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Purpose: Thoracic trauma causes pain and hospitalisation. Middle- and high-income countries have different trauma contexts and populations. To report patients' clinical presentation (pain and shortness of breath) and its influence on hospital length of stay (LOS), acute care management, and discharge destinations in South Africa (SA) and Sweden., Methods: Prospective observational multicenter study by means of clinical record review. Two centers in SA and four centers in Sweden participated. One thousand nine hundred and eighteen adults with thoracic trauma were screened over the 20 months period. Study objectives guided information retrieved from clinical records. Statistical analysis was done with significance at p-value < 0.05., Results: Three-hundred-sixty-four participants were recruited with most being male (n = 170/179 (95%) SA; n = 125/185 (68%) Sweden). Type and mechanism of injury differed (SA penetrating (82%) versus Sweden blunt (95%); SA assaults (90%) versus Sweden falls (44%)). Unilateral haemopneumothorax was common (SA 68%, Sweden 35%) and managed with intercostal drainage. Rib cage injuries were common in the Swedish cohort with rib fixation surgery for 17%. Physiotherapy treatment frequency was mostly daily. Blunt injury resulted in higher pain levels during deep breathing (day 1: p = 0.014; day 2: p < 0.001; day 3: p < 0.001) and shortness of breath during activity (day 1: p = 0.036; day 2: p = 0.003; day 3: p < 0.001). LOS was shorter for SA cohort (5 (± 4) versus 7 (± 5) days; p = 0.024). Age influenced LOS in the blunt injury group. Discharge destination was mostly home (99% SA, 56% Sweden)., Conclusion: Priority care is indicated for those who are older and have blunt thoracic injury to prevent pulmonary complications and prolonged hospitalisation., Competing Interests: Declarations. Conflict of interests: The authors declare no competing interests. The authors declare that they have no relevant financial or non-financial interests to declare. Ethical approval: This study was performed in line with the principles of the Declaration of Helsinki. In South Africa, approval was granted by the University of the Witwatersrand Human Research Ethics (Medical) committee (Date: 27/06/2020; No. M200222). In Sweden, approval was granted by the Regional Ethics Committee for the region of Västra Götaland (Date: 22/10/2019; No. Dnr2019-04848). Permission was obtained from all relevant authorities at the two participating sites in South Africa and the four participating sites in Sweden. Informed consent was obtained from all potential participants before study enrolment., (© 2025. The Author(s).)

Background: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a leading cause of morbidity and mortality in South Africa. Physiotherapy practice and factors that influence management of patients with AECOPD are unknown., Objectives: To explore physiotherapy practice in the management of patients with AECOPD in South African private healthcare settings and to identify and describe factors that influence physiotherapy patient management., Method: The study adopted a qualitative descriptive design using semi-structured interviews. Purposive and snowball sampling was used to identify physiotherapists working in private healthcare in three South African provinces. Individual interviews were conducted face-to-face or via telephone and transcribed verbatim. Content analysis was done using an inductive approach., Results: Participants ( n = 9) working in private hospitals reported that their management is based on patient-specific needs assessment. Treatment interventions included various respiratory physiotherapy techniques and exercise rehabilitation strategies. Patient education on self-management of disease symptoms featured prominently. Enablers of physiotherapy management included supportive workplace relations, conducive work environment, physiotherapists' competence, familial support and patient cooperation. Barriers identified included limited communication, nurses' attitudes, work environment, disease burden, mental health challenges and limited professional development opportunities., Conclusion: Physiotherapists provide individual needs-based care to patients with AECOPD. Various enablers and barriers to physiotherapy patient management have been identified., Clinical Implications: Advocacy for physiotherapy, better communication between multidisciplinary team members and recognition of the need for psychological support are important factors to address to enhance the care provided to patients with AECOPD., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. The author, H.v.A., serves as an editorial board member of this journal. The peer review process for this submission was handled independently, and the author had no involvement in the editorial decision-making process for this manuscript. The authors have no other competing interests to declare., (© 2024. The Authors.)

Protracted return to sport (RTS) following COVID-19 is common due to long-term cardiopulmonary symptoms and persistent fatigue. In athletes, low exercise tolerance may result in emotional distress. The aim of this study is to assess the symptom severity, the management thereof and the impact on quality of life (QOL) as endurance athletes return to their preillness level of sports participation. A cross-sectional survey-based mixed methods study of long-distance athletes was performed. Quantitative data included sport and disease characteristics, fatigue score and management of persistent symptoms. A total of 295 survey responses were included. The mean age was 45.1 (10.2) years and 54.7% were male. Barriers to exercise included tachycardia (72%), fatigue (72%), dyspnoea (58%) and inability to exercise at high intensities (75%). High physical and mental fatigue scores were found, the former significantly predicting return to sport. Qualitative data were collected through open-ended questions exploring challenges faced when returning to sport post-COVID-19 convalescence and the impact on their QOL. Biopsychosocial well-being constituted three themes: Physical, Psychological and Social. Categories with high code frequencies included persistent cardiopulmonary symptoms, physical fatigue, emotional distress and social disengagement. Mixing the methods revealed that the athletes' QOL deteriorated due to protracted RTS after COVID-19. A multidisciplinary approach to management may be required by endurance athletes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Cheryl Anne Haley et al.)

Background: The global coronavirus disease 2019 (COVID-19) pandemic irrevocably influenced our lives, yet research in a diversity of countries is lacking. Cardiorespiratory fitness may be impaired for up to a year post-COVID-19 infection., Objectives: Our study aimed to compare acute and exertional symptoms, fatigue, and exercise performance in masters-age endurance athletes according to their return-to-sport status., Method: A cross-sectional survey-based observational study of long-distance runners and cyclists was conducted. Data were stratified into two groups: those who returned to their pre-illness level of sport and those who did not and were compared statistically., Results: A total of 308 survey responses were included in the analysis. The mean age of the athletes was 44.9 + 10.2 years, with 55.2% being male. The group that did not return to their pre-illness level of sport (31.5%) had more post-COVID sequelae, worse illness severity, with a higher frequency of resting and exertional symptoms, notably fatigue and dyspnoea. Decreased exercise capacity was correlated with increased physical fatigue scores., Conclusion: Almost one-third of endurance athletes suffered protracted exercise tolerance post-COVID-19. Long-term symptoms may be more consequential in this athlete population., Clinical Implications: Symptoms that may indicate cardiopulmonary consequences in recreational athletes should be investigated in order to facilitate return to sport and the important mental and physical benefits thereof. This will augment outcomes after respiratory tract infections and management of return to sport and expectations of endurance athletes., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2024. The Authors.)

Objectives: To measure and compare the clinimetric properties of the Chelsea Critical Care Physical Assessment (CPAx) and Physical Function in Intensive Care Test-scored (PFIT-s) for assessment of physical function and activity., Design: Prospective cohort design using crossover-randomisation of the sequence in which participants were assessed with CPAx and PFIT-s., Setting: Surgical and transplant intensive care units (ICU) in an academic hospital., Participants: Adults who underwent elective open abdominal surgery. Consecutive sampling was used to enrol 69 participants., Interventions: Physical function and activity were assessed on ICU days one, three, five and at ICU discharge using the CPAx and PFIT-s in random order., Main Outcome Measures: Responsiveness to change, minimal clinically important difference (MCID), floor and ceiling effect, and convergent validity., Results: CPAx demonstrated a large responsiveness (effect size index (ESI)= 0.83) and PFIT-s moderate responsiveness (ESI=0.73) to change in scores. MCID for CPAx was 2.1 (standard error of measurement (SEM) 1.1) and for PFIT-s 0.6 (SEM=0.3). CPAx had no floor effect and a small ceiling effect (9%, n = 6) at ICU discharge compared to 2% (n = 1) floor and 48% (n = 32) ceiling effects of PFIT-s. Moderate convergent validity was found for both tools at ICU admission (n = 67, r = 0.62, p < 0.001) and discharge (n = 67, r = 0.51, p < 0.001)., Conclusion: CPAx is most responsive to changes in physical function and activity scores, has no floor and limited ceiling effects and moderate convergent validity, and is recommended for similar cohorts. CONTRIBUTION OF THE PAPER., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Endurance sports primarily attract recreational athletes over 35 years, who impose an exceptionally rigorous and sustained demand on their cardiorespiratory systems., Objectives: This study aimed to determine the influence of COVID-19 on the cardiovascular, pulmonary, and skeletal muscle function of endurance athletes with exercise intolerance. Secondly, it aimed to compare the exercise response of endurance athletes post-COVID-19 to those unaffected using cardiopulmonary exercise test-related variables., Methods: This is a prospective observational cohort study of endurance athletes. An exposure group with protracted exercise tolerance underwent a resting lung function test and maximal cardiopulmonary exercise test. These were repeated after eight weeks of endurance training and compared to the published reference values and a control group of athletes unaffected by COVID-19., Results: The post-COVID-19 exposure group (n=57), mean age 44.5±8.1years showed a poorer ventilatory threshold (p=0.004), and workload (p=0.05), with higher respiratory exchange ratio (p=0.05) than the control group (n=34), mean age 41.8±7.7 years. Maximal inspiratory pressure improved at follow-up in the COVID-19 group compared to the controls (p=0.03). Increased odds of pulmonary and skeletal muscle limitation to aerobic capacity were found in the COVID-19 group. The COVID-19 group responded positively to endurance training with improved VO 2 peak (p=0.005), maximal inspiratory pressure (p=0.04), oxygenpulse (p=0.02), and maximal workload (p<0.001)., Conclusion: COVID-19 has led to pulmonary and extrapulmonary limitations to exercise capacity. Tailored intensity and duration of physical activity are vital after COVID-19 to restore skeletal muscle health. This multidisciplinary rehabilitation approach will optimise the resumption of participation in long-distance events., Competing Interests: Conflict of interest and source of funding: Filters for each participant for the spirometry were kindly sponsored by Respiratory Care Africa (Pty) Ltd. This research project was partially funded by the South African Society of Physiotherapy. Neither Respiratory Care Africa (Pty) Ltd nor The South African Society of Physiotherapy were involved in the conceptualisation, data collection, analysis, or interpretation of the research. The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors or the publisher. The authors declare that no conflicts of interest relevant to this article exists.

Background: Surgical resection is a common treatment for patients with colorectal cancer. Patients undergoing surgery are at risk of functional deterioration as a response to surgical stress. Furthermore, patients with cancer often present with systemic problems as well as a functional decline. The study aimed to create a framework for preoperative education for patients undergoing colorectal cancer resection., Methods: Five databases were utilised to find intervention-based studies describing the content, mode, setting and timing of delivery of preoperative education for patients undergoing abdominal surgery. Physiotherapists were purposively sampled to participate in a focus group session using a seven-step nominal group technique (NGT) with the goal to reach consensus on the proposed content of a preoperative patient education programme., Results: Seventeen studies were reviewed. Results indicate that the mode and timing of the education provided are heterogenous. Content included in the education programs described were breathing exercises, coughing techniques, verbal advice, physical exercises, surgical information, postoperative pain management, nutritional support, relaxation techniques and information about postoperative complications. Six physiotherapists participated in the focus group discussion. Ideas generated in the focus group were similar to those described in the literature., Conclusion: Results from both the narrative review and the focus group session assisted the authors to develop a framework for the content, timing, setting and mode of delivery of physiotherapy preoperative education for patients undergoing surgical resection for colorectal cancer.Contribution: The framework can be used to inform a physiotherapy preoperative education programme for patients undergoing surgery for colorectal cancer.

Background: Physiotherapy skills such as suction and manual hyperinflation (MHI) are used to manage patients in intensive care. Performing these skills effectively and safely requires a level of expertise. It is unknown whether a once-off preclinical high-fidelity simulation activity incorporating these skills would translate to clinical practice inclusion., Objectives: To determine students' perceptions of a simulation-based education (SBE) activity and clinical educators' opinions of students' implementation of skills into practice., Method: Our study consisted of two parts: a retrospective record review of students' feedback with the Simulation Effectiveness Tool - Modified (SET-M) and the Simulation Laboratory Questionnaire. A nominal group technique (NGT) with clinical educators provided information on students' skills implementation. Descriptive data analysis was undertaken., Results: Six SBE sessions, lasting 3 hours each, with 49 students ( n = 8-9 students per session) were undertaken. Students perceived the teaching activity positively. Five (33.33%) of 15 clinical educators participated in the NGT. Participants had a mean age of 35.8 (± 8.9) years, were qualified for 13.9 (± 8.9) years and had been supervising students for 7.8 (± 6.7) years. The clinical educators' top five opinions regarding students' implementation of the intensive care unit (ICU) skills were: handling skills improved, students had greater confidence performing these skills, students were more observant of a patient's response to the skill being performed, students had better theoretical knowledge and students had more accurate recall for precautions., Conclusion: Clinical educators reported a change in students' clinical practice with regard to skills implementation., Clinical Implications: A once-off preclinical SBE activity influences students' ICU practice., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2022. The Authors.)

Patients with life-threatening illnesses in intensive care receive management that improves their chances for survival. The physical outcomes of individuals infected with HIV who survive an intensive care unit (ICU) stay are not well known. The purpose was to describe the physical outcomes of ICU survivors in a high HIV prevalent area and highlight challenges as it relates to study feasibility. A pilot study at a tertiary-care university-affiliated hospital was done. Participants were assessed at ICU and ward admission, hospital discharge, three and six months following discharge. The profile and physical function, assessed with the ICU Mobility Scale, Karnofsky Performance Status Scale and six-minute walk test, of participants was determined. The EQ-5D-3 L provides information on participants' health-related quality of life (HRQOL). The pilot study consists of five patients (n = 173 screened). All were independently mobile and on antiretroviral therapy prior to hospital admission. Respiratory and peripheral muscle weakness were present with variable performance in physical function across participants. Improvement in function occurred over time but participants still had physical dysfunction at six months. Pain/physical discomfort and anxiety/depression were common complaints influencing HRQOL. ICU survivors, who are HIV-positive, present with significant physical dysfunction who require rehabilitation to reduce disability.

Purpose: Implementing early mobilisation in intensive care is challenging, and a detailed knowledge of factors that may hinder or facilitate implementation is essential for success. The study was done to explore the perceived barriers and facilitators to early mobilisation by physiotherapists in Zimbabwean and South African public sector hospital ICUs., Methods: A qualitative study was done in eight public sector hospitals from South Africa and four hospitals from Zimbabwe. Physiotherapists from the participating hospitals who had at least two years working experience in ICU were invited to participate in semi-structured, in-depth, face-to-face interviews. Purposive sampling was done. Data collected included interpretation of early mobilisation, perceived barriers, and facilitators to early mobilisation. Data analysis was done using the content analysis method., Findings: A total of 22 physiotherapists were interviewed. In defining the activities regarded as early mobilisation, there was diversity in relation to the specific activities and the nature of the patients in which the defined activities were suitable for. Perceived barriers which emerged included lack of professional autonomy or boundaries, motivation, and clinical skills. Perceived facilitators to early mobilisation included the availability of guidelines, good communication, adequate staff, and mobilisation equipment., Conclusions: Barriers and facilitators to early mobilisation are multifactorial. There is need for multidisciplinary team collaboration and planning before implementing early mobilisation activities.Implications to rehabilitationProfessional roles/identity and or boundaries emerged to be a barrier that hinder implementation of early mobilisation if not clearly defined.Non-rotational physiotherapy coverage was highlighted to be important in facilitating good communication and teamwork and sustainability of services in ICU.Good communication channels and referrals between different disciplines should be employed in ICU to prevent delay in rendering services to ICU patients.

Background: Rib fractures are a common thoracic injury and notable source of chest pain. Chest pain may lead to compromised respiratory and physical function., Objectives: Our study aimed to synthesise the evidence on the effectiveness of nonpharmacological therapeutic interventions on pain and physical function in adults admitted with rib fractures to acute care settings. Secondary outcomes included length of stay (LOS), respiratory complications, respiratory function and mortality rate., Method: A systematic literature search of English articles in nine databases was conducted. The Joanna Briggs Institute's System for the Unified Management, Assessment and Review of Information (SUMARI) was used to conduct our study. Articles written from January 2000 to December 2017 were considered and a search update was completed in 2021. Meta-analysis was conducted for pre- versus post-bundle of care implementation for LOS, pneumonia incidence and mortality rate. Certainty of evidence was appraised using the grading of recommendations, assessment, development and evaluation (GRADE) approach., Results: Sixteen studies were included ( n = 2034). Certain interventions were shown to improve respiratory function and reduce pain, pulmonary complications, LOS and mortality rate. No interventions were identified which objectively improved physical function. Meta-analysis showed a statistically significant reduction in relative risk of developing pneumonia ( p = 0.00) by 63% following bundled care implementation. Certainty of evidence for this outcome was rated as very low following GRADE appraisal., Conclusion: Nonpharmacological therapeutic interventions used in combination with pharmacological management are viable treatment options to reduce pain, improve respiratory function and reduce the incidence of respiratory complications following acute rib fractures., Clinical Implications: Acupuncture, transcutaneous electrical nerve stimulation (TENS), noninvasive ventilation (NIV) modalities, physiotherapy techniques and multidisciplinary pathways used alongside pharmacological interventions are effective modalities for use in the treatment of acute rib fractures. Multidisciplinary care pathways are important management strategies and reduce the risk of developing pneumonia., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2022. The Authors.)

Introduction: Coronavirus disease 2019 (COVID-19) is a viral respiratory disease and is associated with significant morbidity in the intermediate and chronic phases of recovery from the disease. The health benefits of respiratory and extremity muscle strengthening exercise therapy are well-described for those with cardiac failure and interstitial lung disease and are suggested to improve functional ability for patients recovering from COVID-19. The aim of this case report is to share the effects of standard physiotherapy management on exercise endurance, respiratory function and return to work, implemented for patients with COVID-19 in the intermediate phase of their recovery., Patient Presentation: Two cases of COVID-19 were admitted to a private healthcare facility in Johannesburg. They presented with shortness of breath and decreased endurance. One had COVID-19 myocarditis and the other chronic post-COVID-19 organising pneumonia with pulmonary fibrosis., Management and Outcome: Both patients were admitted to ICU, provided oxygen therapy and supportive care as well as physiotherapy management in hospital and after hospital discharge. Physiotherapy management included inspiratory muscle training therapy, and cardiovascular and resistance exercise therapy. Improvements in peak expiratory flow rate and six-minute walk distance were observed for both cases at 6- and 7-months follow-up, respectively., Conclusion: Our case report illustrates the value of ongoing physiotherapy management, utilising progressive exercise therapy prescription, to aid the return to optimal functioning for survivors of COVID-19 in the intermediate phase of their recovery., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2022. The Authors.)

Background: Lifestyle-related factors have been linked with risk for colorectal cancer. Data describing the relationship between lifestyle factors of South African patients who present with colorectal cancer and their survival is sparse., Objectives: The objectives were to describe the profile of patients with colorectal cancer; to determine the association between lifestyle-related factors and survival, and to compare results of patients in the private and public sectors., Methods: A retrospective review and secondary analysis of information of patients with colorectal cancer were conducted. The independent samples t-test and Mann Whitney U test were administered to determine differences in the clinical presentation. Pearson's Chi-Squared and Eta (η) tests were used to determine the association between survival and lifestyle-related factors., Results: Data of 441 patients were included. When compared to the public sector cohort, patients in the private sector cohort were older (p=0.0110), had earlier stages of cancer at the time of diagnosis (p<0.001), had a higher percentage of current alcohol consumption (p<0.001) and had higher survival rates (p<0.001). Waist circumference was shown to have a large-strength effect on survival (η2=0.266)., Conclusion: Emphasis should be placed on anthropometric screening and education to effect long-term behaviour change. Physiotherapists are well placed to provide screening and non-pharmacological interventions for patients with colorectal cancer., (© 2022 Whelan M et al.)

Background: Patients with major burns suffer with pain, which impacts their physical function during hospitalisation., Objectives: To describe the demographics, burn characteristics, clinical course, physical function, complications developed after major burns and to establish predictors of non-independent physical function at hospital discharge., Method: Records of all consecutive adult burn admissions to a Level 1 Trauma Centre between 2015 and 2017 were screened retrospectively against our study criteria, using the Trauma Bank Data Registry. Anonymised data from included records were captured on specifically designed data extraction forms. Descriptive statistics were used to summarise findings. A regression analysis was undertaken to establish predictors of non-independent function at discharge., Results: Males represented 87.7% ( n = 64) of included records ( n = 73). Median age was 38 (interquartile range [IQR]: 22). Thermal burns were most reported ( n = 47, 64.4%), followed by median total body surface area (TBSA) 31% and head and arms were most affected (60.3% and 71.2%). Injury severity was high with median intensive care unit (ICU) length of stay (LOS) of 17 (IQR: 34) and hospital LOS 44 (IQR: 31) days. Wound debridement was mostly performed ( n = 27, 36.9%) with limb oedema as a common complication ( n = 15, 21.7%). Muscle strength and functional performance improved throughout LOS. None of the variables identified were predictors of non-independent function at hospital discharge., Conclusion: Adults with major burns were predominantly male, in mid-life and sustained thermal injury with a high injury severity. Decreased range of motion (ROM) of affected areas, 'fair' muscle strength and independent function were recorded for most patients at hospital discharge., Clinical Implications: These findings contribute to the limited body of evidence on the profile, clinical course and outcomes of South African adult burn patients., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2022. The Authors.)

Background: For patients with colorectal cancer, surgical resection of the primary tumour remains the best treatment option. Surgery for colorectal cancer is being performed on patients who would previously not have been considered as suitable candidates. It remains to be seen which factors influence hospital length of stay (LOS) and the development of acute postoperative complications in South African patients., Objectives: The objectives of our study were to determine the modifiable factors that influence patients' development of postoperative complications and hospital LOS and, to identify the types of postoperative complications that develop., Method: A retrospective review and secondary analysis of information in an existing database of patients with colorectal cancer were conducted. Regression analysis statistics were used to determine the predictors of postoperative outcomes. The level of significance at which testing was performed was set at 5% ( p ≤ 0.05)., Results: Data of 125 patients were included. Surgical site infections and postoperative paralytic ileus were the most frequently reported postoperative complications. Preoperative vigorous-intensity physical activity ( p = 0.048, β = -0.000) and functional performance status ( p = 0.05, β = 0.926) significantly predicted hospital LOS and the incidence of postoperative complications, respectively., Conclusion: Preoperative physical activity and functional performance levels are predictors of acute postoperative outcomes in a private South African cohort of patients with colorectal cancer. Future research which includes other modifiable factors is required to make informed suggestions for changes in clinical practice., Clinical Implications: Patients requiring surgery for colorectal cancer should be screened for signs of physical deconditioning and referred for physiotherapy intervention before elective surgery to optimise their recovery., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this research article., (© 2021. The Authors.)

Rationale: Understanding current early mobilization practice of patients in intensive care unit (ICU) is critical to the design and implementation of strategies to facilitate its application in a diverse population of critically ill patients encountered in public sector hospitals., Aim: To evaluate the organizational structures of South African public sector hospital ICUs and to describe early mobilization practices in these units., Methods: A cross-sectional survey was done in participating public hospitals from eight provinces in South Africa. Convenience sampling was done. Data collected included hospital and ICU structure, adult patient demographic and clinical data, and mobilization activities done in ICU over the previous 24 hours prior to the day of the survey., Results: A total of 29 ICUs from 13 participating hospitals were surveyed resulting in 205 patient records. Majority of the surveyed ICUs were "open" type (n = 16; 55.2%). A standardized sedation scoring system was used in 18 units (62.1%) and only two units (6.9%) had an early mobilization protocol in place. Mean age of the patients surveyed was 43.5 (±17.7) years and 148 (72.2%) patients were on mechanical ventilation. Primary reasons for admission to ICU included traumatic injury (n = 86; 42%) and postoperative care (n = 33; 16.1%). Mobilization activities performed in the previous 24 hours included turning the patient in bed (n = 88; 42.9%), marching on the spot (n = 9; 4.4%) and walking (n = 10; 4.9%). Out-of-bed mobilization was done in only 40 (19.5%) patients. The most common barriers to early mobilization included patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%). The type of ventilation was found to have a significant positive relationship with out-of-bed patient mobilization (P = .000)., Conclusions: A small proportion of patients attained their highest level of mobilization in ICU. The type of ventilation influenced early mobilization practices in public sector ICUs in South Africa., (© 2020 John Wiley & Sons, Ltd.)

Background: In the intensive care unit (ICU) environment, inter-professional team collaborations have direct impact on patient care outcomes. Current evidence shows that providing physiotherapy to ICU patients shortens their length of stay and reduces their incidence of ventilator associated pneumonia and severity of critical illness neuropathy. Physiotherapists' perceptions of their interactions with nurses and doctors as inter-professional team members in the ICU is important., Objectives: To identify barriers and enablers of physiotherapists' interactions with inter-professional team members in adult ICU settings, identify solutions to the barriers and determine if perceptions of interactions with ICU team members differ between junior and senior physiotherapists., Methods: A qualitative study was done using semi-structured group discussions. Participants were recruited using convenience sampling. Participants were junior and senior physiotherapists from four private and four public sector hospitals in urban Johannesburg, South Africa. Interviews were audio recorded. Recordings were transcribed and direct content analysis of data was done to create categories, subcategories and themes., Results: Twenty-two junior and 17 senior ICU physiotherapists participated in the study. Barriers raised by physiotherapists regarding communication with inter-professional team members in the ICU were non-ICU trained staff working in ICU, personality types, lack of professional etiquette, and frequent rotation of ICU staff. Enablers of communication with inter-professional team members were presence of team members in ICU during the day, good time management, teamwork approach to care and sharing of knowledge. Differing paradigms of teamwork among health professionals was highlighted as a cause of tension in the ICU inter-professional collaborations., Conclusion: Physiotherapists are important members of the inter-professional ICU team. Exploring their interactions with other team members identified solutions that may improve collaboration between inter-professional team members to facilitate improved patient outcomes. Inter-professional education should inform ICU policies to create an environment that fosters teamwork. Finding creative ways to adequately staff the ICU without losing quality or driving up costs of care are matters that should take priority among policy makers., Contributions of the Study: Physiotherapists are essential and strategically placed in the ICU to reduce length of stay, and prevent patient physical function decline post ICU admission. This work explored physiotherapists' perceptions of collaboration within inter-professional teams in the ICU and identified barriers that impede communication in inter-professional teams and suggested solutions. This research will contribute in improving collaboration between inter-professional teams in the ICU setting., Competing Interests: Conflicts of interest: None.

Background: Trauma injury remains a significant health risk for all on a global level. Patients with trunk trauma suffer blood loss, inflammation and hypoxia and are at risk of developing respiratory and musculoskeletal complications during their recovery. Physiotherapists are an integral part of the interprofessional team that manages patients who sustain trunk trauma., Objectives: To describe the physiotherapy management of adult patients with trunk trauma, their quality of life, post-discharge rehabilitation service provision, and outcome measures used in the physiotherapy management., Method: A non-systematic narrative review of published literature was performed., Results: Mobilisation, functional exercises, deep breathing exercises and active coughing are used to optimise patients' respiratory and musculoskeletal functioning. Some physiotherapists educate patients on the use of pain management strategies to reduce discomfort from rib fractures, surgical sites and intercostal drainage bottle tubing. Survivors of trunk trauma experience limitations in physical function up to two years. Little is known about post-discharge rehabilitation service provision to these patients after discharge. Few physiotherapists use outcome measures as part of their daily clinical practice., Conclusion: Physiotherapy management of patients with blunt or penetrating trunk trauma during hospitalisation and after discharge is a field of clinical practice that is rich for high-quality research related to service provision, cost analysis and interventions used., Clinical Implications: Physiotherapy clinicians and researchers can use the findings of this review as a guide to their management of adult patients recovering from trunk trauma., Competing Interests: The author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article., (© 2020. The Authors.)

Background: Effective disease management for people living with human immunodeficiency virus (PLWH) includes the encouragement of physical activity. Physical function capacity in PLWH may be influenced by a variety of factors., Objectives: This study describes the physical function capacity as assessed with the 6-minute walk test (6MWT) of an urban cohort of PLWH and determined whether a history of pulmonary tuberculosis (PTB), anthropometric measures, age and gender predicted distance walked., Method: Secondary data collected from 84 PLWH on antiretroviral therapy were analysed. Information included 6MWT distance, anthropometric measurements and demographic profiles. Descriptive and inferential statistics were undertaken on the data. A regression analysis determined predictive factors for 6MWT distance achieved. Significance was set at a p -value of ≤ 0.05., Results: The study consisted of 66 (78.6%) women and 18 (21.4%) men with a mean age of 39.1 (± 9.2) years. The 6MWT distance of the cohort was 544.3 (± 64.4) m with men walking further (602.8 [± 58.6] m) than women (528.3 [± 56.4] m); however, women experienced greater effort. The majority of the sample did not report a history of PTB ( n = 67; 79.8%). Age, gender and anthropometric measures were associated with 6MWT distance, but of low to moderate strength. The regression equation generated included age and gender. This model was statistically significant ( p < 0.00) and accounted for 34% of the total variance observed., Conclusion: Age and gender were predictive factors of physical function capacity and women experienced greater effort., Clinical Implications: This study provides information on the physical function capacity of PLWH and a suggested 6MWT reference equation for PLWH in South Africa., Competing Interests: The authors have declared that no competing interests exist., (© 2019. The Authors.)

Background: Tuberculosis (TB) remains a significant healthcare problem. Understanding physical and functional impairments that patients with active TB present with at the time of diagnosis and how these impairments change over time while they receive anti-TB therapy is important in developing appropriate rehabilitation programmes to optimise patients' recovery., Objectives: The aim of this study was to assess the acceptability, implementation and practicality of conducting a prospective, observational and longitudinal trial to describe physical and functional impairments of patients with active TB., Method: A feasibility pilot study was performed. Patients with acute pulmonary TB admitted to an urban quaternary-level hospital were recruited. Physical (muscle architecture, mass and power, balance, and breathlessness) and functional (exercise capacity) outcomes were assessed in hospital, and at 6 weeks and 6 months post-discharge. Descriptive statistics were used to analyse the data., Results: High dropout ( n = 5; 41.7%) and mortality ( n = 4; 33.3%) rates were observed. Limitations identified regarding study feasibility included participant recruitment rate, equipment availability and suitability of outcome measures. Participants' mean age was 31.5 (9.1) years and the majority were human immunodeficiency virus (HIV) positive ( n = 9; 75%). Non-significant changes in muscle architecture and power were observed over 6 months. Balance impairment was highlighted when vision was removed during testing. Some improvements in 6-minute walk test distance were observed between hospitalisation and 6 months., Conclusion: Success of a longitudinal observational trial is dependent on securing adequate funding to address limitations observed related to equipment availability, staffing levels, participant recruitment from additional study sites and participant follow-up at community level. Participants' physical and functional recovery during anti-TB therapy seems to be limited by neuromusculoskeletal factors., Competing Interests: The authors have declared that no competing interests exist.

Background: Adverse events (AEs) are common during treatment of drug-resistant tuberculosis (DR-TB). Little is known about the health-related quality of life (HRQoL) of patients receiving treatment for DR-TB or the effect of AEs on HRQoL., Methods: We conducted a cross-sectional study among adult patients with laboratory-confirmed rifampicin resistant tuberculosis (TB) on DR-TB treatment at a public-sector outpatient DR-TB clinic in Johannesburg, South Africa between 02/2015-01/2018. Data on HRQoL using the Medical Outcomes Short Form-36 (SF-36) questionnaire and self-reported AEs were collected by trained interviewers through face-to-face interviews. We report averages for the eight major domains and mental (MCS) and physical health (PCS) component summary scores, stratified by whether AEs were reported in the last four weeks. For comparative purposes, we enrolled two other patient groups and included data on a separate group of healthy adults., Results: We enrolled 149 DR-TB patients (median age 36 years IQR 29-43, 55% male, 77.9% HIV-positive, 81% on ART, 61.8% on a standard long-course regimen and 44.3% on DR-TB treatment for less than 6 months). 58/149 (38.9%) patients reported a total of 122 AEs in the preceding 4 weeks, of these the most common were joint pain (n = 22), peripheral neuropathy (n = 16), hearing loss (n = 15), nausea and vomiting (n = 12) and dizziness or vertigo (n = 11). SF-36 domains and summary scores (MCS and PCS) were lower in those who reported an AE compared to those who did not, and both were lower than healthy adults. Compared to those who did not report an AE, patients who reported AEs were more likely to have a low MCS (aRR 2.24 95% CI 1.53-3.27) and PCS (aRR 1.52 95% CI 1.07-2.18) summary score. HRQoL was lower among those on DR-TB treatment for 6 months or less., Conclusion: Results show that DR-TB had a substantial impact on patients' quality of life, but that AEs during the early months on treatment may be responsible for reducing HRQoL even further. Our findings highlight the negative effects of injectable agents on HRQoL. Patients require an integrative patient-centered approach to deal with DR-TB and HIV and the potential overlapping toxicities which may be worsened by concurrent treatment.

Background: Critically ill patients following traumatic injury or major surgery are at risk of loss of skeletal muscle mass, which leads to decreased physical function. Early rehabilitation in an intensive care unit (ICU) is thought to preserve or restore physical functioning. The Chelsea critical care physical assessment (CPAx) is a measurement tool used to assess physical function in the ICU., Objectives: To determine whether the use of the CPAx tool as part of physiotherapy patient assessment, in two adult trauma and surgical ICU settings where early patient mobilisation forms part of standard physiotherapy practice, had an impact on ICU and hospital length of stay (LOS) through delivery of problem-oriented treatment plans., Method: A single-centred pre-post quasi-experimental study was conducted. The population was a consecutive sample of surgical and trauma ICU patients. Participants' functional ability was assessed with the CPAx tool on alternative days during their ICU stay, and rehabilitation goals were modified according to their CPAx score. Intensive care unit and hospital LOS data were collected and compared to data of a matched historical control group. Descriptive and inferential statistics were used., Results: A total of 26 ICU patients were included in the intervention group ( n = 26). They received CPAx-guided therapy, and outcomes were matched with ICU patients in the historical control group ( n = 26). The median sequential organ failure assessment (SOFA) score was significantly higher in the control group ( p = 0.005) (3.5 [IQR 2-6.3]) versus (2 [IQR 1.8-2.5]) for the intervention group. The median admission CPAx score for the intervention group was 33.5 (IQR 16.1-44), and the median ICU discharge score was 38 (IQR 28.5-43.8). No significant differences were found in ICU days (control 2.7 [IQR 1.1-5.2]; intervention 3.7 [IQR 2.3-5.4]; p = 0.27) or hospital LOS (control 13.5 [IQR 9.3-18.3]; intervention 11.4 [IQR 8.4-20.3], p = 0.42). Chelsea critical care physical assessment scores on ICU admission had a moderate negative correlation with hospital LOS ( r = -0.58, p = 0.00, n = 23). Chelsea critical care physical assessment scores at ICU discharge had strong positive correlation with discharge SOFA scores ( r = 0.7; p = 0.025; n = 10)., Conclusion: Problem-oriented patient rehabilitation informed by the CPAx tool resulted in improvement of physical function but did not reduce ICU or hospital LOS., Clinical Implications: A higher level of physical function at ICU admission, measured with CPAx, was associated with shorter hospital LOS., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this manuscript.

Review Question/objectives: The review question is: what are the effects of non-pharmacological therapeutic interventions on pain and physical function in adults with rib fractures?The objectives of this systematic review are to determine.

Background: Recent evidence shows that early mobilisation of patients in an intensive care unit (ICU) is feasible, safe and associated with improvement in patients' clinical outcomes. However, its successful implementation is dependent on several factors, which include ICU structure and organisational practices., Objectives: To evaluate the structure and organisational practices of Zimbabwean government hospital ICUs and to describe early mobilisation practices of adult patients in these units., Methods: A cross-sectional survey was conducted in all government hospitals in Zimbabwe. Data collected included hospital and ICU structure, adult patient demographic data and mobilisation activities performed in the ICU during the 24 hours prior to the day of the survey., Results: A total of five quaternary level hospitals were surveyed, with each hospital having one adult ICU. Four of the units were open-type ICUs. The majority of the units ( n =3; 60%) reported that they had a permanent physiotherapist who covered their unit, but none of the physiotherapists worked solely in the ICU. The nurse-to-patient ratio across all units was 1:1. None of the units utilised a standardised sedation scoring system or a standardised outcome measure to assess patient mobility status. Only one ICU (20%) had a patient eligibility guideline for early mobilisation in place. Across the ICUs, 40 patients were surveyed. The median (interquartile range) age was 33 (23.3 - 38) years and 24 (60%) were mechanically ventilated. Indications for admission into the ICU included acute respiratory failure ( n =12; 30%) and postoperative care ( n =10; 25%). Mobilisation activities performed in the previous 24 hours included turning the patient in bed ( n =39; 97.5%), sitting over the edge of the bed ( n =10; 25%) and walking away from the bedside ( n =2; 5%). The main reason listed for treatment performed in bed was patients being sedated and unresponsive ( n =13; 32.5%)., Conclusion: Out-of-bed mobilisation activities were low and influenced by patient unresponsiveness and sedation, staffing levels and lack of rehabilitation equipment in ICU., Competing Interests: Conflicts of interest. None.

Background: Prolonged inflammation and infection associated with being critically ill and the ensuing physical inactivity has proven negative effects on the recovery of physical function, psychological health and reintegration into society for intensive care unit (ICU) survivors. Limited evidence is available on changes in biopsychosocial outcomes for South Africans recovering from an episode of critical illness., Objectives: To determine changes in biopsychosocial outcomes for a mixed cohort of ICU survivors in hospital and at 1 month and 6 months after discharge., Method: A prospective, observational, longitudinal study was conducted. Severity of illness, mechanical ventilation (MV) duration and ICU and hospital length of stay (LOS) were recorded. Physical function in ICU test-scored (PFIT-s) was performed at discharge from ICU and hospital. At 1 month and 6 months, peripheral muscle strength, exercise endurance, health-related quality of life (HRQOL), depression status and return to work were assessed. Descriptive and inferential statistics were used., Results: Participants ( n = 24) had a median age of 51.5 years, majority were male ( n = 19; 79%) and most were employed before admission ( n = 20; 83%). At 6 months, 11 participants ( n = 11) were part of the final sample. Median PFIT-s changed significantly (0.3 points; p = 0.02) between ICU and hospital discharge. Peripheral muscle strength improved significantly for upper and lower limbs over 6 months ( p = 0.00-0.03) but change in median 6-minute walk test distance (65m) was not significantly different. Significant improvements occurred in mean Medical Outcomes Short Form-36 (SF-36) physical health component scores (8.8 ± 7.6; p = 0.00). Mean SF-36 mental health component scores had a strong negative relationship with MV duration ( r = -0.7; p = 0.01), LOS ( r = -0.56; p = 0.04) and Patient Health Questionnaire 9 scores ( r = -0.72; p = 0.01). Six participants (55%) returned to employment., Conclusion: Clinically important improvements in biopsychosocial outcomes related to physical function and social factors were observed. Limitations in mental aspects of HRQOL were present at 6 months and some reported mild depressive symptoms., Clinical Implications: Intensive care unit survivors with a history of prolonged MV duration and hospital LOS who exhibit limitations in mental HRQOL, and signs of depressive symptoms should be referred to a psychologist for evaluation., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Rationale, Aims, and Objectives: Physiotherapists are integral members of the intensive care unit (ICU) team. Clinicians working in ICU are dependent on their own experience when making decisions regarding individual patient management thus resulting in variation in clinical practice. No formalized clinical practice guidelines or standards exist for the educational profile or scope of practice requirements for ICU physiotherapy. This study explored perceptions of physiotherapists on minimum clinical standards that ICU physiotherapists should adhere to for delivering safe, effective physiotherapy services to critically ill patients., Method: Experienced physiotherapists offering a service to South African ICUs were purposively sampled. Three focus group sessions were held in different parts of the country to ensure national participation. Each was audio recorded. The stimulus question posed was "What is the minimum standard of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs?" Three categories were explored, namely, knowledge, skill, and attributes. Themes and subthemes were developed using the codes identified. An inductive approach to data analysis was used to perform conventional content analysis., Results: Twenty-five physiotherapists participated in 1 of 3 focus group sessions. Mean years of ICU experience was 10.8 years (±7.0; range, 3-33). Three themes emerged from the data namely, integrated medical knowledge, multidisciplinary teamwork, and physiotherapy practice. Integrated medical knowledge related to anatomy and physiology, conditions that patients present with in ICU, the ICU environment, pathology and pathophysiology, and pharmacology. Multidisciplinary teamwork encompassed elements related to communication, continuous professional development, cultural sensitivity, documentation, ethics, professionalism, safety in ICU, and technology. Components related to physiotherapy practice included clinical reasoning, handling skills, interventions, and patient care., Conclusions: The information obtained will be used to inform the development of a list of standards to be presented to the wider national physiotherapy and ICU communities for further consensus-building activities., (© 2017 John Wiley & Sons, Ltd.)

Background: The healthcare sector requires graduates with the ability to confidently assess and manage the majority of the medical conditions seen in hospitals., Objective: To establish whether the most prevalent medical conditions treated by physiotherapists in Gauteng (South Africa) state health facilities align with the University of the Witwatersrand (Wits) physiotherapy curriculum., Methods: This was a retrospective review of condition-related statistics from physiotherapy departments within the Gauteng province state health facilities. Data from all Gauteng government hospitals that had submitted at least 75% of their physiotherapy condition-related statistics to the provincial statistics coordinator from January 2012 to December 2014 were considered and compared to medical conditions covered in the Wits 2015 physiotherapy curriculum to check if all conditions listed in the Gauteng statistics appeared within the Wits curriculum document. The number of teaching hours for the common conditions was noted to check the emphasis given to these conditions in the curriculum., Results: Eighty-three per cent of the hospitals submitted 75% of their monthly statistics. Overall, the most common conditions treated were lower limb fractures (13%) followed by stroke (7.6%) ( n = 705 597). Within the neuro-musculoskeletal category, the most common conditions after lower limb fractures were soft tissue injuries (15.1%) ( n = 330 511). The most common cardiopulmonary conditions were tuberculosis (24.9%), followed by pneumonia (13.8%) ( n = 94 895). The most common neurological conditions were stroke (30.9%) followed by cerebral palsy (17%) ( n = 174 024). Within the non-specified categories, the number of intensive care unit (ICU) patients was the highest (23%), followed by sputum induction (21%) ( n = 138 187). The most common conditions that were emphasised within the Wits curriculum as indicated by the teaching hours: fractures, 14.5 (66%) of 22 third-year orthopaedics hours; stroke, 30 (73%) of 41 third-year neurology hours; soft tissue injuries, 18 (38%) of 48 fourth-year neuro-musculoskeletal hours; back lesions, 24 (50%) of 48 fourth-year neuro-musculoskeletal hours; and ICU patients, 30 (79%) of 38 fourth-year cardiopulmonary hours., Conclusion: The Wits physiotherapy curriculum covers all medical conditions treated by physiotherapists within the Gauteng state health facilities, and overall, the curriculum prepares the students to practise in a variety of situations., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Research Question/objective: The objectives of this scoping review are to describe the physical impairments and subsequent level of function of adult individuals infected with the human immunodeficiency virus (HIV) admitted to an acute care hospital, determine the outcome measures used by rehabilitation professionals when evaluating said impairments and level of function in the population of interest, and identify the rehabilitation interventions offered to individuals while in hospital as a means of addressing these physical impairments and individuals' functional status.Specifically, the research questions are:The current scoping review will comprehensively identify the physical impairments of people living with HIV when admitted to an acute care hospital and highlight the subsequent influence on their level of function as a means of emphasizing the disability present. Findings regarding the rehabilitation interventions offered could inform clinical practice as a means of mapping which interventions are offered to address the related physical impairments and thus highlight areas for future research.

Review Objective/question: The objective of this review is to examine and map the range of physical impairments and activity limitations experienced by people infected with tuberculosis (TB). The levels of evidence that are currently available on this topic will also be reported. More specifically, the review questions are: What types of physical impairments and activity limitations have been reported for people infected with TB? What types of rehabilitation strategies are used for people with TB infection to address physical impairments and activity limitations?Findings from this scoping review may inform a systematic review to explore the effectiveness of rehabilitation strategies used to address physical impairments and activity limitations in people with TB infection.

Background and Purpose: A head-down tilt position could influence diaphragm excursion due to abdominal content displacement. The purpose of the study was to determine if excursion could be influenced by a head-down tilt position and if this change in excursion alters the diaphragm function., Design: Prospective quasi-experimental study., Participants: Seventy healthy adult students., Intervention: Four head-down tilt positions: 1) 15° (30 seconds); 2) 15° (120 seconds); 3) 30° (30 seconds); and 4) 30° (120 seconds)., Outcome Measures: Change in diaphragm excursion was assessed using M-Mode ultrasound and diaphragm function was recorded in terms of the peak expiratory flow rate (PEFR) and thoracic expansion. Data were analyzed using descriptive statistics, Analysis of Variance (ANOVA), Kruskal Wallis and student's t-test., Results: The cohort consisted of 56 women (80%) and 14 men (20%) with a mean age of 20.7 (±1.7) years and a mean body mass index (BMI) of 23.0 (±3.7) kg/m(2). The greatest mean change in the hemi-diaphragm, for both genders measured from rest, was 38.8 (±11.5) mm on the left and 39.4 (±11.9) mm on the right. The greatest stretch occurred after a 30° head-down tilt for 30 seconds for both the right and left hemi-diaphragms in males and right hemi-diaphragm in females. The left hemi-diaphragm in females achieved its maximum stretch after 30° head-down tilt for 120 seconds. No significant changes in thoracic expansion or PEFR were observed but baseline values were less than predicted., Conclusion: Optimal change in hemi-diaphragm excursion was obtained utilizing 30° head-down tilt positions in healthy subjects.

Background: Ischaemic heart disease (IHD) is a global health problem and specifically relevant in the African context, as the presence of risk factors for IHD is increasing. People living with the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (PLWHA) are at increased risk for IHD due to increased longevity, treatment-specific causes and viral effects., Aim: To determine the self-perception and behaviour in relation to risk for IHD in a cohort of South African PLWHA., Methods: A qualitative study using semi-structured interviews with a card-sort technique was used to gather data from 30 individuals at an HIV clinic in Johannesburg. Descriptive analysis and conventional content analysis were done to generate the findings., Results: The median age of the cohort was 36.5 (31.8-45.0) years and they were mostly women (n = 25; 83.3%) who were employed (n = 17; 56.7%) and supporting dependents (n = 26; 86.7%). Fifteen (50%) participants did not perceive themselves at risk of IHD and reported having adequate coping behaviour, living a healthy lifestyle and being healthy since initiating therapy. Twelve (40%) did feel at risk because they experienced physical symptoms and had poor behaviour. Knowledge and understanding related to IHD, insight into own risk for IHD and health character in a context of HIV infection were three themes., Conclusion: This study highlights that participants did not perceive themselves to be at risk of IHD due to their HIV status or antiretroviral management. Education strategies are required in PLWHA to inform their personal risk perception for IHD.

Rationale, Aims and Objectives: Physiotherapists form an important part of the inter-professional team that cares for critically ill patients in intensive care units (ICU). No formalized clinical practice guidelines or standards exist for the educational profile or scope of practice requirements for physiotherapy within critical care, which poses a threat to physiotherapy practice and professional credibility., Methods: The aim of this paper was to describe the nominal group technique (NGT) used to identify the minimum standards of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs., Results: Twenty-five subjects participated in one of three forums. Sixty-six concepts were considered in the three domains (knowledge, skills and attitudes). Not all concepts were discussed by all three focus groups. Just over half (54% n=14) the concepts generated in the knowledge domain; a third of the concepts (35% n=7) generated in the skills domain and only 10% (n=2) of attitudes were consistently raised by all three groups. Almost two-thirds of the concepts generated (62% n=41) were considered in more than one domain. Only six concepts reached the threshold consensus level across all three focus groups, four knowledge parameters and two skills., Conclusion: The NGT allowed for the cross-stimulation of ideas in an engaging yet anonymous and structured manner. The importance of discussion in reaching consensus is highlighted. Going forward, it is intended to use the concepts generated through this process as the foundation for further consensus-building activities among the wider physiotherapy and intensive care communities., (© 2014 John Wiley & Sons, Ltd.)

The promotion of physical activity is encouraged in people living with HIV and AIDS (PLWHA) as a means of promoting wellness and health. Adherence to programmes that promote exercise is often reduced, and home-based programmes are suggested to improve adherence. This study investigated the personal and environmental factors that cause barriers and facilitators of physical activity in a home-based pedometer walking programme as a means of highlighting adherence challenges. An observational study nested in a randomised controlled trial was conducted in a cohort of South African PLWHA on antiretroviral therapy over a six-month period. Descriptive analysis and qualitative content analysis of 42 participants who underwent physical activity modification assisted with data review. The mean age of the sample was 38.7 (±8.9) years, consisted mostly of women (n = 35; 83.3%) who were employed (n = 19; 45.2%) but earning very little (less than R500 per month) and often single or widowed (n = 23; 54.8%). Barriers to physical activity identified included physical complaints, e.g., low-energy levels; psychological complaints, e.g., stress levels; family responsibility, e.g., being primary caregivers; the physical environment, e.g., adverse weather conditions; social environment, e.g., domestic abuse and crime; and workplace, e.g., being in a sedentary job. Facilitators of physical activity included support and encouragement from friends and family, religious practices during worship and community environment, e.g., having access to parks and sport fields. The study is of benefit as it highlights personal and environmental factors that need to be considered when developing or implementing a home-based walking programme in PLWHA.

Objective: People infected with the human immunodeficiency virus are at an increased risk of developing ischemic heart disease (IHD); however, the effects of an education and home-based pedometer walking program on risk factors of IHD are not known., Methods: We conducted a 12-month randomized study of an education and home-based pedometer walking program in 84 human immunodeficiency virus-infected individuals with risk factors of IHD., Results: Pedometer step count of the control and intervention groups improved significantly (P = 0.03 for both groups) at 6 months but was not significant at 12 months (P = 0.33 and 0.21, respectively). Significant between-group effects were observed in 6-minute walk test distance (P = 0.01), waist to hip ratio (P = 0.00), glucose (P = 0.00), and high-density lipoprotein (P = 0.01) over the 12-month period. The program did not result in change in high-sensitivity C-reactive protein as it was associated with perceived stress (r = 0.23; P = 0.03), weight (r = 0.28; P = 0.01), body mass index (r = 0.35; P < 0.00), waist (r = 0.28; P = 0.01) and hip circumference (r = 0.28; P = 0.01). Multivariate generalized estimation equation analysis demonstrated an inverse association between interaction and perceived stress (logB = -0.01; 95% confidence interval: -0.02 to -0.01; P <0.00) and body mass index (logB = -0.02; 95% confidence interval: -0.03 to -0.002; P = 0.02) at group level., Conclusion: An education and home-based pedometer walking program improves physical activity levels, and beneficial changes in other IHD risk factors were noted.

Background: People with neuromuscular disorders (NMDs) may have weak respiratory (breathing) muscles which makes it difficult for them to effectively cough and clear mucus from the lungs. This places them at risk of recurrent chest infections and chronic lung disease. Mechanical insufflation-exsufflation (MI-E) is one of a number of techniques available to improve cough efficacy and mucus clearance., Objectives: To determine the efficacy and safety of MI-E in people with NMDs., Search Methods: On 7 October 2013, we searched the following databases from inception: the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, and EMBASE. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for ongoing trials. We conducted handsearches of reference lists and conference proceedings., Selection Criteria: We considered randomised or quasi-randomised clinical trials, and randomised cross-over trials of MI-E used to assist airway clearance in people with a NMD and respiratory insufficiency. We considered comparisons of MI-E with no treatment, or alternative cough augmentation techniques., Data Collection and Analysis: Two authors independently assessed trial eligibility, extracted data, and assessed risk of bias in included studies according to standard Cochrane methodology. The primary outcome was mortality throughout follow-up or at six months follow-up., Main Results: Five studies with a total of 105 participants were found to be eligible for inclusion in this review. All included trials were short-term studies (two days or less), measuring immediate effects of the interventions. There was insufficient detail in the reports to assess methods of randomisation and allocation concealment. All five studies were at a high risk of bias from lack of blinding. The studies did not report on mortality, morbidity, quality of life, serious adverse events or any of the other prespecified outcomes. One study was a randomised cross-over trial conducted over two days, in which investigators applied two interventions twice daily in randomly assigned order, with a reverse cross-over the following day. Four studies applied multiple interventions for cough augmentation to each participant, in random order. One study reported fatigue as an adverse effect of MI-E, using a visual analogue scale. Peak cough expiratory flow (PCEF) was the most common outcome measure and was reported in four studies. Based on three studies, MI-E may improve PCEF compared to an unassisted cough. All interventions increased PCEF to the critical level necessary for mucus clearance. The included studies did not clearly show that MI-E improves cough expiratory flow more than other cough augmentation techniques. Based on one study, which was at risk of assessor bias, the addition of MI-E may reduce treatment time when added to a standard airway clearance regimen with manually assisted cough. MI-E appeared to be as well tolerated as other cough augmentation techniques, based on three studies which reported comfort visual analogue scores., Authors' Conclusions: The results of this review do not provide sufficient evidence on which to base clinical practice as we were unable to address important short- and long-term outcomes, including adverse effects of MI-E. There is currently insufficient evidence for or against the use of MI-E in people with NMDs. Further randomised controlled clinical trials are needed to test the safety and efficacy of MI-E.

Purpose: Many patients who have suffered traumatic injuries require mechanical ventilation (MV). Weaning is the transition from ventilatory support to spontaneous breathing. The purpose of this study was to determine whether the use of a nurse and a physiotherapist-driven protocol to wean and extubate patients from MV resulted in decreased MV days and intensive care unit (ICU) length of stay (LOS)., Methods: A prospective cohort of 28 patients (Phase I), weaned according to the protocol developed for the Union Hospital Trauma Unit, was matched retrospectively with a historical cohort of 28 patients (Phase II), weaned according to physician preference. Pairs in the two groups were matched for gender, age, type, and severity of injury., Results: For mean MV days, the groups did not differ statistically significantly (p 0.3; 14.4 days vs. 16.3 days), although the reduction in MV is clinically significant in view of the complications of additional MV days. The difference of 0.2 days for ICU LOS was not statistically significant (p = 0.9; 20.8 days vs. 21.0 days) demonstrating that the reduction in MV days may not result in the reduction of ICU LOS. The rate of re-intubation was similar between the groups (Phase I = 3/28 vs. Phase II = 4/24)., Conclusion: The use of a weaning and extubation protocol led by nursing staff and physiotherapists resulted in a clinically significant reduction in MV time, reducing risk of ventilator-associated complications. The role of physiotherapists and nursing staff in weaning and extubation from MV could be greatly expanded in South African ICUs.

Objective: To facilitate knowledge synthesis and implementation of evidence supporting early physical activity and mobilization of adult patients in the intensive care unit and its translation into practice, we developed an evidence-based clinical management algorithm., Methods: Twenty-eight draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n = 7) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus - semi-interquartile range <0.5 - were collated into the algorithm., Results: The draft algorithm statements were edited and six additional statements were formulated. The 34 statements related to assessment and treatment were grouped into three categories. Category A included statements for unconscious critically ill patients; Category B included statements for stable and cooperative critically ill patients, and Category C included statements related to stable patients with prolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algorithm statements, only 50% (17/34) of the statements were rated essential., Conclusion: The evidence-based clinical management algorithm developed through an established Delphi process of consensus by an international inter-professional panel provides the clinician with a synthesis of current evidence and clinical expert opinion. This framework can be used to facilitate clinical decision making within the context of a given patient. The next step is to determine the clinical utility of this working algorithm.