ICEAGE trial - Incidence of Complications following Emergency Abdominal surgery: Get Exercising.

Intervention participants as soon as practical after surgery will receive: 1) Non-restricted number of physiotherapist provided education and instruction sessions on postoperative recovery and complication prevention with breathing exercises and physical activity; 2) Daily physiotherapist supervised early rehabilitation sessions lasting at least 30-minutes; and, 3) at least four coached deep breathing and coughing exercise sessions in the first two postoperative days. Rehabilitation program: Rehabilitation will consist of a combination of ambulation and non-ambulatory chair or bed-based exercises starting as soon as possible after surgery and continuing daily thereafter for at least the next five postoperative days or until at least five daily sessions are delivered. Exercises will be provided in a top-down hierarchical sequence starting each session with the maximum physical activity type the participant is able to attempt, starting from ambulation. Exercise delivery progresses sequentially down the protocol until at least 30-minutes of activity has been accumulated. For example, participants will first be assisted to ambulate for at least 15-minutes with a goal to achieve at least 30-minutes. If time ambulated is less than 30-minutes, the participant will attempt resistive lower limb exercises in standing for the remaining time or until fatigue limits performance. If time still remains less than 30-minutes, participants will attempt upper limb/lower limb resistance exercises in sitting until fatigued. This process continues (including bed based active-assisted exercise, passive limb mobilisation, functional electrical stimulation) until a minimum total treatment time of 30-minutes has been reached. A treating physiotherapist is also permitted to prescribe a personalised training activity based on a detected functional deficit to be incorporated within the rehabilitation program. All activity (except passive mobilisation or functional electrical stimulation) in the program must aim to be continuous for more than one minute, at an intensity of at least three on the Borg 10-point VAS of perceived exertion and where breathing is deeper than at rest. The treating physiotherapist will use a stopwatch to ensure the treatment session is at least 30-minutes and can provide a walking aid if clinically indicated. Interval training is permitted, however, rest-time cannot exceed the preceding active period. Once rest-time becomes greater than the preceding work-time, the exercise session is considered completed. The initial starting exercise for each rehabilitation session will be made pragmatically at the discretion of the treating physiotherapist using their own past experience and knowledge base regarding the participant’s current clinical and physiological status. No specific sedation score or assessment screening tool will be used to guide this decision. All sessions will be conducted by a physiotherapist until at least the fifth postoperative day unless the supervising physiotherapist is confident that a therapy assistant or the participant will undertake the rehabilitation programme exactly as prescribed for the minimum 30-minutes. After the fifth postoperative day, daily treatment with a physiotherapist or therapy assistant will continue until a referral for sub-acute rehabilitation services is made; participant is discharged from hospital; or once a threshold score is met, whichever occurs first. If the patient meets the discharge score prior to the fifth postoperative day, daily treatment will continue until the fifth postoperative day but cease thereafter. Breathing exercises: The mode, type, and timing of delivery of deep breathing and coughing (DB&C) exercises will be provided as per the control group. Intervention group participants will receive at least three additional physiotherapist-coached DB&C sessions in the first two postoperative days. At least four sessions will be provided in total. Beyond the second day additional coached DB&C can be provided at the discretion of the treating physiotherapist if they consider the patient incapable of performing exercises unsupervised or requires additional respiratory exercises to prevent a postoperative pulmonary complication are indicated. Similar to the control group, no additional prophylactic respiratory interventions apart from the DB&C exercises will be provided.