Within the first six months of the trial we interviewed a convenience sample of participants in the week after their surgery.21 This was to explore further participants’ opinions on preoperative education and to assess the feasibility of delivering a memorable and impactful preoperative intervention that had the potential to change behaviour. Lancet 2014;384:495-503. Participants were screened using a standardised validated diagnostic tool789101820 consisting of eight symptomatic and diagnostic criteria (see box 1).  |  USA.gov. Upper abdominal surgery (UAS) has the potential to cause post-operative pulmonary complications (PPCs). BMJ Evid Based Med. Our format of preoperative physiotherapy education and training was a single 30 minute intervention with minimal potential to harm and provided within existing multidisciplinary hospital clinics that patients are already required to attend before surgery. These patients reviewed the information booklet intended to be provided to all trial participants and were asked to comment on the type of information about respiratory complications, breathing exercises, and postoperative physiotherapy and recovery they would have liked to have been provided with before their own surgery. 2020 Jul 28;10(7):e037280. If nursing staff provided respiratory devices (eg, incentive spirometry or positive expiratory pressure devices), site investigators removed these and recorded the incidence (see appendix). Our trial could have been strengthened with equal distribution of representation from other sites and involvement from other countries. Pre-operative physiotherapy management Pre-operatively, 16 respondents (34.8%) reported that all patients were seen on a face-to-face basis, 19 (41.3%) reported that only some patients were seen pre-operatively (usually based on risk assessment) and 11 (23.9%) reported seeing no patients before surgery. Four participants (two each in both groups) acquired a PPC in the first three postoperative days, progressing to respiratory sepsis, multi-organ failure, and then death. See: http://creativecommons.org/licenses/by-nc/4.0/. The physiotherapist then trained the intervention participants on how to perform the prescribed breathing exercises, as detailed in the booklet, and they were coached for at least three repetitions. Randomisation occurred before the preoperative physiotherapy assessment. Objective: Following newly published meta-analysis data showing a strong association between mortality and PPCs,4 we added a further secondary outcome of 12 month all cause mortality one year into the trial. surgery pathways,19 or where preoperative education is provided at outpatient clinics many weeks before surgery and by physiotherapists of different experience levels; both confounders of typical current practice at public and private hospitals. This phase begins as soon as you are discharged from surgery and carries on until your tissues have healed, the swelling from surgery has dissipated and the pain associated with the surgery has mostly resolved. 2018 Jul;64(3):194. doi: 10.1016/j.jphys.2018.04.006. Epub 2018 Jun 9. Epub 2018 Nov 15. Allocation concealment in randomised controlled trials: are we getting better? Objective To assess the efficacy of a single preoperative physiotherapy session to reduce postoperative pulmonary complications (PPCs) after upper abdominal surgery. General anaesthetic is medication used in surgery with the purpose being loss of consciousness. Our results were adjusted to control for prespecified confounders imbalanced at baseline; however, our trial could have been further improved by using stratified randomisation according to known confounders—for example, surgical category and respiratory comorbidity. The Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy (LIPPSMAck-POP) trial tested the hypothesis that preoperative education and breathing exercise training delivered within six weeks of surgery by physiotherapists reduces the incidence of PPCs after upper abdominal surgery. Setting: Pragmatically, when we were unable to provide interventions face to face, the booklet was mailed to patients and assessment and education were provided by telephone. PAC=preadmission clinic, Time to diagnosis of a postoperative pulmonary complication after surgery. This association was stronger in patients having colorectal surgery, those younger than 65 years, men, or where an experienced physiotherapist provided the education. There are many evidences that the number of PPC after abdominal surgery and open-heart surgery is reduced by preoperative PT programs. cardiorespiratory clinical lead physiotherapist, Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial, Correction for vol. No difference in all cause mortality between groups was seen at six weeks and 12 months, although a sustained separation between groups favouring the intervention group starting at four months was evident (adjusted hazard ratio 0.78, 95% confidence interval 0.41 to 1.48, P=0.45; fig 3a). Despite these limitations, exploratory subgroup analysis of our population revealed that in cohorts with stronger reductions in PPCs attributable to the intervention there was also a corresponding stronger signal to a reduction in length of stay. 5. The aim of this study was to ascertain the current physiotherapy management of patients having sustained major chest trauma and to investigate how such practices varied internationally. No differences were detected in the other secondary measures of hospital length of stay, readiness for hospital discharge, unplanned readmissions or length of stay in intensive care, hospital readmissions at six weeks, and all ambulation attainment measures (table 3 and appendix). PPC=postoperative pulmonary complication. (a) 12 month mortality between groups; (b) 12 month mortality between groups in subgroup treated by experienced physiotherapists. Assessors, postoperative physiotherapists, and participants were masked to group allocation. Our PPC reduction of an adjusted 52% relative risk reduction is less than that reported in methodologically weaker trials with limitations on generalisability.1718 A Pakistani trial18 of 224 patients who were young (mean age 37), having minor surgeries, and of a reasonably healthy premorbid status, reported that preoperative education by medical registrars resulted in earlier postoperative mobilisation and a 76% relative reduction in PPCs. Competing interests All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare that IB received grants from the Clifford Craig Foundation (CCF), University of Tasmania, and Waitemata District Health Board to fund participating sites for physiotherapists to provide preoperative interventions outside of current standard care and for research assistants to acquire data. Further research is required to investigate benefits to mortality and length of stay. In these participants we therefore did not assess days to discharge from assisted ambulation. Written informed consent was gained before randomisation. Site investigators monitored and reported divergence from this protocol. Education focused on PPCs and their prevention through early ambulation and self directed breathing exercises to be initiated immediately on regaining consciousness after surgery. To determine a statistically significant difference in length of stay requires a larger sample size or meta-analysis to confirm effect. An independent audit of our randomisation process found no evidence of a failure in sequential allocation (see appendix). -, Fernandez-Bustamante A, Frendl G, Sprung J, et al. We excluded patients if they were current hospital inpatients, required organ transplants, required abdominal hernia repairs, were unable to ambulate for more than one minute, and were unable to participate in a single physiotherapy preoperative session within six weeks of surgery. 2020 Sep 22;4(6):1022-41. doi: 10.1002/bjs5.50347. 2019 Apr 25;365:l1862. A PPC was diagnosed when four or more of these eight criteria were present at any time from midnight to midnight each postoperative day. At the primary participating centre the consent form contained a section where participants could elect to receive a newsletter where updates on the trial would be provided and results disseminated. -, Neto AS, Hemmes SN, Barbas CS, et al. Despite concerted methodological efforts to ensure internal validity of the trial, baseline imbalances did exist between the groups. Pre-Operative Physiotherapy. Patient details were marked on envelopes to record that randomisation was in order of recruitment. Prescribing gait aids like walkers or canes and instructing on their use 6. It is possible that this was due to the difference in experience level of the preoperative physiotherapists, although the 95% confidence interval is within the bounds of PPC risk reduction at the other sites, and may rather be a function of a limited sample. At these clinics patients are seen by a nurse, anaesthetist, doctor, and, if required, a stomal therapist. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. Steps of physiotherapy in abdominal surgery Preoperative assessment Postoperative physiotherapy Postoperative assessment Postoperative training Preoperative physiotherapy Preoperative training 5. Primary and secondary outcome assessors were masked to group allocation and not involved in postoperative clinical management. Similarly, point estimates across almost all other secondary outcomes in our trial favoured the intervention group, with sensitivity analyses strengthening these relations further. Setting Multidisciplinary preadmission clinics at three tertiary public hospitals in Australia and New Zealand. Eleven physiotherapists with varying levels of experience provided the preoperative interventions. To explore variations of effect and to validate the main results, we performed further exploratory post hoc adjusted analyses of subgroup effects (experience level of preoperative physiotherapist, site, and participant age, sex, surgical category, and predicted PPC risk score) in PPCs, hospital stay, and 12 month mortality. HHS Neither CCF nor the University of Tasmania have managerial authority over IKR’s work. Cluster randomised controlled trial, Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. The physiotherapists included students, new graduates, senior physiotherapists, through to a physiotherapist with 15 years of acute surgical practice and extensive experience in patient education. Online ahead of print. For the purposes of this trial, conservative goals (minimum 10% absolute risk reduction from a 20% baseline PPC risk) were set considering time passed since previous audits and trials, known improvements in perioperative care during this time, and methodological limitations of previous research. Contributors: IB conceived and designed the study, coordinated the trial, prepared the first draft of the manuscript, and was responsible for the final manuscript. However, as these time points are truncated in patients who died, we also performed a sensitivity analysis using Cox proportional hazards regression with or without adjustment for covariates, where deaths were treated as censored times without failure. The patients, postoperative physiotherapists, hospital staff, and statisticians were unaware of group assignment. Considering the effect gradient according to experience level, further research is required to assess the repeatability of this intervention to ensure that it is provided with a similar degree of rigour across all treating therapists. For our population the average length of stay was 11.4 (SD 11.0) days, with a range of 1 to 105 days. The preadmission physiotherapy session for control and intervention participants consisted of a standardised physical and subjective assessment.20 The physiotherapist gave participants an information booklet containing written and pictorial information about PPCs and potential prevention with early ambulation and breathing exercises. Fernandez-Bustamante A, Sprung J, Parker RA, Bartels K, Weingarten TN, Kosour C, Thompson BT, Vidal Melo MF. IKR receives a salary from the CCF to perform statistical analysis and provide study design advice for studies receiving grants from the CCF. Interventions: All authors revised manuscript drafts, approved the final manuscript, and contributed intellectually important content. These covariates were selected to assist in hypothesis generation according to known factors influencing the incidence of PPCs and the successful provision of an education based intervention. Individualized PEEP to optimise respiratory mechanics during abdominal surgery: a pilot randomised controlled trial. When you arrive at Hospital you should report to the Admitting Department on the main floor. LAS VEGAS investigators Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - an observational study in 29 countries. Ethical approval: This study was approved by the Human Research Ethics Committee (Tasmania) Network, Tasmania, Australia (H0011911) and the Health and Disability Ethics Committee, New Zealand (14/NTA/233) and informed written consent was given by all patients. No physiotherapy related information other than that contained within the booklet was provided to control participants. These results are directly applicable to the tens of millions of patients listed for elective major abdominal surgery worldwide. IB is the guarantor of the paper and takes responsibility for the integrity of the work as a whole, from inception to published article. 2019 Jun 29;4:20190013. doi: 10.2490/prm.20190013. The Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy A single preoperative physiotherapy session reduced pulmonary complications after upper abdominal surgery. Boden I, Skinner EH, Browning L, et al. In the lead, up to your surgery, your original condition may have caused some secondary issues, such as reduced movement and strength. Principles of physiotherapy in abdominal surgery A.THANGAMANI RAMALINGAM PT, MSc (PSY),MIAP 2. Background: Upper abdominal surgery (UAS) has the potential to cau se post-operative pulmonary complications (PPCs). We thank the LIPPSMAck POP research assistants, Kate Sullivan and Bronte Biggins-Tosch, for their dedication and thoroughness throughout the trial; the medical students at the University of Tasmania School of Medicine and Leanne Fung (MD)for working as masked assessors; all physiotherapists at the participating sites for assisting in providing the interventions and delivering the standardised postoperative ambulation protocol over the two year trial period; and the participants for their contribution to knowledge in this area. Secondary outcomes were hospital acquired pneumonia, length of hospital stay, utilisation of intensive care unit services, and hospital costs. UAS=upper abdominal surgery. Glob J Perioperative Med 3(1): 001-006. Considering the strong association between PPCs and mortality and the consistent findings across three trials, four countries, and 1000 patients1718 that preoperative education significantly reduces PPCs; we recommend that future studies should investigate additional PPC prophylactic interventions to augment preoperative physiotherapy education, particularly targeting high risk patients. Therefore, there is a moderate to high likelihood that maldistributions between groups occurred simply by chance. At the New Zealand site, the reduction in PPCs was less than at Australian sites. Neither CCF nor the University of Tasmania have managerial authority over IKR’s work. We also recorded most known perioperative confounders, including preoperative functional status, intraoperative fluid administered, transfusions, ventilation strategies, and postoperative analgesia and antibiotic management, and we adjusted the results for baseline imbalances in variables known to influence PPCs. The statistical analysis plan was prespecified20 and we used STATA (version 14.1) for all analyses. Additionally, preoperative education to prevent PPCs has not been tested in the context of recent advances in perioperative management, such as minimally invasive surgery or enhanced recovery after surgery pathways,19 or where preoperative education is provided at outpatient clinics many weeks before surgery and by physiotherapists of different experience levels; both confounders of typical current practice at public and private hospitals. This suggests that our length of stay findings may be limited by sample size and heterogeneous response rates rather than by a lack of effect from the intervention. 2018 Jul;64(3):194. doi: 10.1016/j.jphys.2018.04.008. Participants 441 adults aged 18 years or older who were within six weeks of elective major open upper abdominal surgery were randomly assigned through concealed allocation to receive either an information booklet (n=219; control) or preoperative physiotherapy (n=222; intervention) and followed for 12 months. These were unsealed for initial analysis after the final participant had reached the six week follow-up. Weiser TG, Regenbogen SE, Thompson KD, et al. Physiotherapy Funding acknowledgements: Not applicable Relevance to physical therapy globally: Internationally, physiotherapists are widely involved in the management of patients undergoing major visceral surgery. To assess standardisation of postoperative ambulation we measured hours from surgery until participants were ambulant with a physiotherapist for longer than one minute, days until ambulant for longer than 10 minutes, and days until discharged from assisted ambulation. IKR also receives information technology and library services from the University of Tasmania. Funding: This study was an investigator initiated trial funded by competitive research grants from the Clifford Craig Foundation, Launceston, Australia, the University of Tasmania (virtual Tasmanian Academic Health Science Precinct), Tasmania, Australia, and the Awhina Contestable Research Grant from the Waitemata District Health Board and Three Harbours Health Foundation, Auckland, New Zealand, Support was provided from departmental sources at each participating study centre (Launceston General Hospital, North West Regional Hospital, North Shore Hospital) and through sponsorship by the Tasmanian Health Service-North to support IB for the period of the trial. The primary outcome was incidence of a PPC within 14 postoperative days, or hospital discharge, whichever came sooner. Further research is required to investigate benefits to mortality and length of stay. 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