Development of a reconditioning program for elderly abdominal surgery patients: the Elder-friendly Approaches to the Surgical Environment–BEdside reconditioning for Functional ImprovemenTs (EASE-BE FIT) pilot study

Prior to program development, the author AM, a kinesiologist, shadowed in-hospital physical and occupational therapists who were responsible for the standard physical therapy of the population group of interest. The purpose of this was to familiarize the author with current hospital rehabilitation practices, safe movement with recent incision sites, common areas of physical weakness for elderly inpatients, and the accessibility of the hospital ward. The program was based around the progressive use of multi-disciplinary teams within Alberta’s Health Care system. The goal of the program was to provide a uniform transitional program that all members of the health-care team would be knowledgeable about and comfortable using. The program was designed with input from exercise physiologists, physical therapists, occupational therapists, and surgeons.

An initial list of exercises was selected by authors AM and MM, based on expert opinion and the American College of Sports Medicine’s recommendations for elderly individuals [17], with the guiding intention that the exercises were simple enough that a lay person could teach, be taught, or perform the exercises with minimal guidance. These exercises targeted lower limb strength, balance, and endurance and would be expected to support participants in independent living and ambulation once discharged. The exercises chosen were reviewed by all authors, as well as the in-hospital physical and occupational therapists, and consensus was reached for all exercises included in the final program, after several rounds of edits and discussion. Three exercise levels, of increasing difficulty, of the program were generated, and visual instructional materials and patient logbooks were created (Table 1). The program materials were trialed with non-study participant elderly surgical inpatients prior to implementation for user feedback and refinement.

Testing of the BEdside reconditioning for Functional ImprovemenTs (BE FIT) program was done using a prospective, sequential before-and-after sub-study of the Elder-friendly Approaches to the Surgical Environment (EASE) study [18]. The main EASE study’s aim is to assess the impact of an elder-friendly surgical unit through capacity alignment, an interdisciplinary care team, an evidence-informed care pathway, the BE FIT reconditioning program, and transition optimization. The full protocol of the EASE study is published, and the Human Research Ethics Boards of the University of Alberta granted ethics approval (Pro00047180) [18].

Participants for EASE-BE FIT sub-study were consecutively enrolled elderly patients (≥ 65 years old) who had been referred directly to Acute Care Surgery services for emergency abdominal surgery at the University of Alberta Hospital in Edmonton, Canada, from May 2015 to May 2016. Patients were excluded if they (1) received elective or palliative surgery, (2) were admitted due to trauma, (3) were dependent in three or more activities of daily living or were non-ambulatory prior to admission, and (4) could not read/speak or comprehend English. The research coordinator approached the eligible patients prior to their surgery, and willing participants were consented.

Participants included prior to the implementation of the BE FIT program received only usual care, which may have included physical therapy if it was requested by the clinical team (Usual Care cohort). The physiotherapist would assess the frequency and timing of the clinical physiotherapy involvement, independent of the study. Participants included after the BE FIT program implementation received usual care plus the BE FIT reconditioning program beginning on postoperative day 2 (BE FIT cohort). The appropriate level of the program was determined using the participant’s frailty within 2 weeks prior to admission, assessed using CHSA Clinical Frailty Scale [19], along with informal interview of the participant on postoperative day 2. The exercises were demonstrated to the participant, and the first set of exercises was supervised to ensure they were being performed safely. The participants were instructed to perform the exercises three times per day until discharged, and the visual diagram of the exercises was provided to remind the participant of proper technique. The logbook was provided to encourage compliance, and the participants were told to notify the clinical or study team if they needed re-teaching of the exercises or modifications; however, as the program was intended to be self-directed, the study team did not initiate follow-up with the participant nor monitor adherence to the exercises.

Chart review was completed to determine age, sex, race, marital status, living situation prior to admission, type of surgery, postoperative physical and occupational therapy intervention, any occurrence of in-hospital falls, discharge status, and length of stay.

Participants completed a 30-s sit-to-stand (STS) test on postoperative day 2 (prior to receiving the BE FIT program for the BE FIT cohort) and again on the day of discharge. The STS test is a measurement used to assess functional lower extremity strength in older adults [20]. Briefly, a participant rises to a full stand from being seated in a chair, without the use of their arms, and then returns back to the initial seated position. The number of full repetitions that are completed in 30 s is recorded. As all participants had recent abdominal incisions, participants were permitted to use their arms to assist them into a standing position if they felt necessary. More repetitions are indicative of better functional performance.

Six weeks after discharge, for those participants who returned for their scheduled follow-up with their surgeon, a Timed Up and Go (TUG) test was completed [21]. The TUG test is a commonly used screening tool for falls risk. The participant is timed while they rise from a chair, walk 3 m at a comfortable and safe pace, turn and walk back to the chair, and sit down again. Faster time indicates a better functional performance.

Sample size was calculated based on the few normative values currently published in scientific literature, along with the established minimal clinically important difference scores (2.6 stands in the STS [22] and 3.5 s in the TUG [23]). For a statistical significance of p = 0.05 and a power value of 0.90, the necessary value for the STS tests was based on the mean and standard deviation values normalized by Jones et al. [24] on community-dwelling older adults, suggesting a minimum sample of 11. For the TUG, using mean and standard deviation scores normalized by Steffen et al. [25], a sample size of 22 is suggested. We therefore attempted to enroll a minimum of 60 participants (30 in each group) to increase power and attempt to have equivalent distribution of baseline characteristics between groups.

A total of 66 participants were enrolled in the study with 33 participants in each group. The Usual Care group had more intestinal revision or resection surgeries (p = 0.001), had fewer cholecystectomies (p = 0.04), were more often mild or moderately frail (p = 0.02), and received more physical or occupational therapy intervention (p = 0.009) compared to the BE FIT group (see Table 2). Four participants in the BE FIT group did not perform the reconditioning program, as they were discharged on postoperative day 2; for those who completed the program (n = 29), median number of possible rehab days was 3 (IQR 1–6) and mean (SD) adherence was reported as 2.56 (0.65), suggesting that participants completed 83% of their exercises. The logbook was completed by 18 (55%) of BE FIT participants. Two falls occurred during the duration of the study (one Usual Care, one BE FIT), but neither was associated with performance of the functional testing or completion of the BE FIT program.

Several BE FIT participants responded with comments such as “More exercises,” “Enjoyed the program, wish I could take it home,” and “Please provide this to other hospitals” in the logbook and commented that it was helpful to be given direction on moving after surgery, as they felt unsure if it was allowed. However, four (12%) of participants felt that postoperative day 2 was too soon to complete exercises after surgery (either due to pain or beliefs that bed rest would be most beneficial to them) and either delayed beginning the program or chose not to complete the exercises during their hospital stay. No concerns were brought forth by the clinical team regarding the program.

Overall, 10 (15%) of participants completed the STS reps without using their arms, 37 (56%) completed their STS reps with the assistance of using their arms, and 19 (29%) used a combination of without-arm and with-arm reps. Combining all reps, regardless of arm use, the BE FIT group completed 5.0 (3.9) more stands at discharge compared to postoperative day 2, while the Usual Care group completed 2.7 (3.0) (between group difference 2.3 (0.45) stands, p = 0.01). After adjusting for sex, Clinical Frailty Scale, and surgery type, the difference of difference was 1.9 (0.94) (p = 0.05) (see Fig. 1).

Loss to follow-up at 6 weeks post-discharged occurred for 19 (56%) participants in the Usual Care group and 10 (30%) participants in the BE FIT group. BE FIT participants completed the TUG in 9.0 (2.8) s, while the Usual Care completed it in 13.1 (5.2) s (difference between groups, 4.0 (1.3), p = 0.004). After adjusting for sex, Clinical Frailty Scale, and surgery type, the difference between groups remained significant (mean difference 4.1 (1.4), p = 0.006) (see Fig. 1).