Quality of Life Clinical Trial
Official title:
The Assessment of the Feasibility of a Home Based Post-operative Exercise Training Programme Targeting Physical and Cognitive Function in Older Patients Undergoing Major Body Surgery
The primary aim of this study is to establish if it is possible for patients who have undergone major body surgery to complete a home based exercise training program and complete the assessments required to measure physical and cognitive function. If the investigators can establish that it is feasible to complete the training and test's then further research can follow using these methods to determine whether it is possible to improve the physical function of older patients undergoing major abdominal surgery in the period following surgery by using a simple exercise regimen that can be carried out at home. By targeting physical function in this way the investigators hope to determine if it is a method for improving frailty and well being. In turn it may also have a positive impact on health service provision.
Frailty is a geriatric syndrome describing a lack of physiological reserve. It is an
independent risk factor for morbidity, mortality and increased length of hospital stay. Five
criteria can be used to describe Frailty: weight loss, exhaustion, diminished hand-grip
strength, slow walking speed, and low physical activity. Sarcopenia, the loss of skeletal
muscle mass and strength, is a key component of all of these criteria and of Frailty itself.
By assessing Frailty, vulnerable patients can be recognised early so that additional measures
can be implemented. Interventions to ameliorate the severity of an individual's Frailty are
currently the focus of much attention as these can positively impact on the patients physical
and cognitive function and well-being. In turn this has a positive impact on health service
provision reducing hospital length of stay, morbidity and mortality.
The exercise programme used in this study incorporates the High-Intensity Functional Exercise
(HIFE) programme for older individuals developed by Umea University Sweden with exercises
incorporated from the Help the Aged Preventing Falls Programme. The exercises are designed
such that they can be performed at home with no additional aids. The participants will be
required to begin the programme on discharge from hospital and undertake exercises three
times per week. They will receive instruction, help and support prior to discharge and
throughout the 6 month exercise period. The participants will be required to complete an
exercise diary to monitor their compliance with the programme and to determine the
feasibility of a home based exercise programme as an intervention measure.
The outcome measures of physical function will be assessed by the Handgrip strength and Step
Box testing plus questionnaires assessing daily activities, Sarcopenia will be assessed using
the Handgrip test to measure muscle strength and quantification of muscle mass through muscle
ultrasound (USS) imaging. Cognitive function will be assessed by the use of validated
questionnaire and online cognitive tests. Frailty by the Reported Edmonton Frail Scale.
Experimental design and methods:
Potential participants will be identified from local multidisciplinary team (MDT) meetings.
These are held weekly and all patients undergoing major cavity intra-abdominal surgery are
discussed at the relevant MDT for their surgical speciality. Those patients who meet the
eligibility criteria will be noted by the usual care team and they will make the initial
approach to the patient regarding the study.
30 participants will be recruited to the study and allocated randomly to either the exercise
intervention arm or the control arm of the study. Participants will be involved in the study
for approximately 8 months depending upon when they are recruited to the study
pre-operatively. The post-operative exercise programme runs for 6 months.
All aspects of the screening process are part of the standard NHS pre-operative assessment
and include National Health Service (NHS) blood tests, ECG, clinical examination and medical
questionnaire.
Participants will be asked to attend five testing sessions, one pre-operatively and four
postoperatively. These sessions will wherever possible be timed with planned clinic
appointments scheduled as part of the standard NHS care provided by their surgical
speciality. The first session shall occur at the time of the pre-operative assessment and
will require the participant to complete all of the assessments (detailed below). The second
session occurs three days postoperatively whilst the participant is an inpatient, of the
physical assessments only the handgrip strength test shall be completed. The remaining three
sessions occur at 6 weeks, 3 months and 6 months post-operatively and all of the assessments
shall be completed. At each session blood tests for monitoring of Haemoglobin levels and
inflammatory markers shall be collected, some of which will be a part of the standard NHS
care.
Assessment of physical function and Sarcopenia:
Handgrip test: Three readings (maximal isometric contraction of the hand using the Takei hand
dynamometer) for each hand will be recorded with the average of the three readings
calculated.
Step Box test: Participants will complete three sets of step box steps. The first set
involves 10 steps at a slow pace, the second set, 20 steps at normal walking pace and the
final set, 20 steps as fast as they can. The height of the step is dependent upon the height
of the participant. The time to complete each set and the heart rate during stepping and in
the recovery period is recorded.
The recovery period is 5 minutes or the time taken for the heart rate to return within 5 bpm
of the resting heart rate.
Ultrasound of vastus lateralis: Ultrasound images will be taken of the vastus lateralis at a
point 2/3 along the axis from the greater trochanter of the femur and the knee joint-line. At
this point a sagittal image will be captured to delineate the anterior and posterior borders
of the muscle. Muscle depth, bulk and muscle pennation angle will be calculated.
Assessment of Frailty:
Reported Edmonton Frail Scale: This is a validated frailty scoring system.
Assessment of Cognition:
The Montreal Cognitive Assessment (MoCA) questionnaire is a validated cognitive screening
tool to screen for mild to moderate cognitive impairment.
Computerised Cognitive test battery: This involves two computerised tests, the Simon test and
the Symbol Substitution test.
Questionnaires:
The following validated questionnaires will be used; The Duke Activity Status Index (DASI)
assess activities of daily living, the EQ5D evaluates health status, the International
Physical Activity - Short Form (IPAC-SF) questionnaire assess physical activity. Depression
shall also be screened for by using the Geriatric Depression Scale (GDS).
Assessment of Feasibility:
The feasibility of the intervention will be determined through interviews, exercise diary's
and feedback questionnaires.
Removal of participants from the study:
Patients will be withdrawn from the study if they wish to withdraw consent or loose the
capacity to consent. Further if they develop post-operative complications of the
cardio-vascular system, cerebrovascular system or complications of the operative wound site.
Also if they discontinue with the exercise programme either temporarily or permanently.
Sample size calculation:
This is a feasibility study, there is no current data from which to estimate the sample size.
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