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Changing functional status within 6 months posttreatment is prognostic of overall survival in patients with head and neck cancer: NRG Oncology Study.
Eldridge, RC, Pugh, SL, Trotti, A, Hu, K, Spencer, S, Yom, SS, Rosenthal, D, Read, N, Desai, A, Gore, E, et al
Head & neck. 2019;(11):3924-3932
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Abstract
BACKGROUND Is posttreatment functional status prognostic of overall survival in patients with head and neck cancer (HNC). METHODS In an HNC clinical trial, 495 patients had two posttreatment functional assessments measuring diet, public eating, and speech within 6 months. Patients were grouped by impairment (highly, moderately, modestly, or not impaired) and determined if they improved, declined, or did not change from the first assessment to the second. Multivariable Cox models estimated overall mortality. RESULTS Across all three scales, the change in posttreatment patient function strongly predicted overall survival. In diet, patients who declined to highly impaired had three times the mortality of patients who were not impaired at both assessments (hazard ratio [HR] = 3.60; 95% confidence interval, 2.02-6.42). For patients improving from highly impaired, mortality was statistically similar to patients with no impairment (HR = 1.38; 95% CI, 0.82-2.31). CONCLUSIONS Posttreatment functional status is a strong prognostic marker of survival in patients with HNC.
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Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation.
van Rooijen, S, Carli, F, Dalton, S, Thomas, G, Bojesen, R, Le Guen, M, Barizien, N, Awasthi, R, Minnella, E, Beijer, S, et al
BMC cancer. 2019;(1):98
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most prevalent type of cancer in the world. Surgery is the only curative option. However, postoperative complications occur in up to 50% of patients and are associated with higher morbidity and mortality rates, lower health related quality of life (HRQoL) and increased expenditure in health care. The number and severity of complications are closely related to preoperative functional capacity, nutritional state, psychological state, and smoking behavior. Traditional approaches have targeted the postoperative period for rehabilitation and lifestyle changes. However, recent evidence shows that the preoperative period might be the optimal moment for intervention. This study will determine the impact of multimodal prehabilitation on patients' functional capacity and postoperative complications. METHODS/DESIGN This international multicenter, prospective, randomized controlled trial will include 714 patients undergoing colorectal surgery for cancer. Patients will be allocated to the intervention group, which will receive 4 weeks of prehabilitation (group 1, prehab), or the control group, which will receive no prehabilitation (group 2, no prehab). Both groups will receive perioperative care in accordance with the enhanced recovery after surgery (ERAS) guidelines. The primary outcomes for measurement will be functional capacity (as assessed using the six-minute walk test (6MWT)) and postoperative status determined with the Comprehensive Complication Index (CCI). Secondary outcomes will include HRQoL, length of hospital stay (LOS) and a cost-effectiveness analysis. DISCUSSION Multimodal prehabilitation is expected to enhance patients' functional capacity and to reduce postoperative complications. It may therefore result in increased survival and improved HRQoL. This is the first international multicenter study investigating multimodal prehabilitation for patients undergoing colorectal surgery for cancer. TRIAL REGISTRATION Trial Registry: NTR5947 - date of registration: 1 August 2016.
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Classes of vitamin D status and functional outcome after hip fracture: a prospective, short-term study of 1350 inpatients.
Di Monaco, M, Castiglioni, C, Di Carlo, S, La Marmora, E, Filipovic, I, Milano, E, Minetto, MA, Massazza, G
European journal of physical and rehabilitation medicine. 2019;(1):56-62
Abstract
BACKGROUND Vitamin D depletion is associated with unfavourable outcomes after hip fracture. However, the classes of vitamin D status currently in use, which are defined according to serum calcifediol levels, have not been validated for their predictive capability of the functional recovery. AIM: To investigate the association between serum calcifediol categorized into 4 classes and the functional recovery after hip fracture. DESIGN Prospective, short-term observational study. SETTING Rehabilitation hospital in Italy. POPULATION We evaluated 1350 of 1412 inpatients with hip fracture. METHODS Serum calcifediol was measured by an immunoenzymatic assay 14.7±4.4 (mean±SD) days after surgery and categorized into 4 classes: I class <12 ng/mL; II class 12-20 ng/mL; III class 21-29 ng/mL; IV class ≥30ng/mL. The functional outcome was assessed by using the Barthel Index. RESULTS We found a significant difference in Barthel index scores at the end of inpatient rehabilitation across the 4 classes of vitamin D status: χ2 (3, N.=1350) 27.2; P<0.001. The difference persisted after adjustment for 8 covariates (P=0.004). By comparing pairs of classes, we found that Barthel index scores were lower in the 829 patients of the I class than in the 275 of the II (P=0.005) who had in turn Barthel index scores lower than the 132 patients of the III class (P=0.038). Conversely, no significant differences emerged between the patients of the III class and the 114 patients of the IV class (P=0.421). The results did not materially change when Barthel Index effectiveness was substituted for Barthel Index scores as the outcome measure. CONCLUSIONS Calcifediol levels below 12ng/mL were associated with a worse recovery than those between 12 and 20ng/mL that were in turn associated with a worse recovery than those between 21 and 29 ng/mL. Conversely, no significant differences were found between the patients with calcifediol between 21 and 29ng/mL and those with calcifediol ≥30 ng/mL. CLINICAL REHABILITATION IMPACT Despite caution due to the observational design, our study suggests that vitamin D depletion should be treated after hip fracture to optimize the functional outcome, with a target level for serum calcifediol of 21-29ng/mL and no further advantages associated with calcifediol levels of 30ng/mL or higher.
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Timing of periarticular injection has no effect on postoperative pain and functional recovery in simultaneous bilateral total knee arthroplasty: a prospective randomized, double-blinded trial.
Laoruengthana, A, Jarusriwanna, A, Rattanaprichavej, P, Rasamimongkol, S, Varakornpipat, P, Pongpirul, K
BMC musculoskeletal disorders. 2019;(1):162
Abstract
BACKGROUND Given no consensus on optimal timeframe of periarticular multimodal drug injection (PMDI) in knee osteoarthritis patients undergoing total knee arthroplasty (TKA), this study was aimed to compare the postoperative pain and the functional recovery in patients who underwent simultaneous bilateral TKA (SBTKA) and received PMDI at the different intraoperative time points. METHODS This prospective, randomized, double-blinded controlled trial study included 48 patients who underwent SBTKA and received PMDI mixture, either before prosthetic implantation (late PMDI), or just after knee arthrotomy (early PMDI). Each subject's knees were randomly selected to different PMDI administration time points. The outcome parameters were postoperative pain assessed by using a visual analog scale (VAS), the maximal angle of knee flexion, and quadriceps function from day 1 to 6 weeks after surgery. RESULTS Late PMDI revealed slightly higher VAS at 6 and 12 h after the operation than early PMDI administration. Afterward, the VAS tended to be lower in the late than early PMDI administration until the end of the study, but without statistical significance. The time difference between early and late PMDI had no effect on postoperative VAS, while older age resulted in significantly less pain. No statistical differences between the two groups in all other outcome parameters were observed. CONCLUSIONS Postoperative pain reduction and functional recovery of SBTKA with early and late PMDI administration were not significantly different. The time interval of PMDI between knees did not confound the comparison of postoperative pain and functional recovery in SBTKA. TRIAL REGISTRATION The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database No. TCTR20170617001 on 16 June 2017.
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Effect of Enhanced Recovery After Surgery program on pancreaticoduodenectomy: a randomized controlled trial.
Hwang, DW, Kim, HJ, Lee, JH, Song, KB, Kim, MH, Lee, SK, Choi, KT, Jun, IG, Bang, JY, Kim, SC
Journal of hepato-biliary-pancreatic sciences. 2019;(8):360-369
Abstract
BACKGROUND This study aims to investigate the noninferiority of Enhanced Recovery After Surgery (ERAS) for pancreaticoduodenectomy (PD). METHODS In this single-center trial, we randomly assigned 276 adult patients who underwent open PD into ERAS and conventional groups with 138 patients in each, from 2015 through 2017. The primary endpoint was the incidence of overall morbidity until postoperative 3 months. The secondary endpoints were in-hospital or 30-day mortality, postoperative length of stay (LOS), nutritional status and overall hospital costs. RESULTS Overall morbidity was reported in 64 patients (52.0%, ERAS group) and in 68 patients (54.8%, conventional group) (risk difference [RD] -2.81 percentage points (pp); 90% two-sided confidence interval -13.24 to 7.63). Mortality did not occur in any patients. The two groups did not differ significantly in median postoperative LOS (both 11 days; RD -8.46 pp), body mass index (22.4 ± 2.75 vs. 22.4 ± 2.65 kg/m2 ; RD -3.48 pp), Patient-Generated Subjective Global Assessment score over 4 (45 [40.5%] vs. 50 [43.1%] patients; RD -2.56 pp), and median overall hospital cost (15.61 vs. 16.04, ×106 KRW; RD -6.08 pp). CONCLUSIONS Even in PD, modified ERAS protocol was not inferior to conventional protocol, while reducing treatment burden.
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Left ventricular assist device recovery: does duration of mechanical support matter?
Pham, BN, Chaparro, SV
Heart failure reviews. 2019;(2):237-244
Abstract
Heart failure is a widespread condition in the United States that is predicted to significantly increase in prevalence in the next decade. Many heart failure patients are given a left ventricular assist device (LVAD) while they wait for a heart transplant, while those that are not able to undergo a heart transplant may be given an LVAD permanently. However, past studies have observed a small subset of heart failure patients that recovered cardiac function of their native heart after being placed on an LVAD. As a result, some patients have been able to have their LVAD explanted and no longer needed a heart transplant. In this review, we analyzed the data of 15 studies that observed recovery of cardiac function in LVAD patients in order to investigate the effects that duration of LVAD support has on patient outcomes. From our review, we identified that there may be negative consequences of prolonged duration of mechanical support such as myocardial atrophy and abnormal calcium cycling as well as circumstances that may allow for a longer duration of LVAD support such as in patients using a continuous-flow LVAD, non-ischemic cardiomyopathy patients, and the specific pharmacological therapy.
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Timeline of functional recovery after hip fracture in seniors aged 65 and older: a prospective observational analysis.
Fischer, K, Trombik, M, Freystätter, G, Egli, A, Theiler, R, Bischoff-Ferrari, HA
Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2019;(7):1371-1381
Abstract
UNLABELLED We investigated the timeline of functional recovery after hip fracture over 12 months in adults age ≥ 65 years using objective lower extremity function tests and subjective physical functioning. Objective functional recovery was largely complete in the first 6 months, whereas subjective recovery improved up to 9 months after hip fracture. INTRODUCTION Hip fractures are a major cause of loss of function among seniors. We assessed the timeline of objective and subjective functional recovery after hip fracture. METHODS We conducted a prospective observational secondary analysis of a 1-year clinical trial on vitamin D and home exercise treatment and complications after hip fracture among 173 patients age ≥ 65 years (mean age 84 years; 79.2% women; 77.4% community-dwelling) conducted from January 2005 through December 2007. Lower extremity function (Timed Up and Go test (TUG), knee extensor and flexor strength) and grip strength was assessed at baseline and at 6 and 12 months follow-up. Subjective physical functioning was assessed using the SF-36 questionnaire also at 3 and 9 months follow-up. Multivariable-adjusted repeated-measures models were used to assess the timeline of functional recovery in the total population and in subgroups of patients. RESULTS Lower extremity function including TUG (- 61.1%), knee extensor (+ 17.6%), and knee flexor (+ 11.6%) strength improved significantly in the first 6 months (P < 0.001). However, between 6 and 12 months, there was no further significant improvement for any of the functional tests. Grip strength decreased from baseline to 6 months (- 7.9%; P < 0.001) and from 6 to 12 months (- 10.8%; P < 0.001). Subjective physical functioning improved from 3 to 9 months (+ 15.2%, P < 0.001), but no longer thereafter. CONCLUSIONS Functional recovery after hip fracture may be largely complete in the first 6 months for objective functional tests, whereas may extend up to 9 months for subjective recovery, with oldest-old, female, institutionalized, and cognitively impaired patients recovering most poorly. CLINICAL TRIALS REGISTRY (ORIGINAL TRIAL): NCT00133640.
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Brain Motor Control Assessment Post Early Intensive Hand Rehabilitation After Spinal Cord Injury.
Zoghi, M, Galea, M
Topics in spinal cord injury rehabilitation. 2018;(2):157-166
Abstract
Background: The Brain Motor Control Assessment (BMCA) is a surface electromyography (sEMG)-based measure of motor output from the central nervous system during a variety of reflex and voluntary motor tasks. Objective: The aim of this study was to assess the pattern of voluntary movements in patients with spinal cord injury (SCI) to investigate whether BMCA could add more resolution to clinical assessments and the recovery path of these patients. Method: Ten participants were recruited from the Royal Talbot Rehabilitation Centre as part of a multicenter randomized controlled trial. Four participants received usual care while the other 3 participants received usual care plus an intensive task-specific hand training program in conjunction with functional electrical stimulation for 8 weeks. BMCA assessments were completed for 7 participants at this center 4 times over a period of 1 year. Results: Generalized linear model analysis showed a significant main effect of task (p < .001) and assessment time (p = .003) on the Similarity Index. However, there were no significant interactions among the factors (p > .05). Based on ARAT or summed upper limb strength scores, some participants showed significant improvement after 8 weeks of rehabilitation, however this improvement was not reflected in the pattern of muscle activation that was captured by BMCA. Conclusion: The quantifiable features of BMCA through surface EMG may increase the resolution of SCI characterization by adding subclinical details to the clinical picture of lesion severity and progression during rehabilitation.
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Nutritional Status Changes and Activities of Daily Living after Hip Fracture in Convalescent Rehabilitation Units: A Retrospective Observational Cohort Study from the Japan Rehabilitation Nutrition Database.
Nishioka, S, Wakabayashi, H, Momosaki, R
Journal of the Academy of Nutrition and Dietetics. 2018;(7):1270-1276
Abstract
BACKGROUND Several studies have suggested that malnutrition impedes functional recovery in patients with hip fracture, but there are few reports on improvement in nutritional status and return to activities of daily living (ADL) in these patients. OBJECTIVE This study was conducted to evaluate the relationship between change in nutritional status and recovery of ADL in malnourished patients after hip fracture and to identify predictors of functional recovery among the characteristic features of undernutrition. DESIGN This was a retrospective observational cohort study. PARTICIPANTS/SETTING Data for patients aged ≥65 years with hip fracture and malnutrition (Mini Nutritional Assessment-Short Form [MNA-SF] score ≤7) at the time of admission to convalescent rehabilitation units were obtained from the Japan Rehabilitation Nutrition Database between November 2015 and August 2017. MAIN OUTCOME MEASURES The main outcome measures were Functional Independence Measure (FIM) at discharge and the proportion of patients discharged home. STATISTICAL ANALYSES PERFORMED Patients were divided into two groups based on MNA-SF scores at discharge: improvement in nutritional status (>7, IN group) and non-improvement in nutritional status (≤7, NN group). Clinical characteristics and outcomes were compared between the groups. Multivariable regression analysis was performed to adjust for confounders including age, sex, comorbidity, pre-fracture ADL level, and FIM score on admission. RESULTS Of 876 patients, 110 met the eligibility criteria (mean age, 85 years; 78.2% female); 77 of the patients were assigned to the IN group and 33 to the NN group. The patients in the IN group were younger and had higher FIM and MNA-SF scores on admission than those in the NN group. At discharge, the median FIM score was significantly higher in the IN group than in the NN group (110 vs 83, P<0.001). Multivariable analysis revealed a significant association between improvement in nutritional status and higher FIM score at discharge (B=7.377 [B=partial regression coefficient], P=0.036) but no association with discharge to home. Mobility, neuropsychological impairment, and weight loss subscores of MNA-SF were independently associated with discharge FIM score (R2=0.659). CONCLUSIONS In older patients with hip fracture and malnutrition, improvement in nutritional status was independently associated with improved performance of ADL during inpatient rehabilitation. Weight loss may be an important nutritional indicator for these patients.
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Biomechanical changes and recovery of gait function after total hip arthroplasty for osteoarthritis: a systematic review and meta-analysis.
Bahl, JS, Nelson, MJ, Taylor, M, Solomon, LB, Arnold, JB, Thewlis, D
Osteoarthritis and cartilage. 2018;(7):847-863
Abstract
OBJECTIVE To determine the change in walking gait biomechanics after total hip arthroplasty (THA) for osteoarthritis (OA) compared to the pre-operative gait status, and to compare the recovery of gait following THA with healthy individuals. METHODS Systematic review with meta-analysis of studies investigating changes in gait biomechanics after THA compared to (1) preoperative levels and (2) healthy individuals. Data were pooled at commonly reported time points and standardised mean differences (SMDs) were calculated in meta-analyses for spatiotemporal, kinematic and kinetic parameters. RESULTS Seventy-four studies with a total of 2,477 patients were included. At 6 weeks postoperative, increases were evident for walking speed (SMD: 0.32, 95% confidence intervals (CI) 0.14, 0.50), stride length (SMD: 0.40, 95% CI 0.19, 0.61), step length (SMD: 0.41, 95% CI 0.23, 0.59), and transverse plane hip range of motion (ROM) (SMD: 0.36, 95% CI 0.05, 0.67) compared to pre-operative gait. Sagittal, coronal and transverse hip ROM was significantly increased at 3 months (SMDs: 0.50 to 1.07). At 12 months postoperative, patients demonstrated deficits compared with healthy individuals for walking speed (SMD: -0.59, 95% CI -1.08 to -0.11), stride length (SMD: -1.27, 95% CI -1.63, -0.91), single limb support time (SMD: -0.82, 95% CI -1.23, -0.41) and sagittal plane hip ROM (SMD: -1.16, 95% CI -1.83, -0.49). Risk of bias scores ranged from seven to 24 out of 26. CONCLUSIONS Following THA for OA, early improvements were demonstrated for spatiotemporal and kinematic gait patterns compared to the pre-operative levels. Deficits were still observed in THA patients compared to healthy individuals at 12 months.