BACKGROUND: Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM.METHODS: A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists).RESULTS: Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained.CONCLUSION: Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.
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BackgroundEarly structured mobilization has become a key element of Enhanced Recovery After Surgery programs to improve patient outcomes and decrease length of hospital stay. With the intention to assess and improve early mobilization levels, the 8-point ordinal John Hopkins Highest Level of Mobility (JH-HLM) scale was implemented at two gastrointestinal and oncological surgery wards in the Netherlands. After the implementation, however, healthcare professionals perceived a ceiling effect in assessing mobilization after gastrointestinal and oncological surgery. This study aimed to quantify this perceived ceiling effect, and aimed to determine if extending the JH-HLM scale with four additional response categories into the AMsterdam UMC EXtension of the JOhn HOpkins Highest Level of mObility (AMEXO) scale reduced this ceiling effect.MethodsAll patients who underwent gastrointestinal and oncological surgery and had a mobility score on the first postoperative day before (July–December 2018) or after (July–December 2019) extending the JH-HLM into the AMEXO scale were included. The primary outcome was the before-after difference in the percentage of ceiling effects on the first three postoperative days. Furthermore, the before-after changes and distributions in mobility scores were evaluated. Univariable and multivariable logistic regression analysis were used to assess these differences.Results Overall, 373 patients were included (JH-HLM n = 135; AMEXO n = 238). On the first postoperative day, 61 (45.2%) patients scored the highest possible mobility score before extending the JH-HLM into the AMEXO as compared to 4 (1.7%) patients after (OR = 0.021, CI = 0.007–0.059, p ConclusionsA substantial ceiling effect was present in assessing early mobilization in patients after gastrointestinal and oncological surgery using the JH-HLM. Extending the JH-HLM into the AMEXO scale decreased the ceiling effect significantly, making the tool more appropriate to assess early mobilization and set daily mobilization goals after gastrointestinal and oncological surgery.
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BACKGROUND: Apart from clinical experience and theoretical considerations, there is a lack of evidence that the level of adherence to in-hospital mobilization protocols is related to functional recovery in patients after resection for lung cancer. The objectives of the study were to determine (1) the relationship between adherence to the in-hospital mobilization protocol and physical fitness at hospital discharge and (2) the value of physical fitness measures at discharge in predicting physical functioning 6 weeks and 3 months postoperatively.METHODS: This observational study included 62 patients who underwent surgical resection for lung cancer. Adherence to the in-hospital mobilization protocol was abstracted from patients' records. Physical fitness measures before the operation and at hospital discharge included handgrip strength, 30-second sit-to-stand test, and 6-minute walk test (6MWT). Self-reported physical functioning was assessed preoperatively and 6 weeks and 3 months postoperatively, using the Medical Outcome Study 36-Item Short Form (SF-36) Physical Function subscale (RAND Corp, Santa Monica, CA). Linear regression analyses were used to estimate the relationships of interest, adjusting for potential confounders.RESULTS: Level of adherence to the mobilization protocol was significantly and independently related to handgrip strength, sit-to-stand test, and 6MWT at discharge. Handgrip strength and 6MWT at discharge significantly predicted SF-36 Physical Function at 6 weeks and 3 months postoperatively. The sit-to-stand test only predicted SF-36 Physical Function at 6 weeks.CONCLUSIONS: Suboptimal postoperative mobilization after surgical resection for lung cancer negatively affects physical fitness at discharge. Our results underline the importance of adherence to early postoperative mobilization protocols. Measuring physical fitness at discharge may be useful to inform clinicians on elective referral of patients for postdischarge rehabilitation.
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This dissertation describes the dynamics of motor competence (MC) development from early childhood (EC) to middle childhood (MCD). Being motor competent in early childhood creates a window of opportunity for taking part in physical activities later in childhood and adulthood. However, there is a worrying trend in MC development during childhood. This trend shows that, last decades, children struggle more with executing fundamental movement skills (e.g., hopping, dribbling, balancing, throwing and catching) and that general motor fitness levels of children are decreasing. A delay in MC development during childhood has a negative impact on the general health status later in life. Therefore, it is important to support young children to develop their MC. The main research question of this dissertation was: How can motor competence be promoted as efficient and effective as possible in early childhood by sport professionals? Chapter 2 showed that MC development from early to middle childhood proceeds with variation. The majority of the children had a stable ‘normal’ or increasing ‘high’ development of MC over time. However, a concerning level of 18.2% of the young children showed an undesirable pattern (i.e., a negative course of motor development over time and a ‘low’ MQ score during the final measurement) of MC development as they grow older. Chapters 3 and 4 showed that characteristics of the social and physical home environment and direct living environment were associated with MC disparities during early childhood. Both parenting practices and parental PA-involved behaviours were relevant modifiable factors. For example, stronger parental active transportation routines and PA parental practices decreased the odds of a lower MC. Also, the presence of a home garden decreased the likelihood of children being classified as low motor competent. With regard to gender differences, girls showed lower levels of MC compared to boys. Special attention should also be paid to obese children as they experience less enjoyment of PA compared with normal weighted peers (chapter 3). Excessive body weight is also a risk factor associated with an undesirable MC development, just like lack of sports participation (chapter 5). Intervention strategies (chapter 6) incorporating all fundamental movement skills with a great variety of activities for at least 3 to 4 times a week seem to be most effective to stimulate MC development. Methodological and didactical aspects like deliberate practice and play should be implemented together with training and coaching sessions for sport professionals to increase the effectiveness of the interventions. With respect to the efficiency of promoting MC development, policy makers and sport professionals should pay more attention on early childhood and especially focus on those children at risk for a delay in MC development. So, overweighted children and children not participating in organized sports should be given more attention by sport professionals. Additionally, the effectiveness of MC interventions can be increased by making use of the home environment, childcare context and school context of young children. Sport professionals can act as connectors between parents, school, and sports clubs.
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Objective This scoping review aims to identify complex health interventions (CHI’s) to prevent early childhood caries (ECC), explore the level of complexity of the identified CHI’s, and explore the details of their development, evaluation, and implementation. Introduction Many interventions to prevent ECC have multiple interacting components and can be seen as CHI’s. Recent reviews on these interventions have found inconclusive effects, which may be due to differences in the development, evaluation, and implementation of CHI’s. Inclusion criteria This scoping review will consider clinical trials reporting CHI’s to prevent ECC that starts during pregnancy or in the first year of life. Studies in the English language will be included regardless of the country of origin, sociocultural setting, or context. Methods This review will follow the Joanna Briggs Institute methodology for scoping reviews. An initial search of PubMed identified keywords and Medical Subject Headings terms. A second search of PubMed, Embase, Clarivate Analytics/Web of Science Core Collection, ClinicalTrials.gov, and the Wiley/Cochrane Library will follow. Two independent reviewers will perform title and abstract screening, retrieve and review full-text studies, and extract data. The reference lists of all included sources will be screened for additional CHI’s or relevant publications about a specific CHI. Data charting will be utilised based on study characteristics and intervention complexity. A 39-item instrument will be used to explore the details in the description of the CHI’s development, evaluation, and implementation. The results will be presented in tables, visual outputs, and a narrative summary in response to the review questions. Discussion The proposed review will generate evidence which may provide a direction for the future design of studies on CHI’s to prevent ECC and more complete information for those who want to adopt successful interventions to prevent ECC.
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PurposeEarly mobilization of critically ill patients improves functional recovery, but is often hampered by tubes, drains, monitoring devices and muscular weakness. A mobile treadmill with bodyweight support facilitates early mobilization and may shorten recovery time to independent ambulation as compared to usual care physiotherapy alone.Materials and methodsSingle center RCT, comparing daily bodyweight supported treadmill training (BWSTT) with usual care physiotherapy, in patients who had been or were mechanically ventilated (≥48 h) with ≥MRC grade 2 quadriceps muscle strength. BWSTT consisted of daily treadmill training in addition to usual care physiotherapy (PT). Primary outcome was time to independent ambulation measured in days, using the Functional Ambulation Categories (FAC-score: 3). Secondary outcomes included hospital length of stay and serious adverse events.ResultsThe median (IQR) time to independent ambulation was 6 (3 to 9) days in the BWSTT group (n = 19) compared to 11 (7 to 23) days in the usual care group (n = 21, p = 0.063). Hospital length of stay was significantly different in favour of the BWSTT group (p = 0.037). No serious adverse events occurred.InterpretationBWSTT seems a promising intervention to enhance recovery of ambulation and shorten hospital length of stay of ICU patients, justifying a sufficiently powered multicenter RCT.Trial registration number: Dutch Trial Register ID: NTR6943.
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BACKGROUND: Early mobilization has been proven effective for patients in intensive care units (ICUs) to improve functional recovery. However, early mobilization of critically ill, often mechanically ventilated, patients is cumbersome because of the attachment to tubes, drains, monitoring devices and muscle weakness. A mobile treadmill with bodyweight support may help to initiate mobilization earlier and more effectively. The aim of this study is to assess the effectiveness of weight-supported treadmill training in critically ill patients during and after ICU stay on time to independent functional ambulation. METHODS: In this randomized controlled trial, a custom-built bedside body weight-supported treadmill will be used and evaluated. Patients are included if they have been mechanically ventilated for at least 48 hours, are able to follow instructions, have quadriceps muscle strength of Medical Research Council sum-score 2 (MRC 2) or higher, can sit unsupported and meet the safety criteria for physical exercise. Exclusion criteria are language barriers, no prior walking ability, contraindications for physiotherapy or a neurological condition as reason for ICU admission. We aim to include 88 patients and randomize them into either the intervention or the control group. The intervention group will receive usual care plus bodyweight-supported treadmill training (BWSTT) daily. The BWSSTT consists of walking on a mobile treadmill while supported by a harness. The control group will receive usual care physiotherapy treatment daily consisting of progressive activities such as bed-cycling and active functional training exercises. In both groups, we will aim for a total of 40 minutes of physiotherapy treatment time every day in one or two sessions, as tolerated by the patient. The primary outcome is time to functional ambulation as measured in days, secondary outcomes include walking distance, muscle strength, status of functional mobility and symptoms of post-traumatic stress. All measurements will be done by assessors who are blinded to the intervention on the regular wards until hospital discharge. DISCUSSION: This will be the first study comparing the effects of BWSTT and conventional physiotherapy for critically ill patients during and after ICU stay. The results of this study contribute to a better understanding of the effectiveness of early physiotherapy interventions for critically ill patients. TRIAL REGISTRATION: Dutch Trial Register (NTR) ID: NL6766. Registered at 1 December 2017.
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Background: There is an emergence of mobile health (mHealth) interventions to support self-management in patients with chronic obstructive pulmonary disease (COPD). Recently, an evidence-driven mHealth intervention has been developed to support patients with COPD in exacerbation-related self-management: the Copilot app. Health care providers (HCPs) are important stakeholders as they are the ones who have to provide the app to patients, personalize the app, and review the app. It is, therefore, important to investigate at an early stage whether the app is feasible in the daily practice of the HCPs. Objective: The aim of this study is to evaluate the perceived feasibility of the Copilot app in the daily practice of HCPs. Methods: A multimethods design was used to investigate how HCPs experience working with the app and how they perceive the feasibility of the app in their daily practice. The feasibility areas described by Bowen et al were used for guidance. HCPs were observed while performing tasks in the app and asked to think aloud. The System Usability Scale was used to investigate the usability of the app, and semistructured interviews were conducted to explore the feasibility of the app. The study was conducted in primary, secondary, and tertiary care settings in the Netherlands from February 2019 to September 2019. Results: In total, 14 HCPs participated in this study—8 nurses, 5 physicians, and 1 physician assistant. The HCPs found the app acceptable to use. The expected key benefits of the app were an increased insight into patient symptoms, more structured patient conversations, and more tailored self-management support. The app especially fits within the available time and workflow of nurses. The use of the app will be influenced by the autonomy of the professional, the focus of the organization on eHealth, costs associated with the app, and compatibility with the current systems used. Most HCPs expressed that there are conditions that must be met to be able to use the app. The app can be integrated into the existing care paths of primary, secondary, and tertiary health care settings. Individual organizational factors must be taken into account when integrating the app into daily practice. Conclusions: This early-stage feasibility study shows that the Copilot app is feasible to use in the daily practice of HCPs and can be integrated into primary, secondary, and tertiary health care settings in the Netherlands. The app was considered to best fit the role of the nurses. The app will be less feasible for those organizations in which many conditions need to be met to use the app. This study provides a new approach to evaluate the perceived feasibility of mHealth interventions at an early stage and provides valuable insights for further feasibility testing.
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Paratonia, a distinctive form of hypertonia in patients with dementia, causes loss of functional mobility in early stage dementia to severe contractures and pain in the late stages. The pathogenesis of paratonia is not well understood. Patients in early stage dementia with diabetes mellitus showed a significantly higher risk for the development of paratonia. Both Alzheimer disease and diabetes mellitus are related to higher concentrations of advanced glycation end-products (AGEs). The purpose of this study is to explore the association of AGEs with the prevalence and severity of paratonia in patients with Alzheimer disease.DESIGN: Observational longitudinal, 1-year follow-up cohort study with 3 assessments.SETTING: Day care centers for patients with dementia.PARTICIPANTS: A total of 144 community-dwelling patients with early stage Alzheimer or Alzheimer/vascular disease were recruited from 24 dementia day care centers in The Netherlands.MEASUREMENTS: The presence of paratonia (Paratonia Assessment Instrument), the severity of paratonia (Modified Ashworth Scale for paratonia), and AGE levels (AGE-reader).RESULTS: From the 144 participants (56.3% female and 43.7% male, with a mean [standard deviation] age of 80.7 [7.7] years), 118 participants were available for final follow-up. A significant association between AGE levels and the presence of paratonia (odds ratio 3.47, 95% confidence interval [CI] 1.87-6.44, P < .001) and paratonia severity (β = 0.17, 95% CI 0.11-0.23, P < .001) was determined. In participants who developed paratonia and those with persistent paratonia throughout the study the AGE levels (95% CI -0.38 to -0.13, P < .001 and 95% CI -0.46 to -0.06, P = .012, respectively) and the severity of paratonia (95% CI -0.60 to -0.35, P < .001 and 95% CI -0.38 to -0.12, P < .001, respectively) significantly increased, whereas the AGE levels remained stable in those participants without paratonia. Notwithstanding, change in AGE levels was not significantly (P = .062) related to change in paratonia severity, mixed model analyses provided evidence for both a significant time and between participant effect of AGEs on paratonia severity.CONCLUSIONS: This study suggests that elevated AGE levels are a contributing factor to paratonia and its severity and could be the result of peripheral biomechanical changes reducing elasticity and increasing stiffness. These results provide a new perspective on paratonia and gives rise to further research whether paratonia could be postponed or movement stiffness can be improved by reducing AGE levels.
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Early mobilisation after abdominal surgery is necessary to avoid complications and increase recovery. However, due to a variety of factors, failure of early mobilisation is seen in clinical practice. The aim of this study is to investigate the perspectives of nurses and patients of the Haaglanden Medical Center (HMC) how to increase mobilisation frequency after colorectal surgery in the oncological surgery ward. This explorative study employed qualitative data collection and analysis by means of semi-structured interviews with patients and nurses. Patients were included when they had a colorectal resection, were older than 18 years and spoke Dutch. The interviews were audiotaped and verbatum transcribed. A thematic content analysis was performed. It was concluded that mobilisation can be increased when it is incorporated in daily care activities and family support during visiting hours. Appropriate information about mobilisation and physical activity is needed for nurses, patients and family and the hospital environment should stimulate mobilisation.
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