Six-minute walk test distance at time of hospital discharge is strongly and independently associated with all-cause mortality following cardiac surgery.

We investigated the impact of distance covered in the six-minute walk test (6mWT) before being discharged from the hospital after cardiac surgery on the risk of all-cause mortality. Our study included 1127 patients who underwent cardiac surgery and then took part in a standardised physiotherapist-supervised inpatient rehabilitation programme during 2007-2017. The percentage of the predicted 6mWT distance, and the lower limit of normal distance was calculated based on individual patients' age, sex, and body mass index. We used Cox regression with adjustment for confounders to determine multivariable-adjusted hazard ratios (HRs) for mortality. Over a median follow-up period of 6.4 (IQR: 3.5-9.2) years, 15% (n = 169) patients died. We observed a strong and independent inverse association between 6mWT distance and mortality, with every 10 m increase in distance associated to a 4% reduction in mortality (HR: 0.96, 95% CI 0.94-0.98, P < 0.001). Those in the top tertile for predicted 6mWT performance had a 49% reduced risk of mortality (HR: 0.51, 95% CI 0.33-0.79) compared to those in the bottom tertile. Patients who met or exceeded the minimum normal 6mWT distance had 36% lower mortality risk (HR: 0.64, 95% CI 0.45-0.92) compared to those who did not meet this benchmark. Subgroup analysis showed that combined CABG and valve surgery patients walked less in the 6mWT compared to those undergoing isolated CABG or valve surgeries, with a significant association between 6mWT and mortality observed in the isolated procedure groups only. In conclusion, the longer the distance covered in the 6mWT before leaving the hospital, the lower the risk of mortality.

An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy.

Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contribute to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8 weeks. This perspective paper proposes that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. A clinical paradigm shift is encouraged, one that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.

Effect of physical activity in the first five days after cardiac surgery.

OBJECTIVES: To quantify physiotherapist-supervised and independent physical activity undertaken from the first to the fifth day after cardiac surgery (POD1 to POD5), and to relate the amount of physical activity undertaken with hospital stay and postoperative physiological functional capacity on POD6. METHODS: Physiotherapist-supervised and independent physical activity were monitored in 83 adult patients undergoing cardiac surgery, using a bi-axial accelerometer and skin sensors that measured, galvanic skin response and body temperature. Patients completed a 6-min walk test (6MWT) on POD6. Step count and physical activity intensity (METs; metbolic equivalents) were the main outcome measures. RESULTS: Males exhibited significantly higher physiotherapist-supervised and independent physical activity step counts and time ≥ 3 METS (p < 0.0001). The 6MWT distance on POD6 was greater in men (mean 393 m, standard deviation (SD) 108 m) than women (mean 300 m, SD 121 m) (p = 0.005). Mean length of stay in hospital was 9 days (SD 3 days) and was negatively correlated with overall physiotherapist-supervised (R = -0.70), independent physical activity step counts (R = -0.62), and combined physiotherapist-supervised (R = -0.65) and independent (R = -0.43) physical activity time ≥ 3 METs. CONCLUSION: Physiotherapist-supervised activity fosters improvements in postoperative physiological functional capacity and reduces length of stay in hospital following cardiac surgery.

What makes men leak? An investigation of objective and self-report measures of urinary incontinence early after radical prostatectomy.

AIMS: Pelvic floor muscle training for patients having radical prostatectomy promotes contraction of these muscles in anticipation of activities that may provoke urine leakage. The aims of this study were: to determine the contribution of the individual activities comprising a standardised 1-hour pad test (1HPT) to overall urine leakage early after radical prostatectomy; and to investigate relationships between the 1HPT, 24-hour pad test (24HPT) and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) early after radical prostatectomy. METHODS: A prospective analysis of patients having radical prostatectomy and receiving pelvic floor muscle training (n = 33). Participants completed the 1HPT, 24HPT and ICIQ-SF at 3 and 6 weeks postoperatively. Participants wore a separate, pre-weighed continence pad for each of the seven activities comprising the 1HPT; pads were weighed separately and together to calculate activity-related and overall urine leakage. RESULTS: Walking at a comfortable speed and drinking while sitting were the two activities contributing most to overall urine leakage, albeit these activities also comprised 75% of 1HPT time. All component activities contributed a minimum 7 ± 5% of overall urine leakage. There were significant and strong to very strong correlations between all of the 1HPT, 24HPT, and ICIQ-SF at 3 weeks postoperatively. There were significant decreases in 24HPT (P = 0.032) and ICIQ-SF (P = 0.001) but no significant change in 1HPT from 3 to 6 weeks postoperatively. CONCLUSIONS: Pelvic floor muscle training should include contraction of these muscles in sedentary and walking postures. The 1HPT correlates well with the 24HPT, but may not be sensitive to early postoperative improvements in urinary leakage.

Can a physical activity monitor provide a valid measure of arm elevation angle? A study to assess agreement between the SenseWear Mini Armband and the universal goniometer.

BACKGROUND: We undertook the current study to assess whether an accelerometer-based physical activity monitor, the SenseWear Mini Armband (SMA), could be used to provide data on static arm elevation, and to assess the agreement between static arm elevation measures obtained using SMA-derived data and those obtained with a universal goniometer. METHODS: Using a universal goniometer, healthy adult subjects (n = 25, age 30 ± 9 years) had each of right and left arms positioned in a series of set positions between arm-by-side and maximal active arm flexion (anteversion), and arm-by-side and maximal active arm abduction. Subjects wore the SMA throughout positioning, and SMA accelerometer data was used to retrospectively calculate/derive arm elevation angle using a manufacturer-provided algorithm. The Bland-Altman method was used to assess agreement between goniometer-set and SMA-derived arm elevation angles. RESULTS: There were significant differences between goniometer-set and SMA-derived arm elevation angles for elevation angles ≤ 30 degrees and ≥ 90 degrees (p < 0.05). Bland-Altman plots showed that the greater the angle of elevation, the greater the mean difference between goniometer-set and SMA-derived elevation angles. Adjustment of the manufacturer-provided algorithm for deriving arm elevation angle corrected for this systematic difference, and resulted in 95% limits of agreement ± 12 degrees (flexion) and ± 13 degrees (abduction) across the full range of arm elevation. CONCLUSIONS: The SMA can be used to record data allowing derivation of static arm elevation angle in the upright position, 95% limits of agreement with the universal goniometer being similar to those reported for digital inclinometers and gyroscopes. Physiotherapists looking for innovative methods of recording upper limb range of motion should consider the potential of accelerometer-based physical activity monitors such as the SMA.

A multicomponent theory-based intervention improves uptake of pelvic floor muscle training before radical prostatectomy: a 'before and after' cohort study.

OBJECTIVE: To assess the effect of a multicomponent theory-based intervention, incorporating patient information guides, an evidence summary, audit and feedback processes and a provider directory, in the provision/receipt of preoperative pelvic floor muscle training (PFMT) among patients undergoing radical prostatectomy. SUBJECTS AND METHODS: Over an 18-month period (9 months before and 9 months after the intervention), we measured the provision/receipt of preoperative PFMT using surveys of patients undergoing radical prostatectomy at one public hospital (n = 32) and two private hospitals (n = 107) in Western Sydney, Australia, as well as practice audits of associated public sector (n = 4) and private sector (n = 2) providers of PFMT. Self-report urinary incontinence was assessed 3 months after radical prostatectomy using the International Consultation on Incontinence Questionnaire - Urinary Incontinence Form (ICIQ-UI Short Form). RESULTS: There was a significant increase in the proportion of survey respondents receiving preoperative PFMT post-intervention (post-intervention: 42/58 respondents, 72% vs pre-intervention: 37/81 respondents, 46%, P = 0.002). There was a corresponding significant increase in provision of preoperative PFMT by private sector providers (mean [sd] post-intervention: 16.7 [3.7] patients/month vs pre-intervention: 12.1 [3.6] patients/month, P = 0.018). Respondents receiving preoperative PFMT had significantly better self-report urinary incontinence at 3 months after radical prostatectomy than those who did not receive preoperative PFMT (mean [sd] ICIQ-UI Short Form sum-scores: 6.2 [5.0] vs 9.2 [5.8], P = 0.002). CONCLUSIONS: The intervention increased the provision/receipt of preoperative PFMT among patients undergoing radical prostatectomy. Additional component strategies aimed at increasing the use of public sector providers may be necessary to further improve PFMT receipt among patients undergoing radical prostatectomy in the public hospital system.

Relationships between perioperative physical activity and urinary incontinence after radical prostatectomy: an observational study.

BACKGROUND: Higher physical activity levels are continence-protective in non-prostate cancer populations. Primary aims of this study were to investigate changes in physical activity levels over the perioperative period in patients having radical prostatectomy, and relationships between perioperative physical activity levels and post-prostatectomy urinary incontinence. METHODS: A prospective analysis of patients having radical prostatectomy and receiving perioperative physiotherapy including pelvic floor muscle training and physical activity prescription (n = 33). Physical activity levels were measured using the International Physical Activity Questionnaire and/or the SenseWear Pro3 Armband at four timepoints: before preoperative physiotherapy, the week before surgery, and 3 and 6 weeks postoperatively. Urinary incontinence was measured at 3 and 6 weeks postoperatively using a 24-hour pad test and the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ). RESULTS: Physical activity levels changed significantly over the perioperative period (p < 0.001). At 6 weeks postoperatively, physical activity levels did not differ significantly from baseline (p = 0.181), but remained significantly lower than the week before surgery (p = 0.002). There was no significant interaction effect between preoperative physical activity category and time on the 24-hour pad test (p = 0.726) or ICIQ (p = 0.608). Nor were there any significant correlations between physical activity levels and the 24-hour pad test and ICIQ at 3 or 6 weeks postoperatively. CONCLUSIONS: This study provides novel data on perioperative physical activity levels for patients having radical prostatectomy. There was no relationship between perioperative physical activity levels and post-prostatectomy urinary incontinence, although participants had high overall preoperative physical activity levels and low overall urinary incontinence.

Barriers and enablers to the provision and receipt of preoperative pelvic floor muscle training for men having radical prostatectomy: a qualitative study.

BACKGROUND: Strong evidence exists to support preoperative pelvic floor muscle training (PFMT) to reduce the severity and duration of urinary incontinence after radical prostatectomy. Receipt of preoperative PFMT amongst men having radical prostatectomy in Western Sydney, however, is suboptimal. This study was undertaken to investigate barriers and enablers to provision/receipt of preoperative PFMT from the perspectives of potential referrers to and providers of PFMT, and of men having radical prostatectomy. METHODS: A qualitative research design was used. Semi-structured, one-to-one interviews were conducted with participants from three groups: (i) current and potential referrers to PFMT, including urological cancer surgeons, urological cancer nurses and general practitioners (n = 11); (ii) current and potential providers of PFMT across public and private sector hospital and outpatient settings, including physiotherapists and continence nurses (n = 14); and (iii) men having had radical prostatectomy at a specific public and co-located private hospital in Western Sydney (n = 13). Interview schedules were developed using Michie's theoretical domains for investigating the implementation of evidence-based practice, and allowed participants to identify potential and actual barriers and enablers to preoperative PFMT. Transcribed interview data were analysed using a framework approach, and key themes were identified. RESULTS: Participant groups concurred that a recommendation for PFMT from the urological cancer surgeon, accompanied with a referral to a specific provider, was a key enabler of preoperative PFMT. Perceived barriers varied between participant groups and across public and private healthcare settings. Perceptions of financial cost of private sector PFMT, limited knowledge amongst referrers of public sector providers of PFMT, and limited awareness amongst patients of the benefits of PFMT were all posited to contribute to suboptimal PFMT provision and receipt. CONCLUSIONS: This study has provided valuable data on barriers and enablers to preoperative PFMT, with implications for the planning of a behaviour change intervention to improve provision and receipt of preoperative PFMT in Western Sydney.

Preoperative pelvic floor physiotherapy improves continence after radical retropubic prostatectomy.

OBJECTIVES: Urinary incontinence is a predictable sequela of radical retropubic prostatectomy, and is most severe in the early postoperative phase. The present study aimed to evaluate the effect of a physiotherapist-guided pelvic floor muscle training program, commenced preoperatively, on the severity and duration of urinary continence after radical retropubic prostatectomy. METHODS: A retrospective analysis of men undergoing radical retropubic prostatectomy by one high-volume surgeon (n = 284) was carried out. The intervention group received physiotherapist-guided pelvic floor muscle training from 4 weeks preoperatively (n = 152), whereas the control group was provided with verbal instruction on pelvic floor muscle exercise by the surgeon alone (n = 132). Postoperatively, all patients received physiotherapist-guided pelvic floor muscle training. The primary outcome measure was 24-h pad weight at 6 weeks and 3 months postoperatively. Secondary outcome measures were the percentage of patients experiencing severe urinary incontinence, and patient-reported time to one and zero pad usage daily. RESULTS: At 6 weeks postoperatively, the 24-h pad weight was significantly lower (9 g vs 17 g, P < 0.001) for the intervention group, which also showed less severe urinary incontinence (24-h pad weight >50 g; 8/152 patients vs 33/132 patients, P < 0.01). There was no significant difference between groups in the 24-h pad weight at 3 months (P = 0.18). Patient-reported time to one and zero pad usage was significantly less for the intervention group (P < 0.05). Multivariate Cox regression showed that preoperative physiotherapist-guided pelvic floor muscle training reduced time to continence (1 pad usage daily) by 28% (P < 0.05). CONCLUSIONS: A physiotherapist-guided pelvic floor muscle training program, commenced 4 weeks preoperatively, significantly reduces the duration and severity of early urinary incontinence after radical retropubic prostatectomy.

Does the mode of exercise influence recovery of functional capacity in the early postoperative period after coronary artery bypass graft surgery? A randomized controlled trial.

OBJECTIVES: The purpose of this study was to compare the effectiveness of moderate-intensity stationary cycling and walking exercise programmes in the early postoperative period after first-time coronary artery bypass graft surgery. METHODS: In this prospective trial, 64 patients (57 men, 7 women, mean age = 66 ± 9 years) performed twice daily, moderate-intensity exercise sessions, of 10-min duration, from postoperative day 3 until discharge from hospital. Patients were randomly assigned to stationary cycling or walking exercise intervention groups. Preoperative and discharge functional exercise capacity and health-related quality of life were assessed using 6-min walk and cycle assessments and the SF-36 version 2.0 questionnaire. Compliance with exercise was calculated as the proportion of scheduled exercise sessions completed. RESULTS: There were no significant differences between intervention groups at hospital discharge for 6-min walk distance (cyclists: 402 ± 93 m vs walkers: 417 ± 86 m, P = 0.803), 6-min cycle work (cyclists: 15.0 ± 6.4 kJ vs walkers: 14.0 ± 6.3 kJ, P = 0.798) or health-related quality of life. There was no significant difference between intervention groups for postoperative length of hospital stay (P = 0.335). Compliance rates for intervention groups were cyclists: 185/246 (75%) scheduled exercise sessions completed vs walkers: 199/242 (82%) scheduled exercise sessions completed (P = 0.162). CONCLUSIONS: Stationary cycling provides a well-tolerated and clinically effective alternative to walking in the early postoperative period after coronary artery bypass graft surgery. The optimal frequency, intensity and duration of exercise in the early postoperative period require further investigation. (Clinical trials register: Australian New Zealand Clinical Trials Registry; identification number: ACTRN12608000359336; http://www.anzctr.org.au/trial_view.aspx?ID=82978).

Supervised moderate intensity exercise improves distance walked at hospital discharge following coronary artery bypass graft surgery--a randomised controlled trial.

BACKGROUND: This study aimed to determine whether a structured, inpatient (or Phase 1 cardiac rehabilitation), physiotherapy-supervised walking program, with or without musculoskeletal and respiratory exercises, might improve walking capacity and other parameters for patients undergoing coronary artery bypass graft surgery (CABG). METHODS: Ninety-three patients awaiting first-time CABG over a 12-month period were randomised to one of three post-operative physiotherapy regimens: 'standard intervention', consisting of gentle mobilisation; 'walking exercise', consisting of a physiotherapy-supervised, moderate intensity walking program; and 'walking/breathing exercise', consisting of the same moderate intensity walking program, musculoskeletal exercises and respiratory exercises. Primary outcomes; six-minute walking assessment (6MWA) distance, vital capacity and health-related quality of life, were measured pre-operatively, at discharge from hospital and at four weeks following discharge. RESULTS: Walking and walking/breathing exercise groups had significantly higher 6MWA distance (444+/-84 m, 431+/-98 m, respectively) than the standard intervention group (377+/-90 m) at discharge from hospital. There was no significant difference between intervention groups for 6MWA distance at four-week follow-up. There was no significant difference between intervention groups in terms of vital capacity and health-related quality of life. CONCLUSIONS: A physiotherapy-supervised, moderate intensity walking program in the inpatient phase following CABG improves walking capacity at discharge from hospital. The performance of respiratory and musculoskeletal exercises confers no additional benefit to the measured outcomes.