Perioperative care for major elective surgery: a survey of Brazilian physiotherapists / Cuidados perioperados de cirurgias eletivas de grande porte: um levantamento dos fisioterapeutas brasileiros

Abstract Introduction: Major surgeries are highly complex procedures and have a higher incidence of respiratory morbidity and mortality compared to other types of surgery. Postoperative pulmonary complications (PPC) are common after such surgeries and are associated with increased hospital stay, health care costs and surgical patient mortality. Objective: To investigate the most commonly used physical therapy techniques for the prevention and treatment of PPC among thoracic and abdominal surgery patients in all regions of Brazil. Methods: A total of 489 randomly selected physiotherapists who provided perioperative care for patients undergoing elective abdominal, thoracic or cardiac surgeries participated in this study. A questionnaire with nine questions about routine care and therapeutic choices for the surgical population was developed and assessed by 10 specialists before being administered to the physiotherapists. Results: Among the physiotherapists (63% with at least 5 years of experience with surgical patients), 50.9% considered the patient's surgical risk in their treatment either always or often. A total of 53.8% patients were treated by the physiotherapist following a physician's prescription. The most mentioned physical therapy techniques used to prevent PPC were postoperative mobilization/exercises (59.3%), postoperative lung expansion (52.8%), and preoperative advice (50.7%). In addition, 80.6% of the physiotherapists believe that incentive spirometry prevents PPC, while 72.8% expected this effect from positive airway pressure devices. Conclusion: Most physiotherapists in Brazil who work with surgical patients offer preoperative professional advice, use postoperative early mobilization and lung expansion techniques to prevent PPC, and consider the patient's surgical risk during treatment. In addition, some physical therapy sessions are routinely performed preoperatively.

Resumo Introdução: As cirurgias de grande porte são procedimentos de alta complexidade, apresentando maior incidência de morbi-mortalidade respiratória em comparação com outros tipos de cirurgia. Complicações pulmonares pós-operatórias (CPP) são comuns após tais cirurgias e estão associadas ao aumento da permanência hospitalar, dos custos com saúde e da mortalidade do paciente. Objetivo: Investigar as técnicas de fisioterapia mais utilizadas em todas as regiões do Brasil para o tratamento das CPP após cirurgias torácicas e abdominais. Métodos: Participaram deste estudo 489 fisioterapeutas selecionados aleatoriamente, que atuam na assistência perioperatória de cirurgias eletivas abdominais, torácicas ou cardíacas. Um questionário com nove questões sobre cuidados de rotina e escolhas terapêuticas na população cirúrgica foi elaborado e avaliado por 10 especialistas antes de ser aplicado aos fisioterapeutas. Resultados: Entre os fisioterapeutas (63% com pelo menos 5 anos de experiência com pacientes cirúrgicos), 50,9% considera o risco cirúrgico do paciente em seu tratamento sempre ou frequentemente; 53,8% dos pacientes foram tratados pelo fisioterapeuta após prescrição médica. As técnicas fisioterapêuticas mais citadas para a prevenção de CPP foram: mobilização/exercícios pós-operatórios (59,3%), técnicas de expansão pulmonar pós-operatória (52,8%) e orientações pré-operatórias (50,7%). Além disso, 80,6% dos fisioterapeutas acreditam que a espirometria de incentivo previne CPP, assim como 72,8% esperam esse efeito da pressão positiva nas vias aéreas. Conclusão: A maioria dos fisioterapeutas que trabalham com pacientes cirúrgicos no Brasil utiliza orientações profissionais pré-operatórias e técnicas de mobilização precoce e expansão pulmonar pós-operatória com o objetivo de prevenir CPP. A maioria dos fisioterapeutas costuma considerar o risco cirúrgico do paciente durante o tratamento. Além disso, algumas sessões de fisioterapia são realizadas rotineiramente no pré-operatório.

Activities of Daily Living and Life-Space Mobility in Older Adults with Chronic Obstructive Pulmonary Disease.

Purpose: The aim of this study was to investigate whether limitation during the performance of activities of daily living (ADL) was associated with life-space mobility in older people with chronic obstructive pulmonary disease (COPD), and to generate a regression model for life-space mobility score. Patients and Methods: This cross-sectional study with a convenience sample included older people (aged ≥60 years old) with COPD. We assessed participants' lung function (spirometry), life-space mobility (University of Alabama at Birmingham Study of Aging Life-Space Assessment questionnaire), severity of dyspnea (Modified Dyspnea Index) and limitation during the performance of ADL (London Chest Activity of Daily Living). We used Pearson's correlation to investigate the associations between the measures, and multiple linear regression to detect which of the measures influenced life-space mobility. Statistical significance was set at 5%. Results: Fifty participants completed all the assessments (29 females [58%]; mean ± SD age of 67 ± 6 years old, FEV1 47 ± 29% of predicted, and body mass index 22.5 ± 11.6 kg/m2). Their mean scores for life-space mobility and for limitation during the performance of ADL were 49.7 ± 27.2 and 16.46 ± 9.74, respectively. We found a strong inverse correlation between limitation during the performance of ADL and life-space mobility (r = -0.57, p = <0.01) as well as between severity of dyspnea and life-space mobility (r= 0.86, p= <0.01). Both sex and limitation during the performance of ADL were considered as independent factors associated to life-space mobility (R2= 0.56). Conclusion: In this study, limitations during the performance of ADL and dyspnea had a strong correlation with life-space mobility in older adults with COPD. Also, alongside sex, the limitation during the performance of ADL is an independent factor associated with life-space mobility in a regression model.

Physiotherapist advice to older inpatients about the importance of staying physically active during hospitalisation reduces sedentary time, increases daily steps and preserves mobility: a randomised trial.

QUESTIONS: Does advice from a physiotherapist about the importance of staying physically active during hospitalisation improve activity, mobility, strength, length of stay, and complications in older inpatients? What barriers to physical activity during hospitalisation do older inpatients perceive? DESIGN: Randomised controlled trial with concealed allocation, intention-to-treat analysis, and blinded assessment. PARTICIPANTS: Sixty-eight people who were aged > 60 years and admitted to a university hospital ward. INTERVENTION: In addition to usual hospital care, the experimental group received a booklet with content about the deleterious effects of hospitalisation and the importance of staying active during hospitalisation. The control group received usual hospital care only. OUTCOME MEASURES: The amount of physical activity was measured via accelerometry during the hospital admission. Mobility was assessed using the de Morton Mobility Index (DEMMI), and muscle strength was assessed using a handgrip dynamometer. Length of stay and complications were extracted from hospital records. The barriers to staying active during hospitalisation were investigated via a questionnaire. RESULTS: Accelerometry showed a mean between-group difference of 974 steps/day (95% CI 28 to 1919) in favour of the experimental group. The intervention also increased moderate-intensity physical activity and reduced sedentary time, although these effects might be trivially small. Experimental group participants were about one-fifth as likely to lose mobility during their hospital admission (two of 33) than control group participants (10 of 35), relative risk 0.21 (95% CI 0.05 to 0.90). Effects of the intervention were unclear regarding muscle strength, length of stay and incidence of complications between the groups. Patients reported that the main barriers to remaining active during hospitalisation were dyspnoea, lack of space, and fear of contracting infection. CONCLUSION: In older inpatients, the addition of advice from a physiotherapist about maintaining activity during hospitalisation increases the level of physical activity and prevents loss of mobility. REGISTRATION: ClinicalTrials.govNCT03297567.

A study of measurement properties of the Life-Space Assessment questionnaire in older adults with chronic obstructive pulmonary disease.

OBJECTIVE: To test the measurement properties (reliability, interpretability, and validity) of the Life-Space Assessment questionnaire for older adults with chronic obstructive pulmonary disease. DESIGN: Clinimetric study. SETTING: Pneumology service, ambulatory care, São Paulo, SP, Brazil. PARTICIPANTS: Consecutive sample of older adults ( n = 62; 38 (61%) men, 24 (39%) women) with chronic obstructive pulmonary disease. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Life-Space Assessment questionnaire assesses five space levels visited by the older adult in four weeks prior to the assessment. We tested the following measurement properties of this questionnaire: reliability (reproducibility assessed by a type-2,1 intraclass correlation coefficient (ICC2,1); internal consistency assessed by the Cronbach's alpha; measurement error by determining the standard error of measurement (SEM)), interpretability (minimum detectable change with 90% confidence (MDC90); ceiling and floor effects by calculating the proportion of participants who achieved the minimum and maximum scores), and validity by Pearson's correlation test between the Life-Space Assessment questionnaire scores and number of daily steps assessed by accelerometry. RESULTS: Reproducibility (ICC2,1) was 0.90 (95% confidence interval (CI): 0.84-0.94), and internal consistency (Cronbach's α) was 0.80 (range = 0.76-0.80 for each item deleted). SEM was 3.65 points (3%), the MDC90 was 0.20 points, and we observed no ceiling (2%) or floor (6%) effects. We observed an association between the score of the Life-Space Assessment questionnaire and daily steps ( r = 0.43; P = 0.01). CONCLUSION: Life-Space Assessment questionnaire shows adequate measurement properties for the assessment of life-space mobility in older adults with chronic obstructive pulmonary disease.

Systemic effects of chronic obstructive pulmonary disease in young-old adults' life-space mobility.

PURPOSE: The objective was to assess whether dyspnea, peripheral muscle strength and the level of physical activity are correlated with life-space mobility of older adults with COPD. PATIENTS AND METHODS: Sixty patients over 60 years of age (40 in the COPD group and 20 in the control group) were included. All patients were evaluated for lung function (spirometry), life-space mobility (University of Alabama at Birmingham Study of Aging Life-Space Assessment), dyspnea severity (Modified Dyspnea Index), peripheral muscle strength (handgrip dynamometer), level of physical activity and number of daily steps (accelerometry). Groups were compared using unpaired t-test. Pearson's correlation was used to test the association between variables. RESULTS: Life-space mobility (60.41±16.93 vs 71.07±16.28 points), dyspnea (8 [7-9] vs 11 [10-11] points), peripheral muscle strength (75.16±14.89 vs 75.50±15.13 mmHg), number of daily steps (4,865.4±2,193.3 vs 6,146.8±2,376.4 steps), and time spent in moderate to vigorous activity (197.27±146.47 vs 280.05±168.95 minutes) were lower among COPD group compared to control group (p<0.05). The difference was associated with the lower mobility of COPD group in the neighborhood. CONCLUSION: Life-space mobility is decreased in young-old adults with COPD, especially at the neighborhood level. This impairment is associated to higher dyspnea, peripheral muscle weakness and the reduced level of physical activity.