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BACKGROUND: A multidisciplinary approach is required for the management of long COVID. The aim of this study was to determine the feasibility (demand, implementation, practicality, acceptability, and limited efficacy) of an allied-health-led multidisciplinary symptom management service (ReCOV) for long COVID. METHODS: A single-group observational cohort feasibility study was conducted to determine demand (referrals), acceptability (survey), implementation (waitlist times, health professions seen), practicality (adverse events), and limited efficacy (admission and discharge scores from the World Health Organization Disability Assessment Scale, Brief Illness Perception Questionnaire (BIPQ), Patient Health Questionnaire, and EuroQol 5D-5L). Data are presented as median [interquartile range] or count (percentage). RESULTS: During the study, 143 participants (aged 42.00 [32.00-51.00] years, 68% women) participated in ReCOV. Participants were waitlisted for 3.86 [2.14-9.86] weeks and engaged with 5.00 [3.00-6.00] different health professionals. No adverse events occurred. The thematic analysis revealed that ReCOV was helpful but did not fully meet the needs of all participants. Limited efficacy testing indicated that participants had improved understanding and control (p < 0.001) of symptoms (BIPQ) and a small improvement in EQ VAS score (median difference 5.50 points [0.00-25.00], p = 0.004]). CONCLUSIONS: A multidisciplinary service was safe and mostly acceptable to participants for the management of long COVID. Further research should investigate the clinical and cost effectiveness of such a service, including optimal service duration and patient outcomes.

This document provides an update to the recommendations for physiotherapy management for adults with coronavirus disease 2019 (COVID-19) in the acute hospital setting. It includes: physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the use of physiotherapy treatments and personal protective equipment. New advice and recommendations are provided on: workload management; staff health, including vaccination; providing clinical education; personal protective equipment; interventions, including awake proning, mobilisation and rehabilitation in patients with hypoxaemia. Additionally, recommendations for recovery after COVID-19 have been added, including roles that physiotherapy can offer in the management of post-COVID syndrome. The updated guidelines are intended for use by physiotherapists and other relevant stakeholders caring for adult patients with confirmed or suspected COVID-19 in the acute care setting and beyond.

PURPOSE: Exercise is emerging as a vital aspect of care to alleviate the physical and psychosocial symptom burden associated with allogeneic bone marrow transplantation (BMT). Understanding the patient perspective regarding exercise is important to move towards implementation. This study aimed to characterise experiences and views regarding participation in an exercise program in adults receiving treatment for haematological disease with allogeneic BMT. METHODS: Individual semi-structured interviews were conducted with 35 participants from either an early- or late-commencing supervised group-based exercise program. Using an inductive, conventional approach to qualitative content analysis data were independently analysed by two researchers. RESULTS: Six major themes and 33 sub-themes were identified: this encompassed motivation, physical opportunity and capability to exercise; psychosocial effects of group-based exercise; experienced impact of participation in an exercise program; and intervention design considerations. Key barriers to exercise included symptom severity and fluctuating health and distance or difficult access to an exercise facility or equipment, whilst facilitators included encouragement from staff; peer support in the group-based setting; flexibility; education; and ability to measure change. CONCLUSION: This study highlights the importance of a flexible approach to exercise with consideration of individual symptoms and preferences. The perceived psychological impact of exercise should not be underestimated; future exercise programs should be designed in partnership with patients, with consideration of group-based activities to reduce social isolation if this is feasible in the treatment context. Intervention design should also acknowledge the individual's physical and psychological capability, opportunity and automatic and reflective motivation to direct and sustain exercise behaviours following BMT.

BACKGROUND: Access to exercise therapy for cancer survivors is poor. Professional development to support exercise professionals in delivering these interventions is needed. Few online resources exist for exercise professionals to address this issue. OBJECTIVE: To develop and evaluate a freely available online toolkit to support exercise professionals working with cancer survivors. METHODS: A 2-phase, experience-based co-design approach was used to develop and evaluate the online toolkit. The two phases were as follows: 1) needs identification and co-design of resources and platform and 2) pilot evaluation. Four co-design workshops were conducted, transcribed, and thematically analyzed to identify key elements for the toolkit. For the pilot evaluation, a customized survey (the Determinants of Implementation Behavior Questionnaire) was distributed to exercise professionals at baseline and 3 months after launch of the online toolkit to determine its usability, utility, and effectiveness in improving their knowledge, confidence, and behavior. Results were reported as the median and interquartile range and changes were calculated using non-parametric tests. Website analytics described site usage after the initial evaluation. RESULTS: Twenty-five exercise professionals participated in co-designing 8 key elements of the online Cancer Exercise Toolkit: the homepage and pages for getting started, screening and safety, assessment, exercise prescription, education, locations, and resources. For the pilot evaluation, 277/320 respondents (87% of whom were physiotherapists) from 26 countries completed the survey at baseline, with 58 exercise professionals completing follow-up surveys at 3 months. Exercise professionals' knowledge, skills, and confidence in delivering exercise therapy to cancer survivors increased 3 months after baseline (items 1, 6, and 8: median score 5, IQR 3 to 6) to follow-up (items 1 and 6: median score 6, IQR 5 to 6; item 8: median score 5, IQR 5 to 7; P<.0

INTRODUCTION: Exercise is important in the postoperative management of lung cancer, yet no strong evidence exists for delivery of home-based programmes. Our feasibility (phase I) study established feasibility of a home-based exercise and self-management programme (the programme) delivered postoperatively. This efficacy (phase II) study aims to determine whether the programme, compared with usual care, is effective in improving physical function (primary outcome) in patients after lung cancer surgery. METHODS AND ANALYSIS: This will be a prospective, multisite, two-arm parallel 1:1, randomised controlled superiority trial with assessors blinded to group allocation. 112 participants scheduled for surgery for lung cancer will be recruited and randomised to usual care (no exercise programme) or, usual care plus the 12-week programme. The primary outcome is physical function measured with the EORTC QLQ c30 questionnaire. Secondary outcomes include health-related quality of life (HRQoL); exercise capacity; muscle strength; physical activity levels and patient reported outcomes. HRQoL and patient-reported outcomes will be measured to 12 months, and survival to 5 years. In a substudy, patient experience interviews will be conducted in a subgroup of intervention participants. ETHICS AND DISSEMINATION: Ethics approval was gained from all sites. Results will be submitted for publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12617001283369.

BACKGROUND: Patients presenting for major surgery with low cardiorespiratory fitness (deconditioning) and other modifiable risk factors are at increased risk of postoperative complications. This study investigated the feasibility of delivering prehabilitation in high-risk patients scheduled for major abdominal cancer surgery. METHODS: Eligible patients in this single-center cohort study included patients with poor fitness (objectively assessed by cardiopulmonary exercise testing, CPET) scheduled for elective major abdominal cancer surgery. Patients were recruited to participate in a prehabilitation program that spanned up to 6 weeks pre-operatively and comprised aerobic and resistance exercise training, breathing exercise, and nutritional support. The primary outcome assessed pre-specified feasibility targets: recruitment >70%, retention >85%, and intervention adherence >70%. Secondary outcomes were assessed for improved pre-operative functional status and health-related quality of life and for postoperative complications. RESULTS: Eighty-two (34%) out of 238 patients screened between April 2018 and December 2019 were eligible for recruitment. Fifty (61%) patients (52% males) with a median age of 71 (IQR, 63-77) years participated in the study. Baseline oxygen consumption the at anaerobic threshold and at peak exercise (mean±SD: 9.8±1.8 and 14.0±2.9 mL/kg/min, respectively) confirmed the deconditioned state of the study cohort. The retention rate within the prehabilitation program was 84%, with 42 participants returning for repeat CPET testing. While >60% of participants preferred to do home-based prehabilitation, adherence to the intervention was low-with only 12 (28%) and 15 (35%) of patients having self-reported compliance >70% with their exercise prescriptions. CONCLUSION: Our prehabilitation program in high-risk cancer surgery patients did not achieve pre-specified targets for recruitment, retention, and self-reported program adherence. These findings underpin

Objectives: This systematic review set out to identify, evaluate and synthesise the evidence examining the effect of prehabilitation including exercise on postoperative outcomes following abdominal cancer surgery. Methods: Five electronic databases (MEDLINE 1946-2020, EMBASE 1947-2020, CINAHL 1937-2020, PEDro 1999-2020, and Cochrane Central Registry of Controlled Trials 1991-2020) were systematically searched (until August 2020) for randomised controlled trials (RCTs) that investigated the effects of prehabilitation interventions in patients undergoing abdominal cancer surgery. This review included any form of prehabilitation either unimodal or multimodal that included whole body and/or respiratory exercises as a stand-alone intervention or in addition to other prehabilitation interventions (such as nutrition and psychology) compared to standard care. Results: Twenty-two studies were included in the systematic review and 21 studies in the meta-analysis. There was moderate quality of evidence that multimodal prehabilitation improves pre-operative functional capacity as measured by 6 min walk distance (Mean difference [MD] 33.09 metres, 95% CI 17.69-48.50; p = <0.01) but improvement in cardiorespiratory fitness such as preoperative oxygen consumption at peak exercise (VO2 peak; MD 1.74 mL/kg/min, 95% CI -0.03-3.50; p = 0.05) and anaerobic threshold (AT; MD 1.21 mL/kg/min, 95% CI -0.34-2.76; p = 0.13) were not significant. A reduction in hospital length of stay (MD 3.68 days, 95% CI 0.92-6.44; p = 0.009) was observed but no effect was observed for postoperative complications (Odds Ratio [OR] 0.81, 95% CI 0.55-1.18; p = 0.27), pulmonary complications (OR 0.53, 95% CI 0.28-1.01; p = 0.05), hospital re-admission (OR 1.07, 95% CI 0.61-1.90; p = 0.81) or postoperative mortality (OR 0.95, 95% CI 0.43-2.09, p = 0.90). Conclusion: Multimodal prehabilitation improves preoperative functional capacity with reduction in hospital length of stay. This supports the need for ongoing r

Background: Prehabilitation to maximize exercise capacity before lung cancer surgery has the potential to improve operative tolerability and patient outcomes. However, translation of this evidence into clinical practice is limited. Aims: To determine the acceptability and perceived benefit of prehabilitation in lung cancer among thoracic surgeons. Procedure: 198 cardiothoracic surgeons within Australia and New Zealand were surveyed to evaluate their attitudes and perceived benefits of prehabilitation in lung cancer. Results: Response rate was 14%. A moderate proportion of respondents reported that there is a need to refer lung resection patients to preoperative physiotherapy/prehabilitation, particularly high-risk patients or those with borderline fitness for surgery. 91% of surgeons were willing to delay surgery (as indicated by cancer stage/type) to optimize patients via prehabilitation. The main barriers to prehabilitation reported were patient comorbidities and access to allied health professionals, with 33% stating that they were unsure who to refer to for prehabilitation in thoracic surgery. This is despite 60% of the cohort reporting that pulmonary rehabilitation is available as a preoperative resource. 92% of respondents believe that further research into prehabilitation in lung cancer is warranted. Conclusion: The benefits of prehabilitation for the oncology population have been well documented in the literature over recent years and this is reflected in the perceptions surgeons had on the benefits of prehabilitation for their patients. This survey demonstrates an interest among cardiothoracic surgeons in favor of prehabilitation, and therefore further research and demonstration of its benefit is needed in lung cancer to facilitate implementation into practice.

This document outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It includes: recommendations for physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the selection of physiotherapy treatments and personal protective equipment. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.

Exercise training is playing an increasing role in lung cancer care. Lung cancer is associated with significant burden to the individual and healthcare system. There is now substantial evidence that exercise training is safe, feasible and effective at improving several outcomes in people with lung cancer, especially in those with NSCLC. Exercise is beneficial across the lung cancer disease and treatment pathway, including in patients with early stage disease before and after surgery, and in patients with advanced disease. This review describes the impact of lung cancer and lung cancer treatment on patient health outcomes and summarizes the aims, safety, feasibility and effects of exercise training in the context of both early stage and advanced stage lung cancer. The paper also includes a discussion of current topical discussion areas including the use of exercise in people with bone metastases and the potential effect of exercise on suppression of tumour growth. Finally, seven clinical questions are included, which are a priority to be addressed by future research over the next decade as we strive to progress the field of lung cancer and improve patient outcomes.

OBJECTIVE: To assess the feasibility, safety, and preliminary effect of a 12-week multi-modal rehabilitation program targeted at improving health-related quality of life and physical activity levels of patients with lung cancer following treatment. METHODS: Patients with stage I to IIIA non-small cell lung cancer were included 6 to 12 weeks following completion of treatment. The intervention comprised of aerobic exercise (brisk walking), resistance training and 8-style Tai Chi. The 12-week program included 2 supervised center-based sessions per week of 90 minutes duration and home-based exercise. The primary outcomes were the feasibility and safety of the intervention. Secondary outcomes (assessed pre and post program) were physical and patient-reported outcomes. RESULTS: Seventy-eight patients were approached during the 6-month recruitment period and 17 (22%) consented to the study. Eight participants (47%) met the definition of adherence to the program (attending at least 70% of supervised sessions). No serious adverse events occurred. A significant reduction in anxiety and depression was observed post-program. In addition, improvements in respiratory function, sleep quality, and some health-related quality of life domains were observed post-program. There were no significant differences in functional capacity or physical activity levels. CONCLUSION: This multi-modal exercise training program was safe, although the feasibility of the program in its current state is not supported given the low consent rate and low adherence to the intervention.

PURPOSE: Exercise is important in lung cancer, yet most people do not meet the physical activity guidelines. The aim of this study was to characterise the views and experiences of participants with inoperable lung cancer who completed a home-based rehabilitation program. METHODS: Ninety-two participants were recruited (45 intervention group [IG], 47 usual care). Individual semi-structured interviews were conducted with participants randomised to the IG of a trial of home-based exercise, behaviour change and symptom management. Data were independently coded by two researchers, cross-checked and analysed using content analysis with a summary of arising themes. RESULTS: Of the IG (25/45), 55% were interviewed: mean (SD) age 67 (13) years; male 52%; disease stage n (%) III = 9 (36), IV = 11 (44); radical treatment intent n (%) 13 (52). The majority of participants reported program benefits, both in the physical domain (reduced sedentary time and improved strength, fitness and function) and the mental domain (motivation to keep healthy, preventing boredom). Support to self-manage symptoms was well received and many participants reported increased confidence in managing their symptoms. Exercise enablers included having expert health professional support; motivation to be stronger and better prepared for future challenges; and having an achievable and familiar program that was monitored. Treatment side-effects, pain from comorbidities and the weather were exercise barriers. For the majority of participants the use of a Fitbit™ activity tracker, text message exercise reminders and an exercise diary helped to promote adherence. CONCLUSIONS: This home-based rehabilitation program was acceptable to most participants with multiple benefits reported including improved fitness, motivation and ability to manage symptoms.

OBJECTIVE: To explore patient experiences of, and preferences for, physical activity after a lung cancer diagnosis. METHODS: This was a qualitative study involving seven patients who had been treated for lung cancer within the previous 2 years. Participants attended a focus group interview. Conventional content analysis methodology was used to analyse the text by two independent researchers. RESULTS: Eight major themes emerged from the data. These were as follows: the influence of past lifestyle and chronic disease; the perceived benefits of physical activity; using physical activity to facilitate return to activities of daily living; the impact of symptoms, capacity and motivation; family and peer support; access to services; health professionals; and enjoyment of different types of physical activity. Patients suggested several factors that could improve their healthcare experience. These include access to exercise professionals particularly after cancer treatment; access to information about physical activity in different formats; supervision from health professionals and peer support; and use of behaviour change strategies to achieve sustainable increases in physical activity. CONCLUSION: Our results should be considered in the improvement of lung cancer care pathways as we strive to implement physical activity services into routine clinical care.

Pulmonary rehabilitation is a core aspect in the management of patients with chronic respiratory diseases. This paper describes a practical approach to establishing pulmonary rehabilitation for patients with non-COPD diagnoses using examples from the interstitial lung disease (ILD), pulmonary hypertension (PH), bronchiectasis and lung cancer patient populations. Aspects of pulmonary rehabilitation, including the rationale, patient selection, setting of programmes, patient assessment and training components (both exercise and non-exercise aspects), are discussed for these patient groups. Whilst there are many similarities in the rationale and application of pulmonary rehabilitation across these non-COPD populations, there are also many subtle differences, which are discussed in detail in this paper. With consideration of these factors, pulmonary rehabilitation programmes can be adapted to facilitate the inclusion of respiratory patients with non-COPD diagnoses.

Background: In inoperable lung cancer, evidence is limited regarding physical activity (PA) and associations with other outcomes. Aims: in the usual care (UC) group of an RCT to (1) explore whether baseline PA was associated with improved follow-up outcomes, (2) identify baseline variables associated with higher follow-up PA and in all RCT participants, to (3) analyse patterns of objectively measured PA, and (4) report on characteristics of those who were able to maintain or increase PA levels. Methods: exploratory analyses of an assessor-blinded RCT. Outcomes, assessed at baseline, nine weeks and six months, included PA (seven-days of accelerometry), six-minute walk distance (6MWD), muscle strength, symptoms, mood and health-related quality of life (HRQoL). Results: 92 participants were randomised, 80 completed baseline accelerometry (39 intervention group (IG), 41 UC), characteristics: mean (SD) age 63.0 (12.3) years, 56% male, 51% stage IV disease. Baseline PA: median (IQR) steps/day 2859.6 (2034.0–3849.2) IG versus 3195.2 (2161.2–4839.0) UC. Associations between baseline PA and six-month outcomes were significant for HRQoL and 6MWD. PA at six months was significantly associated with baseline age, 6MWD and quadriceps strength. Between-group change score (steps/day) mean differences (95% CI) at nine weeks (174.5 (−1504.7 to 1853.7), p = 0.84) and six months (574.0 (−1162.3 to 2310.3), p = 0.52). Conclusions: further research is required to determine patient subgroups deriving the greatest benefits from PA interventions.

BACKGROUND: Lung cancer is associated with poor health-related quality of life (HRQoL) and high symptom burden. This trial aimed to assess the efficacy of home-based rehabilitation versus usual care in inoperable lung cancer. METHODS: A parallel-group, assessor-blinded, allocation-concealed, randomised controlled trial. Eligible participants were allocated (1:1) to usual care (UC) plus 8 weeks of aerobic and resistance exercise with behaviour change strategies and symptom support (intervention group (IG)) or UC alone. Assessments occurred at baseline, 9 weeks and 6 months. The primary outcome, change in between-group 6 min walk distance (6MWD), was analysed using intention-to-treat (ITT). Subsequent analyses involved modified ITT (mITT) and included participants with at least one follow-up outcome measure. Secondary outcomes included HRQoL and symptoms. RESULTS: Ninety-two participants were recruited. Characteristics of participants (UC=47, IG=45): mean (SD) age 64 (12) years; men 55%; disease stage n (%) III=35 (38) and IV=48 (52); radical treatment 46%. There were no significant between-group differences for the 6MWD (n=92) at 9 weeks (p=0.308) or 6 months (p=0.979). The mITT analyses of 6MWD between-group differences were again non-significant (mean difference (95% CI): 9 weeks: -25.4 m (-64.0 to 13.3), p=0.198 and 6 months: 41.3 m (-26.7 to 109.4), p=0.232). Significant 6-month differences, favouring the IG, were found for HRQoL (Functional Assessment of Cancer Therapy-Lung: 13.0 (3.9 to 22.1), p=0.005) and symptom severity (MD Anderson Symptom Inventory-Lung Cancer: -2.2 (-3.6 to -0.9), p=0.001). CONCLUSIONS: Home-based rehabilitation did not improve functional exercise capacity but there were improvements in patient-reported exploratory secondary outcomes measures observed at 6 months. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12614001268639).

INTRODUCTION: Physical activity (PA) is important in lung cancer. OBJECTIVES: To investigate PA levels and health-related quality of life (HRQoL) of patients with lung cancer in China and compare this to a similar cohort in Australia. METHODS: Prospective cohort study. 71 patients from China (group CH) and 90 patients from Australia (group AU) with newly diagnosed lung cancer. Questionnaires assessed self-reported PA levels and HRQoL at baseline (diagnosis) and 8 weeks. RESULTS: At baseline, group CH were engaged in less overall PA than group AU (Physical Activity Scale for the Elderly [PASE] total score: median [IQR] group CH, 56 [32-59]; group AU, 66 [38-116]; P < .005), and less occupational and household activity ( P < .005). However, at baseline, group CH reported significantly more walking time than group AU (median [IQR]: group CH, 210 [150-315] min/wk; group AU, 55[0-210] min/wk; P < .0005). Global HRQoL scores were similar between groups (P = .038). Over 8 weeks, group CH increased their overall PA levels ( P < .005) and walking time ( P = .008), and HRQoL remained unchanged. The comparison group AU experienced a reduction in PA levels ( P = .02) and HRQoL ( P < .005). CONCLUSIONS: A diagnosis, patients in China were less physically active than those in Australia. Following diagnosis, patients in China increased their PA levels, whereas those in Australia reduced their PA levels. Research is required to explore potential reasons behind differences, and this may inform research/clinical services to facilitate patients with lung cancer to be more active.

This study aimed to investigate computer and internet access and education attained in patients with chronic obstructive pulmonary disease (COPD) as potential barriers to implementation of telemedicine. We prospectively assessed 98 patients admitted with an acute exacerbation of COPD (mean age: 70.5 ± 9.3 years; force expired volume in the first second: 0.75 ± 0.39 L; 59% male) recording educational level attained and home computer and internet access. Hospital readmission surveillance occurred up to 2.7 (2.6-2.8) years following the index hospital admission. Only 16% of patients had a computer and only 14% had internet access; this group were younger and more educated than those without a computer. There was no difference in hospital readmissions over 2 years between those with and without access to a computer or internet. Only 12% of the whole cohort were educated to a school leaving age of 16 years and this group were more likely to be still working. School leaving age was directly associated with fewer hospital readmissions ( r = 0.251, p = 0.031). In conclusion, these data highlight the current challenges to the widespread implementation of telehealth in COPD patients as there is limited availability of computer and internet access with such patients demonstrating a lower level of education achievement.

OBJECTIVES: Advanced musculoskeletal physiotherapy (AMP) services are a safe, effective model of care, but without broad-scale healthcare implementation to date. The aim of the present study was to identify the barriers and enablers to implementation of 12 AMP services from the perspective of clinical staff. METHODS: In a qualitative study, 12 participants (physiotherapists), from 12 different healthcare networks (seven metropolitan, three regional, two rural), were included. Their departments implemented AMP services (orthopaedic postoperative joint replacement review, n = 10; general orthopaedic, n = 1; emergency, n = 1; and neurosurgery n = 1) over a 12-month period. Participants completed a structured survey specifically designed for the study. Thematic analysis was used, with themes mapped to the validated Theoretical Domains Framework. RESULTS: Nine major themes emerged from the data regarding barriers and enablers to the implementation of the AMP services from the perspective of clinical staff. These were: demand/capacity; model of care; the organization; stakeholders; communication; planning and processes; evaluation; workforce; and learning and assessment framework. Important enablers included engagement and buy-in from key stakeholders and medical staff, and well-established AMP learning frameworks for training and operational frameworks. Barriers included competitive funding environment, and issues that hindered effective communication. The knowledge, skills, availability, motivation and experience of the advanced musculoskeletal physiotherapists had a large impact on the implementation. CONCLUSIONS: The study identified a number of factors that should be considered for successful implementation of AMP services across healthcare services or wider healthcare networks.

BACKGROUND: The routine implementation of sternal precautions to prevent sternal complications that restrict the use of the upper limbs is currently worldwide practice following a median sternotomy. However, evidence is limited and drawn primarily from cadaver studies and orthopaedic research. Sternal precautions may delay recovery, prolong hospital discharge and be overly restrictive. Recent research has shown that upper limb exercise reduces post-operative sternal pain and results in minimal micromotion between the sternal edges as measured by ultrasound. The aims of this study are to evaluate the effects of modified sternal precautions on physical function, pain, recovery and health-related quality of life after cardiac surgery. METHODS/DESIGN: This study is a phase II, double-blind, randomised controlled trial with concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. Patients (n = 72) will be recruited following cardiac surgery via a median sternotomy. Sample size calculations were based on the minimal important difference (two points) for the primary outcome: Short Physical Performance Battery. Thirty-six participants are required per group to counter dropout (20%). All participants will be randomised to receive either standard or modified sternal precautions. The intervention group will receive guidelines encouraging the safe use of the upper limbs. Secondary outcomes are upper limb function, pain, kinesiophobia and health-related quality of life. Descriptive statistics will be used to summarise data. The primary hypothesis will be examined by repeated-measures analysis of variance to evaluate the changes from baseline to 4 weeks post-operatively in the intervention arm compared with the usual-care arm. In all tests to be conducted, a p value <0.05 (two-tailed) will be considered statistically significant, and confidence intervals will be reported. DISCUSSION: The Sternal Management Accelerated Recovery Trial (S.M.A.R.T.)

BACKGROUND: Lung cancer is one of the most commonly diagnosed cancers, and is a leading cause of cancer mortality world-wide. Due to lack of early specific symptoms, the majority of patients present with advanced, inoperable disease and five-year relative survival across all stages of non-small cell lung cancer (NSCLC) is 14%. People with lung cancer also report higher levels of symptom distress than those with other forms of cancer. Several benefits for survival and patient reported outcomes are reported from physical activity and exercise in other tumour groups. We report the protocol for a study investigating the benefits of exercise, behaviour change and symptom self-management for patients with recently diagnosed, inoperable, NSCLC. METHODS: This multi-site, parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aims to assess functional and patient-reported outcomes of a multi-disciplinary, home-based exercise and supportive care program for people commencing treatment. Ninety-two participants are being recruited from three tertiary-care hospitals in Melbourne, Australia. Following baseline testing, participants are randomised using concealed allocation, to receive either: a) 8 weeks of home-based exercise (comprising an individualised endurance and resistance exercise program and behaviour change coaching) and nurse-delivered symptom self-management intervention or b) usual care. The primary outcome is the between-group difference in the change in functional exercise capacity (six-minute walk distance) from baseline to post-program assessment. Secondary outcomes include: objective and self-reported physical activity levels, physical activity self-efficacy, behavioural regulation of motivation to exercise and resilience, muscle strength (quadriceps and grip), health-related quality of life, anxiety and depression and symptom interference. DISCUSSION: There is a lack of evidence regarding the benefit of exercise intervention for

PURPOSE: Despite evidence and clinical practice guidelines supporting physical activity (PA) for people with lung cancer, this evidence has not translated into clinical practice. This review aims to identify, evaluate and synthesise studies examining the barriers and enablers for patients with lung cancer to participate in PA from the perspective of patients, carers and health care providers (HCPs). METHODS: Systematic review of articles using electronic databases: MEDLINE (1950-2016), CINAHL (1982-2016), EMBASE (1980-2016), Scopus (2004-2016) and Cochrane (2016). Quantitative and qualitative studies, published in English in a peer-reviewed journal, which assessed the barriers or enablers to PA for patients with lung cancer were included. Registered-PROSPERO (CRD4201603341). RESULTS: Twenty-six studies (n = 9 cross-sectional, n = 4 case series, n = 11 qualitative) including 1074 patients, 23 carers and 169 HCPs were included. Barriers and enablers to PA were identified (6 major themes, 18 sub-themes): Barriers included patient-level factors (physical capability, symptoms, comorbidities, previous sedentary lifestyle, psychological influences, perceived relevance), HCP factors (time/knowledge to deliver information) and environmental factors (access to services, resources, timing relative to treatment). Enablers included anticipated benefits, opportunity for behaviour change and influences from HCPs and carers. CONCLUSION: This systematic review has identified the volume of literature demonstrating that barriers and enablers to PA in lung cancer are multidimensional and span diverse factors. These include patient-level factors, such as symptoms, comorbidities, sedentary lifestyle, mood and fear, and environmental factors. These factors should be considered to identify and develop suitable interventions and clinical services in attempt to increase PA in patients with lung cancer.

PURPOSE: To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers. METHODS: Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454. RESULTS: Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment. CONCLUSIONS: The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice.

AIMS: This study evaluated the construct validity of the Australian Pelvic Floor Questionnaire against two alternative measures of the severity of bladder and bowel symptoms. METHODS: This was an exploratory analysis of data from two prospective studies. Patients who had undergone surgery for colorectal cancer were analysed. Bladder and bowel symptoms were measured using three validated questionnaires: the Australian Pelvic Floor Questionnaire, the International Consultation on Incontinence Questionnaire Short Form Questionnaire for urinary incontinence and the International Consultation on Incontinence Questionnaire-Bowel Module post-cancer treatment. RESULTS: The study sample consisted of 44 participants, including 25 men and 19 women. The Australian Pelvic Floor Questionnaire bladder and bowel domain scores demonstrated moderate positive correlations with the International Consultation on Incontinence Questionnaire Short Form Questionnaire for urinary incontinence (r = 0.74, P < 0.01) and the International Consultation on Incontinence Questionnaire-Bowel Module (r = 0.69-0.78, P < 0.01). Similar results were obtained in each gender subgroup. CONCLUSIONS: This study suggested that the Australian Pelvic Floor Questionnaire may be a valid measurement tool for use in colorectal cancer populations in clinical trials and practice. Future research using larger cohorts is warranted.

Physical activity (PA) levels are low in patients with lung cancer. Emerging evidence supports the use of interventions to increase PA in this population. We aimed to (1) identify and synthesize outcome measures which assess PA levels in patients with lung cancer and (2) to evaluate, synthesize and compare the psychometric properties of these measures. A systematic review of articles from searches was conducted of five electronic databases and personal records. Eligible studies were those which assessed PA using either performance-based or patient-reported measures. For aim 2, studies identified in aim 1 reporting on at least one psychometric property (validity, reliability, responsiveness or measurement error) were included. Two independent reviewers assessed eligibility and risk of bias with the COnsensus-based Standards for the selection of health status Measurement INstruments. Thirty-four studies using 21 different measures of PA were identified. Seventeen studies used performance-based measures. The Godin Leisure Time Exercise Questionnaire (GLTEQ) was the most frequently used patient-reported measure. Psychometric properties were reported for 13 of these measures and most frequently for movement sensors. Two studies reported on properties of the GLTEQ. Quality ratings for risk of bias were low. There is significant heterogeneity amongst studies regarding method of PA measurement along the lung cancer continuum. Greater consensus could be achieved by using a consensus approach such as a Delphi process. Future studies should include assessment of psychometric properties of the measurement tool being used. Currently, it is recommended where feasible, both performance-based and patient-reported measurements of PA should be undertaken.

BACKGROUND: There is emerging evidence regarding the efficacy of exercise training to improve exercise capacity for individuals with non-small cell lung cancer (NSCLC). Cardiopulmonary exercise testing (CPET) is the gold standard measure of exercise capacity; however this laboratory test has limitations for use in research and clinical practice. Alternative field walking tests are the six-minute walk test (6MWT), incremental-shuttle walk test (ISWT) and endurance-shuttle walk test (ESWT); however there is limited information about their clinimetric properties in NSCLC. AIMS: In NSCLC to determine the 1) criterion validity of the 6MWT, ISWT and ESWT against CPET; 2) construct validity of the 6MWT, ISWT and ESWT against measures of function, strength, respiratory function and health-related quality of life (HRQoL); and 3) clinical applicability of the tests. METHODS: Twenty participants (40 % male, mean ± SD age 66.1 ± 6.5 years) with stage I-IIIb NSCLC completed the 6MWT, ISWT, ESWT and CPET within six months of treatment. Testing order was randomised. Additional measures included Eastern Cooperative Oncology Group Performance-Status (ECOG-PS, function), respiratory function, hand-grip dynamometry and HRQoL. Correlations and regression analyses were used to assess relationships. RESULTS: The ISWT demonstrated criterion validity with a moderate relationship between ISWT distance and CPET peak oxygen consumption (r = 0.61, p = 0.007). Relationships between CPET and six minute walk distance (6MWD) (r = 0.24, p = 0.329) or ESWT time (r = 0.02, p = 0.942) were poor. Moderate construct validity existed for the 6MWD and respiratory function (forced vital capacity % predicted r = 0.53, p = 0.019; forced expiratory volume in the first second % predicted r = 0.55, p = 0.015). There were no relationships between the walking tests and measures of function, strength or HRQoL. The ESWT had a ceiling effect with 18 % reaching maximum time. No floor effects were seen in the tests. T

INTRODUCTION: With growing awareness of the importance of rehabilitation, new measures are being developed specifically for use in the intensive care unit (ICU). There are currently 26 measures reported to assess function in ICU survivors. The Physical Function in Intensive care Test scored (PFIT-s) has established clinimetric properties. It is unknown how other functional measures perform in comparison to the PFIT-s or which functional measure may be the most clinically applicable for use within the ICU. The aims of this study were to determine (1) the criterion validity of the Functional Status Score for the ICU (FSS-ICU), ICU Mobility Scale (IMS) and Short Physical Performance Battery (SPPB) against the PFIT-s; (2) the construct validity of these tests against muscle strength; (3) predictive utility of these tests to predict discharge to home; and (4) the clinical applicability. This was a nested study within an ongoing controlled study and an observational study. METHODS: Sixty-six individuals were assessed at awakening and ICU discharge. Measures included: PFIT-s, FSS-ICU, IMS and SPPB. Bivariate relationships (Spearman's rank correlation coefficient) and predictive validity (logistic regression) were determined. Responsiveness (effect sizes); floor and ceiling effects; and minimal important differences were calculated. RESULTS: Mean ± SD PFIT-s at awakening was 4.7 ± 2.3 out of 10. On awakening a large positive relationship existed between PFIT-s and the other functional measures: FSS-ICU (rho = 0.87, p < 0.005), IMS (rho = 0.81, p < 0.005) and SPPB (rho = 0.70, p < 0.005). The PFIT-s had excellent construct validity (rho = 0.8, p < 0.005) and FSS-ICU (rho = 0.69, p < 0.005) and IMS (rho = 0.57, p < 0.005) had moderate construct validity with muscle strength. The PFIT-s and FSS-ICU had small floor/ceiling effects <11% at awakening and ICU discharge. The SPPB had a large floor effect at awakening (78%) and ICU discharge (56%). All tests demonstrated responsiven

INTRODUCTION: Intensive care unit-acquired weakness (ICU-AW) is a significant problem. There is currently widespread variability in the methods used for manual muscle testing and handgrip dynamometry (HGD) to diagnose ICU-AW. This study was conducted in two parts. The aims of this study were: to determine the inter-rater reliability and agreement of manual muscle strength testing using both isometric and through-range techniques using the Medical Research Council sum score and a new four-point scale, and to examine the validity of HGD and determine a cutoff score for the diagnosis of ICU-AW for the new four-point scale. METHODS: Part one involved evaluation of muscle strength by two physical therapists in 29 patients ventilated >48 hours. Manual strength testing was performed by both physical therapists using two techniques: isometric and through range; and two scoring systems: traditional six-point Medical Research Council scale and a new collapsed four-point scale. Part two involved assessment of handgrip strength conducted on 60 patients. A cutoff score for ICU-AW was identified for the new four-point scoring system. RESULTS: The incidence of ICU-AW was 42% (n = 25/60) in this study (based on HGD). In part one the highest reliability and agreement was observed for the isometric technique using the four-point scale (intraclass correlation coefficient = 0.90: kappa = 0.72 respectively). Differences existed between isometric and through-range scores (mean difference = 1.76 points, P = 0.005). In part two, HGD had a sensitivity of 0.88 and specificity of 0.80 for diagnosing ICU-AW. A cutoff score of 24 out of 36 points was identified for the four-point scale. CONCLUSIONS: The isometric technique is recommended with reporting on a collapsed four-point scale. Because HGD is easy to perform and sensitive, we recommend a new two-tier approach to diagnosing ICU-AW that first tests handgrip strength with follow-up strength assessment using the isometric technique for muscl

The 6-minute walk distance (6MWD) is one of the most commonly used measures of functional capacity in lung cancer, however, the minimal important difference (MID) has not been established. The aims of this exploratory study are, in lung cancer, to estimate (1) the MID of the 6MWD and (2) relationship between 6MWD, demographic and disease-related factors. Fifty-six participants with stage I-IV lung cancer completed the 6MWD prior to treatment and 10 weeks later. No exercise intervention occurred. Additional measures included European Organization for Research and Treatment of Cancer questionnaire (EORTC-QLQ-C30) and questionnaires assessing function, physical activity and symptoms. MID was calculated using anchor- and distribution-based methods. The mean 6MWD decline in participants classed as deteriorated was 60 m compared with 16 m in participants classed as not-deteriorated (p = 0.01). The receiver operating curve indicated a cut-off value for clinically relevant change to be 42 m (95% confidence interval (CI) 6-75) (area under curve = 0.66, 95% CI 0.51-0.81) or a 9.5% change. Distribution-based methods indicated an MID between 22 m (95% CI 18-26) and 32 m (95% CI 20-42). Higher 6MWD correlated with better function (r = -0.42, p = 0.001), physical activity (r = 0.56, p < 0.005) and dyspnoea (r = -0.44, p = 0.001). The MID for deterioration of the 6MWD in lung cancer is estimated to be between 22 m and 42 m or a change of 9.5%.

INTRODUCTION: Increasingly physical activity (PA) is being recognized as an important outcome in non-small cell lung cancer (NSCLC). We investigated PA using novel global positioning system (GPS) tracking individuals with NSCLC and a group of similar-aged healthy individuals. METHODS: A prospective cross-sectional multicenter study. Fifty individuals with NSCLC from 3 Australian tertiary hospitals and 35 similar-aged healthy individuals without cancer were included. Individuals with NSCLC were assessed pretreatment. Primary measures were triaxial accelerometery (steps/day) and GPS tracking (outdoor PA behavior). Secondary measures were questionnaires assessing depression, motivation to exercise, and environmental barriers to PA. Between-group comparisons were analyzed using analysis of covariance. RESULTS: Individuals with NSCLC engaged in significantly less PA than similar-aged healthy individuals (mean difference 2363 steps/day, P = .007) and had higher levels of depression (P = .027) and lower motivation to exercise (P = .001). Daily outdoor walking time (P = .874) and distance travelled away from home (P = .883) were not different between groups. Individuals with NSCLC spent less time outdoors in their local neighborhood area (P < .001). A greater number of steps per day was seen in patients who were less depressed (r = .39) or had better access to nonresidential destinations such as shopping centers (r = .25). CONCLUSION: Global positioning system tracking appears to be a feasible methodology for adult cancer patients and holds promise for use in future studies investigating PA and or lifestyle behaviors.

PURPOSE: Following surgical lung resection, patients frequently suffer functional decline and reduced activity levels. Despite this exercise interventions are not routinely provided. This study aimed to establish the safety and feasibility of exercise administered following lung resection in an Australian setting. METHOD: Pilot randomized controlled trial. Fifteen individuals (53% male), mean ± standard deviation age 65.5 ± 16.1 years, undergoing surgery for suspected lung cancer. Randomization occurred postoperatively. Control arm received protocolized inpatient respiratory physiotherapy. Intervention arm additionally received twice daily exercise until discharge home and twice weekly as outpatient for 8 weeks. Outcome measures (safety, feasibility, functional capacity, functional mobility, and health-related quality of life [HRQoL]) were assessed preoperatively and 2 and 12 weeks postoperatively. RESULTS: Fifteen participants (lung cancer n = 10) were assigned to control (n = 8) and intervention (n = 7) groups. Inpatient exercise was delivered on 71% of occasions (35 out of 49 planned sessions). Four participants attended outpatient exercise sessions and these participants attended sessions on 81% of occasions (52 out of 64 planned sessions). No adverse events occurred. There was a significant between group difference in 6-Minute Walk Test (6MWT; P = .024). In both groups the 6MWT declined from baseline to 2 weeks postoperative and then improved up to 12 weeks; improvements were greater in the intervention group. Intervention was associated with positive trends of improvement in some HRQoL domains. CONCLUSIONS: Exercise intervention performed in the inpatient and outpatient settings for individuals following lung resection was safe and feasible. The uptake rate for outpatient exercise was 57%, similar to previous trials; however, adherence was excellent within the subgroup of participants who attended. Further research is required to investigate the best setting o

BACKGROUND: The measurement properties of instruments used to assess functional capacity, physical activity and muscle strength in participants with non-small cell lung cancer (NSCLC) have not been systematically reviewed. OBJECTIVES: To identify outcome measures used to assess these outcomes in participants with NSCLC; and to evaluate, synthesise and compare the measurement properties of the outcome measures identified. DATA SOURCES: A systematic review of articles using electronic databases MEDLINE (1950-2012), CINAHL (1982-2012), EMBASE (1980-2012), Cochrane Library (2012), Expanded Academic ASAP (1994-2012), Health Collection Informit (1995-2012) and PEDRO (1999-2012). Additional studies were identified by searching personal files and cross referencing. Eligibility Criteria for Study Selection: Search one: studies which assessed functional capacity, physical activity or muscle strength in participants with NSCLC using non-laboratory objective tests were included. Search two: studies which evaluated a measurement property (inter- or intra-rater reliability; measurement error; criterion or construct validity; or responsiveness) in NSCLC for one of the outcome measures identified in search one. Studies published in English from 1980 were eligible. Data Extraction and Methodological Quality Assessment: data collection form was developed and data extracted. Methodological quality of studies was assessed by two independent reviewers using the 4-point COSMIN checklist. RESULTS: Thirteen outcome measures were identified. Thirty-one studies evaluating measurement properties of the outcome measures in participants with NSCLC were included. Functional capacity was assessed using the six- and twelve-minute walk tests; incremental- and endurance-shuttle walk tests; and the stair-climbing test. Criterion validity for three of these measures was established in NSCLC but not the reliability or responsiveness. Physical activity was measured using accelerometers and pedometers. O

OBJECTIVES: To systematically review the instruments used to assess postural control and fear of falling in people with chronic obstructive pulmonary disease (COPD), and to synthesize and evaluate their breadth of content and measurement properties. DATA SOURCES: MEDLINE, EMBASE, Web of Science, CINAHL, CENTRAL, PsycINFO, PEDro, and OTSeeker databases searched in September 2012. STUDY SELECTION: Two independent reviewers performed the selection of articles, the ICF linking process and quality assessment. Only quantitative studies were included, irrespective of language or publication date. DATA EXTRACTION: This systematic review comprised two phases. Phase 1 aimed to identify the commonly used instruments to assess postural control and fear of falling in the COPD literature. The breadth of content of each instrument was examined based on the International Classification of Functioning, Disability and Health (ICF). In phase 2, a measurement property search filter was adopted and used in four electronic databases to retrieve properties reported in the COPD population. The COSMIN checklist was used to assess the methodological quality of each measurement property reported. DATA SYNTHESIS: Seventeen out of 401 publications were eligible in phase 1. Seventeen instruments were identified including 15 for postural control and 2 for fear of falling assessment. The Berg Balance Scale, the Short Physical Performance Battery, and the Activities-specific Balance Confidence (ABC) scale were the most frequently used instruments to assess postural control and fear of falling respectively. The ICF categories covered varied considerably among instruments. The Balance Evaluation Systems test and ABC presented the greatest breadth of content. Measurement properties reported included criterion predictive validity (4 instruments), construct validity (11 instruments) and responsiveness (1 instrument), with inconsistent findings based on 'fair' and 'poor' quality studies. CONCLUSIONS: Dif

CONTEXT: The role of exercise intervention for patients with Non-small cell lung cancer (NSCLC) has not been systematically reviewed to date. OBJECTIVE: To identify, evaluate and synthesize the evidence examining (1) the effect of exercise intervention on exercise capacity, health related quality of life (HRQoL), physical activity levels, cancer symptoms and mortality for patients with NSCLC; and (2) the safety and feasibility of exercise intervention for a population with NSCLC. DATA SOURCES: A systematic review of articles using the electronic databases MEDLINE (1950-2010), CINAHL (1982-2010), EMBASE (1980-2010), TRIP (1997-2010), Science Direct (1994-2010), PubMed (1949-2010), Cochrane Library (2010), Expanded Academic ASAP (1994-2010), Meditext Informit (1995-2010), PEDRO (1999-2010) and DARE (2010). Additional studies were identified by manually cross referencing all full text reports and personal files were searched. No publication date restrictions were imposed. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials (RCTs), case-control studies and case series assessing exercise intervention to improve exercise capacity, HRQoL, level of daily physical activity, cancer symptoms or mortality of patients with NSCLC were included. Only articles available in English and published in a peer reviewed journal were included. DATA EXTRACTION: A data collection form was developed by one reviewer and data extracted. Data extraction was cross checked by a second reviewer. RESULTS AND DATA SYNTHESIS: 16 studies on 13 unique patient groups totalling 675 patients with NSCLC met the inclusion criteria. The majority of studies were case series (n=9) and two RCTs were included. Studies exercising participants pre-operatively reported improvements in exercise capacity but no change in HRQoL immediately post exercise intervention. Studies exercising participants post-treatment (surgery, chemotherapy or radiotherapy) demonstrated improvements in exercise capacity b