Casey L. Peiris

Correction: additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: a randomised controlled trial [BMC Medicine, 11, (2013), 198]

Authors’ correction note On reviewing our recently published trial in BMC Medicine [1], we realised that there were some minor errors in the demographic data reported in Table 1 and in 2 sentences of the accompanying text. Specifically, our sample comprised 365 men, not 359 as reported, and there were some very minor differences in the numbers of participants reported in each diagnostic category. The main contributing factors for the minor errors were misinterpretation of gender neutral first names, and grouping of the diagnostic codes assigned during data collection for reporting. We believe these changes do not affect the results or conclusions of our study, and are confident in the processes we employed (full double data entry by two independent teams) to ensure the integrity of the rest of our data. Table 1 has been corrected and the first two sentences in the accompanying text in the methods when describing the participants should read: Participants had a mean (SD) age of 74 (13) years and 631 (63%) were women (Table 1). A total of 581 (58%) participants were admitted with an orthopedic diagnosis, 203 (20%) with a neurological diagnosis and 212 (21%) participants were admitted with other disabling impairments. A total of 94% of participants were living independently in the community prior to their acute hospital admission. This is a Correction article on http://www.biomedcentral. com/1741-7015/11/198.

Extra Physical Therapy Reduces Patient Length of Stay and Improves Functional Outcomes and Quality of Life in People With Acute or Subacute Conditions: A Systematic Review

OBJECTIVES To investigate whether extra physical therapy intervention reduces length of stay and improves patient outcomes in people with acute or subacute conditions. DATA SOURCES Electronic databases CINAHL, MEDLINE, AMED, PEDro, PubMed, and EMBASE were searched from the earliest date possible through May 2010. Additional trials were identified by scanning reference lists and citation tracking. STUDY SELECTION Randomized controlled trials evaluating the effect of extra physical therapy on patient outcomes were included for review. Two reviewers independently applied the inclusion and exclusion criteria, and any disagreements were discussed until consensus could be reached. Searching identified 2826 potentially relevant articles, of which 16 randomized controlled trials with 1699 participants met inclusion criteria. DATA EXTRACTION Data were extracted using a predefined data extraction form by 1 reviewer and checked for accuracy by another. Methodological quality of trials was assessed independently by 2 reviewers using the PEDro scale. DATA SYNTHESIS Pooled analyses with random effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) were used in meta-analyses. When compared with standard physical therapy, extra physical therapy reduced length of stay (SMD=-.22; 95% CI, -.39 to -.05) (mean difference of 1d [95% CI, 0-1] in acute settings and mean difference of 4d [95% CI, 0-7] in rehabilitation settings) and improved mobility (SMD=.37; 95% CI, .05-.69), activity (SMD=.22; 95% CI, .07-.37), and quality of life (SMD=.48; 95% CI, .29-.68). There were no significant changes in self-care (SMD=.35; 95% CI, -.06-.77). CONCLUSIONS Extra physical therapy decreases length of stay and significantly improves mobility, activity, and quality of life. Future research could address the possible benefits of providing extra services from other allied health disciplines in addition to physical therapy.

Additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: a randomized controlled trial

AbstractBackgroundMany inpatients receive little or no rehabilitation on weekends. Our aim was to determine what effect providing additional Saturday rehabilitation during inpatient rehabilitation had on functional independence, quality of life and length of stay compared to 5 days per week of rehabilitation.MethodsThis was a multicenter, single-blind (assessors) randomized controlled trial with concealed allocation and 12-month follow-up conducted in two publically funded metropolitan inpatient rehabilitation facilities in Melbourne, Australia. Patients were eligible if they were adults (aged ≥18 years) admitted for rehabilitation for any orthopedic, neurological or other disabling conditions excluding those admitted for slow stream rehabilitation/geriatric evaluation and management. Participants were randomly allocated to usual care Monday to Friday rehabilitation (control) or to Monday to Saturday rehabilitation (intervention). The additional Saturday rehabilitation comprised physiotherapy and occupational therapy. The primary outcomes were functional independence (functional independence measure (FIM); measured on an 18 to 126 point scale), health-related quality of life (EQ-5D utility index; measured on a 0 to 1 scale, and EQ-5D visual analog scale; measured on a 0 to 100 scale), and patient length of stay. Outcome measures were assessed on admission, discharge (primary endpoint), and at 6 and 12 months post discharge.ResultsWe randomly assigned 996 adults (mean (SD) age 74 (13) years) to Monday to Saturday rehabilitation (n = 496) or usual care Monday to Friday rehabilitation (n = 500). Relative to admission scores, intervention group participants had higher functional independence (mean difference (MD) 2.3, 95% confidence interval (CI) 0.5 to 4.1, P = 0.01) and health-related quality of life (MD 0.04, 95% CI 0.01 to 0.07, P = 0.009) on discharge and may have had a shorter length of stay by 2 days (95% CI 0 to 4, P = 0.1) when compared to control group participants. Intervention group participants were 17% more likely to have achieved a clinically significant change in functional independence of 22 FIM points or more (risk ratio (RR) 1.17, 95% CI 1.03 to 1.34) and 18% more likely to have achieved a clinically significant change in health-related quality of life (RR 1.18, 95% CI 1.04 to 1.34) on discharge compared to the control group. There was some maintenance of effect for functional independence and health-related quality of life at 6-month follow-up but not at 12-month follow-up. There was no difference in the number of adverse events between the groups (incidence rate ratio = 0.81, 95% CI 0.61 to 1.08).ConclusionsProviding an additional day of rehabilitation improved functional independence and health-related quality of life at discharge and may have reduced length of stay for patients receiving inpatient rehabilitation.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12609000973213 Please see related commentary: http://www.biomedcentral.com/10.1186/1741-7015-11-199.

Moderate-intensity exercise reduces fatigue and improves mobility in cancer survivors: a systematic review and meta-regression

QUESTION Is there a dose-response effect of exercise on inflammation, fatigue and activity in cancer survivors? DESIGN Systematic review with meta-regression analysis of randomised trials. PARTICIPANTS Adults diagnosed with cancer, regardless of specific diagnosis or treatment. INTERVENTION Exercise interventions including aerobic and/or resistance as a key component. OUTCOME MEASURES The primary outcome measures were markers of inflammation (including C-reactive protein and interleukins) and various measures of fatigue. The secondary outcomes were: measures of activity, as defined by the World Health Organizations International Classification of Functioning, Disability and Health, including activities of daily living and measures of functional mobility (eg, 6-minute walk test, timed sit-to-stand and stair-climb tests). Risk of bias was evaluated using the PEDro scale, and overall quality of evidence was assessed using the Grades of Research, Assessment, Development and Evaluation (GRADE) approach. RESULTS Forty-two trials involving 3816 participants were included. There was very low-quality to moderate-quality evidence that exercise results in significant reductions in fatigue (SMD 0.32, 95% CI 0.13 to 0.52) and increased walking endurance (SMD 0.77, 95% CI 0.26 to 1.28). A significant negative association was found between aerobic exercise intensity and fatigue reduction. A peak effect was found for moderate-intensity aerobic exercise for improving walking endurance. No dose-response relationship was found between exercise and markers of inflammation or exercise duration and outcomes. Rates of adherence were typically high and few adverse events were reported. CONCLUSIONS Exercise is safe, reduces fatigue and increases endurance in cancer survivors. The results support the recommendation of prescribing moderate-intensity aerobic exercise to reduce fatigue and improve activity in people with cancer. REVIEW REGISTRATION PROSPERO CRD42015019164.

Additional Saturday Allied Health Services Increase Habitual Physical Activity Among Patients Receiving Inpatient Rehabilitation for Lower Limb Orthopedic Conditions: A Randomized Controlled Trial

OBJECTIVE To determine whether adults with lower limb orthopedic conditions who received additional weekend physical therapy (PT) and occupational therapy (OT) demonstrated increased habitual physical activity. DESIGN Randomized controlled trial. SETTING Inpatient rehabilitation center. PARTICIPANTS Adults (N=105, 72 women; mean age ± SD, 74±12y) admitted with a lower limb orthopedic condition, cognitively alert and able to walk. INTERVENTION The control group received PT and OT Monday to Friday; in addition, the experimental group also received a full Saturday PT and OT service. Participants wore an activity monitor for 7 days. MAIN OUTCOME MEASURES Daily steps and daily upright time (hours). RESULTS Overall, participants took a mean of 589±640 steps per day and spent a mean of 1.2±0.9 hours upright per day. Experimental group participants took more than twice as many steps (mean difference, 428 steps; 95% confidence interval [CI], 184-673) and spent 50%±20% more time upright (mean difference, 0.5h; 95% CI, 0.1-0.9) than control group participants on Saturdays. In the days after additional therapy, experimental group participants took 63%±28% more steps (mean difference, 283 steps; 95% CI, 34-532) and spent 40%±17% more time upright (mean difference, 0.4h; 95% CI, 0.1-0.8) per day than participants in the control group. CONCLUSIONS Providing additional rehabilitation services on the weekend increased habitual activity, but patients with lower limb orthopedic conditions admitted to rehabilitation remained relatively inactive even with additional therapy.

Patients receiving inpatient rehabilitation for lower limb orthopaedic conditions do much less physical activity than recommended in guidelines for healthy older adults: an observational study

QUESTION Are ambulant patients who are admitted for inpatient rehabilitation for a lower limb orthopaedic condition active enough to meet current physical activity guidelines? DESIGN Prospective observational study. PARTICIPANTS Adults admitted for inpatient rehabilitation for a lower limb orthopaedic condition who were cognitively alert and able to walk independently or with assistance. OUTCOME MEASURES Participants wore an activity monitor for three full days. Daily time spent in moderate intensity physical activity was used to determine whether the levels of physical activity recommended in clinical guidelines were achieved. RESULTS Fifty-four participants with a mean age of 74 years (SD 11) took a median of 398 (IQR 140 to 993) steps per day and spent a median of 8 (IQR 3 to 16) minutes walking per day. No participant completed a 10-minute bout of moderate intensity physical activity during the monitoring period. One participant accumulated 30 minutes of moderate intensity physical activity and nine participants accumulated 15 minutes of moderate intensity physical activity in a day. Physical activity was associated with shorter length of stay (r=-0.43) and higher functional status on discharge (r=0.39). CONCLUSIONS Adults with lower limb orthopaedic conditions in inpatient rehabilitation are relatively inactive and do not meet current physical activity guidelines for older adults. Results of this study indicate that strategies to increase physical activity are required.

Early Aquatic Physical Therapy Improves Function and Does Not Increase Risk of Wound-Related Adverse Events for Adults After Orthopedic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES To investigate whether early postoperative aquatic physical therapy is a low-risk and effective form of physical therapy to improve functional outcomes after orthopedic surgery. DATA SOURCES Databases MEDLINE, CINAHL, AMED, Embase, and PEDro were searched from the earliest date available until October 2011. Additional trials were identified by searching reference lists and citation tracking. STUDY SELECTION Controlled trials evaluating the effects of aquatic physical therapy on adverse events for adults <3 months after orthopedic surgery. Two reviewers independently applied inclusion and exclusion criteria, and any disagreements were discussed until consensus could be reached. Searching identified 5069 potentially relevant articles, of which 8 controlled trials with 287 participants met inclusion criteria. DATA EXTRACTION A predefined data extraction form was completed in detail for each included study by 1 reviewer and checked for accuracy by another. Methodologic quality of included trials was assessed independently by 2 reviewers using the PEDro scale. DATA SYNTHESIS Pooled analyses were performed using random effects model with inverse variance methods to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) (continuous outcomes) and risk difference and 95% CIs (dichotomous outcomes). When compared with land-based physical therapy, early aquatic physical therapy does not increase the risk of wound-related adverse events (risk difference=.01, 95% CI -.05 to .07) and results in improved performance of activities of daily living (SMD=.33, 95% CI=.07-.58, I(2)=0%). There were no significant differences in edema (SMD=-.27, 95% CI=-.81 to .27, I(2)=58%) or pain (SMD=-.06, 95% CI=-.50 to .38, I(2)=32%). CONCLUSIONS After orthopedic surgery aquatic physical therapy improves function and does not increase the risk of wound-related adverse events and is as effective as land-based therapy in terms of pain, edema, strength, and range of motion in the early postoperative period.

A study protocol of a randomised controlled trial incorporating a health economic analysis to investigate if additional allied health services for rehabilitation reduce length of stay without compromising patient outcomes

BackgroundReducing patient length of stay is a high priority for health service providers. Preliminary information suggests additional Saturday rehabilitation services could reduce the time a patient stays in hospital by three days. This large trial will examine if providing additional physiotherapy and occupational therapy services on a Saturday reduces health care costs, and improves the health of hospital inpatients receiving rehabilitation compared to the usual Monday to Friday service. We will also investigate the cost effectiveness and patient outcomes of such a service.Methods/DesignA randomised controlled trial will evaluate the effect of providing additional physiotherapy and occupational therapy for rehabilitation. Seven hundred and twelve patients receiving inpatient rehabilitation at two metropolitan sites will be randomly allocated to the intervention group or control group. The control group will receive usual care physiotherapy and occupational therapy from Monday to Friday while the intervention group will receive the same amount of rehabilitation as the control group Monday to Friday plus a full physiotherapy and occupational therapy service on Saturday. The primary outcomes will be patient length of stay, quality of life (EuroQol questionnaire), the Functional Independence Measure (FIM), and health utilization and cost data. Secondary outcomes will assess clinical outcomes relevant to the goals of therapy: the 10 metre walk test, the timed up and go test, the Personal Care Participation Assessment and Resource Tool (PC PART), and the modified motor assessment scale. Blinded assessors will assess outcomes at admission and discharge, and follow up data on quality of life, function and health care costs will be collected at 6 and 12 months after discharge. Between group differences will be analysed with analysis of covariance using baseline measures as the covariate. A health economic analysis will be carried out alongside the randomised controlled trial.DiscussionThis paper outlines the study protocol for the first fully powered randomised controlled trial incorporating a health economic analysis to establish if additional Saturday allied health services for rehabilitation inpatients reduces length of stay without compromising discharge outcomes. If successful, this trial will have substantial health benefits for the patients and for organizations delivering rehabilitation services.Clinical trial registration numberAustralian and New Zealand Clinical Trials Registry ACTRN12609000973213

Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data

QUESTIONS Among people receiving inpatient rehabilitation after stroke, does additional weekend physiotherapy and/or occupational therapy reduce the length of rehabilitation hospital stay compared to those who receive a weekday-only service, and does this change after controlling for individual factors? Does additional weekend therapy improve the ability to walk and perform activities of daily living, measured at discharge? Does additional weekend therapy improve health-related quality of life, measured 6 months after discharge from rehabilitation? Which individual, clinical and hospital characteristics are associated with shorter length of rehabilitation hospital stay? DESIGN This study pooled individual data from two randomised, controlled trials (n=350) using an individual patient data meta-analysis and multivariate regression. PARTICIPANTS People with stroke admitted to inpatient rehabilitation facilities. INTERVENTION Additional weekend therapy (physiotherapy and/or occupational therapy) compared to usual care (5 days/week therapy). OUTCOME MEASURES Length of rehabilitation hospital stay, independence in activities of daily living measured with the Functional Independence Measure, walking speed and health-related quality of life. RESULTS Participants who received weekend therapy had a shorter length of rehabilitation hospital stay. In the un-adjusted analysis, this was not statistically significant (MD -5.7 days, 95% CI -13.0 to 1.5). Controlling for hospital site, age, walking speed and Functional Independence Measure score on admission, receiving weekend therapy was significantly associated with a shorter length of rehabilitation hospital stay (β=7.5, 95% CI 1.7 to 13.4, p=0.001). There were no significant between-group differences in Functional Independence Measure scores (MD 1.9 points, 95% CI -2.8 to 6.6), walking speed (MD 0.06 m/second, 95% CI -0.15 to 0.04) or health-related quality of life (SMD -0.04, 95% CI -0.26 to 0.19) at discharge. DISCUSSION Modest evidence indicates that additional weekend therapy might reduce rehabilitation hospital length of stay. CLINICAL TRIAL REGISTRATION ACTRN12610000096055, ACTRN12609000973213. [English C, Shields N, Brusco NK, Taylor NF, Watts JJ, Peiris C, et al. (2016) Additional weekend therapy may reduce length of rehabilitation stay after stroke: a meta-analysis of individual patient data.Journal of Physiotherapy62: 124-129].

Long-term home and community-based exercise programs improve function in community-dwelling older people with cognitive impairment: a systematic review

QUESTION Do long-term (> 3 months) home or community-based exercise programs improve function, reduce falls and prevent hospital readmissions in older people with cognitive impairment? DESIGN Systematic review and meta-analysis of randomised, controlled trials. Electronic databases (CINAHL, PubMed, Medline, Embase, AMED) were searched from the earliest date possible until March 2016. PARTICIPANTS Older adults (≥ 65 years) with cognitive impairment living in the community. INTERVENTION Supervised home or community-based exercise programs longer than 3 months. OUTCOME MEASURES The primary outcomes were function (including balance and activities of daily living), falls and hospital readmissions. RESULTS Of 1011 studies identified, seven trials with 945 participants met the inclusion criteria. Compared with no intervention, long-term exercise programs improved functional independence in basic activities of daily living by a moderate and significant amount (SMD 0.77, 95% CI 0.17 to 1.37, I2=67%), and improved functional independence in instrumental activities of daily living by a small and significant amount (SMD 0.44, 95% CI 0.03 to 0.86, I2=42%). Long-term exercise improved balance (mean difference in functional reach test 5.2cm, 95% CI 0.5 to 9.9, I2=76%). Data from two individual trials suggest that long-term exercise programs also reduce falls in older people with cognitive impairment. However, there was limited reporting of the effect of exercise on hospital readmissions for this group of people. CONCLUSIONS Long-term home and community-based exercise programs improve function in older adults living in the community with cognitive impairment. Review registration: PROSPERO CRD42015029602. [Lewis M, Peiris CL, Shields N (2016) Long-term home and community-based exercise programs improve function in community-dwelling older people with cognitive impairment: a systematic review.Journal of Physiotherapy63: 23-29].