Patients with poor baseline walking capacity are most likely to improve their functional status with multimodal prehabilitation

[Prehabilitation, therapeutic innovation]

The concept of prehabilitation emerged in the United States in the 1940s to maintain the performance of American soldiers notably through good nutrition and sport. It was then a question of optimising the patient's health status in a pre-treatment situation and reducing surgical stress. The specific collaborative programme Proadapt, comprising multiprofessional expertise, was put in place for elderly patients in 2016.

The role of prehabilitation in frail surgical patients: A systematic review

INTRODUCTION

Increasing emphasis is being placed on the detection of frailty in the pre-operative setting given its association with surgical morbidity and mortality. Prehabilitation seeks to increase the physiological reserve of frail patients, attenuating the risk of irreversible functional decline following surgery.

AIM/HYPOTHESIS

This systematic review appraises the evidence available for prehabilitation in frail surgical patients. We proposed that exercise prehabilitation would especially benefit frail patients, with improvements in pre-operative functional capacity, and reductions in complications and length of hospital stay.

METHODS

A literature search was conducted in MEDLINE, PubMed and CINAHL databases. Studies were included if they consisted of a prehabilitation intervention in frail patients undergoing surgery and specified a frailty model/index. Eight studies were included for analysis, 2 of which are ongoing studies.

RESULTS

In 3 studies, prehabilitation consisted of an exercise intervention alone. There was a high feasibility of prehabilitation and a trend to improved pre-operative function, however, no evidence of improved post-operative functional recovery was there. In 2 studies, prehabilitation consisted of both exercise and nutritional interventions. Reductions in mortality and duration of hospital stay were reported, but the quality of evidence was judged to be very low. There was a lack of evidence of improved outcomes following pre-operative inspiratory muscle training in frail patients.

DISCUSSION

This systematic review focuses on prehabilitation in frail surgical patients and reports that evidence supporting any outcome is limited, despite high feasibility and acceptability. There is a need for large randomised controlled trials to better establish the effects of prehabilitation in frail patients.

Preoperative Preparations for Enhanced Recovery After Surgery Programs: A Role for Prehabilitation

Preoperative risk assessment is valuable only if subsequent targeted optimization of patient care is allowed. Early assessment of high-risk surgical patients is essential to facilitate appropriate optimization. Preoperative assessment and optimization should not be exclusively focused on patients' comorbidities, but also include nutritional assessment, functional capacity, and promote healthy life style habits that affect surgical outcomes (eg, smoking cessation); it requires a multidisciplinary approach.

Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial

BACKGROUND

Prehabilitation has been previously shown to be more effective in enhancing postoperative functional capacity than rehabilitation alone. The purpose of this study was to determine whether a weekly supervised exercise session could provide further benefit to our current prehabilition program, when comparing to standard post-surgical rehabilitation.

METHODS

A parallel-arm single-blind randomized control trial was conducted in patients scheduled for non-metastatic colorectal cancer resection. Patients were assigned to either a once weekly supervised prehabilitation (PREHAB+, n = 41) or standard rehabilitation (REHAB, n = 39) program. Both multimodal programs were home-based program and consisted of moderate intensity aerobic and resistance exercise, nutrition counseling with daily whey protein supplementation and anxiety-reduction strategies. Perioperative care was standardized for both groups as per enhanced recovery after surgery (ERAS^®) guidelines. Functional exercise capacity, as determined by the 6-minute walk test distance (6MWD), was the primary outcome. Exercise quantity, intensity and energy expenditure was determined by the CHAMPS questionnaire.

RESULTS

Both groups were comparable for baseline walking capacity (PREHAB+: 448 m [IQR 375-525] vs. REHAB: 461 m [419-556], p=.775) and included a similar proportion of patients who improved walking capacity (>20 m) during the preoperative period (PREHAB+: 54% vs. REHAB: 38%, p = .222). After surgery, changes in 6MWD were also similar in both groups. In PREHAB+, however, there was a significant association between physical activity energy expenditure and 6MWD (p < .01). Previously inactive patients were more likely to improve functional capacity due to PREHAB+ (OR 7.07 [95% CI 1.10-45.51]).

CONCLUSIONS

The addition of a weekly supervised exercise session to our current prehabilitation program did not further enhance postoperative walking capacity when compared to standard REHAB care. Sedentary patients, however, seemed more likely to benefit from PREHAB+. An association was found between energy spent in physical activity and 6MWD. This information is important to consider when designing cost-effective prehabilitation programs.

Comprehensive Preoperative Assessment and Global Optimization

To successfully deliver greater perioperative value-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing preoperative management and its associated services and care provider skills must be expanded. New models of preoperative management are needed, which rely extensively on continuously evolving evidence-based best practice, as well as telemedicine and telehealth, including mobile technologies and connectivity. Along with conventional comorbidity optimization, prehabilitation can effectively promote enhanced postoperative recovery. This article focuses on the opportunities and mechanisms for delivering value-based, comprehensive preoperative assessment and global optimization of the surgical patient.

Patient engagement to enhance recovery for children undergoing surgery

For over 20 years enhanced recovery protocols (ERPs) have been used to decrease the physiologic stress and inflammation of surgery using evidence-based principles. ERPs include optimizing patient preparation, creating less trauma using minimally invasive anesthetic and surgical techniques, and regular audit of outcomes. A critical aspect of ERPs is patient engagement in all phases of care, which facilitates effective team function and focused oversight of patient flow through the system. Counseling extends beyond traditional review of surgical risks and benefits, by creating clear daily patient goals, establishing pain management plans, optimizing nutrition, and defining criteria for discharge. The patient and family are provided written and visual media resources to review. This counseling and education clearly outlines the bidirectional expectations, ensures preparedness, and empowers the patient and family by explaining the logic surrounding many of the ERP interventions. The patient and family are, in turn, activated as key stakeholders in the process and have a shared vision with the healthcare team. Most patients enjoy being considered partners and agents in their own healthcare. ERPs facilitate an optimal surgical experience that can improve patient satisfaction, outcomes, and value.

Prehabilitation: a new area of integration between geriatricians, anesthesiologists, and exercise therapists

Surgery in combination with risk factors such as poor physical and nutritional status have detrimental effects on short- and long-term aspects of recovery and quality of life, especially in elderly patients whose functional reserve is limited. Strategies to minimize these effects and accelerate return to baseline levels have focused on the intra- and post-operative period; however, this may not be the most opportune time to intervene. Instead, the preoperative period may be a more emotionally salient and physically enabling time to initiate an intervention aimed at attenuating surgical stress and enhancing recovery after surgery. The process of increasing patients' functional reserve in anticipation for surgery is referred to as prehabilitation. Elements of surgical prehabilitation programs include a structured exercise program consisting of both resistance and aerobic training, supplemented by flexibility exercises and nutritional optimization through counselling and supplementation. In general, individuals who are the least fit and the most sedentary have shown the most improvement when they initiate an exercise program. Since their physiologic reserve is limited, even small amounts of physical training can yield significant improvements. The interaction of physical activity and nutrition promotes anabolism, thereby preparing patients to better withstand the stress of surgery and subsequently mitigating the impact on postoperative outcome.

Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: General and digestive surgery population characterization

INTRODUCTION

Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes.

OBJECTIVE

To characterize surgical population in a university hospital.

METHODS

All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected.

RESULTS

One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity.

CONCLUSIONS

The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome.

Systematic review of exercise training in colorectal cancer patients during treatment

Colorectal cancer surgery results in considerable postoperative morbidity, mortality and reduced quality of life. As many patients will undergo additional (neo)adjuvant therapy, it is imperative that each individual optimize their physical function. To elucidate the potential of exercise in patient optimization, we investigated the evidence for an exercise program before and after surgical treatment in colorectal cancer patients. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions, the guidelines of the Physical Therapy Journal and the PRISMA guidelines. No literature pertaining to exercise training during preoperative neoadjuvant treatment was found. Seven studies, investigating the effects of regular exercise during adjuvant chemotherapy for patients with colorectal cancer or a mixed population, were identified. A small effect (effect size (ES) 0.4) of endurance/interval training and strength training (ES 0.4) was found in two studies conducted in patients with colorectal and gastrointestinal cancer. In five studies that included a mixed population of cancer patients, interval training resulted in a large improvement (ES 1.5; P≤.05). Endurance training alone was found to increase both lower extremity strength and endurance capacity. The effects of strength training in the lower extremity are moderate, whereas, in the upper extremity, the increase is small. There is limited evidence available on exercise training during treatment in colorectal cancer patients. One study concluded exercise therapy may be beneficial for colorectal cancer patients during adjuvant treatment. The possible advantages of training during neoadjuvant treatment may be explored by prehabilitation trials.

Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience

BACKGROUND

Multimodal prehabilitation is a preoperative conditioning intervention in form of exercise, nutritional assessment, whey protein supplementation, and anxiety-coping technique. Despite recent evidence suggesting that prehabilitation could improve functional capacity in patients undergoing colorectal surgery for cancer, all studies were characterized by a relatively small sample size. The aim of this study was to confirm what was previously found in three small population trials.

MATERIAL AND METHODS

Data of 185 participants enrolled in a pilot single group study and two randomized control trials conducted at the McGill University Health Center from 2010 to 2015 were reanalyzed. Subjects performing trimodal prehabilitation (exercise, nutrition, and coping strategies for anxiety) were compared to the patients who underwent the trimodal program only after surgery (rehabilitation/control group). Functional capacity was assessed with the six-minute walk test (6MWT), a measure of the distance walked over six minutes (6MWD). A significant functional improvement was defined as an increase in 6MWD from baseline by at least 19 m. Changes in 6MWD before surgery, at four and eight weeks were compared between groups.

RESULTS

Of the total study population, 113 subjects (61%) underwent prehabilitation. Changes in 6MWD in the prehabilitation group were higher compared to the rehabilitation/control group during the preoperative period {30.0 [standard deviation (SD) 46.7] m vs. -5.8 (SD 40.1) m, p < 0.001}, at four weeks [-11.2 (SD 72) m vs. -72.5 (SD 129) m, p < 0.01], and at eight weeks [17.0 (SD 84.0) m vs. -8.8 (SD 74.0) m, p = 0.047]. The proportion of subjects experiencing a significant preoperative improvement in physical fitness was higher in those patients who underwent prehabilitation [68 (60%) vs. 15 (21%), p < 0.001].

CONCLUSION

In large secondary analysis, multimodal prehabilitation resulted in greater improvement in walking capacity throughout the whole perioperative period when compared to rehabilitation started after surgery.