Surgery is a stressor that causes large physiological changes ranging from tissue trauma, immobility, and systemic effects, to psychological distress. After upper ...
G Model
JPHYS-423; No. of Pages 1 Journal of Physiotherapy xxx (2018) xxx–xxx
Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys
Appraisal
Critically appraised paper: Preoperative physiotherapy education halved postoperative pulmonary complications in patients after upper abdominal surgery [commentary] Commentary Strong claims require strong evidence. The Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy (LIPPSMAck-POP) is the latest and most robust trial (PEDro 9/10) demonstrating that a single preoperative physiotherapy session halves respiratory complications after major abdominal surgery. Previous trials have reported very large effects: a 70 to 80% reduction.1 Is this too good to be true? Maybe if based on a single trial, but three positive trials across four countries with a combined sample size of close to 1000 provide very strong evidence. In our trial, group imbalances were present at baseline. Mathematical modelling indicates that imbalances are statistically likely (>70% likelihood) to occur when >50 variables are reported. In accordance with recommendations,2 it is important to specify a priori key variables known to influence postoperative pulmonary complications and to adjust results for these if required. Rather than speculation, this is a deliberate measure to ensure that results are a true reflection of independent treatment effects. Additionally, the imbalances are small in absolute numbers; at most, baseline covariate balance differed by eight people. Considering the large effect size, robust trial methods, and detailed statistical analysis, it is unlikely that these small imbalances affected the overall outcome. LIPPSMAck-POP confirmed the findings of previous trials: preoperative education, in addition to early ambulation, prevents
postoperative pulmonary complications.1 Most importantly, timing is vital. Patients should commence breathing exercises immediately after surgery, not a day or two later as per usual physiotherapy service in Australia. Preadmission clinics are the opportune time to train patients on these breathing exercises. While physiotherapy in preoperative clinics is still common practice in Europe, Australian physiotherapists have disinvested from this highly effective therapy over the past 20 years. Considering the mounting evidence also supporting preoperative exercise training,3 it is time for physiotherapists to turn back the clock and get back into preop! Provenance: Invited. Not peer reviewed. Ianthe Boden on behalf of the LIPPSMAck POP investigators Physiotherapy Department, Allied Health Services, Tasmanian Health Services, North Launceston General Hospital, Australia References 1. Reeve J, et al. N Z J Physiother. 2016;44:33–39. 2. Pocock S, et al. Stat Med. 2002;21:2917–2930. 3. Barberan-Garcia A, et al. Ann Surg. 2018;267:50–56.
