Annals of Internal Medicine | 2019
Review: Extra physical therapy improves some outcomes by a small amount in acute or subacute health conditions
Abstract
Question In patients with acute or subacute health conditions, do additional physical therapy services reduce hospital length of stay and improve health outcomes? Review scope Included studies compared an increased duration or frequency of physical therapy with a usual amount of physical therapy in adults 18 years of age who had acute events (including acute exacerbations of chronic diseases) and were treated in acute or subacute settings. Physical therapy interventions had to be delivered or supervised by physical therapists and provided as described by the American Physical Therapy Association. Studies of physical therapy for risk factor management of chronic conditions or that added a different treatment to usual care were excluded. Outcomes included length of stay, walking ability, self-care, activity outcomes, and mortality. PROSPERO CRD42017064827. Review methods This is an update of a 2011 review. MEDLINE, EMBASE/Excerpta Medica, CINAHL, AMED, and PEDro (2010 to Jun 2017); and reference lists were searched for randomized controlled trials (RCTs). 24 RCTs (n =3262, 53% women) met the selection criteria. Patients had neurologic, orthopedic, cardiothoracic, and mixed rehabilitation diagnoses. Of the trials that described their extra physical therapy, patients received extra sessions (14 RCTs), longer sessions (3 RCTs), or extra and longer sessions (2 RCTs). Patients in the additional therapy group received a mean 12.2 min/d of extra therapy, as reported in 15 RCTs. RCT quality, as measured by the PEDro scale, ranged from 4 to 8 (mean 6.7) out of 11; 17 trials concealed allocation, and 18 reported blinding of outcome assessors. Main results Additional and usual physical therapy groups did not differ for mortality (relative risk 1.07, 95% CI 0.6 to 1.93); other outcomes are in the Table. Conclusion In patients with acute or subacute health conditions, extra physical therapy services slightly reduce hospital length of stay and improve some health outcomes. Extra physical therapy services vs usual physical therapy in patients with acute or subacute health conditions* Outcomes Number of trials (n) Standardized mean difference (95% CI) Length of stay 12 (2285) 0.21 (0.34 to 0.07) Walking ability 10 (1641) 0.10 (0.06 to 0.26) Self-care 12 (2366) 0.11 (0.03 to 0.19) Activity outcomes 14 (1737) 0.16 (0.04 to 0.28) *CI defined in Glossary. Positive mean difference favors the experimental group for all outcomes except length of stay. Assessed with speed, 6-minute walk test, Functional Independence Measure locomotion, and Rivermead Mobility Index. Assessed with Functional Independence Measure, Barthel Index, and Modified Iowa Level of Assistance Scale. Assessed with the Timed Up and Go Test, Rivermead Mobility Index, and Knee Society Scale (activities of daily living function). Commentary Treatment during acute or subacute hospitalization typically focuses on medical management of the reason for admission rather than the potential harms of hospitalization-related immobility. However, clinicians are becoming more aware of the adverse effects that can occur within a few days of immobility, including reduction in muscle mass, weakness, frailty, increased risk for falls, hip fractures, and reduced functional status (1, 2). The review by Peiris and colleagues showed that physical therapy can improve function and reduce length of stay in hospitalized patients, but there are several issues to consider. Physical therapy can be provided by physiotherapists, physiotherapy assistants, and nurses, but delivery of physical therapy is complicated when patients are medically unstable and/or on acute medical or surgical wards without rehabilitation facilities. Moreover, it can be difficult to determine which components of physical therapy are critical for improvements in outcomes, especially when physical therapy is delivered to patients who receive other care, including assistance with personal hygiene, transferring, and transport for medically necessary investigations. The trial by Martnez-Velilla and colleagues found that an exercise program during acute hospitalization improved functional capacity at discharge. The intervention did not require treatment by a trained physiotherapist, and the trial did not assess such physiotherapy-relevant outcomes as range of motion, weakness, or stiffness of muscles. Thus, results of this RCT can be generalized to acute medical or surgical wards without dedicated physiotherapy staff. Mounting evidence shows that physical therapy improves such other clinically important outcomes as activities of daily living, bone health, mood, and cognition, all of which can be negatively affected by immobility (3). The RCT by Martnez-Velilla and colleagues showed that a multicomponent exercise intervention improved Barthel scores for independence and cognitive levels in hospitalized elderly patients. The systematic review by Palmer and colleagues provides evidence for the beneficial effects of exercise on quality of life and physical function in community-dwelling patients with CHF. No adverse events (e.g., falls) related to physical therapy were reported in the reviews by Peiris and colleagues and Palmer and colleagues or in the RCT by Martnez-Velilla and colleagues. A trial included in the review by Peiris and colleagues suggests that exercise rehabilitation for subacute patients may be cost-effective (4). The 2 systematic reviews and RCT reported here show that physical or exercise therapy can improve clinically important physiologic and functional outcomes in adults and can reduce length of stay in older patients who have been admitted for a short hospital stay.