Helena van Aswegen

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice

Objective: To facilitate knowledge synthesis and implementation of evidence supporting early physical activity and mobilization of adult patients in the intensive care unit and its translation into practice, we developed an evidence-based clinical management algorithm. Methods: Twenty-eight draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n = 7) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus – semi-interquartile range <0.5 – were collated into the algorithm. Results: The draft algorithm statements were edited and six additional statements were formulated. The 34 statements related to assessment and treatment were grouped into three categories. Category A included statements for unconscious critically ill patients; Category B included statements for stable and cooperative critically ill patients, and Category C included statements related to stable patients with prolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algorithm statements, only 50% (17/34) of the statements were rated essential. Conclusion: The evidence-based clinical management algorithm developed through an established Delphi process of consensus by an international inter-professional panel provides the clinician with a synthesis of current evidence and clinical expert opinion. This framework can be used to facilitate clinical decision making within the context of a given patient. The next step is to determine the clinical utility of this working algorithm.

Effects of an education and home-based pedometer walking program on ischemic heart disease risk factors in people infected with HIV: a randomized trial.

Objective:People infected with the human immunodeficiency virus are at an increased risk of developing ischemic heart disease (IHD); however, the effects of an education and home-based pedometer walking program on risk factors of IHD are not known. Methods:We conducted a 12-month randomized study of an education and home-based pedometer walking program in 84 human immunodeficiency virus–infected individuals with risk factors of IHD. Results:Pedometer step count of the control and intervention groups improved significantly (P = 0.03 for both groups) at 6 months but was not significant at 12 months (P = 0.33 and 0.21, respectively). Significant between-group effects were observed in 6-minute walk test distance (P = 0.01), waist to hip ratio (P = 0.00), glucose (P = 0.00), and high-density lipoprotein (P = 0.01) over the 12-month period. The program did not result in change in high-sensitivity C-reactive protein as it was associated with perceived stress (r = 0.23; P = 0.03), weight (r = 0.28; P = 0.01), body mass index (r = 0.35; P < 0.00), waist (r = 0.28; P = 0.01) and hip circumference (r = 0.28; P = 0.01). Multivariate generalized estimation equation analysis demonstrated an inverse association between interaction and perceived stress (logB = −0.01; 95% confidence interval: −0.02 to −0.01; P <0.00) and body mass index (logB = −0.02; 95% confidence interval: −0.03 to −0.002; P = 0.02) at group level. Conclusion:An education and home-based pedometer walking program improves physical activity levels, and beneficial changes in other IHD risk factors were noted.

The use of a weaning and extubation protocol to facilitate effective weaning and extubation from mechanical ventilation in patients suffering from traumatic injuries: A non-randomized experimental trial comparing a prospective to retrospective cohort

Purpose Many patients who have suffered traumatic injuries require mechanical ventilation (MV). Weaning is the transition from ventilatory support to spontaneous breathing. The purpose of this study was to determine whether the use of a nurse and a physiotherapist-driven protocol to wean and extubate patients from MV resulted in decreased MV days and intensive care unit (ICU) length of stay (LOS). Methods: A prospective cohort of 28 patients (Phase I), weaned according to the protocol developed for the Union Hospital Trauma Unit, was matched retrospectively with a historical cohort of 28 patients (Phase II), weaned according to physician preference. Pairs in the two groups were matched for gender, age, type, and severity of injury. Results: For mean MV days, the groups did not differ statistically significantly (p  =  0.3; 14.4 days vs. 16.3 days), although the reduction in MV is clinically significant in view of the complications of additional MV days. The difference of 0.2 days for ICU LOS was not statistically significant (p  =  0.9; 20.8 days vs. 21.0 days) demonstrating that the reduction in MV days may not result in the reduction of ICU LOS. The rate of re-intubation was similar between the groups (Phase I  =  3/28 vs. Phase II  =  4/24). Conclusion: The use of a weaning and extubation protocol led by nursing staff and physiotherapists resulted in a clinically significant reduction in MV time, reducing risk of ventilator-associated complications. The role of physiotherapists and nursing staff in weaning and extubation from MV could be greatly expanded in South African ICUs.

Developing minimum clinical standards for physiotherapy in South African intensive care units: the nominal group technique in action

RATIONALE, AIMS AND OBJECTIVES Physiotherapists form an important part of the inter-professional team that cares for critically ill patients in intensive care units (ICU). No formalized clinical practice guidelines or standards exist for the educational profile or scope of practice requirements for physiotherapy within critical care, which poses a threat to physiotherapy practice and professional credibility. METHODS The aim of this paper was to describe the nominal group technique (NGT) used to identify the minimum standards of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs. RESULTS Twenty-five subjects participated in one of three forums. Sixty-six concepts were considered in the three domains (knowledge, skills and attitudes). Not all concepts were discussed by all three focus groups. Just over half (54% n=14) the concepts generated in the knowledge domain; a third of the concepts (35% n=7) generated in the skills domain and only 10% (n=2) of attitudes were consistently raised by all three groups. Almost two-thirds of the concepts generated (62% n=41) were considered in more than one domain. Only six concepts reached the threshold consensus level across all three focus groups, four knowledge parameters and two skills. CONCLUSION The NGT allowed for the cross-stimulation of ideas in an engaging yet anonymous and structured manner. The importance of discussion in reaching consensus is highlighted. Going forward, it is intended to use the concepts generated through this process as the foundation for further consensus-building activities among the wider physiotherapy and intensive care communities.

'If you have a problem with your heart, you have a problem with your life': Self-perception and behaviour in relation to the risk of ischaemic heart disease in people living with HIV.

Background Ischaemic heart disease (IHD) is a global health problem and specifically relevant in the African context, as the presence of risk factors for IHD is increasing. People living with the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (PLWHA) are at increased risk for IHD due to increased longevity, treatment-specific causes and viral effects. Aim To determine the self-perception and behaviour in relation to risk for IHD in a cohort of South African PLWHA. Methods A qualitative study using semi-structured interviews with a card-sort technique was used to gather data from 30 individuals at an HIV clinic in Johannesburg. Descriptive analysis and conventional content analysis were done to generate the findings. Results The median age of the cohort was 36.5 (31.8–45.0) years and they were mostly women (n = 25; 83.3%) who were employed (n = 17; 56.7%) and supporting dependents (n = 26; 86.7%). Fifteen (50%) participants did not perceive themselves at risk of IHD and reported having adequate coping behaviour, living a healthy lifestyle and being healthy since initiating therapy. Twelve (40%) did feel at risk because they experienced physical symptoms and had poor behaviour. Knowledge and understanding related to IHD, insight into own risk for IHD and health character in a context of HIV infection were three themes. Conclusion This study highlights that participants did not perceive themselves to be at risk of IHD due to their HIV status or antiretroviral management. Education strategies are required in PLWHA to inform their personal risk perception for IHD.

Hydrotherapy in the management of chronic obstructive pulmonary disease: a qualitative systematic review

Abstract Background: Many people worldwide suffer from chronic obstructive pulmonary disease (COPD). Diverse medical conditions have been treated using hydrotherapy for many years but its use in the treatment of COPD is a recent development. Its use in the COPD population may lead to improvements in cardiopulmonary outcomes and quality of life (QoL) and the mastery of activities of daily living (ADL) in people with this disease. Objectives: To determine the effects of hydrotherapy on cardiopulmonary function, QoL, and ADL in people with COPD. Method: Studies relating to adults with non-acute, non-terminal COPD were located by searching electronic databases. Included studies were critically appraised by two independent reviewers using the Lewis, Olds, and Williams tool. Results: Nine studies met the inclusion criteria (n = 207 subjects). Sample sizes of individual studies varied between 10 and 43 subjects. Three studies were of above average methodological quality, two were of average, and four were of a poor quality. Thirty-five outcome measures were identified. Cardiopulmonary parameters showed positive increases when the immersed COPD subjects exhaled into water. Aspects of QoL improved with physical training in water. Group hydrotherapy improved ADL performance. Conclusions: The few included studies, which address the use of hydrotherapy in the management of COPD, had small sample sizes and were mainly of low to moderate methodological quality. Hydrotherapy may improve cardiopulmonary, QoL, and ADL outcomes in the COPD population. Investigation into the effects of combined breathing and physical exercise during hydrotherapy, in the COPD population, is needed.

Changes in biopsychosocial outcomes for a mixed cohort of ICU survivors

Background Prolonged inflammation and infection associated with being critically ill and the ensuing physical inactivity has proven negative effects on the recovery of physical function, psychological health and reintegration into society for intensive care unit (ICU) survivors. Limited evidence is available on changes in biopsychosocial outcomes for South Africans recovering from an episode of critical illness. Objectives To determine changes in biopsychosocial outcomes for a mixed cohort of ICU survivors in hospital and at 1 month and 6 months after discharge. Method A prospective, observational, longitudinal study was conducted. Severity of illness, mechanical ventilation (MV) duration and ICU and hospital length of stay (LOS) were recorded. Physical function in ICU test-scored (PFIT-s) was performed at discharge from ICU and hospital. At 1 month and 6 months, peripheral muscle strength, exercise endurance, health-related quality of life (HRQOL), depression status and return to work were assessed. Descriptive and inferential statistics were used. Results Participants (n = 24) had a median age of 51.5 years, majority were male (n = 19; 79%) and most were employed before admission (n = 20; 83%). At 6 months, 11 participants (n = 11) were part of the final sample. Median PFIT-s changed significantly (0.3 points; p = 0.02) between ICU and hospital discharge. Peripheral muscle strength improved significantly for upper and lower limbs over 6 months (p = 0.00–0.03) but change in median 6-minute walk test distance (65m) was not significantly different. Significant improvements occurred in mean Medical Outcomes Short Form-36 (SF-36) physical health component scores (8.8 ± 7.6; p = 0.00). Mean SF-36 mental health component scores had a strong negative relationship with MV duration (r = −0.7; p = 0.01), LOS (r = −0.56; p = 0.04) and Patient Health Questionnaire 9 scores (r = −0.72; p = 0.01). Six participants (55%) returned to employment. Conclusion Clinically important improvements in biopsychosocial outcomes related to physical function and social factors were observed. Limitations in mental aspects of HRQOL were present at 6 months and some reported mild depressive symptoms. Clinical implications Intensive care unit survivors with a history of prolonged MV duration and hospital LOS who exhibit limitations in mental HRQOL, and signs of depressive symptoms should be referred to a psychologist for evaluation.

Physical impairments and activity limitations experienced by people with tuberculosis: a scoping review protocol.

Review objective/question: The objective of this review is to examine and map the range of physical impairments and activity limitations experienced by people infected with tuberculosis (TB). The levels of evidence that are currently available on this topic will also be reported. More specifically, the review questions are: What types of physical impairments and activity limitations have been reported for people infected with TB? What types of rehabilitation strategies are used for people with TB infection to address physical impairments and activity limitations? Findings from this scoping review may inform a systematic review to explore the effectiveness of rehabilitation strategies used to address physical impairments and activity limitations in people with TB infection.