spiral.imperial.ac.uk€¦ · Web viewSpecifically, it would help to answer whether activity...
Transcript of spiral.imperial.ac.uk€¦ · Web viewSpecifically, it would help to answer whether activity...
The Relationship between Physical Activity and Post-operative Length of Hospital Stay: A
Systematic Review
Abstract
Background: Recovery from surgery has traditionally been measured using specific outcome
measures, such as length of hospital stay. However, advances in technology have enabled
the measurement of continuous, objective physical activity data in the perioperative period.
The aim of this systematic review was to determine the relationship between length of
hospital stay and physical activity data for patients undergoing surgery.
Methods: A systematic search of EMBASE, Medline and the Cochrane Library, from
inception until January 2017, was performed to identify all study designs that evaluated
physical activity after surgery. Studies were included if a wearable sensor measured patient
activity as an in-patient and the length of hospital stay was reported. Only English articles
were included.
Results: Six studies with a total of 343 participants were included in this review. All the
studies were prospective observational studies. Each study used a different sensor, with the
commonest being a tri-axial accelerometer, and multiple different physical activity outcome
measures were used, thereby prohibiting meta-analysis. Four of the studies demonstrated a
relationship between physical activity levels and length of hospital stay, while two studies
did not show any significant relationship.
Conclusion: The amount of physical activity performed post-operatively negatively
correlates with the length of hospital stay. This suggests that objective physical activity data
1
collected by body worn sensors may be capable of predicting functional recovery post-
operatively.
Keywords
Sensor, peri-operative monitoring, post-operative outcome, surgical recovery, fast-track, physical activity
2
INTRODUCTION
Traditionally recovery from surgery has been measured using specific outcomes measures
for both short and long-term follow up. These include complication and readmission rates,
re-operation rates, 30-day mortality and morbidity, with the most commonly used measure
being length of hospital stay[1, 2]. As well as these measures being standardised they are
easily available, they do not require any extra input from the patient themselves, and are
therefore easier to obtain and use. However, return to base line function will usually occur
after the inpatient stay has been completed and will frequently run a varied course[3]. In
this vein, more recent studies have used quality of life (QoL) questionnaires as surrogate
functional outcome measures. These aim to assess when patients returned to normal life
and function following surgery[4, 5]. QoL questionnaires, which often detail activities of
daily living, offer an insight into physical function but are often very subjective[6].
Physical activity is an important component for recovery after surgery, both as a way to help
reduce post-operative complications, e.g. pneumonia and venous thromboembolism[7], and
as a marker of functional recovery[8]. Up until recently the ability to assess physical activity
has mainly been through self-reporting questionnaires or physical function tests[9, 10].
These tests tend to assess activity and function at one point in time only. However,
advances in technology have led to the emergence of sensors that can measure objective
physical activity unobtrusively and continuously over a longer period of time[11]. These
small, light-weight, body worn sensors have been used in a variety of healthcare settings
including during the peri-operative period [12-15].
3
To date there has been no consensus in the literature concerning a possible correlation
between objective physical activity data and more traditional outcome measures, in
particular, length of stay. Knowing whether accurate objective physical activity data
correlate with less sophisticated outcome measures that are currently used would
potentially give clinicians and researchers an extra tool to better understand and improve
patient recovery. Specifically, it would help to answer whether activity sensors can be
utilised during the acute post-operative period to detect patients at risk of a protracted
recovery, with potentially poorer long term outcomes, thus highlighting the need for extra
clinical input and care at an appropriate stage.
Therefore, the aim of this systematic review was to determine the relationship between
objectively measured physical activity recorded by body worn sensors and the length of
hospital stay in the acute inpatient setting.
4
METHODS
Literature Search
A systematic review was conducted in accordance with the guidelines for the “Preferred
Reporting Items for Systematic Review and Meta-analyses”[16]. A literature search was
performed using Medline, EMBASE and the Cochrane Library, from inception until January
2017, combining MESH and all-field search terms for “physical activity” AND
“accelerometer” AND “postoperative”. Detailed search criteria are presented in Appendix A.
The full texts of original articles and relevant reviews were obtained. Additional studies
relevant to this review were identified through reference lists.
Inclusion Criteria
The search included any study that evaluated patients’ physical activity or body movement
in the perioperative period. Studies were included if the body movement was monitored by
a wearable body sensor. Papers were only included if there was physical activity data
available for the in-patient stay as well as hospital length of stay data. The search was
restricted to articles written in English. Randomised controlled trials (RCTs), observational
studies and case series were included. Study authors were contacted when extra
data/information was required to be able to determine whether the study was eligible for
inclusion.
Exclusion Criteria
Studies involving children and adolescents were excluded. Studies where physical activity
was only measured pre-operatively or post-operatively in the community were excluded.
Studies where sensor equipment was placed on structural equipment only, e.g. on a
5
wheelchair, on furniture or walls were excluded. Conference abstracts and single case
reports were excluded.
Study Selection
Two reviewers conducted the literature search and independently reviewed the titles and
abstracts to select potentially relevant articles (A.A. and C.P) and a consensus was reached.
Any discrepancies between reviewers were referred to a third reviewer (R.M.K.) before a
final decision was made on inclusion. Endnote was used to manage the bibliographic
searches.
Study Quality
The quality of each selected article was assessed using the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) system[17]. The GRADE system classifies
quality of evidence into four levels; high, moderate, low or very low. The design of study is
evaluated along with evidence of study limitations, inconsistencies, indirectness,
imprecision and publication bias[18]. This tool was utilised since it assesses the quality of
randomised controlled trials as well as observational studies.
Data Extraction
The following data were extracted: (1) study features including study design, number of
patients, patient demographics; (2) activity sensor details including type of sensor, body
placement, length of time sensor worn, sensor output measures e.g. time spent in activity
level, Metabolic Equivalent of Tasks (METs) hours, number of steps, energy expenditure; (3)
length of hospital stay.
6
7
RESULTS
Search Results
Initially 2,147 potentially relevant titles were identified. After removal of duplicates 1,805
titles and abstracts were screened and 1,585 records were excluded (Figure 1). Full texts
were obtained for the remaining 220 studies. The inter-rater agreement between reviewers
was good (kappa score 0.651, p<0.0005). Eighteen eligible studies were found. Four studies
included the full data necessary to meet the inclusion criteria of this review[19-22]. Authors
of the remaining 14 studies were contacted in an attempt to obtain additional analyses or
full data sets. Contact details for authors of 2 studies could not be obtained[23, 24]. Of the
authors we were able to contact, 1 provided additional data, but it transpired that no in-
patient activity data had been recorded, only out-patient activity, and therefore the study
was excluded from the review[25]. Two authors were unable to provide the study data[26,
27], 2 study authors[28, 29] sent us the extra data needed, while the remaining 8 authors
did not respond to our communication[30-36]. Therefore, 6 studies were ultimately
included in this review (Figure 1).
Study Design and Quality
Using the GRADE tool to assess for study quality, all six studies were rated as low quality.
This was due to the studies all being observational in nature with no evidence of a large
magnitude of effect and the high possibility of confounders minimising any effects seen.
Study characteristics
The 6 studies included in this review were published between 2007-2016 with 4 different
surgical cohorts. Two studies assessed cardiothoracic patient cohorts, 2 studies enrolled an
8
orthopaedic patient cohort, 1 study included a general surgical patient cohort (including
upper GI, hepatobiliary and colorectal) while 1 study reported upon a vascular patient
cohort. Five studies monitored physical activity after elective surgery and 1 study monitored
patient activity after emergency surgery. Out of the 6 studies, 5 had in-patient physical
activity monitoring for the entire cohort, 1 study only had in-patient activity data for half the
cohort and therefore only those data were included in this review. In total, 343 patients
were included in this review, with the largest assessed study having recruited 149 patients.
The mean age of participants in all five studies was 68.3 years of age. The characteristics of
the study populations are shown in Table 1.
Study aims and outcomes
Only 1 study specifically stated the aim of determining whether length of stay was related to
physical activity[19]. One study documented physical activity as their primary and length of
stay as their secondary outcome measures[21]. Four studies mentioned physical activity and
length of hospital stay as outcome measures, but did not state if they were defined as
primary or secondary outcomes measures[20, 22, 28, 29].
Sensor characteristics
Different sensors were used in each of the six studies; full sensor details are included in
Table 2. Five of the sensors were accelerometers (1 uni-axial[21], 4 tri-axial[20, 22, 28, 29]),
and the sixth study used the Positional Activity Logger[19], a position sensor which uses
three mercury tilt switches. Each study used only 1 sensor per patient and these were
attached to the lower limb in 4 studies (the thigh in 3 [19, 21, 29] and the ankle in 1 [20]),
the upper arm in 1 study[22] and the waist in the final study[28]. The sensor was worn both
9
pre and post-operatively in 2 studies[28, 29], otherwise monitoring was only undertaken
post-operatively. Sensors were worn continuously in 5 of the studies, but only during waking
hours in 1 study[29], for a time period ranging from 4 to 17 days. In 2 studies the sensor was
worn until day of discharge[20, 28], in 3 further studies the sensor was worn until day 4
post-operatively[19, 22, 29] and in the final study the sensor was worn up to 7 days post-
operatively (or earlier if discharged prior to this)[21].
Physical activity outputs
The outputs of objective physical activity varied for each sensor within each study. Most
studies presented 2 or more variables which had been derived from the sensor. No single
variable or output was used in all 6 studies. The most common output used was total
number of steps per day, which was reported by 5 of the studies[20-22, 28, 29]. Other
outputs included time spent in activities of differing intensities[21, 22, 29], energy
expenditure (EE)[21, 22] and time spent in an upright position ‘uptime’[19] or daily physical
activity as METs hours per day[28].
Length of stay and physical activity
Four studies reported a relationship between physical activity levels and length of hospital
stay[19, 20, 22, 28]. Browning et al[19] demonstrated that the amount of time patients
spent sitting upright increased each day over the 4 post-operative days (p < 0.001) and that
this ‘uptime’ predicted length of stay (r2 = 0.5, p < 0.001). Cook et al reported that patients
who walked more on their first and second recovery days had shorter hospital stays (p <
0.05)[20]. Agostini et al demonstrated that patients who were less active had a significantly
longer median post-operative length of stay (6 days vs 5 days, p = 0.013)[22]. We analysed
10
the raw data received from Matsuo et al’s study[28] using Spearman’s rank-order
correlation, and found a strong negative correlation between length of hospital stay and
total number of steps taken on the fourth post-operative day (rs = -0.599, p = 0.03).
However, there was no significant correlation between total number of steps taken on any
other post-operative day (1-3, 5-7) or METs-hours on any post-operative day and length of
stay (rs = -0.403 - 0.378, p > 0.05). We analysed the data from Schotanus et al[29] using
Spearman’s rank-order correlation. This was a small cohort of 10 patients and no correlation
was found between length of stay and number of steps taken on days 1,2 or 3 post-
operatively (rs = -0.394 - 0.248, p > 0.05). Another small study concluded that no measures
of activity, either total number of steps per day or amount of time spent in different
activities, were associated with length of stay (r = 0.18 - 0.34, p > 0.05)[21].
11
DISCUSSION
This is the first systematic review that investigates the relationship between objectively
measured physical activity recorded by worn sensors in the inpatient post-operative period
and length of hospital stay. This systematic review has identified 6 studies including elective
and emergency surgical patients which cover a wide range of surgical specialties. Overall the
findings suggest that the amount of physical activity performed whilst on the ward as an
inpatient following surgery negatively correlates with length of hospital stay. However, the
heterogeneity of activity sensors used, and the outcomes reported prohibits meta-analysis.
A systematic review looking at physical activity levels in healthy older adults and those in a
healthcare setting showed similar heterogeneity of sensor types and sensor outputs[37].
The most common variables reported were energy expenditure, total time walking and total
time in all activity, with many sensors also reporting more than one output variable. A more
recent review by Montoye et al [38] also showed a diverse range of sensors used and a
range of physical activity outputs, with cut-points/counts per minute being the most
reported. This shows that although our study has heterogenous data, this is not unique, as
there are many accelerometer devices on the market, and currently there is no
compatibility to compare multiple different physical activity outputs.
Although there were only 6 papers included in this review, other papers which did not fit
the inclusion criteria but still describe activity monitoring in the peri-operative period, show
a similar heterogeneity as those studies included in this review. The majority, 8 out of 12
studies, used tri-axial accelerometers[25, 30-33, 35, 39-41], but 9 different sensors were
used in total. Sensor output included activity counts[21, 39, 42], steps[25, 35, 40, 41],
energy expended[40, 41], raw accelerometry data/ cumulative acceleration[30, 31] and time
12
spent in activity intensities[25, 32, 34]. Again, there was no single output measure within
these studies, and some studies used multiple output measures. Surgical specialty included
Cardiothoracics (5), Colorectal (3), Upper GI Surgery (2), Orthopaedics (1), and Transplant
Surgery (1) and sensor placement varied by study and included ankle, wrist and waist.
Some studies comparing open and laparoscopic surgery have also used accelerometers to
monitor physical activity between these two groups. A shorter length of stay as well as a
shorter time to return to pre-operative activity levels was found in the laparoscopic group
compared with the open group [30] [31]. Although these findings are similar to the present
study, and suggest a relationship between length of hospital stay and objectively monitored
physical activity, there are other recent studies which did not show any significant
difference. A study by Basse et al [39] looking at functional recovery in open compared with
laparoscopic resections showed that both groups had a 2-day median LOS with an equally
high degree of mobilisation on the first post-operative day. Zutshi et al [27] compared a
traditional post-operative care protocol to a fast-track approach. They did not find any
difference in physical activity and suggest that there are other factors associated with length
of hospital stay than purely levels of physical activity. Furthermore, although length of
hospital stay is one of the most commonly used outcome measure following surgery, it is
still seen as a surrogate marker for recovery from surgery. Many factors can influence length
of stay including surgical approach and operation type, hospital policy for discharge, patient
preference, community support available, as well as surgeon preference. It is, however, a
measure that is easily collected, frequently reported and allows comparisons to be made
between clinicians, institutions and regions. Although being fit for discharge would likely
give more information about patients’ functional recovery, it is less easily collected and is
also subjective in nature. Other less subjective markers of recovery include mortality, 30-day
13
re-admission and complication rates. Although they are useful in highlighting events that
mark a major shift in the recovery trajectory they do not measure functional recovery itself.
This is where objective markers of recovery, like physical activity levels, could supersede the
more subjective or surrogate measures. Physical activity levels could help clinicians and
researchers to measure recovery from surgery from the moment a patient leaves theatre,
whilst on the ward during inpatient recovery until baseline activity levels are achieved back
in the community.
This review has some limitations. There were only 6 studies included which were all low
quality according to the GRADE tool. Three of the studies, which showed little or no
correlation between physical activity and length of stay, had very small numbers of
participants. From the six studies, four different surgical specialty patient cohorts were
used, contributing to the heterogeneity of the data included in this review. Each study had
participants’ wearing the sensor for varying amounts of time and on different positions of
the body, although previous studies have shown that there is a similarity in activity output
measured at different anatomical sites[43, 44]. All the studies were only observational in
nature, nevertheless, the assessed data are encouraging.
This review describes a new technology that has been introduced relatively recently into the
medical and surgical market, and though there are only minimal studies included, with
heterogenous data, it is the first of its kind, and the literature in this domain will expand as
technology in the clinical setting becomes more common-place. These technologies warrant
further investigation in the future via larger observational studies and RCTs with focused
study aims and well defined primary and secondary outcome measures.
14
CONCLUSION
This systematic review suggests that post-operative physical activity negatively correlates
with the length of hospital stay. This is an important, though intuitive, finding that suggests
objective physical activity data collected by body worn sensors may be capable of predicting
functional recovery post-operatively. These technologies could be useful in the future to
help clinicians identify patients that need extra clinical input, but further study is necessary
first to ensure the evidence of correlation is robust.
Acknowledgments
The authors would like to thank T. Matsuo et al (Sakakibara Heart Institute of Okayama,
Japan) and M. Schotanus et al (Department of Orthopaedic Surgery, Zuyderland Medical
Centre, The Netherlands) for providing their raw study data to be included in this systematic
review.
15
REFERENCES
[1] P.O. Hendry, J. Hausel, J. Nygren, K. Lassen, C.H. Dejong, O. Ljungqvist, K.C. Fearon, E.R.A.S.S. Group, Determinants of outcome after colorectal resection within an enhanced recovery programme, Br J Surg 96(2) (2009) 197-205.[2] A. Neville, L. Lee, I. Antonescu, N.E. Mayo, M.C. Vassiliou, G.M. Fried, L.S. Feldman, Systematic review of outcomes used to evaluate enhanced recovery after surgery, Br J Surg 101(3) (2014) 159-170.[3] D.M. Kennedy, P.W. Stratford, S.E. Hanna, J. Wessel, J.D. Gollish, Modeling early recovery of physical function following hip and knee arthroplasty, BMC musculoskeletal disorders 7(1) (2006) 100.[4] T.T. Tran, P. Kaneva, N.E. Mayo, G.M. Fried, L.S. Feldman, Short-stay surgery: what really happens after discharge?, Surgery 156(1) (2014) 20-27.[5] T.E. Miller, M. Mythen, Successful recovery after major surgery: moving beyond length of stay, Perioper Med (Lond) 3 (2014) 4.[6] J.M. Prutkin, A.R. Feinstein, Quality-of-life measurements: origin and pathogenesis, The Yale journal of biology and medicine 75(2) (2002) 79-93.[7] H. Kehlet, Multimodal approach to control postoperative pathophysiology and rehabilitation, Br J Anaesth 78(5) (1997) 606-617.[8] V.A. Lawrence, H.P. Hazuda, J.E. Cornell, T. Pederson, P.T. Bradshaw, C.D. Mulrow, C.P. Page, Functional independence after major abdominal surgery in the elderly, Journal of the American College of Surgeons 199(5) (2004) 762-772.[9] C. Moriello, N.E. Mayo, L. Feldman, F. Carli, Validating the six-minute walk test as a measure of recovery after elective colon resection surgery, Arch Phys Med Rehabil 89(6) (2008) 1083-1089.[10] L.S. Feldman, P. Kaneva, S. Demyttenaere, F. Carli, G.M. Fried, N.E. Mayo, Validation of a physical activity questionnaire (CHAMPS) as an indicator of postoperative recovery after laparoscopic cholecystectomy, Surgery 146(1) (2009) 31-39.[11] M.J. Mathie, A.C. Coster, N.H. Lovell, B.G. Celler, Accelerometry: providing an integrated, practical method for long-term, ambulatory monitoring of human movement, Physiol Meas 25(2) (2004) R1-20.[12] G. Appelboom, E. Camacho, M.E. Abraham, S.S. Bruce, E.L. Dumont, B.E. Zacharia, R. D'Amico, J. Slomian, J.Y. Reginster, O. Bruyère, E.S. Connolly, Smart wearable body sensors for patient self-assessment and monitoring, Arch Public Health 72(1) (2014) 28.[13] O. Aziz, L. Atallah, B. Lo, E. Gray, T. Athanasiou, A. Darzi, G.Z. Yang, Ear-worn body sensor network device: an objective tool for functional postoperative home recovery monitoring, Journal of the American Medical Informatics Association 18(2) (2011) 156-159.[14] C.J. Brown, D.T. Redden, K.L. Flood, R.M. Allman, The underrecognized epidemic of low mobility during hospitalization of older adults, Journal of the American Geriatrics Society 57(9) (2009) 1660-1665.[15] R.M. Kwasnicki, R. Ley Greaves, R. Ali, P.A. Gummett, G.Z. Yang, A. Darzi, J. Hoare, Implementation of objective activity monitoring to supplement the interpretation of ambulatory esophageal PH investigations, Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus / I.S.D.E 29(3) (2016) 255-261.[16] D. Moher, A. Liberati, J. Tetzlaff, D.G. Altman, P.G. The, Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement, PLoS Med 6(7) (2009) e1000097.[17] G.H. Guyatt, A.D. Oxman, G.E. Vist, R. Kunz, Y. Falck-Ytter, P. Alonso-Coello, H.J. Schunemann, GRADE: an emerging consensus on rating quality of evidence and strength of recommendations, Bmj 336(7650) (2008) 924-926.[18] G. Guyatt, A.D. Oxman, E.A. Akl, R. Kunz, G. Vist, J. Brozek, S. Norris, Y. Falck-Ytter, P. Glasziou, H. DeBeer, R. Jaeschke, D. Rind, J. Meerpohl, P. Dahm, H.J. Schunemann, GRADE guidelines: 1.
16
Introduction-GRADE evidence profiles and summary of findings tables, Journal of clinical epidemiology 64(4) (2011) 383-394.[19] L. Browning, L. Denehy, R.L. Scholes, The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study, Australian Journal of Physiotherapy 53(1) (2007) 47-52.[20] D.J.T. Cook, J. E.: Prinsen, S. K.: Dearani, J. A.: Deschamps, C., Functional recovery in the elderly after major surgery: assessment of mobility recovery using wireless technology, Annals of Thoracic Surgery 96(3) (2013) 1057-1061.[21] S.J. Davenport, M. Arnold, C. Hua, A. Schenck, S. Batten, N.F. Taylor, Physical Activity Levels During Acute Inpatient Admission After Hip Fracture are Very Low, Physiotherapy Research International 20(3) (2015) 174-181.[22] P.J.N. Agostini, 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 Cardiothoracic Surgery 9 (2014) 128.[23] O.B. Despond, E.: Sprunger, A. L.: Sloutkis, D., Influence of patient's dressing on spontaneous physical activity and length of hospital stay in surgical patients, Sozial- und Praventivmedizin 44(1) (1999) 8-13.[24] N.S. Redeker, E. Wykpisz, Effects of age on activity patterns after coronary artery bypass surgery, Heart & Lung 28(1) (1999) 5-14.[25] L. Wickerson, S. Mathur, L.G. Singer, D. Brooks, Physical activity levels early after lung transplantation, Physical Therapy 95(4) (2015) 517-525.[26] L. Basse, D.H. Jakobsen, L. Bardram, P. Billesboolle, C. Lund, T. Mogensen, J. Rosenberg, H. Kehlet, Functional recovery after open versus laparoscopic colonic resection: A randomized, blinded study, Annals of Surgery 241(3) (2005) 416-423.[27] M.D. Zutshi, C. P.: Senagore, A. J.: Fazio, V. W., Shorter hospital stay associated with fastrack postoperative care pathways and laparoscopic intestinal resection are not associated with increased physical activity, Colorectal Disease 6(6) (2004) 477-480.[28] T.S. Matsuo, T.: Ishida, A.: Yuguchi, S.: Saito, K.: Nakajima, M.: Ujikawa, T.: Morisawa, T.: Chikazawa, G.: Takahashi, T., Effect of in-hospital physical activity on cardiovascular prognosis in lower extremity bypass for claudication, J Phys Ther Sci 27(6) (2015) 1855-1859.[29] M.G. Schotanus, Y.F. Bemelmans, B. Grimm, I.C. Heyligers, N.P. Kort, Physical activity after outpatient surgery and enhanced recovery for total knee arthroplasty, Knee Surgery, Sports Traumatology, Arthroscopy 4 (2016) 4.[30] Y. Inoue, T. Kimura, H. Noro, M. Yoshikawa, M. Nomura, T. Yumiba, E. Taniguchi, S. Ohashi, S. Souda, H. Matsuda, Is laparoscopic colorectal surgery less invasive than classical open surgery? Quantitation of physical activity using an accelerometer to assess postoperative convalescence, Surgical Endoscopy 17(8) (2003) 1269-1273.[31] Y. Inouez, T. Kimura, S. Fujita, H. Noro, K. Nishikawa, T. Yumiba, E. Taniguchi, S. Ohashi, S. Yoshida, H. Matsuda, A new parameter for assessing postoperative recovery of physical activity using an accelerometer, Surgery Today 33(9) (2003) 645-650.[32] I.D. Van Der Peijl, T.P.M. Vliet Vlieland, M.I.M. Versteegh, J.J. Lok, M. Munneke, R.A.E. Dion, Exercise therapy after coronary artery bypass graft surgery: A randomized comparison of a high and low frequency exercise therapy program, Annals of Thoracic Surgery 77(5) (2004) 1535-1541.[33] S. Takiguchi, Y. Fujiwara, M. Yamasaki, H. Miyata, K. Nakajima, M. Sekimoto, M. Mori, Y. Doki, Laparoscopy-assisted distal gastrectomy versus open distal gastrectomy. A prospective randomized single-blind study, World journal of surgery 37(10) (2013) 2379-2386.[34] G. Arbane, A. Douiri, N. Hart, N.S. Hopkinson, S. Singh, C. Speed, B. Valladares, R. Garrod, Effect of postoperative physical training on activity after curative surgery for non-small cell lung cancer: A multicentre randomised controlled trial, Physiotherapy (United Kingdom) 100(2) (2014) 100-107.[35] T. Takahashi, M. Kumamaru, S. Jenkins, M. Saitoh, T. Morisawa, H. Matsuda, In-patient step count predicts re-hospitalization after cardiac surgery, Journal of Cardiology 66(4) (2015) 286-291.
17
[36] S. Otsuka, T. Morisawa, S. Yuguchi, Y. Hojo, T. Matsuo, M. Nakajima, A. Ishida, T. Takahashi, Clinical importance of change in physical activity after endovascular treatment combined with exercise training in patients with peripheral arterial disease, Heart & Vessels 1 (2016) 1.[37] K. Taraldsen, S.F. Chastin, Riphagen, II, B. Vereijken, J.L. Helbostad, Physical activity monitoring by use of accelerometer-based body-worn sensors in older adults: a systematic literature review of current knowledge and applications, Maturitas 71(1) (2012) 13-19.[38] A.H. Montoye, R.W. Moore, H.R. Bowles, R. Korycinski, K.A. Pfeiffer, Reporting accelerometer methods in physical activity intervention studies: a systematic review and recommendations for authors, British journal of sports medicine (2016).[39] L.J. Basse, D. H.: Bardram, L.: Billesboolle, P.: Lund, C.: Mogensen, T.: Rosenberg, J.: Kehlet, H., Functional recovery after open versus laparoscopic colonic resection: A randomized, blinded study, Annals of Surgery 241(3) (2005) 416-423.[40] S.Z. Barnason, L.: Nieveen, J.: Schulz, P.: Miller, C.: Hertzog, M.: Rasmussen, D., Relationships between fatigue and early postoperative recovery outcomes over time in elderly patients undergoing coronary artery bypass graft surgery, Heart & Lung 37(4) (2008) 245-256.[41] S.Z. Barnason, L.: Nieveen, J.: Schulz, P.: Miller, C.: Hertzog, M.: Tu, C., Influence of a symptom management telehealth intervention on older adults' early recovery outcomes after coronary artery bypass surgery, Heart and Lung: Journal of Acute and Critical Care 38(5) (2009) 364-376.[42] N.S.W. Redeker, E., Effects of age on activity patterns after coronary artery bypass surgery, Heart & Lung 28(1) (1999) 5-14.[43] M. Pat Rapp, F. Nelson, M. Oliver, N. Bergstrom, S.G. Cron, Comparison of commonly used placement sites for activity monitoring, Biological research for nursing 11(3) (2010) 302-309.[44] I. Cleland, B. Kikhia, C. Nugent, A. Boytsov, J. Hallberg, K. Synnes, S. McClean, D. Finlay, Optimal placement of accelerometers for the detection of everyday activities, Sensors (Basel) 13(7) (2013) 9183-9200.
18
APPENDIX A: Embase, Medline & Cochrane Searches
Embase Search (1947 – 2017 Week 2nd Jan)
1. walking/ or locomotion/ or physical activity/ or gait/ or walking speed/
2. ((physical adj1 activit$) or (activity adj1 cycl$) or (functional adj1 mobility) or (activity adj1 level$)
or (motor adj1 activit$) or mobility or (activity adj1 pattern$) or (body adj1 posture$) or gait or
(ambulatory adj1 activit$) or walk$ or (body adj1 movement$) or ambulation or (physical adj1
performance) or (body adj1 motion$) or movement or locomotion).mp. [mp=title, abstract, heading
word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name,
keyword]
3. 1 or 2
4. actimetry/ or measurement/
5. (accelerometer or accelerometry or actigraphy or actigrpah or (objective adj1 measurement) or
(wireless adj1 technology) or (activity adj1 count) or (Patient adj1 assessment) or (patient adj1
track$) or (patient adj1 sensor$) or (patient adj1 logger) or (patient adj1 measurement) or (patient
adj1 monitor$) or (personal adj1 track$) or (personal adj1 sensor$) or (personal adj1 logger) or
(personal adj1 monitor) or (activity adj1 assessment) or (activity adj1 track$) or (activity adj1
sensor$) or (activity adj1 logger) or (activity adj1 measurement) or (activity adj1 monitor$) or
(ambulatory adj1 assessment) or (ambulatory adj1 track$) or (ambulatory adj1 sensor$) or
(ambulatory adj1 logger) or (ambulatory adj1 measurement) or (ambulatory adj1 monitor$) or
(motion adj1 assessment) or (motion adj1 track$) or (motion adj1 sensor$) or (motion adj1 logger)
or (motion adj1 monitor) or (mobility adj1 assessment) or (mobility adj1 track$) or (mobility adj1
sensor$) or (mobility adj1 logger) or (mobility adj1 monitor)).mp. [mp=title, abstract, heading word,
drug trade name, original title, device manufacturer, drug manufacturer, device trade name,
keyword]
6. 4 or 5
7. endoscopic sinus surgery/ or refractive surgery/ or throat surgery/ or open heart surgery/ or
middle ear surgery/ or vitreoretinal surgery/ or computer assisted surgery/ or colon surgery/ or
19
glaucoma surgery/ or larynx surgery/ or spine surgery/ or ear nose throat surgery/ or ureter surgery/
or ligament surgery/ or cornea surgery/ or endoscopic endonasal surgery/ or thorax surgery/ or
endocrine surgery/ or esophagus surgery/ or bladder surgery/ or prostate surgery/ or
transsphenoidal surgery/ or cerebrovascular surgery/ or minor surgery/ or elective surgery/ or
uterine tube surgery/ or joint surgery/ or liver surgery/ or cardiovascular surgery/ or urinary tract
surgery/ or shoulder surgery/ or major surgery/ or pancreas surgery/ or video assisted thoracoscopic
surgery/ or pelvis surgery/ or stomach surgery/ or maxillofacial surgery/ or natural orifice
transluminal endoscopic surgery/ or retina surgery/ or aneurysm surgery/ or colorectal surgery/ or
experimental surgery/ or skin surgery/ or thoracic aorta surgery/ or cancer surgery/ or foot surgery/
or nerve surgery/ or hip surgery/ or cytoreductive surgery/ or breast surgery/ or spinal cord surgery/
or off pump surgery/ or rectum surgery/ or abdominal surgery/ or craniofacial surgery/ or urethra
surgery/ or plastic surgery implant/ or "head and neck surgery"/ or arthroscopic surgery/ or uterus
surgery/ or eye surgery/ or microvascular surgery/ or geriatric surgery/ or aortic arch surgery/ or
endoscopic surgery/ or coronary artery bypass surgery/ or minimally invasive cardiac surgery/ or
artery surgery/ or dental surgery/ or robot assisted surgery/ or nose surgery/ or vascular surgery/ or
orthopedic surgery/ or male genital system surgery/ or descending aorta surgery/ or knee ligament
surgery/ or trachea surgery/ or ascending aorta surgery/ or biliary tract surgery/ or heart valve
surgery/ or thyroid surgery/ or heart surgery/ or computer assisted surgery system/ or strabismus
surgery/ or plastic surgery/ or stapes surgery/ or orthognathic surgery/ or intestine surgery/ or facial
nerve surgery/ or minimally invasive surgery/ or urologic surgery/ or brain surgery/ or
gastrointestinal surgery/ or knee surgery/ or laser surgery/ or gynecologic surgery/ or mitral valve
surgery/ or conversion to open surgery/ or laparoscopic surgery/ or nephron sparing surgery/ or
thymus surgery/ or surgery/ or meniscal surgery/ or emergency surgery/ or vein surgery/ or
decompression surgery/ or retina detachment surgery/ or ear surgery/ or off pump coronary
surgery/ or failed back surgery syndrome/ or skull surgery/ or tendon surgery/ or lung surgery/ or
second look surgery/ or laparoendoscopic single site surgery/ or oral surgery/ or general surgery/ or
coronary artery surgery/ or hand surgery/ or bypass surgery/ or carotid artery surgery/ or "aortic
root surgery"/ or stereotaxic surgery/ or esthetic surgery/ or anus surgery/ or ultrasound surgery/ or
kidney surgery/ or bariatric surgery/ or face surgery/ or aorta surgery/ or endovascular surgery/ or
spleen surgery/
8. (postoperative or (post adj2 surgery) or (after adj2 surgery) or post-surgical or (after adj2
operation) or (post adj2 procedure)).mp. [mp=title, abstract, heading word, drug trade name,
original title, device manufacturer, drug manufacturer, device trade name, keyword]
20
9. 7 or 8
10. 3 and 6 and 9
MEDLINE Search (1946 – 2017 Week 2nd Jan)
1. movement/ or locomotion/ or walking/
2. actigraphy/ or remote sensing technology/
3. specialties, surgical/ or colorectal surgery/ or general surgery/ or gynecology/ or neurosurgery/ or
obstetrics/ or ophthalmology/ or orthognathic surgery/ or orthopedics/ or otolaryngology/ or
surgery, plastic/ or thoracic surgery/ or traumatology/ or urology/
4. (postoperative or (post adj2 surgery) or (after adj2 surgery) or post-surgical or (after adj2
operation) or (post adj2 procedure)).mp. [mp=title, abstract, original title, name of substance word,
subject heading word, keyword heading word, protocol supplementary concept word, rare disease
supplementary concept word, unique identifier]
5. 3 or 4
6. ((physical adj1 activit$) or (activity adj1 cycl$) or (functional adj1 mobility) or (activity adj1 level$)
or (motor adj1 activit$) or mobility or (activity adj1 pattern$) or (body adj1 posture$) or gait or
(ambulatory adj1 activit$) or walk$ or (body adj1 movement$) or ambulation or (physical adj1
performance) or (body adj1 motion$) or movement or locomotion).mp. [mp=title, abstract, original
title, name of substance word, subject heading word, keyword heading word, protocol
supplementary concept word, rare disease supplementary concept word, unique identifier]
7. 1 or 6
8. (accelerometer or accelerometry or actigraphy or actigrpah or (objective adj1 measurement) or
(wireless adj1 technology) or (activity adj1 count) or (Patient adj1 assessment) or (patient adj1
track$) or (patient adj1 sensor$) or (patient adj1 logger) or (patient adj1 measurement) or (patient
21
adj1 monitor$) or (personal adj1 track$) or (personal adj1 sensor$) or (personal adj1 logger) or
(personal adj1 monitor) or (activity adj1 assessment) or (activity adj1 track$) or (activity adj1
sensor$) or (activity adj1 logger) or (activity adj1 measurement) or (activity adj1 monitor$) or
(ambulatory adj1 assessment) or (ambulatory adj1 track$) or (ambulatory adj1 sensor$) or
(ambulatory adj1 logger) or (ambulatory adj1 measurement) or (ambulatory adj1 monitor$) or
(motion adj1 assessment) or (motion adj1 track$) or (motion adj1 sensor$) or (motion adj1 logger)
or (motion adj1 monitor) or (mobility adj1 assessment) or (mobility adj1 track$) or (mobility adj1
sensor$) or (mobility adj1 logger) or (mobility adj1 monitor)).mp. [mp=title, abstract, original title,
name of substance word, subject heading word, keyword heading word, protocol supplementary
concept word, rare disease supplementary concept word, unique identifier]
9. 2 or 8
10. 5 and 7 and 9
Cochrane Library Search up to 2nd Jan 2017
#1 (accelerometer or accelerometry or actigraphy or actigrpah or (objective adj1 measurement)
or (wireless adj1 technology) or (activity adj1 count) or (Patient adj1 assessment) or (patient adj1
track$) or (patient adj1 sensor$) or (patient adj1 logger) or (patient adj1 measurement) or (patient
adj1 monitor$) or (personal adj1 track$) or (personal adj1 sensor$) or (personal adj1 logger) or
(personal adj1 monitor) or (activity adj1 assessment) or (activity adj1 track$) or (activity adj1
sensor$) or (activity adj1 logger) or (activity adj1 measurement) or (activity adj1 monitor$) or
(ambulatory adj1 assessment) or (ambulatory adj1 track$) or (ambulatory adj1 sensor$) or
(ambulatory adj1 logger) or (ambulatory adj1 measurement) or (ambulatory adj1 monitor$) or
(motion adj1 assessment) or (motion adj1 track$) or (motion adj1 sensor$) or (motion adj1 logger)
or (motion adj1 monitor) or (mobility adj1 assessment) or (mobility adj1 track$) or (mobility adj1
sensor$) or (mobility adj1 logger) or (mobility adj1 monitor))
#2 ((physical adj1 activit$) or (activity adj1 cycl$) or (functional adj1 mobility) or (activity adj1
level$) or (motor adj1 activit$) or mobility or (activity adj1 pattern$) or (body adj1 posture$) or gait
or (ambulatory adj1 activit$) or walk$ or (body adj1 movement$) or ambulation or (physical adj1
performance) or (body adj1 motion$) or movement or locomotion)
#3 (postoperative or (post adj2 surgery) or (after adj2 surgery) or post-surgical or (after adj2
operation) or (post adj2 procedure))
22
#4 MeSH descriptor: [Exercise] explode all trees
#5 MeSH descriptor: [Actigraphy] explode all trees
#6 MeSH descriptor: [Specialties, Surgical] explode all trees
#7 #1 or #5
#8 #2 or #4
#9 #3 or #6
#10 #7 and #8 and #9
23
Figure legend
Figure 1. PRISMA Flow Diagram of literature search
24