both exercise and ACTs, and highlight areas for further research.

Exercise as a substitute for traditional airway clearance in cystic fibrosis: a systematic review.

BACKGROUND: Exercise and traditional airway clearance techniques (ACTs) are both routinely recommended for people with cystic fibrosis (CF), with some people using exercise as a substitute for traditional ACTs. The effectiveness of this is unclear. We systematically reviewed the evidence for using exercise as a substitute for traditional ACTs in people with CF. METHODS: A systematic database and literature search were undertaken of studies comparing exercise to rest or traditional ACTs. Primary outcomes were respiratory function, respiratory exacerbations and health-related quality of life. Secondary outcomes included mucociliary clearance (MCC), sputum weight and ease of expectoration. Data are mean difference (95% CI). RESULTS: A total of 12 studies (15 reports) were included, all of short duration (single session to 2 weeks). In crossover trials, exercise did not improve forced expiratory volume in one second in comparison to rest, but peak expiratory flow was increased during treadmill exercise (mean difference (MD) range 1.00-1.16 L/s) and cycle ergometry (1.19 (0.96 to 1.42) L/s). Treadmill exercise improved MCC (2.6 (1.6 to 3.6)%) and ease of expectoration (MD range 1.3-1.8 cm) compared with rest. No consistent differences in respiratory function were evident when exercise was compared with traditional ACTs (four crossover studies). There was no significant difference in MCC or sputum weight in studies where forced expirations were included in the exercise intervention. CONCLUSIONS: Exercise improves ease of expectoration and sputum clearance compared with rest. Exercise, incorporating forced expirations, may have similar effects to traditional ACTs over the short term. There are no data comparing exercise to traditional ACTs over the longer term. PROSPERO REGISTRATION NUMBER: CRD42018102780.

Increased allied health services to general and acute medical units decreases length of stay: comparison with a historical cohort.

Objective The present study evaluated the effect of an initiative to fund increased allied health (AH) services, enabling increased days and both volume and scope of AH services, for general medical in-patients in the Central Adelaide Local Health Network for a 6-month trial period. Methods A quasi-experimental mixed-methods study was undertaken involving general medical in-patients at two acute tertiary-referral public hospitals with a prospective (December 2015-May 2016) and historical comparison (December 2014-May 2015) cohort. Outcome measures compared between the two cohorts included hospital length of stay (LOS), occupied bed-days, adverse events and AH service data. Results After implementation of increased AH services, there were significant decreases in the median (interquartile range) of both hospital LOS (from 7.2 (7.0-8.0) to 6.5 (6.1-6.7) days; P=0.006) and occupied bed-days (from 5295.0 (5200.0-5622.3) to 4662.5 (4335.8-4744.3) bed-days per month; P=0.004). There was no significant change in weekend discharges or adverse events. AH services increased, with the median number of referrals seen by AH professionals per month, occasions of AH service and AH intervention time per month increasing by 17%, 45% and 43% respectively after implementation, along with a faster response time to referrals. Conclusions Increased levels of AH staffing to general medical in-patients were associated with a significant reduction in hospital LOS and occupied bed-days. What is known about the topic? AH services are an important component in the delivery of safe, effective and efficient health care to hospitalised patients. There is little evidence specifically investigating the effect of increased AH services for general medical patients in an acute hospital setting. What does this paper add? This study provides new evidence demonstrating that increasing AH services to general medical in-patients within two acute tertiary-referral public hospitals decreased hospital LOS and occupied bed-days, without an increase in adverse events. What are the implications for practitioners? A funding initiative to enable increased AH services to general medical in-patients significantly reduced hospital LOS and occupied bed-days. These findings will be of considerable interest to other healthcare centres, particularly those where AH levels are below benchmark figures.

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.

INTRODUCTION: The aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients. METHODS: A systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients. RESULTS: Safety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations. CONCLUSION: Consensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

Passive Movements Do not Appear to Prevent or Reduce Joint Stiffness in Medium to Long-Stay ICU Patients: A Randomized, Controlled, Within-Participant Trial.

OBJECTIVES: ICU patients have an increased risk of joint stiffness because of their critical illness and reduced mobility. There is a paucity of evidence evaluating the efficacy of passive movements (PMs). We investigated whether PMs prevent or reduce joint stiffness in ICU patients. DESIGN: A randomized, controlled, within-participant, assessor-blinded study. SETTING: A 48-bed tertiary care adult ICU. PATIENTS: Intubated patients who were expected to be invasively mechanically ventilated for greater than 48 hours with an ICU length of stay greater than or equal to 5 days, and unable to voluntarily move their limbs through full range of motion (ROM). INTERVENTIONS: The ankle and elbow on one side of each participant's body received PMs (10 min each joint, morning and afternoon, 5 d/wk). The other side acted as the control. The PMs intervention continued for as long as clinically indicated to a maximum of 4 weeks. MEASUREMENTS: The primary outcome was ankle dorsiflexion ROM at cessation of PMs. Plantarflexion, elbow flexion and extension ROM, and participant-reported joint pain and stiffness (verbal analog scale [VAS]) were also measured. Outcomes were recorded at baseline and cessation of PMs. For participants whose PMs intervention ceased early due to recovery, additional post-early-cessation of PMs review measurements were undertaken as near as possible to 4 weeks. MAIN RESULTS: We analyzed data from 25 participants with a median (interquartile range) ICU stay of 15.6 days (11.3-25.4). The mean (95% CI) between-side difference for dorsiflexion ROM (with knee extension) at cessation of PMs was 0.4 degrees (-4.4 to 5.2; p = 0.882), favoring the intervention side, indicating there was not a clinically meaningful effect of 5 degrees. No statistically significant differences were found between the intervention and control sides for any ROM or VAS data. CONCLUSIONS: PMs, as provided to this sample of medium to long-stay ICU patients, did not prevent or reduce joint stiffness.

A physiotherapy service to an emergency extended care unit does not decrease admission rates to hospital: a randomised trial.

BACKGROUND: One of the reasons physiotherapy services are provided to emergency departments (EDs) and emergency extended care units (EECUs) is to review patients' mobility to ensure they are safe to be discharged home. AIM: To investigate whether a physiotherapy service to an EECU altered the rate of hospital admission, rate of re-presentation to the ED, visits to community healthcare practitioners, return to usual work/home/leisure activities and patient satisfaction. METHODS: A randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis was undertaken in an EECU. The sample comprised 186 patients (mean age 70 years, 123 (66%) female patients, 130 (70%) trauma) who were referred for physiotherapy assessment/intervention. Referral occurred at any stage of the patients' EECU admission. All participants received medical/nursing care as required. The physiotherapy group also received physiotherapy assessment/intervention. RESULTS: The physiotherapy group had a 4% (95% CI -18% to 9%) lower rate of admission to hospital than the control group and a 4% (95% CI -6% to 13%) higher rate of re-presentation to the ED, which were statistically non-significant (p≥0.45). Differences between groups for use of community healthcare resources, return to usual work/home/leisure activities and satisfaction with their EECU care were small and not significant. CONCLUSION: A physiotherapy service for EECU patients, as provided in this study, did not reduce the rate of hospital admission, rate of re-presentation to the ED, use of community healthcare resources, or improve the rate of return to usual work/home/leisure activities or patient satisfaction. Trial registration number ANZCTRN12609000106235.

Development of a device to measure adherence and pressure characteristics of positive expiratory pressure therapies used by adults with cystic fibrosis.

INTRODUCTION: Positive expiratory pressure (PEP) and oscillating positive expiratory pressure (OscPEP) therapies are often used by people with cystic fibrosis (CF) to facilitate airway clearance. However, suboptimal adherence and poor technique may reduce their effectiveness. OBJECTIVE: To develop a device (PEPtrac) to accurately measure and provide preliminary clinical data of adherence and technique characteristics when airway clearance is performed using PEP/OscPEP devices. METHODS: This study comprised two distinct phases: 1) a benchtop validation study; and 2) clinical study. Benchtop study: Accuracy of PEPtrac was measured by comparing it to video analysis for five different PEP/OscPEP devices. Clinical study: Clinical data were then collected for 18 adults with CF using one of three PEP/OscPEP devices (PariPEP S®, Acapella DH® or Aerobika®) unsupervised. RESULTS: There was 100% agreement between PEPtrac and video analysis data. Clinical data revealed significant variability in expiratory duration and pressure properties between the three PEP/OscPEP devices and between participants. For example, expiratory duration with PariPEP S® (mean [SD] = 4.8 [1.2] sec) was longer (p < .001) than Acapella DH® (3.7 [0.8] sec) and Aerobika® (2.9 [1.1] sec) and Aerobika® had a higher oscillation amplitude than Acapella DH® (6.4 [1.7] vs 5.3 [1.5] cmH2O, p < .001). DISCUSSION: Accurate measurement of PEP/OscPEP adherence and technique using a device such as PEPtrac was possible. Further research is required to investigate the clinical importance of the variability in technique seen in our clinical data.

Variable levels of stress and anxiety reported by physiotherapy students during clinical placements: a cohort study.

OBJECTIVES: Healthcare students are at risk of high stress and anxiety, particularly during clinical placements. This study measured the stress and anxiety levels of physiotherapy students during clinical placements, how stress/anxiety changed over time, effect on academic performance, factors influencing stress/anxiety and coping strategies. DESIGN: A prospective cohort study using surveys collecting quantitative and qualitative data. SETTING: Three sites where physiotherapy students from one university undertook clinical placements. PARTICIPANTS: 109 students across 159 placements. MAIN OUTCOME MEASURES: The State-Trait Anxiety Inventory (STAI [Y2]) provided a baseline measure of general stress level and propensity for anxiety. Perceived stress and anxiety were measured using visual analogue scales (VASs) at baseline and weekly over the 5-weeks duration of placements. A questionnaire sought students' perceptions of factors affecting stress/anxiety and coping strategies. RESULTS: VAS stress/anxiety scores were highly variable between participants. Higher VAS scores were seen at Weeks 3 and 4 compared to Week 5 and placements earlier in the academic year. Baseline VAS scores were significantly associated with Weeks 1-5 VAS scores. Higher VAS scores were associated with poorer academic results. Stress/anxiety were affected by patient complexity, assessments, workload, poor health and family issues. Most participants felt supported by clinical educators/peers, and used coping strategies including exercise and taking breaks. CONCLUSIONS: Physiotherapy students demonstrated highly variable stress/anxiety levels during clinical placements, with higher levels negatively affecting academic performance. Baseline measures of perceived stress/anxiety could potentially highlight students at risk of high levels of stress/anxiety during clinical placements, allowing more targeted interventions. Australian New Zealand Clinical Trials Registry (ACTRN12618000302257).

Comparison of the pressure redistribution qualities of two air-filled wheelchair cushions for people with spinal cord injuries.

BACKGROUND/AIM: People with spinal cord injuries are at high risk of developing pressure ulcers. Wheelchair cushions that redistribute pressure are one prevention strategy to reduce the risk of pressure ulcers in this population. Currently, therapists have only limited evidence concerning the pressure redistribution qualities of wheelchair cushions to guide their cushion selection in clinical practice. The aim of this study was to compare the pressure redistribution qualities of two air-filled cushions currently recommended for people with spinal cord injuries. METHODS: A series of single case studies, based on the methodology used in a previous study, was undertaken on three inpatients with complete spinal cord injury. Interface pressure readings were compared between a Roho® and Vicair® cushion using the Xsensor® Pressure Mapping System. The Roho® cushion is comprised of a series of soft, flexible, inter-connected air cells, and the Vicair® cushion contains separate, sealed cells of air. RESULTS: The Roho® cushion recorded significantly fewer cells with pressures ≥100 mmHg than the Vicair® cushion for the three participants. CONCLUSION: This study has provided evidence that the Roho® cushion has superior pressure redistribution qualities than the Vicair® cushion for a small sample of patients with complete spinal cord injury.

An evaluation of the level of satisfaction with a dedicated inpatient venepuncture service at a rehabilitation centre.

The purpose of this prospective observational study was to determine the levels of satisfaction of the three main 'customers' of a dedicated inpatient venepuncture service at a rehabilitation centre, namely the patients, medical staff and nursing staff. The venepuncture service was delivered by two part-time nurses. One hundred and six patients, 14 medical staff and 35 nurses participated in the study. Three purpose-designed surveys were administered to investigate levels of satisfaction. High degrees of satisfaction were reported by all three 'customer' groups. Patients were highly satisfied with the interpersonal skills of the venepuncture nurses and their ability to obtain blood on the first pass, medical staff agreed that a dedicated venepuncture service gave them more time to spend in patient care, and nursing staff believed that a dedicated venepuncture service caused less disruption to patients' daily schedule.

Inspiratory muscle training is feasible and safe for patients with acute spinal cord injury.

OBJECTIVE: To investigate the feasibility and safety and, to a lesser extent efficacy, of inspiratory muscle training (IMT) for patients with acute complete cervical or thoracic spinal cord injury (SCI). DESIGN: Prospective, observational pilot study comprising a series of case reports. SETTING: Tertiary care, public hospital. PARTICIPANTS: Seven adult subjects with an acute complete cervical or thoracic SCI. INTERVENTIONS: Participants received IMT as soon as their respiratory condition was stable. A high-resistance, low-repetition program of IMT using a POWERbreathe KH1 device was instituted. Training comprised 3-6 sets of 6 breaths, commenced at 50% maximum inspiratory pressure with the training load progressively increased. OUTCOME MEASURES: Feasibility (number of sessions when the criteria to participate in IMT were met/not met), safety (symptoms and physiological stability) before, during and after IMT sessions and efficacy (lung function) were measured. RESULTS: There were 50 sessions in total where participants met the criteria to receive IMT, with a mean (range) of 7.1 (3-11) IMT sessions per participant delivered over 10.7 (4-17) days. IMT was feasible, with all 50 planned sessions of IMT able to be delivered, and safe, with stable physiological parameters and no adverse symptoms or events recorded before, during or after IMT. Maximal inspiratory pressure increased for four participants and forced vital capacity increased for three participants over the duration of their IMT sessions. CONCLUSION: A high-resistance, low-repetition program of IMT was feasible and safe in adults with an acute complete cervical or thoracic SCI whose respiratory status was stable. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN 12614000975695).

Exercise as a therapeutic intervention for people with cystic fibrosis.

INTRODUCTION: The complex multisystem nature of cystic fibrosis (CF) commonly results in reduced exercise tolerance, which is independently associated with poor clinical outcomes. Exercise is routinely recommended as part of the therapeutic regimen in CF to improve both respiratory and non-respiratory impairments. Areas covered: This article summarises the most recent evidence regarding the use of exercise as a therapeutic intervention in CF and discusses some of the practical considerations for exercise prescription in this setting. Clinical trials in progress and future research priorities are outlined. Expert opinion: On the balance of available evidence, exercise is likely to assist in improving physical fitness and health-related quality of life (HRQOL) and may be associated with a slower rate of decline in respiratory function in CF. Limitations to current studies include small sample sizes, study durations insufficient to achieve a training effect and difficulty distinguishing the effects of exercise training from that of other interventions implemented as part of a package of care. Larger, multi-centred trials are required to clarify the role of exercise in CF in improving physical fitness, respiratory function, HRQOL, as a substitute for traditional airway clearance techniques and in the management of common CF-related comorbidities.

Exercise is commonly used as a substitute for traditional airway clearance techniques by adults with cystic fibrosis in Australia: a survey.

QUESTIONS: What airway clearance techniques and exercise regimens are used by adults with cystic fibrosis (CF) in Australia when well or unwell? What proportion of these adults believe that exercise can be used as a substitute for traditional airway clearance techniques, and how have they come to this belief? What type of exercise is used as a substitute for traditional airway clearance techniques? DESIGN: Cross-sectional survey at 13 CF centres in Australia, using a purpose-designed questionnaire. PARTICIPANTS: Six hundred and ninety-two adults with CF completed the questionnaire. OUTCOME MEASURES: The questionnaire included questions about: the participants' current use of traditional airway clearance techniques and exercise, when well and unwell; and beliefs regarding the use of exercise as a substitute for traditional airway clearance techniques. RESULTS: Coughing, huffing and positive expiratory pressure were the most commonly used airway clearance techniques. Walking, jogging and lifting weights were the most commonly used forms of exercise. Overall, 43% of participants believed that exercise could be used as a substitute for traditional airway clearance techniques, with 44% having substituted exercise for traditional airway clearance techniques in the previous 3 months. Personal experience was the most commonly reported factor influencing participants' beliefs about the use of exercise as a substitute for traditional airway clearance techniques. CONCLUSION: Exercise is commonly used as a substitute for traditional airway clearance techniques. Physiotherapists should advise patients that whilst there is some research suggesting a possible mechanism for exercise as a form of airway clearance, there are currently no medium-term to long-term data supporting exercise as a stand-alone form of airway clearance. These results suggest that future research to investigate the clinical effectiveness of exercise as a substitute for traditional airway clearance techniques should be a priority. REGISTRATION: ACTRN12616000994482.

Incidence and severity of shoulder pain does not increase with the use of circuit class therapy during inpatient stroke rehabilitation: a controlled trial.

QUESTIONS: Does circuit class therapy result in a greater incidence or severity of shoulder pain compared with individual therapy? Is the incidence influenced by the degree of active shoulder control? DESIGN: Controlled trial with intention-to-treat analysis. PARTICIPANTS: Sixty-eight people (6 drop-outs) undergoing inpatient rehabilitation after stroke. INTERVENTION: Participants received either individual therapy or group circuit class therapy. OUTCOME MEASURES: Incidence of shoulder pain over the previous 24 hours was measured as a yes/no response while severity of shoulder pain was measured using a visual analogue scale at admission, Week 4, and discharge. RESULTS: There was no greater chance of participants receiving circuit class therapy having shoulder pain at Week 4 (OR 0.95, 95% CI 0.32 to 2.80) or discharge (OR 0.38, 95% CI 0.11 to 1.45) than participants receiving individual therapy. Of those participants who reported pain, there was no difference between groups in the severity of pain at Week 4 (mean difference -0.2 cm, 95% CI -3.2 to 2.7) or discharge (mean difference -2.1 cm, 95% CI -4.8 to 0.6). There was a greater chance of participants who had no active shoulder control having shoulder pain at Week 4 (OR 5.8, 95% CI 1.6 to 20.4) and at discharge (OR 3.8, 95% CI 1.0 to 13.9) than participants who had active shoulder control. CONCLUSION: The incidence and severity of shoulder pain was influenced by degree of active shoulder control but not by type of physiotherapy service delivery. Concerns regarding shoulder pain should not be a barrier to the implementation of circuit class therapy during inpatient stroke rehabilitation.

An advice and exercise program has some benefits over natural recovery after distal radius fracture: a randomised trial.

QUESTION: Does an advice and exercise program improve outcome for adults following distal radius fracture? DESIGN: Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: Fifty-six patients whose fracture had been managed with pins and/or cast. INTERVENTION: The experimental group received a physiotherapist-directed program of advice and exercises. The control group did not receive any physiotherapy intervention. OUTCOME MEASURES: The primary outcome was wrist extension (measured with a goniometer). Secondary outcomes were the other wrist ranges of motion (measured with a goniometer), grip strength (measured with a dynamometer), pain, and activity limitations (measured with questionnaires). These outcomes were measured initially, then three and six weeks later. Participants also rated their satisfaction with physiotherapy intervention at Week 6. RESULTS: No difference was found between groups for the primary outcome of wrist extension (mean difference 6 deg, 95% CI -3 to 14), nor for the secondary outcomes of other range of motion data and grip strength. The difference between groups for pain was -16 points out of 100 (95% CI -27 to -5) at Week 3, and -14 points (95% CI -25 to -3) points at Week 6, and for activity was -13 points out of 100 (95% CI -24 to -2) at Week 3; in favour of the experimental group. The experimental group was also more satisfied with the amount of physiotherapy intervention. CONCLUSION: An advice and exercise program provided some additional benefits over no intervention for adults following distal radius fracture.

Airway clearance by exercising in mild cystic fibrosis (ACE-CF): A feasibility study.

BACKGROUND: People with cystic fibrosis (CF) are encouraged to perform airway clearance techniques on a daily basis. Whilst several short-term studies support a potential role for exercise as an airway clearance technique, to date no medium to longer term studies have investigated the use of exercise as a stand-alone airway clearance technique. OBJECTIVE: To determine the feasibility of a protocol investigating the use of exercise as a stand-alone form of airway clearance in adults with CF. METHODS: Adults with CF and a FEV1 ≥ 70% predicted were eligible. After a four week wash-in period of daily positive expiratory pressure (PEP) and exercise, adherent participants were randomised to either daily PEP plus exercise or exercise-only for three months. Pre-specified thresholds for feasibility for the primary outcomes were rates of recruitment ≥30%, randomisation ≥80% and completion ≥80%. Secondary outcomes included respiratory function tests, respiratory exacerbation rate and health-related quality of life. RESULTS: Of the 57 eligible patients identified, 17 were recruited (30%). After the wash-in period, 13 of the 17 participants (76%) were randomised and all 13 (100%) completed the final assessment. The median (IQR) change in FEV1 (L) over the intervention period was 0.00 (-0.08 - 0.15) L for the PEP plus exercise group and -0.03 (-0.19 - 0.13) L for the exercise-only group. CONCLUSION: The study achieved its a priori target feasibility rates for recruitment and completion but failed to meet the randomisation target rate. Changes in lung function and quality of life were similar between groups. Further refinement of the protocol may be required prior to expansion to a multi-centred trial.

Adherence of adult cystic fibrosis patients with airway clearance and exercise regimens.

BACKGROUND: Regular airway clearance and exercise form an important part of the physiotherapy management of patients with cystic fibrosis (CF). Previous research has found that adherence of these patients with physiotherapy regimens is variable and influenced by factors such as sex and disease severity. To date, the adherence of Australian patients with CF has not been investigated. The aim of this study was to measure the adherence of a sample of Australian adult patients with CF and to ascertain factors that improved or decreased their adherence with physiotherapy. METHODS: Patients attending an Australian CF Unit were surveyed by an independent physiotherapist using a questionnaire based on the Manchester Cystic Fibrosis Compliance Questionnaire. RESULTS: Fifty seven of the 84 patients registered with the Unit (67.9% response rate) completed the survey. Over the previous six months, 96.5% of patients reported doing some form of airway clearance, with 70.2% doing this daily or only occasionally missing one or two days. Regular exercise was performed by 91.2% of patients when well, with 77.8% also exercising regularly when unwell. The most common reasons for non-adherence with airway clearance regimens were being too busy and not being bothered. Being too busy and too tired were the most frequent reasons for decreased adherence with exercise. Frequency of performing airway clearance regimens significantly improved when patients felt unwell. Adherence with exercise regimens was significantly higher in those who worked or studied full time. CONCLUSION: Overall, the levels of adherence with physiotherapy regimens found in this study were considered to be satisfactory and higher than those previously reported in the literature, with time related factors being the most commonly reported reasons for decreasing adherence.

Safety issues that should be considered when mobilizing critically ill patients.

Mobilization is often used by physiotherapists for managing critically ill patients with the aim of treatment including improving respiratory function, level of consciousness, functional ability, and psychological well being, and reducing the adverse effects of immobility. In addition, mobilization may decrease the duration of mechanical ventilation and length of ICU or hospital stay. This article provides ICU practitioners with comprehensive guidelines that can be used to assess the safety of mobilizing critically ill patients. The main safety factors that should be addressed include intrinsic factors related to the patient (eg, medical background, cardiovascular and respiratory reserve, and hematological considerations) and factors extrinsic to the patient (eg, patient attachments, environment, and staffing).

The physiotherapy management of patients undergoing thoracic surgery: a survey of current practice in Australia and New Zealand.

BACKGROUND AND PURPOSE: Physiotherapy is considered an essential component of the management of patients after thoracotomy, yet the type of interventions utilized, and evidence for their efficacy, has not been established. The aim of the present study was to ascertain the current physiotherapy management of patients undergoing thoracotomy and the factors influencing practice among different providers. METHOD: A purpose-designed postal questionnaire was distributed to senior physiotherapists in all thoracic surgical units throughout Australia and New Zealand (n=57). RESULTS: A response rate of 81% was obtained (n=46). Pre-operatively, 16 respondents (35%) reported assessing all thoracotomy patients. The majority of respondents (n=44; 96%) indicated that all patients were seen by physiotherapists after surgery, with 29 respondents (63%) performing prophylactic physiotherapy interventions to prevent post-operative pulmonary complications. Respondents reported that physiotherapy treatment was usually commenced on day one post-operatively (n=37; 80%) with the most commonly used treatment interventions being deep breathing exercises, the active cycle of breathing techniques, cough, forced expiration techniques and sustained maximal inspirations. Most respondents reported that patients first sat out of bed (n=41; 89%), commenced shoulder range of movement (n=23; 50%) and walking (n=32; 70%) on day one post-operatively. The majority of respondents reported that they offered no post-operative pulmonary rehabilitation (n=25; 54%), outpatient follow-up (n=43; 94%) orpost-thoracotomy pain management (n=40; 87%). Respondents indicated that personal experience, literature recommendations and established practice were the factors which most influenced physiotherapy practice. Conclusion. Most patients after thoracotomy receive physiotherapy assessment and/or treatment in the immediate post-operative period, but only one-third were routinely seen pre-operatively and relatively few were reviewed following discharge from hospital. Further studies are required to guide physiotherapists in determining the efficacy of their practices for patients undergoing thoracotomy.

Dietetic and educational interventions improve clinical outcomes of diabetic and obese clients with mental impairment.

AIM: The aim of this study was to evaluate the effect of dietetic and educational interventions provided to clients with type 2 diabetes (with or without obesity) or obesity-only residing in supported residential facilities and characterised by mental impairment. METHODS: A retrospective audit involving the retrieval of information from medical records and databases was undertaken to evaluate the effect of dietetic and educational interventions. Clinical outcomes were weight, body mass index and glycosylated haemoglobin (HbA1c) levels. RESULTS: A total of 91 clients were included, 47 with type 2 diabetes (with or without obesity) and 44 with obesity-only. All but one had schizophrenia, an intellectual disability or another psychological condition. After interventions, the diabetic subgroup demonstrated significant decreases in weight (mean [SD] initial = 101.5 [20.7], final = 97.8 [20.6] kg, P = 0.001) and body mass index (mean [SD] initial = 35.8 [8.1], final = 34.4 [7.8] kg/m2 , P = 0.001) and a non-significant decrease in HbA1c over time. The obesity-only subgroup showed no significant change in outcomes. Factors significantly negatively impacting at least one outcome included the presence of schizophrenia (P ≤ 0.017) and refusal of intervention(s) (P ≤ 0.048), whereas a significant positive impact was seen for a greater total number of visits to a dietitian or diabetes educator (P ≤ 0.024). CONCLUSIONS: These results provide evidence to support the effectiveness of dietetic and educational interventions for this vulnerable client group.