J.J. Dronkers

Preoperative therapeutic programme for elderly patients scheduled for elective abdominal oncological surgery: a randomized controlled pilot study

Objective: Investigation of the feasibility and preliminary effect of a short-term intensive preoperative exercise programme for elderly patients scheduled for elective abdominal oncological surgery. Design: Single-blind randomized controlled pilot study. Setting: Ordinary hospital in the Netherlands. Subjects: Forty-two elderly patients (>60 years). Interventions: Patients were randomly assigned to receive a short-term intensive therapeutic exercise programme to improve muscle strength, aerobic capacity, and functional activities, given in the outpatient department (intervention group; n =22), or home-based exercise advice (control group; n=20). Main measures: Parameters of feasibility, preoperative functional capacity and postoperative course. Results: The intensive training programme was feasible, with a high compliance and no adverse events. Respiratory muscle endurance increased in the preoperative period from 259 ± 273 to 404 ± 349 J in the intervention group and differed significantly from that in the control group (350 ± 299 to 305 ± 323 J; P<0.01). Timed-Up-and-Go, chair rise time, LASA Physical Activity Questionnaire, Physical Work Capacity and Quality of Life (EORTC-C30) did not reveal significant differences between the two groups. There was no significant difference in postoperative complications and length of hospital stay between the two groups. Conclusion: The intensive therapeutic exercise programme was feasible and improved the respiratory function of patients due to undergo elective abdominal surgery compared with home-based exercise advice.

Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial

Objective: To evaluate the feasibility and preliminary effectiveness of therapeutic exercise before total hip replacement in frail elderly. Design: A single-blind, randomized clinical pilot trial. Setting: Outpatient physiotherapy department. Subjects: Frail elderly with hip osteoarthritis awaiting total hip replacement. Interventions: A short (3—6 weeks) tailor-made, therapeutic exercise programme was compared with usual care. Main measures: Feasibility was assessed through patient satisfaction, adherence, occurrence of adverse events and the number of eligible non-volunteers. Preliminary preoperative effectiveness was assessed with performance and self-reported measures of pain, functioning, physical activity and quality of life. Postoperatively we measured functional recovery and length of hospital stay. Results: Sixty-two eligible patients were approached of whom 21 (mean age 76 years) agreed to participate. Exercisers (n = 10), rated the intervention as very good 8.9 (8—10) (10-point rating scale). No serious adverse events occurred. Forty-one (66%) eligible patients did not participate, mainly because of logistic considerations, resulting in selection bias. The intervention group (trainings sessions participated 91%) showed relevant preoperative improvements on the chair-rise time (delta —2.9 seconds; 95% confidence interval (CI) —6.2 to 0.4) and timed-up-and-go (delta —4.4 seconds; 95% CI —9.3 to 0.5). Postoperatively, no significant differences were seen. Conclusions: A short, tailor-made, exercise programme is well tolerated and appreciated in elderly patients awaiting total hip replacement. However, a larger randomized clinical trial in the same setting is not warranted, because of the high number of eligible non-volunteers.

The impact of waiting for total joint replacement on pain and functional status: a systematic review

OBJECTIVE To systematically describe changes in pain and functioning in patients with osteoarthritis (OA) awaiting total joint replacement (TJR), and to assess determinants of this change. METHODS MEDLINE, EMBASE, CINAHL and Cochrane Database were searched through June 2008. The reference lists of eligible publications were reviewed. Studies that monitored pain and functioning in patients with hip or knee OA during the waiting list for TJR were analyzed. Data were collected with a pre-specified collection tool. Methodological quality was assessed and a best-evidence analysis was performed to summarize results. RESULTS Fifteen studies, of which two were of high quality, were included and involved 788 hip and 858 knee patients (mean age 59-72 and main wait 42-399 days). There was strong evidence that pain (in hip and knee OA) and self-reported functioning (in hip OA) do not deteriorate during a <180 days wait. Conflicting evidence was established for the change on self-reported functioning in patients with knee OA waiting <180 days. Moreover, strong evidence was found for an association between the female gender and intensified pain. CONCLUSION Patients with OA do not experience deterioration in pain or self-reported functional status whilst waiting <180 days for TJR. Changes over a longer waiting period are unclear. To strengthen and complement the present evidence, further high-quality studies are needed, in which preferably also performance-based measures are used.

The association of pre‐operative physical fitness and physical activity with outcome after scheduled major abdominal surgery

We studied whether reported physical activity and measurements of fitness (hand, leg and inspiration) were associated with postoperative in‐hospital mortality, length of stay and discharge destination in 169 patients after major oncological abdominal surgery. In multivariate analysis, adequate activity level (OR 5.5, 95% CI 1.4–21.9) and inspiratory muscle endurance (OR 5.2, 95% CI 1.4–19.1) were independently associated with short‐term mortality, whereas conventional factors, such as age and heart disease, were not. Adequate activity level (OR 6.7, 95% CI 1.4–3.0) was also independently associated with discharge destination. The factors that were independently associated with a shorter length of hospital stay were as follows: absence of chronic obstructive pulmonary disease (HR 0.6, 95% CI 0.3–1.1); adequate activity level (HR 0.6, 95% CI 0.4–0.8); and inspiratory muscle strength (HR 0.6, 95% CI 0.5–0.9). For all postoperative outcomes physical activity and fitness significantly improved the predictive value compared with known risk factors, such as age and comorbidities. We conclude that pre‐operative questionnaires of physical activity and measurements of fitness contribute to the prediction of postoperative outcomes.

Preoperative prediction of inpatient recovery of function after total hip arthroplasty using performance-based tests: a prospective cohort study

Abstract Purpose: The aim of this study was to evaluate the value of conventional factors, the Risk Assessment and Predictor Tool (RAPT) and performance-based functional tests as predictors of delayed recovery after total hip arthroplasty (THA). Method: A prospective cohort study in a regional hospital in the Netherlands with 315 patients was attending for THA in 2012. The dependent variable recovery of function was assessed with the Modified Iowa Levels of Assistance scale. Delayed recovery was defined as taking more than 3 days to walk independently. Independent variables were age, sex, BMI, Charnley score, RAPT score and scores for four performance-based tests [2-minute walk test, timed up and go test (TUG), 10-meter walking test (10 mW) and hand grip strength]. Results: Regression analysis with all variables identified older age (>70 years), Charnley score C, slow walking speed (10 mW >10.0 s) and poor functional mobility (TUG >10.5 s) as the best predictors of delayed recovery of function. This model (AUC 0.85, 95% CI 0.79–0.91) performed better than a model with conventional factors and RAPT scores, and significantly better (p = 0.04) than a model with only conventional factors (AUC 0.81, 95% CI 0.74–0.87). Conclusions: The combination of performance-based tests and conventional factors predicted inpatient functional recovery after THA. Implications for Rehabilitation Two simple functional performance-based tests have a significant added value to a more conventional screening with age and comorbidities to predict recovery of functioning immediately after total hip surgery. Patients over 70 years old, with comorbidities, with a TUG score >10.5 s and a walking speed >1.0 m/s are at risk for delayed recovery of functioning. Those high risk patients need an accurate discharge plan and could benefit from targeted pre- and postoperative therapeutic exercise programs.

The Influence of Muscle Weakness on the Association Between Obesity and Inpatient Recovery From Total Hip Arthroplasty

BACKGROUND There is ongoing discussion about whether preoperative obesity is negatively associated with inpatient outcomes of total hip arthroplasty (THA). The aim was to investigate the interaction between obesity and muscle strength and the association with postoperative inpatient recovery after THA. METHODS Preoperative obesity (body mass index [BMI] >30 kg/m2) and muscle weakness (hand grip strength <20 kg for woman and <30 kg for men) were measured about 6 weeks before THA. Patients with a BMI <18.5 kg/m2 were excluded. Outcomes were delayed inpatient recovery of activities (>2 days to reach independence of walking) and prolonged length of hospital stay (LOS, >4 days and/or discharge to extended rehabilitation). Univariate and multivariable regression analyses with the independent variables muscle weakness and obesity, and the interaction between obesity and muscle weakness, were performed and corrected for possible confounders. RESULTS Two hundred and ninety-seven patients were included, 54 (18%) of whom were obese and 21 (7%) who also had muscle weakness. Obesity was not significantly associated with prolonged LOS (odds ratio [OR] 1.36, 95% confidence interval [CI] 0.75-2.47) or prolonged recovery of activities (OR 1.77, 95% CI 0.98-3.22), but the combination of obesity and weakness was significantly associated with prolonged LOS (OR 3.59, 95% CI 1.09-11.89) and prolonged recovery of activities (OR 6.21, 95% CI 1.64-23.65). CONCLUSION Obesity is associated with inpatient recovery after THA only in patients with muscle weakness. The results of this study suggest that we should measure muscle strength in addition to BMI (or body composition) to identify patients at risk of prolonged LOS.

Surgery and functional mobility: doing the right thing at the right time

The pace of change in Western societies is rapid, and this includes change in the healthcare sector which is initiated directly and indirectly by technological and sociocultural innovation. Here, the classic dominant medical approach is complemented by an orientation toward functioning (in line with the WHO International Classification of Functioning, Disability and Health 2002). This more dual orientation is also useful during major life events, like hospital admission for surgery. Anesthetic and surgical state-of-the-art techniques will normally be adequate for tackling the medical problems for which patients were admitted. However, one of the major common side effects, functional decline, before (in the ‘‘waiting’’ period), during and after hospitalization is impressive, especially in old and frail people, and needs complementary prevention and care interventions [1]. Firstly, older adults have a lower muscle mass at admission or are even in a sarcopenic state. Subsequently, surgery itself, especially major abdominal, thoracic and orthopedic surgery, severely challenges the psychophysiological system. The surgical stress response encompasses a wide range of physiological effects, which seriously and directly impair cardiopulmonary and muscle function [2]. Hormonal dysregulation and the inflammatory response contribute to an accelerated loss of lean body tissue. On top of this, post-surgery ‘‘activities’’ like bed rest, still the prevailing and dominant hospital recovery strategy, contribute to a progressive loss of functional capacity via a loss of (lower) extremity strength, power and aerobic capacity. In elderly patients, bed rest induces an approximate threeto sixfold greater rate of muscle mass loss compared to younger, fit persons. In addition, surgery causes three times more muscle mass loss than hospitalizations without surgery [3]. These notions call for action, and this editorial will discuss what types of action. Impaired functioning is a frequently published serious side effect of surgery, but has increasingly been brought to notice in recent decades as life expectancy increased rapidly and more and more elderly had indications for surgery. Covinsky [4] labeled surgical functional decline as ‘‘hospitalization associated disability,’’ In accordance with Covinsky, Lawrence Lee stated: ‘‘focusing only on the physical domain and ignoring the other domains will incorrectly describe this patient as ‘recovered’ from surgery’’ [5]. Recently, hospitalization-associated disability has been recognized as an iatrogenic but preventable disorder [6]. Prevention of a complicated (post)operative course and a swift return to an adequate performance of activities of daily living (ADL) and instrumental ADL (IADL) in older patients is mandatory and essential to preserve independent functioning and quality of life. This will limit direct care costs and additional costs for home care or even admission to a nursing home. The first step in preventive care includes preoperative screening of the patient in order to determine the potential & J. Dronkers jaap.dronkers@hu.nl

Personal meaning in relation to daily functioning of a patient in physical therapy practice: narratives of a patient, a family member, and physical therapist

Abstract Purpose: To get insight into personal meaning of a person involved in a physical therapy intervention. Methods: Mrs. A, a 76-year-old woman is referred to a physical therapist (PT) for assessment of functioning and training before total hip arthroplasty (THA). The patient, her daughter, and PT were asked to write a story about their daily life. Stories were analyzed according to the narrative scheme based on a method to find meaning in daily life, which consists of four phases: 1. Motivation; 2. Competences; 3. Performance; and 4. Evaluation. Results: Mrs. A was mainly motivated by her will to do enjoyable social activities and stay independent. Although she tried her best to undertake activities (performance) that made her proud (evaluation), her pain and physical limitations were anti-competences that motivated her to attend healthcare. Although the PT seemed to be aware of personal participation goals, her main motivation was to improve and evaluate functions and activities. The daughter was motivated by good relationships and did not see herself as informal caregiver. Conclusions: The narrative method was a valuable tool to clarify motivations, competences, and values in the process of creating personal meaning related to functioning. This knowledge could help caregivers in applying patient-centered goal-setting and treatment on a participation level. Implications for rehabilitation Personal meaning of people’s functioning within their daily context can be clarified from daily life stories. This case report demonstrates that motivations and goals may differ between patient and therapist; the PT seems to focus on improving and evaluating functions and activities, while the patient seems to focus her motivations and personal meaning on participation. This approach may help in patient-centered goal-setting at the level of activities and participation.

OP0088-HPR Prediction of Inpatient Functional Recovery for Patients after Total Hip Arthroplasty: the Added Value of Performance-Based Test to Self-Reported Information: A Prospective Cohort Study

Background Variance in functional recovery after total hip arthroplasty (THA) is likely explained by patient-related factors. The Risk Assessment and Predictor Tool (RAPT) [1] is an existing model for predicting recovery for patients after THA. Interestingly, the RAPT only contains self-reported information about the preoperative functional status while recently the Osteoarthritis Research Society International (OARSI) recommended to use performance based test, such as mobility or walking tests, to complement self-reported function [2]. We hypothesize that augmenting the RAPT score with performance-based tests would result in more accurate predictions regarding the inpatient functional recovery of patients after THA. Objectives The aim of this study is to evaluate the RAPT as a prediction tool for adequate or inadequate inpatient functional recovery and to study the predictive value of the model after adding performance-based functional data to this model. Methods We used a prospective cohort study design. Preoperative screening of patients attending for primary or revision THA (Feb - Dec 2012) entailed six independent factors: the RAPT score, four performance-based tests (the timed up and go (TUG) test, the two minutes walk (2MW) test, hand grip strength (HGS) and habitual gait speed measured by ten meters walking test (10mW)), and the Charnley score for comorbidities. The dependent outcome parameter inpatient functional recovery was dichotomized: adequate functional recovery (walking independent with walking aid within 3 days after surgery) and inadequate functional recovery (4 or more days to reach independence in walking). By use of logistic modeling we determined the predictive value of a prediction model based on the RAPT. Consequently we added the performance-based measures to the model. Predictive value was tested using the Area under the curve (AUC). Results A total of 315 consecutive patients were included in the study. Mean age was 69 years (SD 11), 68% were women,mean BMI was 26,8 (SD 4.0) and mean length of stay was 4.1 days (SD 1.6). Delayed functional recovery was apparent in 47 people (15%). All functional tests were statistically related to delayed functional recovery (p<0.05). AUC for RAPT was 0.75 (95% CI 0.68-0.82) while by adding 10mW to RAPT the accuracy (AUC 0.80, 95%CI 0.75-0.86) in predicting functional recovery increased. Conclusions Adding a performance-based tests to the RAPT score resulted in more accurate predictions regarding the inpatient functional recovery of patients after THA. Prediction models including self-reported factors (RAPT) and performance based tests should be optimized to detect low and high risk patients in order to establish (cost)effective and efficient rehabilitation in clinical pathways for THA. References Dobson F, Hinman RS, Roos EM, Abbott JH, Stratford P, Davis AM, Buchbinder R, Snyder-Mackler L, Henrotin Y, Thumboo J, Hansen P, Bennell KL. OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis. Osteoarthritis Cartilage. 2013 Aug;21(8):1042-52. Oldmeadow LB, McBurney H, Robertson VJ. Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty. J Arthroplasty. 2003 Sep;18(6):775-9. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4560

Hoofdstuk 12 Perioperatieve fysiotherapeutische zorg voor patiënten na bovenbuik- of thoraxchrirurgie

Veel patienten die een buik- of thoraxoperatie hebben ondergaan, ontwikkelen een postoperatieve pulmonale complicatie. In dit hoofdstuk wordt het postoperatieve adempatroon beschreven aan de hand van veranderingen van de functionele residuale capaciteit, het ‘tidal volume’ en de vitale capaciteit. Vervolgens worden de fysiotherapeutische behandelmogelijkheden besproken en onderbouwd vanuit de fysiologie en effectonderzoek. Verder komen de factoren die het risico op een postoperatieve pulmonale complicatie verhogen en het belang van het screenen van patienten op deze risicofactoren aan de orde. Tot slot wordt iets gezegd over ontwikkelingen in de perioperatieve zorg die een verschuiving laten zien van de post- naar de preoperatieve zorg en over de manier waarop de fysiotherapie op deze ontwikkelingen kan inspelen.