Mrs Robyn J Stiger

Purpose
This review synthesised the evidence for the effect of prehabilitation interventions on biopsychosocial and service outcomes.

Materials and Methods
A systematic review was conducted. 10 databases were searched to December 2023. Prospective experimental studies exploring prehabilitation interventions in adults undergoing upper gastrointestinal surgery were included. Prehabilitation was any preoperative intervention to improve physical or psychological outcomes. Included studies required a comparator group or alternative preoperative intervention as well as baseline, presurgical and postoperative assessment points. Study quality was assessed using the Cochrane risk of bias tool (v.2). Data synthesis was narrative (SWiM guidance).

Results
6028 studies were screened, with 25 studies included. Prehabilitation interventions were: inspiratory muscle training (five studies n = 450); exercise (nine studies n = 683); psychological (one study n = 400); and nutritional (ten studies n = 487). High quality studies showed preoperative improvements in impairments directly targeted by the interventions. Generally, these did not translate into functional or postoperative improvements, but multimodal interventions were more promising.

Conclusion
Current evidence supports prehabilitation as safe to preserve or improve preoperative function. Heterogeneity in outcomes and variable study quality means definitive conclusions regarding interventions are not yet possible, limiting implementation. Agreement of clinical outcomes and cost effectiveness evaluation is required.

Introduction:
The patient safety agenda suggests that simulation can aid professional capability development, particularly leadership and communication skills [1]. Complex non-technical skills required by effective leaders may be improved by using trained simulated participants (SP) within leadership scenarios. However, evidence in this area is lacking. This study explored the student perspectives of simulation as an educational tool for leadership development in a postgraduate module.

Methods:
Ethical approval was granted by Oxford Brookes University.

A half-day pilot study was co-created by simulation and leadership experts and delivered to 15 international students from diverse backgrounds enrolled on a leadership module. The scenario utilised a trained SP portraying the role of an employee who was part of an organisational change management intervention. The participants were leading the change process. Additional pre-brief time was needed to build psychological safety within the group. The scenario was paused when learning moments were identified, to allow students and observers to participate in the discussions of leadership concepts [2]. There was an overall group debrief at the end. A focus group exploring the student perspectives of their learning experience was conducted following this debrief. The data was audio recorded, anonymously transcribed and analysed.

Results:
Thematic analysis of the focus group data revealed parallels with current literature such as providing safety to participate; representing real life; enabling application of theory to practice and building leadership skills [3]. Analysis also highlighted the recognition and impact of cultural differences on the awareness and use of leadership styles.

“So I think that it’s good to know that at any point we can take something from this toolbox and choose, maybe this didn’t work in the past, so maybe I can try this other style.”

“For me the strengths were that we are all culturally diverse from our discussions, so what we believe or feel about competence as a leader is different for everyone. This made the discussion quite valuable and to understand everyone’s perspective on the problems of leadership.” The study findings were mapped into a conceptual model (Figure 1-A82).

Discussion:
Simulation with a trained SP in a psychologically safe and realistic environment was an effective and culturally competent way to apply relevant leadership theory and skills, within health and social care postgraduate training. This simulation pilot facilitated critical discussions that recognised cultural differences as well as the benefits and challenges of implementing western styles of leadership in other countries.

Ethics statement:
Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

References
1. Health Education England. Technology Enhanced Learning (TEL) [Internet]. 2020 [cited 2024 Mar 11]. Available from: https://www.hee.nhs.uk/sites/default/files/documents/National%20Strategic%20Vision%20of%20Sim%20in%20Health%20and%20Care.pdf.

2. Butler C, McDonald R, Merriman C. Origami debriefing model: unfolding the learning moments in simulation. BMJ Simulation and Technology Enhanced Learning. 2017;4(3):150–151 [cited 2024 Mar 18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8936804/.

3. Botma Y. Nursing student’s perceptions on how immersive simulation promotes theory–practice integration. International Journal of Africa Nursing Sciences [Internet]. 2014;1:1–5. Available from: https://reader.elsevier.com/reader/sd/pii/S221413911400002X?token=BAFD12156F062B27BBF46DF3961F1C5D801028B37EB9DD3B3B4F9843119ABF0F1156AD77018EEE34FF679505883A85B7.

Introduction:
Frailty is a complex, multifactorial syndrome leading to loss of function and independence [1]. The benefits of exercise in frailty prevention are well established, however, strategies to enable older adults to undertake sufficient exercise safely are challenging [2]. The use of virtual reality (VR) alongside an exercise, might be a safe and engaging solution [3]. This study investigated whether there was a difference in muscular activity and heart rate intensity when comparing overground to seated VR-walking, in a young (TDY) and elderly typically developed (TDE) population.

Methods:
Participants were recruited (EthicsRef: HLS/2023/PH/155), and asked to walk for six minutes overground and six minutes within an interactive VR environment. Heart rate and lower limb muscle activity were assessed via a torso-worn heart rate strap and wireless surface electromyography (EMG) respectively. A Split-Plot ANOVA, Mixed-Design Two-Way Repeated Measures ANOVA, was used to assess for differences between walking conditions and age groups in mean heart rate differences. The EMG data was compared via statistical parametric mapping, with a paired-samples t-test.

Results:
Twenty-two participants were recruited (TDY n=12; TDE n=10). EMG analysis showed a higher degree of variability in muscle activity patterns. The rectus and biceps femoris crossed the critical-t value significantly more in the elderly than in the younger population, for example, t(20) = 1.354, p

Discussion:
Results show that seated walking, with VR, does activate muscles in the lower limbs and increases heart rate to a similar range as overground walking. The difference in variability of muscle activity could be caused by unfamiliarity with VR-based interaction(s). The significant differences, between the upper leg muscles, between populations, could be caused by weaker muscles in elderly people. Decreased heart rate in the VR-based environment was expected, yet less than originally expected. More research exploring strength, endurance and patient engagement is needed to evaluate the use of VR in frail patient populations.

Ethics statement:
Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable

References
1. Xue QL. The frailty syndrome: definition and natural history. Clinics in Geriatric Medicine. 2011;27(1):1–15.

2. Elmagd MA. Benefits, need and importance of daily exercise. International Journal of Physical Education, Sports and Health 2016;3(5):22–27.

3. MotusVR. Available from: https://motusvr.com/. [Accessed 11 March 2024].

Osteonecrosis (ON) is a common disabling complication of treatment for patients with acute lymphoblastic
leukaemia (ALL). Reported incidence rates range from 1% to 61% and multiple possible risk factors have been identified. This review explored existing evidence to provide new perspectives and recommendations for future interdisciplinary research. PEDro, CINAHL, AMED, EMBSAE, OVID, EMCARE databases were systematically searched from their inception to March 2022. Published original research reporting the incidence rates of osteonecrosis in patients aged 10–25 with ALL were included. Study reporting quality was assessed against appropriate reporting guidelines (STROBE, CONSORT and CROSS). All relevant data reporting incidence rates and risk factors were extracted for narrative synthesis. 3146 report titles were screened, with 34 studies included (n = 12,056) (30 observational cohort studies, three randomised trials, and one questionnaire study). The median study quality reporting score was 68% (IQR 64–82%). Median overall incidence rate of ON was 51.8% (IQR 41.4–58.9%) and 15.65% (IQR 9.2–24.2%) for asymptomatic and symptomatic patient screening respectively. Five possible risk factor categories were identified: sex assigned at birth, age, ethnicity, steroid regimen, and genotype. The female sex and white ethnicity were consistently reported as risk factors independently associated with an increased risk of osteonecrosis in all studies. A heterogenous body of literature with moderate reporting quality identified a high incidence rate of osteonecrosis in patients with ALL. Future research investigating the efficacy of stratified treatments that focus on reducing the risk of osteonecrosis through modification of steroid
regimen particularly in females of white ethnicity is needed. Obtaining multidisciplinary consensus with regards to screening methodologies and intervention outcomes may also help to improve evidence synthesis in this area. This may in turn facilitate early diagnosis and improve long term patient outcomes through treatment regimen modification and possible prevention of ON progression. 

Introduction: Physiotherapy students lack confidence when applying psychological strategies as part of interaction and assessment. Further research is required to establish consistent approaches to training in prequalifying programmes. The purpose of this study was (a) to document experiences of student physiotherapist to a Stroke-based simulation when applying the model of emotions, adaptation and hope (MEAH) tool, (b) consider if there are different experiences when the tool is applied online versus in-person and (c) provide recommendations for the use and application of the MEAH tool and training for future research and clinical practice.

Methods: An interpretative hermeneutic phenomenological study was undertaken. Two settings were selected in-person and online via zoom©. E-training focussing on the principles of the MEAH was delivered before a 10-minute simulation was undertaken by each student (online or in person). Semi-structured interview examining the experiences of the e-training were analysed using a reflexive thematic analysis. A conversation analysis was applied to 24 recorded in-person conversations.

Results:Twenty-five university final year physiotherapy students completed the in-person study and 13 second year physiotherapy student completed the online study. Thematic analysis: Four major themes across both groups were identified: (a) the content and value of the e-training, (b) the experience and perception of the simulation, (c) the application of the MEAH screening tool and (d) future training needs.

Conversational analysis: Three types of interaction were identified. Type 1 interactions (15/24, 62.5%) followed the form in a very exacting way. Type 2 interactions (3/24, 12.5%) used the tool as an aid to their conversation. Type 3 interactions (6/24, 25%) deviated from the main focus of the tool. Factors which influenced the interaction were identified.

Conclusions: The current study demonstrated that the model of emotions, adaptation and hope can be used to enhance a brief therapeutic interaction for physiotherapy students. Further research and policy recommendations are provided.

Background:
Current evidence suggests that despite being well placed to use psychological strategies to improve complex communication with patients, physiotherapists lack confidence in the application of such strategies [1]. Training to help them to navigate complex interactions with patients presenting with psychological distress is therefore recommended within prequalifying physiotherapy education [2]. A brief therapeutic interaction tool (the model of emotions, adaptation, and hope; MEAH) has been developed for this purpose [3]. The aim of this qualitative study was to explore the experiences of physiotherapy students applying the brief therapeutic interaction using the MEAH in an online setting compared to an in-person setting, within a simulated learning environment.

Methods:
An interpretive hermeneutic phenomenological study design was utilised. Two simulation learning environment settings were selected; (1) 25 final year physiotherapy students experienced the simulation-based activity in the in-person setting on a university campus, and (2) 13 second year physiotherapy students experienced the simulation-based activity in an online setting. A 50-minute pre-recorded e-training lecture was completed prior to all students participating in an individual 10-minute simulation. The simulated patient was played by the same actor in both settings. Two methods of data collection were used: (1) a single semi-structured interview, to consider the experiences of all students across both settings. This data was analysed using reflexive thematic analysis. (2) a live recording of 24 of the in-person student interactions were captured. This data was analysed using conversation analysis.

Results:
Thematic analysis: Four major themes across both groups were identified: (a) the content and value of the e-training (b) the experience and perception of the simulation, (c) the application of the MEAH screening tool, and (d) future training needs. Conversational analysis: Three types of interaction were identified. Type 1 interactions (15/24, 62.5%) followed the form in a very exacting way. Type 2 interactions (3/24, 12.5%) used the tool as an aid to their conversation. Type 3 interactions (6/24, 25%) deviated from the main focus of the tool. Factors which influenced the interaction were identified.

Conclusion:
The simulated practice learning environment provided an ideal way to enhance students’ communication skills, through safe and deliberate practice with a simulated patient. Use of the MEAH tool demonstrated that brief and focused teaching enhanced the perceived confidence of physiotherapy students to undertake difficult patient interactions. Online experiences were perceived more positively compared to in-person training, making it a useful platform to develop student confidence that should be explored further within simulation-based education.

Purpose: This systematic review and meta-analysis aimed to evaluate the effectiveness of inspiratory
muscle training (IMT) on respiratory muscle strength, lung function and quality of life (QOL) in adults
with spinal cord injuries (SCI).
Methods: Databases were searched up to June 2022; CENTRAL, CINAHL, MEDLINE, PEDRo, and PubMed. Following PRISMA reporting guidelines, two independent reviewers selected studies and extracted data. Study quality and levels of evidence were assessed.
Results: Following selection from 624 initial search results, six randomised controlled trials were identified, comprising 124 participants. Quality of Evidence was very low to moderate. Meta-analysis showed that post intervention, IMT significantly improved maximal inspiratory pressure (MD 15.72 cmH2O, 95% CI 5.02, 26.41, p = 0.004) when compared with a control intervention. There was no significant benefit for physical QOL (SMD 0.12, 95% CI −1.01, 1.25, p = 0.84), mental QOL (SMD −0.2, 95% CI −1.72, 1.33, p = 0.80), maximal expiratory pressure (MD 5.19 cmH2O, 95% CI −4.16, 14.55, p = 0.80), or FEV1 (MD 0.26 L, 95% CI −0.19, 0.7, p = 0.26). Sensitivity analyses found larger effects for studies with 8 week interventions (MD 17.5 cmH2O (95% CI 3.36 to 31.66)) and spring loaded devices alone (MD 21.18 cmH2O, 95% CI 9.65 to 32.72).​​​​​​​
Conclusion: Moderate quality evidence suggests IMT improves respiratory strength in adults with an SCI.
The mental and physical QOL outcomes provided very low quality of evidence, with considerable heterogeneity between study results, leading to inconsistency. Further research is warranted to investigate medium and long-term impact of robust IMT protocols, accounting for patient motivation and adherence to

Background To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients.

Methods Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872).

Results Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62–1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality.

Conclusions Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base.