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Three Part Question

Which [physiotherapy treatment] is most effective at [treating or preventing post-operative complications] following [thoracic surgery via lung resection]?

Clinical Scenario

A patient who is to undergo an open thoracotomy for lung resection presents to a physiotherapist. The patient would like to know which physiotherapy treatment is the most effective at treating or preventing post-operative complications.

Search Strategy

AMED, EMBASE, CINAHL and Medline using Athens were reviewed.
The databases were searched using the following terms:
Search 1: Physiotherapy OR “physical therapy” OR exercise OR mobilisation OR stretching.
Search 2: “Lung cancer” OR thoracotomy OR “lung resection”.
Search 3: Function OR “quality of life” OR mobility OR “American shoulder and elbow surgeons standardised shoulder assessment” OR video assisted thoracotomy OR VATS OR strength OR movement OR DASH OR “oxford shoulder score” OR SPADI OR walk OR walking.

Papers written and published after 2000, focusing on lung resection via open thoracotomy

Search Outcome

943 studies were found, of which 435 were unrelated to the clinical question or duplicates. 508 titles were screened, of which 6 were appropriate for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Reeve J; Nichol K; Stiller K; McPherson K; Birch P; Gordon G; Denehy L 2009 New Zealand	Elective pulmonary resection via open thoracotomy 76 patients: 42 experimental group receiving 'standard care'as per a clinical pathway plus targeted physiotherapy including deep breathing exercises, mobility and a progressive shoulder and thoracic cage mobility programme 34 control group who received 'standard care' via a pathway entailing early sitting out of bed, mobilisation and a booklet containing basic respiratory advice and shoulder exercises.	Randomised controlled trial	Incidence of Post operative Pulmonary Complication’s (PPC's)	PPC’s developed in two patients from Intervention group and 1 from control. No significant difference (p = 1.00)	Unusually low incidence of PPC’s (3.9%). Would require much larger sample size than anticipated to demonstrate a powered result. The study was conducted in a single specialist cardiothoracic unit, thus may not be applied to general thoracic patients. No patient blinding was applied. Single unit study. Possible bias: Blinded assessors but the patients were aware of allocation. Staff may have become aware of allocation, despite being blinded.
			Incidence of Post operative Pulmonary Complication’s (PPC's)	Patients managed by a standardised pathway showed low incidence of PPC and was not further improved by the addition of targeted respiratory physiotherapy intervention
			Hospital Length Of Stay (LOS)	No significant difference in LOS between groups, p=0.87 LOS significantly longer in those who developed a PPC (median 17 v 6 days)
			Hospital Length Of Stay (LOS)	Significant difference in time to ambulate 10m (p=0.001) 41% of the intervention group achieving 10m on day 1 v's 12% of control group.
Miranda A; Dutra de Souza H; Almeida Santos B; Cipriano J; Siriani de Oliveira A; Gastaldi A 2015 Brazil	38 patients undergoing pulmonary resection – grouped by extent of surgical procedure; biopsy/nodulectomy, lung segmentectomy or lobectomy.	Cross sectional prospective study	Pain free active range of movement (AROM) of the ipsilateral shoulder	Shoulder flexion decreased 49°(p˂0.05) and 34° shoulder abduction p˂0.05. Shoulder flexion was significantly decreased in all 3 groups on day 1 (p˂0.05). Shoulder abduction was significantly decreased in the segmentectomy/ lobectomy groups (p˂0.05). A significantly larger decrease in shoulder abduction and flexion was seen in the lobectomy group compared to other two groups (p˂0.05).	No blinding demonstrated. Short follow up (2 days post op)
			Pain free active range of movement (AROM) of the contralateral shoulder	Shoulder flexion decreased 4° and shoulder abduction 16°. Significantly decreased shoulder abduction in segmentectomy and lobectomy groups (p˂0.05). A non significant decrease in shoulder flexion in all 3 groups (p˃0.05). Range of movement was lower in lobectomy patient's compared to other 2 surgery groups.
			Pain (Visual Analogue Scale)	No significant difference. Scores of 5-6/10 on Day 1 and 2
Reeve J; Nichol K; Stiller K; McPherson K; Birch P; Gordon I; Denehy L. 2010 New Zealand	Elective pulmonary resection via open thoracotomy 76 patients 42 in experimental group receiving 'standard care' via a clinical pathway and targeted physiotherapy and a supervised progressive shoulder exercise regime and booklet and progressive home exercise programme. 34 control group receiving 'standard care' via a clinical pathway. Booklet provided with basic respiratory advise and. No physiotherapy.	Randomised controlled trial	Pain at baseline, hospital discharge, 1 and 3 months post operatively	Intervention group had significantly less shoulder pain at d/c (95% CI 0.3 to 2.2) Significantly less total pain in intervention group at 1 and 3 months	Assessors blinded but patients were not blinded. High loss to follow up, especially at 3 months. However, intention to treat analysis used.
			Active range of movement	No significant differences
			Shoulder muscle strength	No significant differences.
			Shoulder Pain And Disability Index (SPADI)	at 1 month was 5.7% lower (better) in interventional group. 7.6% better at 3 months in intervention group – indicates better function.
Varela G; Ballesteros E; Jimenez M; Novoa N; Aranda J 2006 Spain	639 patients undergoing an elective lobectomy between 1994 - 2004. From November 2002, an intensive post-operative respiratory physiotherapy programme was instituted. 119 cases were recorded after this date.	Cross sectional study with historical controls.	Post operative pulmonary complications	Pneumonia: 5% in PT group v 9.2% in the control group (95% CI: 0.22 – 1.25); Atelectasis: 2% in the physiotherapy group, 7.7% in the control group (95% CI:0.05 – 0.86)	No blinding to study. Participants were not randomised. Only hospital costs were considered, nothing past discharge from hospital.
			30 day post operative mortality	Mortality lower in the physiotherapy group but non-significant (0.8% in the physiotherapy group v 3.5% in the control group; 95% CO: 0.03 – 1.79)
			Length of stay (LOS)	Median LOS 5.73 days in the physiotherapy group v 8.33 days in the control group (p˂0.001). A total of 151.75 hospital days saved in the physiotherapy group
			Cost of treatment/ hospital stay	Mean daily cost of a lobectomy at the time 590.00€, total of 89,523€ saved in shorter hospital stay.
Agostini P ; Naidu B; Rajesh P; Steyn R; Bishay E; Kalkat M; Singh S. 2014 United Kingdom	Planned thoracotomy and lung resection patients receiving daily respiratory physiotherapy and twice daily mobility with the physiotherapists.	Prospective, observational study as part of a single blind randomised controlled trial	Post-operative perceived pain Scored 0-3	On day 2, 40% with lower activity reported pain of moderate/ severe v 12% with higher activity (p˂0.014). On day 3, 36% v 8% (p=0.004)	Patients were aware they were wearing a monitor, which potentially led them to undertake higher levels of exercise.
			Steps/ Time spent ‘sedentary’ or moderate/ vigorous activity	50 patients took less than 500 steps/day 2-3, demonstrated lower steps 220 v 1128 (p˂0.001) Lower energy expenditure; lower moderate activity levels.
			Length of Stay (LOS)	Significantly longer LOS 6 v 5 (p=0.003) in less active patients
			Post operative pulmonary complications (PPC's)	Significantly increased PPC's in less active patients 20% v 4% (p=0.028)
Arbane G; Tropman D; Jackson D; Garrod R. 2011 United Kingdom	NSCLC patients referred for lung resection via thoracotomy or VATS. Receiving usual nursing care and routine physiotherapy or usual care plus a twice daily mobility and strengthening programme.	Single blind, randomised control trial	Length of stay (LOS)	No significant difference. Mean days 8.9 (intervention) and 11 (control)	Quadriceps strength was difficult to measure with missing points occurring frequently. Repeated measures analysis was used, showing a significant difference in group. The authors have not acknowledged how this may have impacted the results.
			Exercise tolerance: 6MWT	Significant deterioration at 5 days post op with return at 12 weeks (p˂0.001) but not significant between groups (p =0.47)
			Quadriceps muscle strength	No significant difference between groups at 12 weeks but at 5 days p =0.04 for change in strength – control losing strength more
			Post operative pulmonary complications	No significant differences between the groups. 2 in the intervention group; 3 in the control
			Quality of life (QoL)	No significant change for any measure of QoL in either group

Comment(s)

1. Thoracic surgery can lead to the development of atelectasis, pneumonia or loss of shoulder range of motion. 2. Early mobility reduces perceived pain with improved functional levels in the early post-operative period compared to those who are inactive immediately post operatively. 3. Patients who are encouraged to mobilise from day 1, including basic chest clearance exercises as part of a standardised care pathway demonstrated fewer incidences of pneumonia or atelectasis, compared to those who are only encouraged to sit out of bed. 4. Patients who have limited early mobility have a longer length of hospital stay.

Clinical Bottom Line

The current best evidence suggests that the addition of targeted chest physiotherapy did not change patient outcome, as long as good care pathways are in place to ensure early mobility and chest clearance. The current best evidence suggests that the inclusion of shoulder mobility exercises can reduce the risk of reduced function and range of motion.

References

1. Reeve J; Nichol K; Stiller K; McPherson K; Birch P; Gordon G; Denehy Does Physiotherapy reduce the incidence of post-operative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single blind trial European Journal of Cardio-thoracic Surgery 2009; 37: 1158 – 1167
2. Miranda A; Dutra de Souza H; Almeida Santos B; Cipriano J; Siriani de Oliveira A; Gastaldi A Bilateral Shoulder dysfunction related to the lung resection area after thoracotomy. Medicine 2015; 94: 44
3. Reeve J; Nichol K; Stiller K; McPherson K; Birch P; Gordon I; Denehy L. A post-operative shoulder exercise program improves function and decreases pain following open thoracotomy: a randomised trial. Journal of Physiotherapy 2010. 56: 245 – 252.
4. Varela G; Ballesteros E; Jimenez M; Novoa N; Aranda J Cost effectiveness analysis of prophylactic respiratory physiotherapy in pulmonary lobectomy European Journal of Cardio-thoracic Surgery 2006; 29: 216 – 220.
5. Agostini P ; Naidu B; Rajesh P; Steyn R; Bishay E; Kalkat M; Singh S. Potentially modifiable factors contribute to limitation in physical activity following thoracotomy and lung resection: a prospective observational study Journal of Cardio-thoracic Surgery. 2014; 9: 128
6. Arbane G; Tropman D; Jackson D; Garrod Evaluation of an early exercise intervention after thoracotomy non small cell lung cancer, effects on quality of life, muscle strength and exercise tolerance: Randomised controlled trial Lung Cancer. 2011; 71: 229 – 234.