Improving Outcomes in Oesophagectomy Patients

Introduction: Aberdeen Royal Infirmary is a low volume centre carrying out approximately 13 oesophagectomies per annum. Due to minimal exposure to post-operative oesophagectomy patients, staff had low perceived confidence in their management within the Intensive Care Unit (ICU). After an initial pause due to the COVID-19 pandemic, oesophagectomy service provision restarted in June 2020. Prior to this project, no standardised care pathway existed for post-operative oesophagectomy patients. A protocol driven management pathway was implemented within the ICU setting in October 2020. Objective(s): 1. Standardise the first 5 days of post-operative care for oesophagectamies 2. Improve 30 day mortality rate 3. Reduce opiate use on step down to High Dependency Unit (HDU) 4. Improve ICU Medical and Nursing staff perceived confidence in the management of oesophagectomy patients. Method(s): A multi-disciplinary approach was taken, with input from ICU, Surgical, Anaesthetic, Physiotherapy, Nursing, Pain and HDU teams. Standards of care for post-operative oesophagectomy patients were identified and a protocol was subsequently produced for use within ICU with reference to current Enhanced Recovery After Surgery (ERAS) guidelines.1 The protocol covered the first 5 days of post-operative care. It identified tasks to be completed each day and highlighted which staff group was responsible for performing each task. Additionally, an information sheet was distributed to Medical and Nursing ICU staff to educate them on oesophagectomy patients and recognition of potential complications that arise when caring for this patient group. Data on 30 day mortality and opiate use at step down to HDU was collected from electronic notes. This was collected retrospectively prior to implementation of the protocol from January 2019 - July 2020 and prospectively following its implementation, from October 2020 - December 2021. ICU staff perceived confidence in managing post-operative oesophagectomy patients was measured using a combined quiz and survey. It was completed by staff prior to introduction of the protocol. Following implementation of the protocol and distribution of the information sheet, the quiz and survey was repeated to evaluate improvement in staff confidence. Result(s): A total of 38 oesophagectomy cases were identified. 21 cases were reviewed prior to implementation of the protocol, with 1 mortality at 30 days. 17 cases were reviewed following implementation of the protocol, with 0 mortalities at 30 days. Qualitative scoring showed a 20% increase in staff confidence to manage this patient group. Review of drug prescription charts revealed a reduction in dose of modified release opiates at step down to HDU. Conclusion(s): Oesophagectomy is major surgery and causes significant staff anxiety in low volume centres. This protocol has successfully standardised care for this patient group and allowed continuation of this essential service provision during the COVID-19 pandemic. This protocol improved 30 day mortality, reduced opiate use at step down to HDU and improved ICU staff perceived confidence in caring for post-operative oseophagectomy patients.

A prolonged pandemic impacts the mental health of orthopaedic patients

Background and aimsMajority of elective orthopaedic operations are postponed to accommodate the reallocation of healthcare resources to combat the pandemic. The aim of this paper is to evaluate the mental state of orthopaedic patients amidst limited orthopaedic management options. The secondary aim of this paper is to identify areas of significant stressors and to provide avenues for improvements.MethodsA survey was administered on patients in outpatient clinics within a tertiary institution from 31 May to 13 June 2021 where government interventions prevented elective orthopaedic surgeries from being performed. Individuals' fatigue level were assessed with Chalder fatigue scale (CFS) and they were surveyed on their areas of stressors.ResultsA total of 160 orthopaedic patients (67 males and 93 females) were surveyed with an average age of 48.3 years old (range 17-88). 65 out of 160 (40.6%) were deemed to be severely fatigued (CFS > 4) with a higher prevalence amongst females than males (47.3% vs 31.3% respectively.) The top three areas identified as stressors included transmitting to family/friends, travel restrictions/quarantine orders and limitation on recreational/social activities (67.5%, 45.6% and 57.5% respectively). 25.6% of the patients indicated that the increased difficulty in accessing healthcare was a stress factor.Discussion and conclusionThere is a high proportion of severe fatigue amongst orthopaedic patients. Combined with postponement of orthopaedic care and treatment, the detrimental effects of a prolong pandemic can be more pronounced on orthopaedic patients. Identified areas of stressors provide avenues for improvements to safeguard the mental health of orthopaedic patients.

Prevalence of tension-type headache and its correlation with sleep quality among physiotherapy and nursing students from higher education institutions in Klang valley, Malaysia, during the COVID-19 pandemic

Introduction and Aim: Previously tension-type headache (TTH) was found to be highly prevalent among the general population worldwide, but the current data available were limited. Due to the COVID-19 pandemic, many life changes occurred to adapt to the situation, students started e-learning from home and their sleep quality (SQ) might be influenced. Physiotherapy and nursing students were studied as they are rarely being studied by researchers, information about them was very limited. This study aimed to determine the prevalence of TTH, SQ and the type of correlation between the two during the COVID-19 pandemic. Method(s): A cross-sectional study was conducted by sharing the online questionnaires composed of 2 main components: (i) Questionnaire formulated from diagnosing criteria for TTH of ICHD-3 (ii) Pittsburgh Sleep Quality Index (PSQI), to PS and NS students from higher education institutions in Klang Valley, Malaysia. Result(s): A total of 259 respondents were recruited in the study. The prevalence of TTH was 76.8% and SQ had a mean score of 5.12, which indicated poor SQ among PS and NS students, during the COVID-19 pandemic. Correlation between TTH and SQ was proved to be significant in this study (p=0.032, rs =0.133). Conclusion(s): High prevalence of TTH and poor SQ among PS and NS students during the COVID-19 pandemic was determined. There is a weak positive correlation between TTH and SQ during COVID-19 pandemic.Copyright © 2023, Indian Association of Biomedical Scientists. All rights reserved.

Isometric thumb extension exercise as part of a multimodal intervention for de Quervain's syndrome: A randomised feasibility trial

Introduction: de Quervain's syndrome is a painful condition commonly presented to hand therapists. Exercise is utilised as an intervention, but isometric exercise has not been investigated. We aimed to assess the feasibility and safety of isometric thumb extension exercise for de Quervain's syndrome and to explore differences between high-load and low-load isometric exercise. Method(s): This parallel-group randomised clinical feasibility trial included individuals with de Quervain's syndrome. All participants underwent a 2 week washout period where they received an orthosis, education, and range of motion exercises. Eligible participants were then randomised to receive high or low-load isometric thumb extension exercises, performed daily for 4 weeks. Feasibility and safety were assessed by recruitment and drop-out rates, adherence, adverse events, and participant feedback via semi-structured interviews. Secondary outcomes included patient-reported outcomes for pain and function, and blinded assessment of range of motion and strength. Result(s): Twenty-eight participants were randomised. There were no drop-outs after randomisation, and no serious adverse events. Adherence to exercise was 86.7%, with 84% of participants stating they would choose to participate again. There were clinically and statistically significant improvements in pain and function over time (p < 0.001) but not in range of motion or strength. There were no statistically significant between-group differences. Conclusion(s): Isometric thumb extension exercise within a multimodal approach appears a safe and feasible intervention for people with de Quervain's syndrome. A large multi-centre trial would be required to compare high- and low-load isometric exercises. Further research investigating exercise and multimodal interventions in this population is warranted.Copyright © The Author(s) 2023.

The 'Life after ICU' mobile application- a process in creating an accessible patient-centred platform for Intensive Care rehabilitation resources

Introduction: InS:PIRE (Intensive Care Syndrome: Promoting Independence and REcovery) is a multidisciplinary programme whose role is to assist patients in the identification of, and subsequent rehabilitation from the sequelae of an admission to the Intensive Care Unit (ICU). In NHS Aryshire and Arran (NHSAA) InS:PIRE has traditionally consisted of in-person rehabilitation and support meetings to help manage common post-ICU issues. COVID-19 forced all InS:PIRE activities online, and has required services to redesign their delivery of supporting resources to be readily accessible remotely. Thus, the 'Life after ICU' app was created. Objective(s): The role of this application was to help better-provide accessible information to former ICU patients and their relatives, as well as, improve connectivity between medical professionals and patients. Method(s): The app platform was developed by Piota. Resources were chosen for inclusion through surveying InS:PIRE attendees, who identified their main areas of concern. These areas included: physical problems, emotional issues, social issues, family support, COVID specific support, and physiotherapy. The multidisciplinary InS:PIRE team co-ordinated the identification and collation of the appropriate resources. Additionally, the app serves as a platform for InS:PIRE to disseminate information about the on-going programmes as well as allowing attendees to contact the InS:PIRE team. Result(s): A trial version of the 'Life After ICU' app has now been launched. This app will allow patients and their families to readily access the resources they require. Following a trial period, feedback from app users will be collected and further adaptations made. Conclusion(s): Launching the app recognises the wider view of the importance of eHealth, and its role in modernising service-delivery. Indeed, the Scottish National Clinical Strategy recognises this as an area for future development. The efficacy of eHealth interventions for rehabilitation have been acknowledged,1-2 and thus translating them to the ICU context can be considered as a means of improving the holistic rehabilitation of this complex patient group. Furthermore, through providing services easily accessible by patients, this app allows InS:PIRE to realise NHSAA's 'Caring for Ayshire' strategy, whose aim is to provide care closer to home.

ID: 219407 The Cardiac Patient and Neuromodulation, When Anticoagulation Dictates the Intervention

Introduction: Patients with cardiac comorbidities present unique challenges for undergoing interventional pain procedures. Consensus guidelines on safe anticoagulation management are categorized by procedure, patient specific bleeding risk factors, and class of anticoagulation (Table 1, Table 2).1 Specifically, some procedures occur in close proximity to the spinal cord, require large gauge needles and styletted leads, while others are in compressible locations with minimal tissue disruption. Further, pain-induced hypercoagulation increases the risk of thrombo-vascular events.1 This accentuates the importance of interdisciplinary perioperative coordination with the prescribing cardiologist. Case: A 71-year-old male with past-medical-history of CABG, bilateral femoral-popliteal bypass, atrial fibrillation on apixaban and ticagrelor, and multiple cardiac stents presented with intermittent shooting axial back pain radiating to right buttock, lateral thigh, and calf, worsened with activity. MRI demonstrated thoracic myelomalacia, multi-level lumbar disc herniation, and moderate central canal stenosis. An initial multi-model treatment approach utilizing pharmacologic agents, physical therapy, ESI's, and RFA failed to alleviate symptoms. After extensive discussion with his cardiologist, he was scheduled for a three-day SCS trial. Ticagrelor and apixaban were held throughout the 3-day trial and for 5 and 3 days prior, respectively, while ASA was maintained. Successful trial with tip placement at T6 significantly improved function and pain scores (Figure 1). Upon planned percutaneous implant, the cardiologist recommended against surgical implantation and holding anticoagulation. Alternatively, the patient underwent bilateral lumbar medial branch PNS implant with sustained improvement in lower back symptoms. However, he contracted COVID, resulting in delayed lead explanation (>60 days) without complication. Conclusion(s): Interventional pain practice advisories are well established for anticoagulation use in the perioperative period.1,2 However, there is limited high-quality research on the appropriate length to hold anticoagulation prior to surgery for high thrombotic risk patients. Collegial decision making with the cardiologist was required to avoid deleterious procedural complications. However, they may be unfamiliar with the nuances between interventions or between trial and implant. Prospective studies have shown that low risk procedures, such as the PNS, may not require holding anticoagulants.3 Other case data has demonstrated post-SCS epidural hematoma with ASA use after being held for 1-week prior to surgery. Our patient was unable to undergo SCS implant and instead elected for a lower risk procedure with excellent efficacy. 4 However, delayed PNS lead extraction due to COVID19 hospitalization presented further risk of infection and lead fracture.5 PNS may prove to be an appropriate treatment option for patients who are anticoagulated and are not SCS candidates. Disclosure: Elliot Klein, MD,MPH: None, Clarence Kong, MD: None, Shawn Sidharthan, MD: None, Peter Lascarides, DO: None, Yili Huang, DO: NoneCopyright © 2023

Platypnea-Orthodeoxia Syndrome Associated with COVID-19 Pneumonia and Prolonged Treatment Due to Tamsulosin Use: A Case Report

Platypnea-orthodeoxia syndrome (POS) is an extremely rare condition. There are no other cases in the literature where tamsulosin has been reported to prolong POS treatment. A 67-year-old male patient was hospitalized due to COVID-19. He was followed up in the ward after being in the intensive care unit for ten days. There was a significant decrease in saturation (SaO2) when sitting and standing compared to lying. He was diagnosed with POS. However, there was no significant improvement in POS with exercises. After stopping the tamsulosin he was using, there was a dramatic improvement. He was discharged on the 72nd day of his hospitalization. Due to COVID-19, POS is more likely to appear than before. It is a condition that clinicians should recognize. The pathophysiology of POS has not been fully elucidated. The case we present suggests that alpha-blockers may also be related to pathophysiology.©Copyright 2020 by Emergency Physicians Association of Turkey -

New Zealanders with low back pain seeking health care: a retrospective descriptive analysis of Accident Compensation Corporation-funded low back pain healthcare service usage

Introduction. Most New Zealanders experience low back pain (LBP) at least once throughout their lifetime and many seek help from the large range of health providers in primary care. Accident Compensation Corporation (ACC) funds a significant proportion of those claims, but which services are they funding and what are the costs? Method. This was a retrospective audit and descriptive analysis of ACC-funded, non-public hospital healthcare service use by people with LBP in New Zealand (NZ). Outcome measures were the healthcare services accessed by people with ACC-funded LBP,the claims (all occurrences for a service that has generated a payment/ year), single contact (with a service), and costs (NZ$) for services between 2009 and 2020. Results. The number of claims for services were 129 000 for physiotherapy, 105 000 for general practitioner and 59 000 for radiology services. Per single contact, elective surgery and radiology services were the most expensive. During 2009-2020, there were 3.3 million ACC claims for LBP with a total cost of NZ$4 billion. Over this time, there was an increase in claims, costs and single contacts. Costs decreased slightly during 2010 due to changes in healthcare funding and in 2020 due to the COVID-19 pandemic. Discussion. Consumers have considerable choice in where they access health care for ACC-funded LBP services. This study shows the services they use most frequently and the cost to NZ for those services. These data can inform service planning for ACC-funded LBP health care in NZ.

Clinical characteristics, complications, and outcomes of severe COVID-19 ARDS patients supported by ECMO and triaged for lung transplantations

Objectives: More than 200 patients have benefited from lung transplantation who failed to recover from COVID-19-induced acute respiratory distress (ARDS) with conventional ventilatory support and/ or extracorporeal membrane oxygenation support (ECMO) in USA. We aim to share our experience and lessons learned at our institute through this case series. Method(s): After IRB approval, we performed a retrospective chart review and identified 37 patients who received ECMO for COVID-19 induced ARDS between May 2020 through January 2022. Out of these, 12 received a formal consultation from the transplant team. We studied patient characteristics, interventions during ECMO support, and evaluation outcomes. Result(s): Most of our patients had single organ failure i.e., lung, except for two who required dialysis after ECMO initiation. Six out of the 12 patients received bilateral lung transplant. One patient received the transplant before ECMO initiation. However, the patient required two runs of ECMO after the transplant due to postop complications from suspected COVID19 reinfection and deceased on postoperative day 101. All the patients after transplant had an expedited recovery except one who required prolonged hospitalization before starting physical therapy. The median length of hospital stay for the transplant group was 148 (89- 194) days and for the non-transplant group was 114 (58-178) days. The 30-day survival rate was 100% for the transplant group. At a median follow-up of 207 (0- 456) days after discharge, 5(83.3%) patients in the transplant group and 3(50%) patients in the nontransplant group were alive. In the non-transplant group, 4 patients received ECMO support for more than 75 days and at last follow-up 2 were alive and functioning well without needing new lungs. This asks for an objective prospective study to define the timeline of irreversibility of the lung injury. Conclusion(s): Lung transplantation is a viable salvage option in patients with COVI-19 induced irreversible lung injury. However, the irreversibility of the lung injury and the timing of lung transplant remains to be determined case-by-case. (Figure Presented).

THE EFFECTS OF SPINAL STABILIZATION EXERCISES VIA TELEREHABILITATION ON INDIVIDUALS WITH CHRONIC LOW BACK PAIN: A RANDOMIZED CONTROLLED STUDY

BackgroundChronic low back pain is a very common problem worldwide. Reasons such as repetitive problems and lack of a clear treatment cause low back pain to be a serious burden for society [1]. Telerehabilitation provides remote application of rehabilitation services with the developing technology. Especially in the COVID-19 pandemic, the problems experienced in health services have increased the popularity of telerehabilitation services [2].ObjectivesAim in this study is to investigate the effects of spinal stabilization exercises performed remotely with asynchronous video clips on pain, disability, quality of life, trunk flexion range of motion and gait parameters.MethodsA total of 20 individuals with chronic low back pain were included in the study. After recording demographic information, pain levels were evaluated with the Visual Analogue Scale (VAS), disability levels were evaluated with the Oswestry Disability Index (ODI), and quality of life was evaluated with the Nottingham Health Profile (NHP). Trunk flexion range of motion was evaluated with the Valedo ® system (Hocoma, Switzerland), and the spatiotemporal parameters of the gait (step time, cadance) were evaluated with the OPTOGAIT system (OPTOGait, Microgate, Italy). After the evaluation, the individuals were divided into 2 groups. One group did face-to-face progressive spinal stabilization exercises in the clinic, while the other group did the same exercise program remotely with asynchronous videos. The exercise program was 8 weeks, 3 days a week.ResultsThe mean age of the telerehabilitation group (4 M, 5 F) was 41.44 ± 9.74, and their body mass index (BMI) was 26.34 ± 3.1. The mean age of the clinical group (1 M, 8 F) was 41.0 ± 13.0, and their BMI was 27.64 ± 3.55. All parameters were similar in the two groups before treatment. There was a significant difference in parameters except gait parameters in both groups after treatment (p<0.05). In the evaluation between the groups after treatment, the results of the two groups were similar in all parameters (p>0.05) (Table 1).Table 1.Baseline and after treatment characteristics of telerehabilitation and face to face group and comparison of with-in group and between groupTelerehabilitationFace to FaceBaselineAfter Treatmentp valueBaselineAfter Treatmentp valueBetween GroupVAS6.51±1.612.41±1.170.00*6.62±0.952.33±1.980.00*0.79ODI20.66±9.9413.55±100.00*30.22±15.517.11±120.02*0.54NHP131.51±121.2934.0±29.610.01*203.55±60.0763.08±76.240.00*0.66Trunk Flexion Range of Motion99.55±12.24106.55±7.510.04*88.11±15.2694.11±15.180.00*0.09Step length (cm)60.67±9.0764.35±9.580.5153.82±2165.95±9.410.170.54Step Time (sec)0.55±0.040.51±0.080.260.40±0.120.34±0.180.130.06Cadance105.67±9.17106.13±17.460.44103.37±8.64105.31±9.450.670.73ConclusionAccording to the results of our study, it is seen that both methods did not provide any change in gait parameters. However, it has similar effects in reducing pain and disability, improving quality of life, and increasing trunk range of motion. For individuals with chronic low back pain, it seems that remote exercise with asynchronous videos can be as effective a treatment as face-to-face exercise. There is a need for studies to be conducted in a larger population with longer follow-up.References[1] Anderson GB. epidemiological features of chronicles low back pain _ the lance _ 1999;354(9178):581-5.[2] Turolla A, Rossettini G, Viceconti A, Palese A, Geri T. Musculoskeletal physical therapy during the COVID-19 pandemic: is telerehabilitation the answer? Phys. ther. 2020;100(8): 1260-4.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Breathing Retraining Adjuncts - A Systematic Review

Background: The COVID-19 pandemic highlighted the importance of breath and the impact of deficiency of oxygen supply and desaturation on modern medicine. In such situations, positioning, breathing exercises, and counseling are critical to patient survival. Additionally, breathing exercises have been found effective in minimizing pulmonary complications and promoting early recovery in pre and post-surgical conditions. Therefore, this study aimed to identify the existing devices used as adjuncts in breathing retraining and assess their effectiveness in routine chest physiotherapy practice. Method: Randomized controlled trials (RCTs) conducted until July 2022 were included in the review. The electronic databases MEDLINE, PEDro, CINHAL, PUBMED, and Google Patents were searched based on the PRISMA guideline's criteria, and research articles studied devices as adjuncts to physiotherapy in respiratory disorders. Devices that can aid in inspiratory or expiratory exercises with or without resistance are available and can be used during physiotherapy as adjuncts to management. However, not all devices are found to be multifunctional. Conclusion: The study found that devices with functionality involving inspiratory or expiratory exercises with or without resistance can be used during physiotherapy as adjuncts to management. However, not all devices are multifunctional, and further research is needed to identify the most effective devices for use in respiratory disorders. © 2023,Journal for ReAttach Therapy and Developmental Diversities. All Rights Reserved.

Similar symptoms at 3 months post discharge in ICU, COVID-19 ICU, and COVID-19 patients that received non-invasive ventilation in high dependency areas

Introduction: It is well documented that survivors of ICU admissions struggle to return to pre-admission level of function because of both physical and psychological burden. Current guidance therefore recommends a follow-up service to review patients 2-3 months post discharge from ICU [NICE 2009]. Prior to 2020 University Hospitals Bristol and Weston (UHBW) had no such service. With the increase in patient numbers seen during the COVID-19 pandemic, funding was received to provide a follow-up clinic to COVID-19 survivors. Spare clinic spaces were used for non COVID ICU patients. Objective(s): To review symptoms reported by patients in the following 3 groups, COVID-19 patients treated in ICU (COVID ICU), COVID-19 patients treated with continuous positive airway pressure ventilation in high dependency areas (COVID CPAP) and non COVID-19 ICU patients (ICU), at 2-3 months post discharge from UHBW. Method(s): Referred patients had an initial phone call at 8 weeks post discharge. The call identified both physical and psychological symptoms. Advice regarding recovery, signposting to resources and onwards referrals to appropriate specialities were provided. If symptoms indicated, patients would then be referred into the multidisciplinary team follow up clinic. Here they met with an intensivist, clinical psychologist, physiotherapist, occupational therapist, speech and language therapist and dietitian. Result(s): As Graph 1 shows all 3 patient groups had a wide variety of ongoing symptoms at 2-3 months post discharge. Fatigue was the most common symptom reported in all 3 groups. Breathlessness was the second most common symptom reported by COVID patients but was less frequently reported in the ICU population who had a variety of non-respiratory related reasons for admission. COVID ICU patients more commonly reported ongoing problems with their swallowing, voice and communication compared to the COVID CPAP group, most probably due to invasive ventilation. Psychological burden post critical illness was high in all 3 groups. More than 20% of all patients scored =10 on a PHQ-9 depression scale showing moderate to severe depression. More than 15% of all patients scored =10 on a GAD-7 showing moderately severe to severe anxiety. COVID ICU group had the highest incidence of post-traumatic stress disorder (PTSD). This may be linked to the higher level of delirium we saw in this group, as a result of change in practice, such as full PPE and absence of visiting during the pandemic. ICU patients presented with a significantly higher percentage of physiotherapy needs. This is likely because patients with the longest and most complex ICU admissions were selected for the clinic. Sleep likely goes under reported in these results as we only began questioning specifically about this later on in the clinic. Conclusion(s): This data goes some way in supporting current literature that the rehabilitation needs of COVID ICU patients equal that of ICU patients (Puthucheary et al 2021). It also shows the need to follow up patients who receive advanced respiratory support outside of the ICU environment, as their symptoms, and therefore rehabilitation needs are very similar to ICU patients at 2-3 months post discharge.

ICU follow-up clinic provides the opportunity to recognise and address symptoms post critical illness, which may otherwise have been missed

Introduction: It is well documented that survivors of ICU admissions struggle to return to pre-admission level of function because of both physical and psychological burden. Current guidance therefore recommends a follow-up service to review patients 2-3 months post discharge [NICE 2009]. Prior to 2020 University Hospitals Bristol and Weston had no such service. With the increase in patient numbers seen during the COVID-19 pandemic, funding was received to provide a follow-up clinic to COVID-19 survivors. Objective(s): To provide a service that supports and empowers patients with their recovery from critical illness. Improving quality of life, speed of recovery and reducing longer term health care needs. Method(s): Referral criteria for the clinic included COVID-19 patients who received advanced respiratory support within intensive care and the high dependence unit. 8 weeks post discharge patients had a telephone appointment where ongoing symptoms could be identified. Advice around recovery, signposting to resources and onward referrals to appropriate specialities were provided. At 10 weeks post discharge patients had lung function tests and a chest X-ray which were reviewed by respiratory consultants. Based on the combination of these assessments, patients would be discharged or referred into the multidisciplinary team (MDT) follow-up clinic. The face to face clinic consisted of appointments with an intensivist, clinical psychologist, physiotherapist, and occupational therapist. Where needed patients would also be seen by a speech and language therapist or dietitian. Patients were seen only once in follow up clinic but again would be referred onto appropriate services within trust or the community, including but not exclusively community therapy services, secondary care services, SALT, dietetic or psychology clinics. Result(s): One of the key outcomes was the need for 147 onward referrals (an average of 1.13 referrals per patient). This included, 31 referrals to musculoskeletal physiotherapy outpatients for problems originating or made worse by their admission. 20 referrals to secondary care, including cardiology and ENT. 16 referrals to community occupational therapy, for provision of equipment, home adaptations and support in accessing the community. Subjectively, patient feedback was excellent. When asked what they felt was the most valuable thing they had taken from the clinic they reported: "Reassurance";"To know I'm not alone, others feel like this";"They listened to me and gave advice";"The ability to ask anything I wanted and the obvious kindness and support from all the clinicians I saw". Conclusion(s): Onward referral rates made by the follow-up clinic highlight the many issues faced by patients following discharge from ICU and hospital. With timely recognition and management, we can prevent a majority of these symptoms manifesting into chronic problems. This has the potential to lower the long-term burden on health care and improve quality of life for patients in both the short and long term. Without the follow-up clinic, these issues may have been missed or delayed. This reinforces the importance of the follow-up clinic and the need for ongoing investment.

Chest physiotherapy techniques administered by certified specialists to hospitalized patients with COVID-19 in Brazil: A look towards future practice.

BACKGROUND: Chest physiotherapy for hospitalized patients with COVID-19 has been poorly reported. Although recommendations were published to guide physiotherapists, practice might have differed depending on education and training. OBJECTIVE: To analyze the differences in chest physiotherapy applied for hospitalized patients with COVID-19 between certified specialists and non-certified specialists. METHODS: An online questionnaire survey was developed for physiotherapists involved in the management of hospitalized patients with COVID-19. The questionnaire inquired about professional information and characteristics of physiotherapy practice. RESULTS: There were 485 respondents, yielding a completion rate of 76%. Of these, 61 were certified specialists and 424 non-certified specialists. The certified specialists were older, had more years of professional experience, were more qualified, and had better job conditions. For mechanically ventilated patients, the certified specialists used the ventilator hyperinflation maneuver more frequently (50.4% vs 35.1%, p = 0.005), and the hard/brief expiratory rib cage compression (ERCC) (26.9% vs 48.3%, p = 0.016), soft/long ERCC (25.2% vs 39.1%, p = 0.047), and manual chest compression-decompression (MCCD) maneuver (22.4% vs 35.6%, p = 0.001) less often. For spontaneously breathing patients, the certified specialists used the active cycle of breathing technique (30.8% vs 67.1%, p<0.001), autogenic drainage (7.7% vs 20.7%, p = 0.017), and MCCD maneuver (23.1% vs 41.4%, p = 0.018) less frequently. CONCLUSIONS: Certified specialists with higher levels of expertise seem to prefer the use of chest physiotherapy techniques that are applied with the mechanical ventilator over manual techniques. Furthermore, they use techniques that could potentially increase the work of breathing less frequently, mitigating the risk of exacerbating respiratory conditions in patients with COVID-19.

From Strict Bedrest to Early Mobilization: A History of Physiotherapy in the Intensive Care Unit.

Critically ill patients are at risk of post-intensive care syndrome, including physical, cognitive, and psychological sequelae. Physiotherapists are rehabilitation experts who focus on restoring strength, physical function, and exercise capacity. Critical care has evolved from a culture of deep sedation and bed rest to one of awakening and early mobility; physiotherapeutic interventions have developed to address patients' rehabilitation needs. Physiotherapists are assuming more prominent roles in clinical and research leadership, with opportunities for wider interdisciplinary collaboration. This paper reviews the evolution of critical care from a rehabilitation perspective, highlights relevant research milestones, and proposes future opportunities for improving survivorship outcomes.

Effectiveness of exercise training on the dyspnoea of individuals with long COVID: A randomised controlled multicentre trial.

BACKGROUND: COVID-19-related acute respiratory distress syndrome (CARDS) is a severe evolution of the Sars-Cov-2 infection and necessitates intensive care. COVID-19 may subsequently be associated with long COVID, whose symptoms can include persistent respiratory symptoms up to 1 year later. Rehabilitation is currently recommended by most guidelines for people with this condition. OBJECTIVES: To evaluate the effects of exercise training rehabilitation (ETR) on dyspnoea and health-related quality of life measures in people with continuing respiratory discomfort following CARDS. METHODS: In this multicentre, two-arm, parallel, open, assessor-blinded, randomised controlled trial, we enroled adults previously admitted with CARDS to 3 French intensive care units who had been discharged at least 3 months earlier and who presented with an mMRC dyspnoea scale score > 1. Participants received either ETR or standard physiotherapy (SP) for 90 days. The primary outcome was dyspnoea, as measured by the Multidimensional Dyspnoea Profile (MDP), at day 0 (inclusion) and after 90 days of physiotherapy. Secondary outcomes were the mMRC and 12-item Short-Form Survey scores. RESULTS: Between August 7, 2020, and January 26, 2022, 487 participants with CARDS were screened for inclusion, of whom 60 were randomly assigned to receive either ETR (n = 27) or SP (n = 33). Mean MDP following ETR was 42% lower than after SP (26.15 vs. 44.76); a difference of -18.61 (95% CI -27.78 to -9.44; p<10-4). CONCLUSION: People who were still suffering from breathlessness three months after being discharged from hospital with CARDS had significantly improved dyspnoea scores when treated with ETR therapy for 90 days unlike those who only received SP. Study registered 29/09/2020 on Clinicaltrials.gov (NCT04569266).

Mobilisation practices during the SARS-CoV-2 pandemic: A retrospective analysis (MobiCOVID).

BACKGROUND: Corona Virus Disease 2019 (COVID-19) patients display risk factors for intensive care unit acquired weakness (ICUAW). The pandemic increased existing barriers to mobilisation. This study aimed to compare mobilisation practices in COVID-19 and non-COVID-19 patients. METHODS: This retrospective cohort study was conducted at Charité-Universitätsmedizin Berlin, Germany, including adult patients admitted to one of 16 ICUs between March 2018, and November 2021. The effect of COVID-19 on mobilisation level and frequency, early mobilisation (EM) and time to active sitting position (ASP) was analysed. Subgroup analysis on COVID-19 patients and the ICU type influencing mobilisation practices was performed. Mobilisation entries were converted into the ICU mobility scale (IMS) using supervised machine learning. The groups were matched using 1:1 propensity score matching. RESULTS: A total of 12,462 patients were included, receiving 59,415 mobilisations. After matching 611 COVID-19 and non-COVID-19 patients were analysed. They displayed no significant difference in mobilisation frequency (0.4 vs. 0.3, p = 0.7), maximum IMS (3 vs. 3; p = 0.17), EM (43.2% vs. 37.8%; p = 0.06) or time to ASP (HR 0.95; 95% CI: 0.82, 1.09; p = 0.44). Subgroup analysis showed that patients in surge ICUs, i.e., temporarily created ICUs for COVID-19 patients during the pandemic, more commonly received EM (53.9% vs. 39.8%; p = 0.03) and reached higher maximum IMS (4 vs. 3; p = 0.03) without difference in mobilisation frequency (0.5 vs. 0.3; p = 0.32) or time to ASP (HR 1.15; 95% CI: 0.85, 1.56; p = 0.36). CONCLUSION: COVID-19 did not hinder mobilisation. Those treated in surge ICUs were more likely to receive EM and reached higher mobilisation levels.

Functional Impact of Telehealth Physical Therapy Services on Patients Post Hematopoietic Stem Cell Transplant

BACKGROUND AND PURPOSE: Stem cell transplantation (SCT) in patients with hematological cancers results in longstanding physical changes. Commonly reported symptoms include chronic fatigue, global weakness, interference with activities of daily living (ADLs) and aerobic deconditioning. Aside from the sequela of symptoms experienced post SCT, these patients remain in an immunosuppressed state for several months following discharge from the hospital. Patients are often advised by their medical team to isolate themselves unless to attend follow-up outpatient clinic appointments. With the COVID-19 pandemic, this functional gap in the continuum of care worsened. As a result, SCT patients are both hesitant and discouraged to pursue outpatient or home health physical therapy even when these services are warranted. Thus, there is great need for options to safely optimize function for people post-SCT that are suitable in today's ever-changing environment. The purpose of this case series is to describe the functional impact of incorporating telehealth into the continuum of care for post SCT patients. CASE DESCRIPTION: 9 patients post inpatient admission for SCT were triaged to telehealth PT based on their scores on the Short Physical Performance Battery (SPPB) and the Activity Measure for Post Acute Care (AM-PAC) at the time of discharge from inpatient care. Scores on the SPPB ranged from 5-11, and AMPAC scores ranged from 21-24, demonstrating physical impairment. Patients were scheduled to receive telehealth twice a week. Sessions consisted of therapeutic exercises monitored via secure video software. Lab values were monitored via electronic medical record to assess appropriateness for therapy prior to each session. Rating of perceived exertion (RPE) scale and patientowned pulse oximeter were used to monitor patient fatigue levels. Patients' progress was assessed via Lower Extremity Functional Scale (LEFS), Brief Fatigue Inventory (BFI) and 5-times sit to stand (5xSTS) scores. OUTCOME(S): One year post telehealth implementation, patients reported improved independence and achievement of selfselected goals. Notable patient quotes include, "I feel less fearful in climbing up and down the stairs, and I feel more independent with laundry and cooking.which was very important for me." Additionally, patients reported a decrease in LEFS and BFI scores. Initial LEFS scores averaged 40% and dropped to 20% by discharge. Similarly, BFI scores dropped by 2 points at discharge, reflecting improved self-reported functional performance and a return to pre transplant fatigue levels. 5xSTS scores decreased by greater than 3 seconds in 6 of 9 patients, with one patient performing where previously unable. DISCUSSION: Telehealth services provide an additional method of care delivery to those unable to seek it in the traditional sense. For the severely immunocompromised, physical therapy via telehealth provides direct connection to providers trained in oncology rehabilitation serving as a feasible bridge between inpatient and outpatient care for amelioration of side effects associated with SCT.

Behaviour and Feedback of Patients with Gonarthrosis or Coxarthrosis Receiving Teletherapeutic Treatment - A Qualitative Video AnEine qualitative Videoanalysealysis

Background As a result of the corona pandemic, the implementation of physiotherapy as teletherapy was initially permitted for a limited period of time and subsequently approved for an unlimited period of time. Patients with gonarthrosis and coxarthrosis can be a target group.Aim To explore the behavior and feedback of patients with gonarthrosis and coxarthrosis, including patients who have had endoprosthetic treatment, during teletherapeutic treatments using screencasts.Method Patients with gonarthrosis or coxarthrosis, possibly after endoprosthetic treatment, received 6 treatment sessions including 5 by teletherapy. Participants completed the Musculoskeletal and Joint Health Questionnaire (MSK-HQ) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The first and last treatment sessions were videotaped and thereafter transcribed. Coding of the text passages was deductively content-analytic.Results 5 patients were included (2 m, 3w;56 to 78 years;3 gonarthrosis, 2 coxarthrosis;of those 2 with endoprosthesis). The behavior and patients' perspectives were assigned to the main categories of person-related factors, treatment characteristics, point of view or environment-related factors, each with 2-5 subcategories. The evaluation showed a thoroughly positive attitude towards teletherapy. This despite initial doubts and lack of knowledge about the method. Factors such as framework conditions, technology, personal motivation and compliance, as well as the relationship between patient and therapist, were found to influence the patients' attitude towards this method. A mixed therapy design consisting of teletherapy and conventional methods received a preferred resonance. For all participants, a clinically relevant improvement of the WOMAC was observed (7-47 points;improvement MSK-HQ 1-13 points).Conclusion The behavior of the participants shows that a sound planned teletherapy can be well implemented in practice. The description of the patient perspective provides researchers and practitioners with information that can be used for the further development of teletherapeutic treatment concepts for patients with gonarthrosis or coxarthrosis as well as for patients with musculoskeletal complaints in general.

Resiliency among Older Adults Receiving (Roar) Lung Cancer Treatment: A Feasibility Study

PURPOSE/HYPOTHESIS: Poor physical performance and negative mood are two risk factors for functional decline among older adults with lung cancer. Yet, targeted interventions to maintain independence prevent functional decline are not well studied. Our primary objective was to assess the feasibility of a novel virtual health physical therapy (PT) plus progressive muscle relaxation (PMR) intervention with longitudinal microbiome biospecimen collection delivered to older adults with advanced lung cancer. Secondary objectives were to characterize functional status and clinical factors pre and post-study intervention. NUMBER OF SUBJECTS: We accrued adults aged >=60 years with advanced non-small cell or extensive-stage small cell lung cancer receiving treatment at The Ohio State University James Comprehensive Cancer Center (OSU-JCCC) in the Thoracic Oncology department (N=22). There were no exclusion criteria pertaining to Eastern Cooperative Oncology Group (ECOG) performance status, laboratory values, prior cancer diagnoses, presence of comorbidities, or brain metastases. MATERIALS AND METHODS: Participants were asked about functional status, symptoms, mood through the PHQ-9, GAD-7, POMS, and acceptability questions about the program. PT evaluation and assessment included SPPB and 2- or 6-minute walk test outcomes. The study sought to collect gut microbiome samples for every in-person visit and activity monitoring data (Actigraph) on a subset. Feasibility was defined as successfully collecting specimens, wearing an Actigraph activity monitor, and adhering to the intervention. PT and psychologists evaluated participants in-person at the first and final visit. The rest of the 12-week intervention was conducted via virtual health. Physical therapy intervention consisted of endurance, strength, and flexibility exercises. RESULT(S): In total, 22 patients consented and 18 started the intervention (81.8%). Seven microbiome samples were collected from four participants. Six patients collected activity monitoring data. Among the 18 participants, 11 participants (61.1%) completed 70% or more of all the intervention visits. The SPPB data show a moderate effect size (Cohen's d=0.24) from pre- to post-data. On average patients improved by 1.8 total points on the SPPB. Patients demonstrated improvement on timed walk tests throughout intervention from an average of 108 feet pre-intervention to an average of 138.4 feet post intervention. CONCLUSION(S): Despite the challenges of the COVID-19 pandemic, longitudinal biospecimen and correlative data collection were feasible in the context of PT and PMR intervention among older adults with advanced lung cancer. Virtual physical therapy interventions can be safely delivered to improve physical performance as demonstrated by a moderate effect size for the SPPB in this patient population. CLINICAL RELEVANCE: Based on the feasibility study results, delivering a virtual PT intervention to older patients with lung cancer can improve SPPB score leading to decreased frailty and improve quality of life among patients.