Physiotherapy - Research Publications

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    Early rehabilitation in critical care (eRiCC): functional electrical stimulation with cycling protocol for a randomised controlled trial
    Parry, SM ; Berney, S ; Koopman, R ; Bryant, A ; El-Ansary, D ; Puthucheary, Z ; Hart, N ; Warrillow, S ; Denehy, L (BMJ PUBLISHING GROUP, 2012-01-01)
    INTRODUCTION: Intensive care-acquired weakness is a common problem, leads to significant impairment in physical functioning and muscle strength, and is prevalent in individuals with sepsis. Early rehabilitation has been shown to be safe and feasible; however, commencement is often delayed due to a patient's inability to co-operate. An intervention that begins early in an intensive care unit (ICU) admission without the need for patient volition may be beneficial in attenuating muscle wasting. The eRiCC (early rehabilitation in critical care) trial will investigate the effectiveness of functional electrical stimulation-assisted cycling and cycling alone, compared to standard care, in individuals with sepsis. METHODS AND ANALYSIS: This is a single centre randomised controlled trial. Participants (n=80) aged ≥18 years, with a diagnosis of sepsis or severe sepsis, who are expected to be mechanically ventilated for ≥48 h and remain in the intensive care ≥4 days will be randomised within 72 h of admission to (1) standard care or (2) intervention where participants will receive functional electrical muscle stimulation-assisted supine cycling on one leg while the other leg undergoes cycling alone. Primary outcome measures include: muscle mass (quadriceps ultrasonography; bioelectrical impedance spectroscopy); muscle strength (Medical Research Council Scale; hand-held dynamometry) and physical function (Physical Function in Intensive Care Test; Functional Status Score in intensive care; 6 min walk test). Blinded outcome assessors will assess measures at baseline, weekly, at ICU discharge and acute hospital discharge. Secondary measures will be evaluated in a nested subgroup (n=20) and will consist of biochemical/histological analyses of collected muscle, urine and blood samples at baseline and at ICU discharge. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the relevant institution, and results will be published to inform clinical practice in the care of patients with sepsis to optimise rehabilitation and physical function outcomes. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12612000528853.
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    The LIPPSMAck POP (Lung Infection Prevention Post Surgery - Major Abdominal - with Pre-Operative Physiotherapy) trial: study protocol for a multi-centre randomised controlled trial
    Boden, I ; Browning, L ; Skinner, EH ; Reeve, J ; El-Ansary, D ; Robertson, IK ; Denehy, L (BIOMED CENTRAL LTD, 2015-12-15)
    BACKGROUND: Post-operative pulmonary complications are a significant problem following open upper abdominal surgery. Preliminary evidence suggests that a single pre-operative physiotherapy education and preparatory lung expansion training session alone may prevent respiratory complications more effectively than supervised post-operative breathing and coughing exercises. However, the evidence is inconclusive due to methodological limitations. No well-designed, adequately powered, randomised controlled trial has investigated the effect of pre-operative education and training on post-operative respiratory complications, hospital length of stay, and health-related quality of life following upper abdominal surgery. METHODS/DESIGN: The Lung Infection Prevention Post Surgery - Major Abdominal- with Pre-Operative Physiotherapy (LIPPSMAck POP) trial is a pragmatic, investigator-initiated, bi-national, multi-centre, patient- and assessor-blinded, parallel group, randomised controlled trial, powered for superiority. Four hundred and forty-one patients scheduled for elective open upper abdominal surgery at two Australian and one New Zealand hospital will be randomised using concealed allocation to receive either i) an information booklet or ii) an information booklet, plus one additional pre-operative physiotherapy education and training session. The primary outcome is respiratory complication incidence using standardised diagnostic criteria. Secondary outcomes include hospital length of stay and costs, pneumonia diagnosis, intensive care unit readmission and length of stay, days/h to mobilise >1 min and >10 min, and, at 6 weeks post-surgery, patient reported complications, health-related quality of life, and physical capacity. DISCUSSION: The LIPPSMAck POP trial is a multi-centre randomised controlled trial powered and designed to investigate whether a single pre-operative physiotherapy session prevents post-operative respiratory complications. This trial standardises post-operative assisted ambulation and physiotherapy, measures many known confounders, and includes a post-discharge follow-up of complication rates, functional capacity, and health-related quality of life. This trial is currently recruiting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number: ACTRN12613000664741 , 19 June 2013.
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    The Sternal Management Accelerated Recovery Trial (SMART) - standard restrictive versus an intervention of modified sternal precautions following cardiac surgery via median sternotomy: study protocol for a randomised controlled trial
    Katijjahbe, MA ; Denehy, L ; Granger, CL ; Royse, A ; Royse, C ; Bates, R ; Logie, S ; Clarke, S ; El-Ansary, D (BMC, 2017-06-23)
    BACKGROUND: The routine implementation of sternal precautions to prevent sternal complications that restrict the use of the upper limbs is currently worldwide practice following a median sternotomy. However, evidence is limited and drawn primarily from cadaver studies and orthopaedic research. Sternal precautions may delay recovery, prolong hospital discharge and be overly restrictive. Recent research has shown that upper limb exercise reduces post-operative sternal pain and results in minimal micromotion between the sternal edges as measured by ultrasound. The aims of this study are to evaluate the effects of modified sternal precautions on physical function, pain, recovery and health-related quality of life after cardiac surgery. METHODS/DESIGN: This study is a phase II, double-blind, randomised controlled trial with concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. Patients (n = 72) will be recruited following cardiac surgery via a median sternotomy. Sample size calculations were based on the minimal important difference (two points) for the primary outcome: Short Physical Performance Battery. Thirty-six participants are required per group to counter dropout (20%). All participants will be randomised to receive either standard or modified sternal precautions. The intervention group will receive guidelines encouraging the safe use of the upper limbs. Secondary outcomes are upper limb function, pain, kinesiophobia and health-related quality of life. Descriptive statistics will be used to summarise data. The primary hypothesis will be examined by repeated-measures analysis of variance to evaluate the changes from baseline to 4 weeks post-operatively in the intervention arm compared with the usual-care arm. In all tests to be conducted, a p value <0.05 (two-tailed) will be considered statistically significant, and confidence intervals will be reported. DISCUSSION: The Sternal Management Accelerated Recovery Trial (S.M.A.R.T.) is a two-centre randomised controlled trial powered and designed to investigate whether the effects of modifying sternal precautions to include the safe use of the upper limbs and trunk impact patients' physical function and recovery following cardiac surgery via median sternotomy. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry identifier: ACTRN12615000968572 . Registered on 16 September 2015 (prospectively registered).
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    A new two-tier strength assessment approach to the diagnosis of weakness in intensive care: an observational study
    Parry, SM ; Berney, S ; Granger, CL ; Dunlop, DL ; Murphy, L ; El-Ansary, D ; Koopman, R ; Denehy, L (BMC, 2015-02-26)
    INTRODUCTION: Intensive care unit-acquired weakness (ICU-AW) is a significant problem. There is currently widespread variability in the methods used for manual muscle testing and handgrip dynamometry (HGD) to diagnose ICU-AW. This study was conducted in two parts. The aims of this study were: to determine the inter-rater reliability and agreement of manual muscle strength testing using both isometric and through-range techniques using the Medical Research Council sum score and a new four-point scale, and to examine the validity of HGD and determine a cutoff score for the diagnosis of ICU-AW for the new four-point scale. METHODS: Part one involved evaluation of muscle strength by two physical therapists in 29 patients ventilated >48 hours. Manual strength testing was performed by both physical therapists using two techniques: isometric and through range; and two scoring systems: traditional six-point Medical Research Council scale and a new collapsed four-point scale. Part two involved assessment of handgrip strength conducted on 60 patients. A cutoff score for ICU-AW was identified for the new four-point scoring system. RESULTS: The incidence of ICU-AW was 42% (n = 25/60) in this study (based on HGD). In part one the highest reliability and agreement was observed for the isometric technique using the four-point scale (intraclass correlation coefficient = 0.90: kappa = 0.72 respectively). Differences existed between isometric and through-range scores (mean difference = 1.76 points, P = 0.005). In part two, HGD had a sensitivity of 0.88 and specificity of 0.80 for diagnosing ICU-AW. A cutoff score of 24 out of 36 points was identified for the four-point scale. CONCLUSIONS: The isometric technique is recommended with reporting on a collapsed four-point scale. Because HGD is easy to perform and sensitive, we recommend a new two-tier approach to diagnosing ICU-AW that first tests handgrip strength with follow-up strength assessment using the isometric technique for muscle strength testing if handgrip strength falls below cutoff scores. Whilst our results for the four-point scale are encouraging, further research is required to confirm the findings of this study and determine the validity of the four-point scoring system and cutoff score developed of less than 24 out of 36 before recommending adoption into clinical practice.
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    Ultrasonography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function
    Parry, SM ; El-Ansary, D ; Cartwright, MS ; Sarwal, A ; Berney, S ; Koopman, R ; Annoni, R ; Puthucheary, Z ; Gordon, IR ; Morris, PE ; Denehy, L (W B SAUNDERS CO-ELSEVIER INC, 2015-10-01)
    PURPOSE: This study aimed to (1) document patterns of quadriceps muscle wasting in the first 10 days of admission and (2) determine the relationship between muscle ultrasonography and volitional measures. MATERIALS AND METHODS: Twenty-two adults ventilated for more than 48 hours were included. Sequential quadriceps ultrasound images were obtained over the first 10 days and at awakening and intensive care unit (ICU) discharge. Muscle strength and function were assessed at awakening and ICU discharge. RESULTS: A total of 416 images were analyzed. There was a 30% reduction in vastus intermedius (VI) thickness, rectus femoris (RF) thickness, and cross-sectional area within 10 days of admission. Muscle echogenicity scores increased for both RF and VI muscles by +12.7% and +25.5%, respectively (suggesting deterioration in muscle quality). There was a strong association between function and VI thickness (r = 0.82) and echogenicity (r = -0.77). There was a moderate association between function and RF cross-sectional area (r = 0.71). CONCLUSIONS: Muscle wasting occurs rapidly in the ICU setting. Ultrasonography is a useful surrogate measure for identifying future impairment. Vastus intermedius may be an important muscle to monitor in the future because it demonstrated the greatest change in muscle quality and had the strongest relationship to volitional measures.
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    Functional electrical stimulation with cycling in the critically ill: A pilot case-matched control study
    Parry, SM ; Berney, S ; Warrillow, S ; El-Ansary, D ; Bryant, AL ; Hart, N ; Puthucheary, Z ; Koopman, R ; Denehy, L (W B SAUNDERS CO-ELSEVIER INC, 2014-08-01)
    PURPOSE: The purpose was to determine (a) safety and feasibility of functional electrical stimulation (FES)-cycling and (b) compare FES-cycling to case-matched controls in terms of functional recovery and delirium outcomes. MATERIALS AND METHODS: Sixteen adult intensive care unit patients with sepsis ventilated for more than 48 hours and in the intensive care unit for at least 4 days were included. Eight subjects underwent FES-cycling in addition to usual care and were compared to 8 case-matched control individuals. Primary outcomes were safety and feasibility of FES-cycling. Secondary outcomes were Physical Function in Intensive Care Test scored on awakening, time to reach functional milestones, and incidence and duration of delirium. RESULTS: One minor adverse event was recorded. Sixty-nine out of total possible 95 FES sessions (73%) were completed. A visible or palpable contraction was present 80% of the time. There was an improvement in Physical Function in Intensive Care Test score of 3.9/10 points in the intervention cohort with faster recovery of functional milestones. There was also a shorter duration of delirium in the intervention cohort. CONCLUSIONS: The delivery of FES-cycling is both safe and feasible. The preliminary findings suggest that FES-cycling may improve function and reduce delirium. Further research is required to confirm the findings of this study and evaluate the efficacy of FES-cycling.