N.L.U. van Meeteren

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.

Making the elderly fit for surgery

1University Children’s Hospital and Medical Centre Utrecht, Child and Development and Exercise Centre, University Medical Centre Utrecht, PO Box 85090, 3508 AB Utrecht, and 2Department of Physiotherapy, Physical Functioning in Chronicity, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, and Health∼Holland (Topsector Life Sciences and Health), The Hague, The Netherlands (e-mail: h.hulzebos@umcutrecht.nl)

What preoperative patient-related factors predict inpatient recovery of physical functioning and length of stay after total hip arthroplasty? A systematic review

Objective: To identify the preoperative patient-related characteristics predicting inpatient recovery of functioning and/or length of hospital stay after elective primary total hip arthroplasty. Design: A search was conducted of the electronic databases MEDLINE, EMBASE and CINAHL from inception through April 2014. Observational studies were selected for systematic review if they identified clinically relevant preoperative prognostic factors and reported an association between inpatient recovery of physical functioning and/or length of hospital stay. Study participants were adults undergoing an elective primary total hip arthroplasty. Results: Fourteen studies were included, a total of 199,410 individual total hip arthroplasty procedures. Two studies investigated inpatient recovery of physical functioning, no strong level of evidence was found for a relationship between functional recovery and any of the preoperative predictors. Twelve studies investigated the length of hospital stay and reported 19 preoperative prognostic factors. A strong level of evidence suggested that higher scores on the American Society of Anaesthesiologists assessment (OR 3.34 to 6.22, +0.20 days), increased number of comorbidities (RR of 1.10, +0.59 to 1.61 days), presence of heart disease, (RR of 1.59, +0.26 days), and presence of lung disease (RR of 1.30, +0.34 days) were associated with longer lengths of hospital stay following total hip arthroplasty. Conclusion: For the prediction of inpatient recovery of physical functioning no factors with a strong level of evidence were found. For length of stay there was a strong level of evidence for the American Society of Anaesthesiologists score, number of comorbidities, and presence of heart or lung disease.

What Augmented Physical Activity and Empowerment Can Bring to Patients Receiving Total Knee Replacement: Content, Implementation, and Comparative Effectiveness of a New Function-Tailored Care Pathway in a Routine Care Setting

Background. In the routine setting of the 20-bed orthopaedic ward of a regional hospital in Netherlands, we developed, implemented, and evaluated a new, function-tailored perioperative care pathway for patients receiving total knee replacement (TKR), aimed at faster functional recovery by reduction of inactivity and stimulation of self-efficacy of the patients. Methods. To assess effectiveness, we compared, using prospectively collected data from medical files, patient groups before (n = 127) and after (n = 108) introduction of the new care pathway with respect to time to recovery of physical functioning during hospitalisation (five milestones), length of hospital stay (LoS), referrals to an inpatient rehabilitation facility, and readmissions. Multivariable regression was used to adjust results for differences between the two groups in preoperatively assessed risk factors for delayed recovery. Results. Comparison of patient groups before (n = 127) and after (n = 108) introduction of the tailored care pathway showed that the tailored rehabilitation pathway decreased the time to recovery of physical functioning (from 4.5 to 4.1 days, P < 0.05), the mean LoS (from 5.2 days to 4.2 days, P < 0.01). Conclusion. We demonstrated that the introduction of a function-tailored care pathway shortens the hospital stay and accelerates the recovery of physical functioning.

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

Pre-operative functional mobility as an independent determinant of inpatient functional recovery after total knee arthroplasty during three periods that coincided with changes in clinical pathways

Aims To investigate whether pre‐operative functional mobility is a determinant of delayed inpatient recovery of activities (IRoA) after total knee arthroplasty (TKA) in three periods that coincided with changes in the clinical pathway. Patients and Methods All patients (n = 682, 73% women, mean age 70 years, standard deviation 9) scheduled for TKA between 2009 and 2015 were pre‐operatively screened for functional mobility by the Timed‐up‐and‐Go test (TUG) and De Morton mobility index (DEMMI). The cut‐off point for delayed IRoA was set on the day that 70% of the patients were recovered, according to the Modified Iowa Levels of Assistance Scale (mILAS) (a 5‐item activity scale). In a multivariable logistic regression analysis, we added either the TUG or the DEMMI to a reference model including established determinants. Results Both the TUG (Odds Ratio (OR) 1.10 per second, 95% confidence intervals (CI) 1.06 to 1.15) and the DEMMI (OR 0.96 per point on the 100‐point scale, 95% CI 0.95 to 0.98) were statistically significant determinants of delayed IRoA in a model that also included age, BMI, ASA score and ISAR score. These associations did not depend on the time period during which the TKA took place, as assessed by tests for interaction. Conclusion Functional mobility, as assessed pre‐operatively by the TUG and DEMMI, is an independent and stable determinant of delayed inpatient recovery of activities after TKA. Future research, focusing on improvement of pre‐operative functional mobility through tailored physiotherapy intervention, should indicate whether such intervention enhances postoperative recovery among high‐risk patients.

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.

Effects of a pre-operative home-based inspiratory muscle training programme on perceived health-related quality of life in patients undergoing coronary artery bypass graft surgery

OBJECTIVES Pre-operative inspiratory muscle training has been shown to decrease the incidence of postoperative pneumonia and length of hospital stay in patients undergoing coronary artery bypass graft surgery (CABG). This study investigated if this decrease acted as a mediator on the time course of quality of life. DESIGN Complementary analyses of a published randomised controlled trial. SETTING AND PARTICIPANTS The initial trial included patients awaiting CABG surgery at a Dutch university hospital. The secondary analyses used data from the initial trial for patients who had completed at least one quality-of-life questionnaire. METHODS Participants were allocated at random to the intervention group or the usual care group. The intervention group followed a home-based pre-operative inspiratory muscle training programme. Quality of life was measured at five time points. Between-group differences in quality-of-life scores were analysed using mixed linear modelling. RESULTS The secondary analyses used data for 235 patients. In line with the initial trial, pneumonia and length of hospital stay were decreased significantly in the intervention group. The time courses for all patients showed significant improvements in quality of life after surgery compared with baseline. No significant differences in quality of life were observed over time between the two groups. CONCLUSION Despite decreased incidence of pneumonia and length of hospital stay in the intervention group, this study did not find any improvements in quality of life due to the pre-operative home-based inspiratory muscle training programme. Clinical trial registration number ISRCTN17691887.

An evaluation of the validity of the pre-operative oxygen uptake efficiency slope as an indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery.

This study aimed to investigate the validity of the oxygen uptake efficiency slope as an objective and submaximal indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery. Patients ≥ 60 years of age, with a metabolic equivalent score using the Veterans Activity Questionnaire ≤ 7 and scheduled for major colorectal surgery participated in a pre‐operative cardiopulmonary exercise test. The oxygen uptake efficiency slope was calculated up to different exercise intensities, using 100%, 90% and 80% of the exercise data. Data from 71 patients (47 men, mean (SD) age 75.2 (6.7) years) were analysed. The efficiency slope obtained from all the data was statistically significantly different from the values when 90% (p = 0.027) and 80% (p = 0.023) of the data were used. The 90% and 80% values did not differ significantly from each other (p = 0.152). Correlations between the oxygen uptake efficiency slope and the peak oxygen uptake ranged from 0.816 to 0.825 (all p < 0.001), and correlations between oxygen uptake efficiency slope and the ventilatory anaerobic threshold ranged from 0.793 to 0.805 (all p < 0.001). Receiver operating characteristic curves showed that the oxygen uptake efficiency slope is a sensitive and specific predictor of a peak oxygen uptake ≤ 18.2 ml.kg−1.min−1, with an area under the curve (95%CI) of 0.876 (0.780–0.972, p < 0.001) and a ventilatory anaerobic threshold ≤ 11.1 ml.kg−1.min−1, with an area under the curve (95%CI) of 0.828 (0.726–0.929, p < 0.001). These correlations suggest that the oxygen uptake efficiency slope provides a valid (sub)maximal measure of cardiorespiratory fitness in these patients, and the predictive ability described indicates that it might help discriminate patients at higher risk of postoperative morbidity. However, future research should investigate the prognostic value of the oxygen uptake efficiency slope for postoperative outcomes.

Focus op functioneren: voorstel voor een aangepast ICF-schema

De International Classification of Functioning, Disability and Health (ICF) wordt sinds de publicatie in 2001 in toenemende mate gebruikt om het functioneren van mensen en de daarbij relevante factoren te beschrijven, zowel in de zorg als in onderzoek, onderwijs en beleid. Het ICF-begrippenkader bestaat uit: (1) een schema dat de componenten van de ICF weergeeft, inclusief het onderliggende biopsychosociale perspectief; en (2) een standaardterminologie: de verschillende classificaties (functies, anatomische eigenschappen, activiteiten/participatie, externe factoren), bestaande uit hoofdstukken met daaronder categorieen op verschillend detailniveau.