Preoperative exercise therapy in lung surgery patients: A systematic review

Evaluation of the Effect of the Pre-Operative Exercise Training on Weight Loss, Quality of Life, and Cardiopulmonary Parameter in Bariatric Metabolic Surgery: A Systematic Review and Meta-Analysis

The purpose of this study is to assess the impact of pre-surgery exercise training on cardiopulmonary fitness. Ten articles (six RCTs and four non-RCTs) involving 281 individuals were finally included in the synthesis. Regarding the effect on VO2 peak, overall standardized mean differences were 0.71 (95% CI, 0.31 to 1.11, n = 103) with heterogeneity (I2 = 0%, P = 0.49). For 6MWT, overall weighted mean differences (distance in meters) were 31.87 (95% CI, 27.84 to 35.89, n = 100) with heterogeneity (I2 = 0%, P = 0.96). Engaging in pre-bariatric metabolic surgery exercise training might improve anthropometric parameters and cardiopulmonary fitness with no significant changes in components of quality of life. However, considering high levels of heterogeneity, the results should be generalized cautiously.

Effect of exercise on postoperative recovery of patients with non-small cell lung cancer: a systematic review and meta-analysis

Patients with non-small cell lung cancer (NSCLC) in the postoperative recovery period often experience reduced exercise capacity and impaired lung function, which affects their overall quality of life. This paper investigated the effect of exercise interventions on exercise capacity, lung function, quality of life, and symptoms in these patients.

METHODS

We performed a literature search across Cochrane, Embase, PubMed, Web of Science, and EBSCO databases were comprehensively searched for randomized controlled trials (RCTs) from inception to September 2023, all English RCTs were eligible if they assessed the effects of exercise interventions on postoperative NSCLC patients.

RESULTS

Twelve articles met our inclusion criteria, evidencing that exercise interventions could significantly improve the functional capacity of NSCLC patients in postoperative recovery. Notably, Forced Expiratory Volume in 1 s (FEV1) was improved, indicating enhanced lung function. Furthermore, exercise improved the physical and mental health scores of SF-36, along with increased quadriceps strength and relieved dyspnea. However, fatigue levels were not significantly changed.

CONCLUSIONS

Exercise interventions of NSCLC patients in the postoperative recovery are associated with improved functional capacity, lung function, quality of life, and quadriceps strength, as well as alleviated symptoms of dyspnea. These findings underscore the potential benefits of incorporating exercise into postoperative care for NSCLC patients. Nonetheless, further large-scale RCTs are required to solidify the evidence base on the clinical outcomes of exercise following pneumonectomy.

Telerehabilitation physical exercise for patients with lung cancer through the course of their disease: A systematic review

BACKGROUND AND OBJECTIVE

Evidence is shown for the benefits of physical activity, for patients with lung cancer, at different times through the course of the disease. Telerehabilitation can overcome some of barriers often met by patients to practice physical activity. The objective of this systematic review is to assess feasibility and safety of telerehabilitation for patients with lung cancer, its effects on physical capacity, quality of life, symptoms severity, depression and anxiety, survival, lung function, post-operative outcomes, dyspnoea and body composition. Secondary aim was to distinguish the telerehabilitation efficacy between the different phases of the disease.

DATA SOURCE AND SELECTION CRITERIA

Pubmed, PEDro, Scopus, ScienceDirect, randomized controlled trials and non-randomized controlled trials, written in French or English, of telerehabilitation among patients with lung cancer.

RESULTS

Eight studies were included. Telerehabilitation is safe but was characterized by a low recruitment and attendance rate (<70%). It enhances quality of life, muscle mass, depression and anxiety but it does not improve physical capacity (except in preoperative period), symptoms severity, survival, lung function or dyspnoea. After surgery, it ameliorates quality of life, depression and anxiety. During systemic treatments of lung cancer, it improves quality of life, symptoms severity and muscle mass.

CONCLUSION

Telerehabilitation could be proposed in patients with lung cancer as a complementary intervention of hospital-based programme to increase physical activity volume, compliance and self-efficacy. In case the classic programmes are not possible, it could also be an alternative approach for patients unable to participate to a hospital or community-based training programme.

Physical activity for cancer prehabilitation: A scoping review

This scoping review aims to synthesize the current landscape of physical activity in cancer prehabilitation and identify knowledge gaps. We searched MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE for exercise interventions and observational studies that measured exercise or physical activity before cancer treatment from inception to January 20, 2023. Fifty-one articles from 44 unique studies were reviewed, including 32 intervention and 12 observational studies. Surgery is the only treatment modality that has been investigated. Included studies used heterogeneous exercise interventions and measures for physical activity. Colorectal and other gastrointestinal, lung, and urologic cancers are the most studied cancer types. Exercise intervention in cancer prehabilitation is highly feasible. The evidence for improved fitness, functional, psychosocial, and clinical outcomes is promising yet limited. Although research has increased recently, prehabilitation exercise remains a relatively under-investigated area in oncology. We have provided research directions towards an ideal cancer prehabilitation design in the real-world setting.

Effect of Prehabilitation in Lung Cancer Patients Undergoing Lobectomy: A Review

Deaths from lung cancer are mostly caused by smoking. Cough, dyspnea, fatigue, weight loss, and Horner's syndrome are among the symptoms. Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) are the two categories into which lung cancer may be divided. Because of its effectiveness and lower death rates, lobectomy is the primary line of therapy for benign and early-stage lung illnesses. Pulmonary rehabilitation is a routine treatment for thoracic surgery individuals who are at a high risk to improve functional ability, avoid postoperative deterioration, avoid postoperative deterioration, and reduce complications and even hospital stays. Pulmonary rehabilitation is a multifaceted continuum of services intended to help individuals with pulmonary disease and their families reach and sustain their highest possible degree of independence and community functioning, typically provided by an interdisciplinary team of specialists.  The objective of this research was to gather preliminary information and assess the effects of pre-rehabilitation on those suffering from lung cancer and having lobectomy. The pre-rehabilitation program's outcomes include increased lung functional capacity, enhanced quality of life, patient independence in daily living activities, and a shorter hospital stay. Gradually increasing walking distance over time can build endurance, requiring consistency, pacing, proper hydration, nutrition, and regular breaks. This review analyzed the effect of pre-rehabilitation in lung cancer patients undergoing lobectomy. Pre-rehabilitation program for individuals with lung cancer improves both preoperative and postoperative health through various exercises. Pulmonary rehabilitation is a multidisciplinary approach that encourages physical activity, learning about disease, treatment options, and coping mechanisms. Instead of curing the illness, its goal is to lessen its symptoms and limitations. Patients with pulmonary diseases or undergoing thoracic surgery prefer pre-rehabilitation programs due to their non-traumatic nature and fewer resources required. Elastic resistance band exercises are beneficial for lung cancer patients' pre-rehabilitation by strengthening and stretching muscle groups, improving exercise capacity, and supporting white blood cell counts. These exercises can be customized to individual needs, making them a safe and effective addition to a patient's exercise routine. They have to be carried out at least three days a week. Pulmonary exercise, including the use of a tri-ball pulmonary exerciser or three-ball spirometer, can improve lung function, respiratory muscle strength, and exercise capacity in lung cancer patients. It involves breathing techniques, cough exercises, and inflating a balloon. Pulmonary rehabilitation has a positive impact on patient health. Improved lung vital capacity, shorter hospital stays, and fewer problems following surgery are all achieved with pulmonary rehabilitation. The pre-rehabilitation plan allows the patient to resume their daily routines.

Prehabilitation programs for individuals with cancer: a systematic review of randomized-controlled trials

BACKGROUND

Prehabilitation programs focusing on exercise training as the main component are known as a promising alternative for improving patients' outcomes before cancer surgery. This systematic review determined the benefits and harms of prehabilitation programs compared with usual care for individuals with cancer.

METHODS

We searched CENTRAL, MEDLINE, and EMBASE from inception to June 2022, and hand searched clinical trial registries. We included randomized-controlled trials (RCTs) in adults, survivors of any type of cancer, that compared prehabilitation programs that had exercise training as the major component with usual care or other active interventions. Outcome measures were health-related quality of life (HRQL), muscular strength, postoperative complications, average length of stay (ALOS), handgrip strength, and physical activity levels. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias and the certainty of the evidence.

RESULTS

Twenty-five RCTs (2682 participants) published between 2010 and 2022 met our inclusion criteria. Colorectal and lung cancers were the most common diagnoses. The studies had methodological concerns regarding outcome measurement, selective reporting, and attrition. Five prehabilitation programs were compared to usual care (rehabilitation): combined training, aerobic training, respiratory muscle training plus aerobic training, respiratory muscle training plus resistance training, and pelvic floor training. The studies provided no clear evidence of an effect between groups. We assessed the overall certainty of the evidence as very low, downgraded due to serious study limitations and imprecision.

CONCLUSION

Prehabilitation programs focusing on exercise training may have an effect on adults with cancer, but the evidence is very uncertain. We have very little confidence in the results and the true effect is likely to be substantially different from these. Further research is needed before we can draw a more certain conclusion.

SYSTEMATIC REVIEW REGISTRATION

CRD42019125658.

Prehabilitation: a narrative review focused on exercise therapy for the prevention of postoperative pulmonary complications following lung resection

Extensive preventive strategies in the perioperative period are popular worldwide. Novel "prehabilitation" approaches are being defined for every individual surgical discipline. With intention to reduce perioperative morbidity, "prehabilitation" was developed to increase "physical wellness" considering exercise capacity, nutritional status, and psychological support. Thus, prehabilitation could be well-suited for patients undergoing lung cancer surgery. Theoretically, improving physical condition may increase the chances of having a better post-operative course, especially among frail patients. In this review, we describe the concept of prehabilitation with possible benefits, its role in the Enhanced Recovery After Surgery protocols, and its potential for the future.

Effects of exercise prehabilitation and/or rehabilitation on health-related quality of life and fatigue in patients with non-small cell lung cancer undergoing surgery: A systematic review

BACKGROUND

This systematic review aimed to appraise the current available evidence regarding the effects of exercise prehabilitation and rehabilitation on perceived health-related quality of life (HRQoL) and fatigue in patients undergoing surgery for non-small cell lung cancer (NSCLC).

METHODS

Studies were selected according to Cochrane guidelines and assessed for methodological quality and therapeutic quality (the international CONsensus on Therapeutic Exercise aNd Training (i-CONTENT)). Eligible studies included patients with NSCLC performing exercise prehabilitation and/or rehabilitation and postoperative HRQoL and fatigue up to 90-days postoperatively.

RESULTS

Thirteen studies were included. Exercise prehabilitation and rehabilitation significantly improved postoperative HRQoL in almost half of the studies (47%), although none of the studies demonstrated a decrease in fatigue. Methodological quality and therapeutic quality were poor in respectively 62% and 69% of the studies.

CONCLUSION

There was an inconsistent effect of exercise prehabilitation and exercise rehabilitation on improving HRQoL in patients with NSCLC undergoing surgery, with no effect on fatigue. Due to the low methodological and therapeutic quality of included studies, it was not possible to identify the most effective training program content to improve HRQoL and reduce fatigue. It is recommended to investigate the impact of a high therapeutic qualified exercise prehabilitation and exercise rehabilitation on HRQoL and fatigue in larger studies.

Preoperative respiratory therapy in patients undergoing surgery for lung cancer: A randomized controlled trial

BACKGROUND

A preoperative respiratory therapy treatment was performed to analyze the effectiveness, with respect to postoperative air leak and pain, in patients undergoing surgery for lung cancer.

OBJECTIVES

To analyze air leakage and postoperative pain.

MATERIAL AND METHODS

Seventy one patients were studied, with a mean age of 62.58 years. Descriptive variables of gender, carcinogenic pathology, type of surgical incision and lung resection, use of glue and endostapler, and presence of adhesions were analyzed. Likewise, analysis of the quantitative variables of age, body mass index and forced expiratory volume in 1 s Two homogeneous groups resulted. Differentiated, experimental group (EG) that performed preoperative respiratory therapy and control group (CG).

RESULTS

There were statistically significant differences in favor of the EG with respect to postoperative air leak on days 1-2 during the performance of physiotherapy techniques, the food and during the performance of the exercises autonomously. Furthermore, differences in air leakage were observed on days 2-4 during gait. The number of patients decreased to a greater extent in the EG. Regarding pain, there were statistically significant differences in the sample on days 1-4, with greater intensity of pain in the CG and after doing physiotherapy every day except the second.

CONCLUSIONS

Preoperative respiratory therapy in patients undergoing surgery for lung cancer was effective in reducing the number of patients who presented postoperative air leak and reducing pain in the EG.

Exercise training modalities in patients with lung cancer: a protocol for systematic review and network meta-analysis

INTRODUCTION

Lung cancer is a common malignancy and a major cause of cancer-related deaths worldwide, ranking high in terms of morbidity and prevalence. Exercise is a well-established recovery aid for many chronic respiratory conditions and lung cancer. However, it is difficult to determine the superiority of different exercise training modalities using randomised controlled trials (RCTs) or pairwise meta-analyses. Our Bayesian network meta-analysis (NMA) aimed to compare the impact of different perioperative exercise training modalities on lung function, exercise capacity, adverse events, health-related quality of life and mortality in patients undergoing lung cancer surgery, including preoperative and postoperative patients.

METHODS AND ANALYSIS

We will perform a comprehensive literature search using PubMed, EMBASE, Cochrane Library and Web of Science, from inception to May 2022, to identify studies that potentially provide data regarding exercise training modalities for patients with lung cancer. We will assess the risk of bias according to the Cochrane risk-of-bias tool and certainty of evidence for the main outcomes using the Grading of Recommendations Assessment, Development and Evaluation framework. Pairwise meta-analyses will be conducted using a random effects model and Stata software, and the NMA will be analysed using R software.

ETHICS AND DISSEMINATION

Ethical approval and patient consent were not required because this study was a meta-analysis of published RCTs. The results of this study are submitted to a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42021278923.

Preoperative exercise training for people with non-small cell lung cancer

BACKGROUND

Surgical resection for early-stage non-small cell lung cancer (NSCLC) offers the best chance of cure, but it is associated with a risk of postoperative pulmonary complications. It is unclear if preoperative exercise training, and the potential resultant improvement in exercise capacity, may improve postoperative outcomes. This review updates our initial 2017 systematic review.

OBJECTIVES

1. To evaluate the benefits and harm of preoperative exercise training on postoperative outcomes, such as the risk of developing a postoperative pulmonary complication and the postoperative duration of intercostal catheter, in adults scheduled to undergo lung resection for NSCLC. 2. To determine the effect on length of hospital stay (and costs associated with postoperative hospital stay), fatigue, dyspnoea, exercise capacity, lung function and postoperative mortality.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was from 28 November 2016 to 23 November 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which study participants who were scheduled to undergo lung resection for NSCLC were allocated to receive either preoperative exercise training or no exercise training.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. risk of developing a postoperative pulmonary complication; 2. postoperative duration of intercostal catheter and 3.

SAFETY

Our secondary outcomes were 1. postoperative length of hospital stay; 2. postintervention fatigue; 3. postintervention dyspnoea; 4. postintervention and postoperative exercise capacity; 5. postintervention lung function and 6. postoperative mortality. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

Along with the five RCTs included in the original version, we identified an additional five RCTs, resulting in 10 RCTs involving 636 participants. Preoperative exercise training results in a large reduction in the risk of developing a postoperative pulmonary complication compared to no preoperative exercise training (risk ratio (RR) 0.45, 95% CI 0.33 to 0.61; I2 = 0%; 9 studies, 573 participants; high-certainty evidence). The evidence is very uncertain about its effect on postoperative intercostal catheter duration (MD -2.07 days, 95% CI -4.64 to 0.49; I2 = 77%, 3 studies, 111 participants; very low-certainty evidence). Preoperative exercise training is likely safe as studies reported no adverse events. Preoperative exercise training likely results in a reduction in postoperative length of hospital stay (MD -2.24 days, 95% CI -3.64 to -0.85; I2 = 85%; 9 studies, 573 participants; moderate-certainty evidence). Preoperative exercise training likely increases postintervention exercise capacity measured by peak oxygen consumption (MD 3.36 mL/kg/minute, 95% CI 2.70 to 4.02; I2 = 0%; 2 studies, 191 participants; moderate-certainty evidence); but the evidence is very uncertain about its effect on postintervention exercise capacity measured by the 6-minute walk distance (MD 29.55 m, 95% CI 12.05 to 47.04; I2 = 90%; 6 studies, 474 participants; very low-certainty evidence). Preoperative exercise training may result in little to no effect on postintervention lung function (forced expiratory volume in one second: MD 5.87% predicted, 95% CI 4.46 to 7.28; I2 = 0%; 4 studies, 197 participants; low-certainty evidence).  AUTHORS' CONCLUSIONS: Preoperative exercise training results in a large reduction in the risk of developing a postoperative pulmonary complication compared to no preoperative exercise training for people with NSCLC. It may also reduce postoperative length of hospital stay, and improve exercise capacity and lung function in people undergoing lung resection for NSCLC. The findings of this review should be interpreted with caution due to risk of bias. Research investigating the cost-effectiveness and long-term outcomes associated with preoperative exercise training in NSCLC is warranted.

Physical activity in surgical lung cancer patients: a systematic review

PURPOSE

Perioperative exercise could improve health outcomes of surgical lung cancer patients, but less is known about their natural physical activity (PA) behavior before exercise interventions. This review aimed to synthesize evidence on PA, regarding the following: (1) proportion of patients meeting PA guidelines, (2) amount of PA, (3) PA trajectory following surgery, and (4) correlates of PA before or after surgery.

METHODS

We conducted a systematic review using PubMed, CINHAL, Scopus, and SPORTDiscus (July 2021). Observational or experimental studies that measure PA of lung cancer patients before/after surgery were included. We assessed methodological quality using the NIH Quality Assessment Tools and extracted data using a standardized form.

RESULTS

Seventeen studies (25 articles, N = 1737 participants) published between 2009 and 2021 were included. Fourteen studies had sample sizes less than 100. Thirteen studies were of fair quality and four studies were of good quality. Only 23-28% of patients met PA guideline (150 min/week moderate-vigorous PA) at 6 months-6 years after surgery. Patients took an average of 3822-10,603 daily steps before surgery and 3934-8863 steps at 1-3 months after surgery. Physical activity was lower at 1 day-3 months after surgery, compared with preoperative levels. Perioperative PA was positively associated with exercise capacity, quality of life and reduced postoperative complications.

CONCLUSION

This review suggests that PA is low among surgical lung cancer patients, and it may not recover within 3 months following surgery. Physical activity has the potential to improve postoperative outcomes. However, the existing evidence is weak, and future larger longitudinal studies are needed.

Psychological Interventions Prior to Cancer Surgery: a Review of Reviews

Purpose of Review

Patients with cancer who have high levels of psychological distress have poor treatment compliance and worse outcomes. This “review of reviews” provides a narrative synthesis of the impact of psychological prehabilitation interventions on individuals awaiting cancer surgery.

Recent Findings

Twenty reviews of prehabilitation with psychological interventions were identified. There is a trend towards improved psychological outcomes following intervention, particularly when psychologist-led. However, there was considerable heterogeneity within interventions, outcome measures, and timing of assessment precluding numeric synthesis. Methodological limitations including non-blinding, absence of stratification, and underpowered studies were also pervasive.

Summary

Providing psychological support early in the cancer pathway and prior to surgery has the potential to improve psychological health and outcomes. The application of existing knowledge in psycho-oncology, including distress screening, is needed in the prehabilitation setting. Consistent outcome assessments, accurate reporting of intervention components and delivery methods, and a consideration of effective systems and economical implementation strategies would facilitate advancements in this field.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40140-021-00505-x.

Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis

Background

Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity.

Objective

The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy.

Methods

An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL).

Results

Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores.

Conclusion

This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11122-7.

Barriers and Facilitators in Rehabilitation in Chronic Diseases and After Surgery: Is It a Matter of Adherence?

Although it has been generally acknowledged that participating in rehabilitation programs is better for chronic diseases or post-surgery, the adherence rates of these programs remain lower than expected. According to the World Health Organization (WHO), adherence has been defined as follows: "the extent to which a person's behavior corresponds with agreed recommendations from a healthcare provider." In general, rehabilitation is well investigated, and in chronic diseases like chronic obstructive pulmonary disease (COPD), cardiovascular disease, neuromuscular disease, cancer, and even psychiatric diseases like depression, it has been shown that exercise therapy, in particular, has beneficial effects on morbidity, mortality, and convalescence of these patients. The aim of this review is to give an overview of the barriers and facilitators in rehabilitation practices and possible reasons why adherence rates remain low. Regarding potential future research, barriers and facilitators also need to be taken into account. Despite promising research in the field of preoperative exercise therapy (PET) and preoperative rehabilitation (prehab) and the enormous body of evidence in postoperative rehabilitation or rehabilitation in chronic diseases, it is also needed to take into account the accessibility of these prehab facilities in research and in clinical practice.

Feasibility of a novel mixed-nutrient supplement in a multimodal prehabilitation intervention for lung cancer patients awaiting surgery: A randomized controlled pilot trial

OBJECTIVE

To investigate, in lung cancer patients awaiting elective surgery, the feasibility of delivering a novel four-week multimodal prehabilitation intervention and its effects on preoperative functional capacity and health-related quality of life (HRQoL), compared to standard hospital care.

METHODS

Adult patients awaiting elective thoracotomy for lung cancer stages I, II or IIIa, were approached to participate in an open-label, randomized controlled trial of two parallel arms: multimodal prehabilitation combining a mixed-nutrient supplement with structured supervised and home-based exercise training, and relaxation-strategies (Prehab) or standard hospital care (Control). Feasibility was assessed based on recruitment and adherence rates to the intervention and study outcome assessment. Functional capacity, measured by the 6-min walk test (6MWT), and HRQoL were measured at baseline and after four weeks (preoperative).

RESULTS

Within 5 months, 34 patients were enrolled and randomized (2:1) to Prehab (n = 24; median age = 67 years) or Control (n = 10; median age = 69 years); recruitment rate of 58.6%. The study was interrupted by the COVID-19 pandemic. Adherence to the prescribed intensity of the supervised exercise program was 84.1% (SD 23.1). Self-reported adherence to the home-based exercise program was 88.2% (SD 21) and to the nutritional supplement, 93.2% (SD 14.2). Adherence to patients' preoperative assessment was 82% and 88% in Prehab and Control, respectively. The mean adjusted difference in 4-week preoperative 6MWT between groups was 37.7 m (95% CI, -6.1 to 81.4), p = 0.089. There were no differences in HRQoL between groups.

CONCLUSION

Within a preoperative timeframe, it was feasible to deliver this novel multimodal prehabilitation intervention in lung cancer patients awaiting surgery.

Preoperative Exercise Training to Prevent Postoperative Pulmonary Complications in Adults Undergoing Major Surgery. A Systematic Review and Meta-analysis with Trial Sequential Analysis

Rationale: Poor preoperative physical fitness and respiratory muscle weakness are associated with postoperative pulmonary complications (PPCs) that result in prolonged hospital length of stay and increased mortality.Objectives: To examine the effect of preoperative exercise training on the risk of PPCs across different surgical settings.Methods: We searched MEDLINE, Web of Science, Embase, the Physiotherapy Evidence Database, and the Cochrane Central Register, without language restrictions, for studies from inception to July 2020. We included randomized controlled trials that compared patients receiving exercise training with those receiving usual care or sham training before cardiac, lung, esophageal, or abdominal surgery. PPCs were the main outcome; secondary outcomes were preoperative functional changes and postoperative mortality, cardiovascular complications, and hospital length of stay. The study was registered with PROSPERO (International Prospective Register of Systematic Reviews).Results: From 29 studies, 2,070 patients were pooled for meta-analysis. Compared with the control condition, preoperative exercise training was associated with a lower incidence of PPCs (23 studies, 1,864 patients; relative risk, 0.52; 95% confidence interval [CI], 0.41 to 0.66; grading of evidence, moderate); Trial Sequential Analysis confirmed effectiveness, and there was no evidence of difference of effect across surgeries, type of training (respiratory muscles, endurance or combined), or preoperative duration of training. At the end of the preoperative period, exercise training resulted in increased peak oxygen uptake (weighted mean difference [WMD], +2 ml/kg/min; 99% CI, 0.3 to 3.7) and higher maximal inspiratory pressure (WMD, +12.2 cm H₂O; 99% CI, 6.3 to 18.2). Hospital length of stay was shortened (WMD, -2.3 d; 99% CI, -3.82 to -0.75) in the intervention group, whereas no difference was found in postoperative mortality.Conclusions: Preoperative exercise training improves physical fitness and reduces the risk of developing PPCs while minimizing hospital resources use, regardless of the type of intervention and surgery performed.Systematic review registered with https://www.crd.york.ac.uk/prospero/ (CRD 42018096956).

Effects of multimodal prehabilitation on muscle size, myosteatosis, and dietary intake of surgical patients with lung cancer - a randomized feasibility study

Many patients with lung cancer undergo surgery, which can increase the risk for muscle loss, leading to worsened outcomes. A multimodal prehabilitation intervention integrating dietary and muscle assessment may help clinicians better understand changes in these outcomes. This pilot assessed feasibility of multimodal prehabilitation in early-stage surgical lung cancer patients and explored relationships between body composition, muscle characteristics and dietary intake, as well as muscle changes due to prehabilitation. Patients were randomized to one of two groups: multimodal prehabilitation including nutritional supplements (fish oil with vitamin D3 + whey protein with leucine), exercise and relaxation, or standard of care. Physical function, dietary intake and muscle were evaluated at 0 and 4 weeks pre-operatively. Of 87 patients assessed for eligibility, 34 (39%) were randomized and 3 (9%) were lost to follow-up. Median age was 69 years and baseline protein intake was 1.0 g/kg/d. Adherence to exercise (86%) and supplements was high (93%); 3 patients (16%) reported side effects. Supplements significantly increased protein, omega-3 fatty acid, leucine and vitamin D intake. There were no significant changes in muscle characteristics. Multimodal prehabilitation with dietary and muscle analyses proved to be feasible. An adequately powered randomized controlled trial is warranted. ClinicalTrials.gov registration no: NCT04610606. Novelty: • Multimodal prehabilitation incorporating dietary assessment and muscle analysis is feasible for early-stage surgical lung cancer patients. • An adequately powered randomized controlled trial is warranted to further explore functional and post-operative outcomes.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

Potential effectiveness of a surgeon-delivered exercise prescription and an activity tracker on pre-operative exercise adherence and aerobic capacity of lung cancer patients

OBJECTIVES

Pre-operative exercise may improve functional outcomes for lung cancer patients, but barriers associated with cost, resources, and burden make it challenging to deliver pre-operative exercise programs. The goal of this proof-of-concept study was to determine level of moderate-vigorous physical activity (MVPA) and change in aerobic capacity after participation in a home-based pre-operative exercise intervention.

MATERIALS AND METHODS

Eighteen patients scheduled for surgery for suspected stage I-III lung cancer received an exercise prescription from their surgeon and wore a commercially-available device that tracked their daily MVPA throughout the pre-operative period. Descriptive statistics were used to calculate adherence to the exercise prescription. A one-sample t-test was used to explore change in aerobic capacity from baseline to the day of surgery.

RESULTS

Participants exhibited a mean of 20.4 (sd = 46.2) minutes of MVPA per day during the pre-operative period. On average, the sample met the goal of 30 min of MVPA on 16.4% of the days during the pre-operative period. The mean distance achieved at baseline for the 6-min walk test was 456.7 m (sd = 72.9), which increased to 471.1 m (sd = 88.4) on the day of surgery. This equates to a mean improvement of 13.8 m (sd = 37.0), but this difference was not statistically different from zero (p = 0.14). Eight of the 17 participants (47%) demonstrated a clinically significant improvement of 14 m or more.

CONCLUSION

A surgeon-delivered exercise prescription plus an activity tracker may promote clinically significant improvement in aerobic capacity and MVPA engagement among patients with lung cancer during the pre-operative period, but may need to be augmented with more contact with and support from practitioners over time to maximize benefits.

TRIAL REGISTRATION

The study protocol was registered with ClinicalTrials.gov prior to initiating participant recruitment (NCT03162718).

Exercise Training Decreases Hepatic Injury and Metastases Through Changes in Immune Response to Liver Ischemia/Reperfusion in Mice

BACKGROUND AND AIMS

Liver ischemia/reperfusion injury (IRI) induces local and systemic inflammation in which neutrophil extracellular traps (NETs) are major drivers. IRI markedly augments metastatic growth, which is consistent with the notion that the liver IRI can serve as a premetastatic niche. Exercise training (ExT) confers a sustainable protection, reducing IRI in some animal models, and has been associated with improved survival in patients with cancer; however, the impact of ExT on liver IRI or development of hepatic metastases is unknown.

APPROACH AND RESULTS

Mice were randomized into exercise (ExT) and sedentary groups before liver IRI and tumor injection. Computerized dynamic network analysis of 20 inflammatory mediators was used to dissect the sequence of mediator interactions after ischemia/reperfusion (I/R) that induce injury. ExT mice showed a significant decrease in hepatic IRI and tissue necrosis. This coincided with disassembly of complex networks among inflammatory mediators seen in sedentary mice. Neutrophil infiltration and NET formation were decreased in the ExT group, which suppressed the expression of liver endothelial cell adhesion molecules. Concurrently, ExT mice revealed a distinct population of infiltrating macrophages expressing M2 phenotypic genes. In a metastatic model, fewer metastases were present 3 weeks after I/R in the ExT mice, a finding that correlated with a marked increase in tumor-suppressing T cells within the tumor microenvironment.

CONCLUSIONS

ExT preconditioning mitigates the inflammatory response to liver IRI, protecting the liver from injury and metastases. In light of these findings, potential may exist for the reduction of liver premetastatic niches induced by liver IRI through the use of ExT as a nonpharmacologic therapy before curative surgical approaches.

Effect of Exercise Interventions on Quality of Life in Patients With Lung Cancer: A Systematic Review of Randomized Controlled Trials

PROBLEM IDENTIFICATION

Improving quality of life (QOL) is a key issue for patients with lung cancer. Exercise interventions could positively affect patients' QOL; however, there is no clear-cut understanding of the role of exercise in improving QOL in patients with lung cancer.

LITERATURE SEARCH

The PubMed®, Embase®, Cochrane Library, and Web of Science electronic databases were searched from inception to September 6, 2019.

DATA EVALUATION

16 randomized controlled trials met the inclusion criteria. A qualitative synthesis method was used to identify the effect of exercise interventions on QOL in patients with lung cancer.

SYNTHESIS

This review indicates that exercise interventions may have beneficial effects on the QOL of patients with lung cancer. The effectiveness seems to be affected by the duration of the intervention, as well as exercise frequency, intensity, and adherence.

IMPLICATIONS FOR PRACTICE

Exercise interventions can be integrated into management plans for patients with lung cancer to improve their QOL. Healthcare providers should consider developing optimal exercise prescriptions to maximize the results for this population.

Effects of preoperative nutrition and multimodal prehabilitation on functional capacity and postoperative complications in surgical lung cancer patients: a systematic review

OBJECTIVE

To determine the effect of preoperative nutrition and multimodal prehabilitation on clinical and functional outcomes in surgical lung cancer patients.

METHODS

We searched MEDLINE, Cochrane Library and CENTRAL, EMBASE, Scopus, and clinical trial registries ( clinicaltrials.gov , International Clinical Trials Registry Platform and Google Scholar) to identify studies involving a preoperative nutrition-based intervention or multimodal prehabilitation (nutrition with exercise) of at least 7 days, in lung cancer patients awaiting surgery. Studies must have reported results on at least one of the following outcomes: functional capacity, pulmonary function, postoperative complications, and length of hospital stay. The quality of included studies was assessed using the Cochrane risk of bias assessment tool for randomized trials and the modified Newcastle-Ottawa scale for non-controlled trials.

RESULTS

Five studies were included (1 nutrition-only and 4 multimodal prehabilitation studies). Due to substantial heterogeneity in the interventions across studies, a meta-analysis was not conducted. Findings suggest that multimodal prehabilitation, compared with standard hospital care, is associated with improvements in both functional walking capacity and pulmonary function during the preoperative period; however it does not appear to have an effect on postoperative outcomes. Rather, the finding of significantly lower rates of postoperative complications in the intervention group was unique to the nutrition-only study.

CONCLUSION

Multimodal prehabilitation programs that combine nutrition and exercise may have beneficial effects on various physical function outcomes in patients with lung cancer awaiting surgery. Optimizing preoperative nutrition may have postoperative benefits which remain to be confirmed.

What are the impact and the optimal design of a physical prehabilitation program in patients with esophagogastric cancer awaiting surgery? A systematic review

Background

Substantial postoperative complications occur after tumor resection for esophagogastric cancers. Physical prehabilitation programs aim to prepare patients for surgery by improving their functional status with the aim of reducing postoperative complications. This systematic review aims to summarize the effects of physical prehabilitation programs on exercise capacity, muscle strength, respiratory muscle function, postoperative outcomes, and health-related quality of life and to determine the optimal design of such a program to improve these outcomes in esophagogastric cancer patients undergoing tumor resection.

Methods

A systematic literature review was conducted using PubMed, The Cochrane Library, Scopus, and PEDro databases to identify studies evaluating the effects of physical prehabilitation program on exercise capacity, muscle strength, respiratory muscle function, postoperative complications, length of hospital stay, mortality, and health-related quality of life in patients with esophagogastric cancer awaiting surgery. Data from all studies meeting the inclusion criteria were extracted. The quality of each selected study was determined using the Downs and Black checklist.

Results

Seven studies with 645 participants were included. The preoperative exercise program consisted of respiratory training alone in three studies, a combination of aerobic and resistance training in two studies, and a combination of respiratory, aerobic, and resistance training in two studies. Training frequency ranged from three times a day to twice a week and each session lasted between 20 and 75 min. Four studies were of fair quality and three of good quality. Some studies reported improvements in maximal inspiratory pressure, inspiratory muscle endurance, postoperative (pulmonary) complications, and length of hospital stay in the preoperative exercise group compared to the control group.

Conclusion

This systematic review reports the current evidence for physical prehabilitation programs in patients with esophagogastric cancer awaiting surgery. However, due to the limited number of randomized controlled trials, the significant heterogeneity of exercise programs, and the questionable quality of the studies, higher quality randomized controlled trials are needed.

Trial registration

PROSPERO Registration Number: CRD42020176353.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00260-w.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

A feasibility study of an unsupervised, pre-operative exercise program for adults with lung cancer

OBJECTIVE

The purpose of this study was to explore the feasibility, acceptability and perceived utility of the provision of a wearable fitness device and an exercise prescription from a surgeon, prior to surgery for lung cancer.

METHODS

A single-arm, pre-post feasibility study was conducted with 30 participants scheduled for surgery to treat stage I, II or III lung cancer. Participants were given a Garmin Vivoactive HR device and a prescription for 150 min of moderately to vigorous exercise per week. Participants completed assessments on four occasions and completed a semi-structured interview on two occasions. Descriptive statistics were used to assess the feasibility and acceptability of study procedures, including synchronising the Garmin device and engaging in study assessments.

RESULTS

Seventy-nine per cent of enrolled participants completed the pre-operative study activities. Seventy-one per cent of enrolled participants successfully synchronised their device during the pre-operative period. Data were transmitted from the device to the study team for an average of 70% of the pre-operative days.

CONCLUSION

This pilot study demonstrated the feasibility and acceptability of a pre-operative exercise program for patients scheduled to undergo surgery for lung cancer.

TRIAL REGISTRATION

The study protocol was registered with ClinicalTrials.gov prior to the initiation of participant recruitment (NCT03162718).

Exercise Training in Patients With Non-Small Cell Lung Cancer During In-Hospital Chemotherapy Treatment: A RANDOMIZED CONTROLLED TRIAL

This study aimed to assess the impact of exercise training in patients with lung cancer on several outcomes compared to a control group. Results suggest that exercise programs in patients with lung cancer are a practical and beneficial intervention for enhancing mobility and physical fitness.

Purpose:

The aim of this study was to perform a randomized trial to assess the impact of exercise training in patients with non–small cell lung cancer during chemotherapy on several outcomes in comparison to a control group (CG).

Methods:

The exercise training group (ETG) consisted of 20 patients and the CG consisted of 10 patients. In the ETG, a 4-wk in-hospital exercise training program was performed in 2-wk cycles interspersed with consecutive rounds of chemotherapy with cytostatic drugs. The exercise training program was individualized and included warm-up, respiratory muscle exercise, training on a cycle ergometer or treadmill, and Nordic walking. CG participants were assessed before and after 6 wk of chemotherapy alone.

Results:

Comparing pre- and post-intervention values, the ETG demonstrated an increase in 6-min walk distance (486 ± 92 vs 531 ± 103 m, P = .01). In a battery of physical performance tests: Up and Go Test (6.3 ± 1.0 vs 6.0 ± 1.1 sec, P = .01); chair stand (13.3 ± 2.8 vs 14.3 ± 3.4 repetitions, P = .001); and arm curl (18.4 ± 3.1 vs 20.4 ± 3.5 repetitions, P = .001) all improved significantly. Spirometry values also improved: FEV₁ % predicted (76 ± 16 vs 84 ± 15, P = .01), FVC % predicted (87 ± 14 vs 95 ± 13, P = .01), and FEV₁/FVC (73 ± 13% vs 76 ± 12%, P = .04). The exercise training was well tolerated, without any adverse events due to exercise. There were no significant improvements in the CG.

Conclusions:

This study suggests that planned, individualized, and supervised exercise programs in patients with advanced lung cancer during chemotherapy are a practical and beneficial intervention for enhancing mobility and physical fitness.

Preoperative Evaluation for Thoracic Surgery

Preoperative evaluation before thoracic surgery aims to separate those patients who will tolerate surgery and those who are not surgical candidates. Predicted postoperative pulmonary function testing helps make this distinction. The preoperative period represents a time for patient engagement and physical optimization to improve postoperative outcomes.

Preoperative exercise to improve fitness in patients undergoing complex surgery for cancer of the lung or oesophagus (PRE-HIIT): protocol for a randomized controlled trial

BACKGROUND

Patients with cancer of the lung or oesophagus, undergoing curative treatment, usually require a thoracotomy and a complex oncological resection. These surgeries carry a risk of major morbidity and mortality, and risk assessment, preoperative optimisation, and enhanced recovery after surgery (ERAS) pathways are modern approaches to optimise outcomes. Pre-operative fitness is an established predictor of postoperative outcome, accordingly, targeting pre-operative fitness through exercise prehabilitation has logical appeal. Exercise prehabilitation is challenging to implement however due to the short opportunity for intervention between diagnosis and surgery. Therefore, individually prescribed, intensive exercise training protocols which convey clinically meaningful improvements in cardiopulmonary fitness over a short period need to be investigated. This project will examine the influence of exercise prehabilitation on physiological outcomes and postoperative recovery and, through evaluation of health economics, the impact of the programme on hospital costs.

METHODS

The PRE-HIIT Randomised Controlled Trial (RCT) will compare a 2-week high intensity interval training (HIIT) programme to standard preoperative care in a cohort of thoracic and oesophageal patients who are > 2-weeks pre-surgery. A total of 78 participants will be recruited (39 per study arm). The primary outcome is cardiorespiratory fitness. Secondary outcomes include, measures of pulmonary and physical and quality of life. Outcomes will be measured at baseline (T0), and post-intervention (T1). Post-operative morbidity will also be captured. The impact of PRE-HIIT on well-being will be examined qualitatively with focus groups/interviews post-intervention (T1). Participant's experience of preparation for surgery on the PRE-HIIT trial will also be explored. The healthcare costs associated with the PRE-HITT programme, in particular acute hospital costs, will also be examined.

DISCUSSION

The overall aim of this RCT is to examine the effect of tailored, individually prescribed high intensity interval training aerobic exercise on pre-operative fitness and postoperative recovery for patients undergoing complex surgical resections, and the impact on use of health services.

TRIAL REGISTRATION

The study is registered with Clinical Trials.Gov (NCT03978325). Registered on 7th June 2019.

Perioperative Exercise Therapy in Bariatric Surgery: Improving Patient Outcomes

Nowadays, obesity and related comorbidities like type 2 diabetes, hypertension, dyslipidaemia and obstructive sleep apnoea syndrome are considered one of the medical challenges of the 21st century. Even with the rise of bariatric and metabolic surgery, obesity and metabolic syndrome are reaching endemic proportions. Even in 2020, obesity is still a growing problem. There is increasing evidence that next to bariatric surgery, exercise interventions in the perioperative period could give extra beneficial effects. In this regard, effects on anthropometrics, cardiovascular risk factors and physical fitness. The aim of this review is to summarise effects of preoperative and postoperative exercise, tools for screening and directions for future research and implementations.

Intraoperative oxygen challenge for toleration of single lung ventilation in a patient with severe obstructive airway disease: A case report

Perioperative risk assessment is complex in patients with chronic obstructive pulmonary disease who have undergone previous lung resection surgery. A 70-year-old female with severe chronic obstructive pulmonary disease and previous right middle and lower lobectomy, presented for left lower lobe superior segmentectomy. Respiratory function tests revealed a forced expiratory volume in 1 second of 0.72L, a forced vital capacity of 1.93L, and a carbon monoxide transfer factor of 10.0 ml/min/mmHg. A cardiopulmonary exercise test demonstrated little ventilatory reserve with profound arterial desaturation on peak exercise, however, a normal peak oxygen consumption (16.7 ml/min/kg) and a nadir minute ventilation/carbon dioxide slope of 24 implied a limited risk of perioperative cardiovascular morbidity. Given these conflicting results we performed an intraoperative oxygen challenge test under general anaesthesia with sequential ventilation of different lobes of the lung. We demonstrate the use of the oxygen challenge test as an effective intervention to further assess safety and tolerance of anaesthesia of patients with limited respiratory reserve being assessed for further complex redo lung resection surgery. Further, this test was a risk stratification tool that allowed informed decisions to be made by the patient about therapeutic options for treating their lung cancer. The prognostic value of traditional physiological parameters in patients with chronic obstructive pulmonary disease who have undergone previous lung resection surgery is uncertain. The intraoperative oxygen challenge test is another risk stratification tool to assist clinicians in assessment of safety and tolerance of anaesthesia for patients being considered for lung resection.

Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer

BACKGROUND

Decreased exercise capacity and health-related quality of life (HRQoL) are common in people following lung resection for non-small cell lung cancer (NSCLC). Exercise training has been demonstrated to confer gains in exercise capacity and HRQoL for people with a range of chronic conditions, including chronic obstructive pulmonary disease and heart failure, as well as in people with prostate and breast cancer. A programme of exercise training may also confer gains in these outcomes for people following lung resection for NSCLC. This systematic review updates our 2013 systematic review.

OBJECTIVES

The primary aim of this review was to determine the effects of exercise training on exercise capacity and adverse events in people following lung resection (with or without chemotherapy) for NSCLC. The secondary aims were to determine the effects of exercise training on other outcomes such as HRQoL, force-generating capacity of peripheral muscles, pressure-generating capacity of the respiratory muscles, dyspnoea and fatigue, feelings of anxiety and depression, lung function, and mortality.

SEARCH METHODS

We searched for additional randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 2 of 12), MEDLINE (via PubMed) (2013 to February 2019), Embase (via Ovid) (2013 to February 2019), SciELO (The Scientific Electronic Library Online) (2013 to February 2019), and PEDro (Physiotherapy Evidence Database) (2013 to February 2019).

SELECTION CRITERIA

We included RCTs in which participants with NSCLC who underwent lung resection were allocated to receive either exercise training, which included aerobic exercise, resistance exercise, or a combination of both, or no exercise training.

DATA COLLECTION AND ANALYSIS

Two review authors screened the studies and identified those eligible for inclusion. We used either postintervention values (with their respective standard deviation (SD)) or mean changes (with their respective SD) in the meta-analyses that reported results as mean difference (MD). In meta-analyses that reported results as standardised mean difference (SMD), we placed studies that reported postintervention values and those that reported mean changes in separate subgroups. We assessed the certainty of evidence for each outcome by downgrading or upgrading the evidence according to GRADE criteria.

MAIN RESULTS

Along with the three RCTs included in the original version of this review (2013), we identified an additional five RCTs in this update, resulting in a total of eight RCTs involving 450 participants (180 (40%) females). The risk of selection bias in the included studies was low and the risk of performance bias high. Six studies explored the effects of combined aerobic and resistance training; one explored the effects of combined aerobic and inspiratory muscle training; and one explored the effects of combined aerobic, resistance, inspiratory muscle training and balance training. On completion of the intervention period, compared to the control group, exercise capacity expressed as the peak rate of oxygen uptake (VO₂peak) and six-minute walk distance (6MWD) was greater in the intervention group (VO₂peak: MD 2.97 mL/kg/min, 95% confidence interval (CI) 1.93 to 4.02 mL/kg/min, 4 studies, 135 participants, moderate-certainty evidence; 6MWD: MD 57 m, 95% CI 34 to 80 m, 5 studies, 182 participants, high-certainty evidence). One adverse event (hip fracture) related to the intervention was reported in one of the included studies. The intervention group also achieved greater improvements in the physical component of general HRQoL (MD 5.0 points, 95% CI 2.3 to 7.7 points, 4 studies, 208 participants, low-certainty evidence); improved force-generating capacity of the quadriceps muscle (SMD 0.75, 95% CI 0.4 to 1.1, 4 studies, 133 participants, moderate-certainty evidence); and less dyspnoea (SMD -0.43, 95% CI -0.81 to -0.05, 3 studies, 110 participants, very low-certainty evidence). We observed uncertain effects on the mental component of general HRQoL, disease-specific HRQoL, handgrip force, fatigue, and lung function. There were insufficient data to comment on the effect of exercise training on maximal inspiratory and expiratory pressures and feelings of anxiety and depression. Mortality was not reported in the included studies.

AUTHORS' CONCLUSIONS

Exercise training increased exercise capacity and quadriceps muscle force of people following lung resection for NSCLC. Our findings also suggest improvements on the physical component score of general HRQoL and decreased dyspnoea. This systematic review emphasises the importance of exercise training as part of the postoperative management of people with NSCLC.

Intervention Development Process for a Pragmatic Randomized Controlled Trial: The Thoracic Peri-Operative Integrative Surgical Care Evaluation Trial

BACKGROUND

Use of complementary therapies is high among people with cancer despite research gaps. The Thoracic Peri-Operative Integrative Surgical Care Evaluation (POISE) Trial will evaluate the impact of an integrative care intervention delivered by naturopathic doctors (NDs) in conjunction with usual care for patients undergoing surgery for lung, gastric, and esophageal cancer.

OBJECTIVES

To describe the multistep, multidisciplinary process of defining the integrative care intervention to be used in the Thoracic POISE trial using a principle-based approach that is pragmatic, holistic, safe, feasible, evidence driven, and consensus based.

METHODS

An Intervention Development Committee (IDC) made up of a multidisciplinary team of health care providers (NDs, surgeons, oncologists, nurses, dietitians, physiotherapists, pharmacists, and psychologists), researchers, and patients was established to oversee the process. Potential intervention components were identified through a clinical practice survey and expert opinion. Systematic literature reviews were conducted and scores assigned based on the following criteria: usage, safety, goals, feasibility/scalability, and evidence. The IDC selected an intervention to be piloted that consists of a standard palette including core and optional components. Safety, known risks, and interactions with pharmaceuticals were evaluated using industry and professional monographs, a scoping literature review, and consultations with hospital pharmacists.

RESULTS

The clinical practice survey and expert opinion identified 28 components for consideration. Following literature reviews, scoring, consensus from the IDC, and safety and interaction considerations, an intervention palette consisting of core and optional components was defined. The intervention options vary based on the patient's phase of treatment and symptom-specific needs. The intervention includes supplements, physical recommendations (exercise), nutritional counseling, and psychological support (audio scripts).

CONCLUSION

Through a multistep, multidisciplinary process an integrative care intervention was developed for the Thoracic POISE trial. The intervention will be piloted in a single-arm feasibility study, followed by a single-center randomized controlled trial (RCT), and finally a multicenter RCT.

Impact of preoperative exercise therapy on surgical outcomes in lung cancer patients with or without COPD: a systematic review and meta-analysis

Objectives

This meta-analysis aimed to demonstrate the impact of preoperative exercise therapy on surgical outcomes in patients with lung cancer and COPD. Pulmonary function and muscle capacity were investigated to explore their potential links with outcome improvements after exercise.

Methods

Articles were searched from PubMed, Embase, and the Cochrane Library with criteria of lung cancer patients with or without COPD, undergoing resection, and receiving preoperative exercise training. Key outcomes were analyzed using meta-analysis.

Results

Seven studies containing 404 participants were included. Patients receiving preoperative exercise training had a lower incidence of postoperative pulmonary complications (PPCs; OR 0.44, 95% CI 0.27-0.71) and shorter length of hospital stay (standardized mean difference -4.23 days, 95% CI -6.14 to -2.32 days). Exceptionally, pneumonia incidence remained unchanged. Patients with COPD could not obviously benefit from exercise training to reduce PPCs (OR 0.44, 95% CI 0.18-1.08), but still might achieve faster recovery. No significant difference in pulmonary function was observed between the two groups. However, 6MWD and VO₂ peak were significantly improved after exercise training.

Conclusion

Preoperative exercise training may reduce PPCs for lung cancer patients. However, for patients with COPD undergoing lung cancer resection, the role of exercise is uncertain, due to limited data, which calls for more prospective trials on this topic. Rehabilitation exercise strengthens muscle capacity, but does not improve impaired pulmonary function, which emphasizes the possible mechanism of the protocol design.

Home-Based Exercise Prehabilitation During Preoperative Treatment for Pancreatic Cancer Is Associated With Improvement in Physical Function and Quality of Life

Purpose: To investigate relationships among physical activity, changes in physical function, and health-related quality of life (HRQOL) among patients with pancreatic adenocarcinoma enrolled in a home-based exercise prehabilitation program. Methods: Patients with resectable pancreatic adenocarcinoma receiving preoperative chemotherapy and/or chemoradiation were enrolled on this prospective, single-arm trial and were advised to perform ≥60 minutes each of moderate-intensity aerobic exercise and strengthening exercise weekly. Activity was measured via self-report and accelerometers, including moderate-to-vigorous physical activity (MVPA), light physical activity (LPA), and sedentary activity (SA). Physical function measures at baseline and restaging follow-up included 6-minute walk test (6MWT), 5 times sit-to-stand (5×STS), handgrip strength (HGS), 3-m walk for gait speed (GS), and the PROMIS Physical Function Short Form. HRQOL was measured via the FACT-Hep questionnaire. Results: Fifty participants with mean age 66 years (standard deviation = 8 years) were enrolled. The 6MWT, 5×STS, and GS significantly improved from baseline to restaging follow-up (P=.001, P=.049, and P=.009, respectively). Increases in self-reported aerobic exercise, weekly MVPA, and LPA were associated with improvement in 6MWT (β=.19, P=.048; β=.18, P=.03; and β=.08, P=.03, respectively) and self-reported physical functioning (β=.02, P=.03; β=.03, P=.005; and β=.01, P=.02, respectively). Increased weekly LPA was associated with increased HRQOL (β=.03, P=.02). Increased SA was associated with decreased HRQOL (β=-.02,P=.01). Conclusions: Patients with potentially resectable pancreatic cancer exhibit meaningful improvement in physical function with prehabilitation; physical activity was associated with improved physical function and HRQOL. These data highlight the importance of physical activity during treatment for pancreatic cancer.

Precision-Exercise-Prescription in patients with lung cancer undergoing surgery: rationale and design of the PEP study trial

INTRODUCTION

Lung cancer is a significant burden on societies worldwide, and the most common cause of death in patients with cancer overall. Exercise intervention studies in patients with lung cancer have consistently shown benefits with respect to physical and emotional functioning. However, to date, exercise training has not been consistently implemented into clinical practice given that interventions have been costly and not aligned with clinical care.

METHODS/DESIGN

The Precision-Exercise-Prescription (PEP) study is a prospective randomised controlled trial comparing the effectiveness and feasibility of a personalised intervention exercise programme among patients with lung cancer undergoing surgery. Two-hundred patients who are diagnosed with stage primary or secondary lung cancer and are eligible to undergo surgical treatment at Huntsman Cancer Institute comprise the target population. Patients are randomised to either the (1) outpatient precision-exercise intervention group or (2) delayed intervention group. The intervention approach uses Motivation and Problem Solving, a hybrid behavioural treatment based on motivational interviewing and practical problem solving. The dosage of the exercise intervention is personalised based on the individual's Activity Measure for Post-Acute-Care outpatient basic mobility score, and incorporates four exercise modes: mobility, callisthenics, aerobic and resistance. Exercise is implemented by physical therapists at study visits from presurgery until 6 months postsurgery. The primary endpoint is the level of physical function assessed by 6 min walk distance at 2 months postsurgery. Secondary outcomes include patient-reported outcomes (eg, quality of life, fatigue and self-efficacy) and other clinical outcomes, including length of stay, complications, readmission, pulmonary function and treatment-related costs up to 6 months postsurgery.

ETHICS/DISSEMINATION

The PEP study will test the clinical effectiveness and feasibility of a personalised exercise intervention in patients with lung cancer undergoing surgery. Outcomes of this clinical trial will be presented at national and international conferences and symposia and will be published in international, peer-reviewed journals. Ethics approval was obtained at the University of Utah (IRB 00104671).

TRIAL REGISTRATION NUMBER

NCT03306992.

[Effect of A High Intensive Preoperative Rehabilitation on the Perioperative Complications in Patients with Chronic Obstructive Pulmonary Disease Eligible for Lung Cancer Surgery]

背景与目的

慢性阻塞性肺病(chronic obstructive pulmonary diseases, COPD)降低患者心肺功能，可导致患者围手术期风险增加。本研究拟探讨术前短期高强度肺康复训练对肺癌合并COPD患者肺功能及术后并发症的影响。

方法

分析2016年6月-2016年12月101例肺癌合并COPD患者的临床资料，其中肺康复训练组43例，常规治疗组58例，比较两组患者肺功能、术后肺部并发症、住院时间等指标，同时比较肺康复训练组训练前后肺功能相关指标。

结果

两组患者术前一般资料及肺功能无显著差异，康复训练组住院时间更长[(17.23±4.18) d vs (14.41±4.03) d]，但术后住院时间与常规治疗组无显著差异[(8.93±3.78) d vs (9.62±3.98) d]，两组患者术后肺部感染[8例(18.6%) vs 17例(29.3%)]、肺不张[1例(2.3%) vs 1例(1.7%)]、呼吸衰竭[1例(2.3%) vs 2例(3.4%)]等无显著差异。肺康复训练组训练前后FEV₁[(2.06±0.45) L vs (2.15±0.45) L, P < 0.001]、PEF[(4.32±0.90) L/s vs (5.15±1.05) L/s, P < 0.001]、PCO₂[(42.42±2.79) mmHg vs (41.58±2.98) mmHg, P=0.009]改善明显，按亚组分析，康复训练后中-重度COPD亚组FEV₁[(0.16±0.05) L (8.6%) vs (0.06±0.05) L (2.8%)]增加值较轻度COPD亚组更明显。

结论

术前短期肺康复训练可改善肺癌合并COPD患者肺功能，其中中-重度COPD患者肺功能改善更明显。

[Effect of A High Intensive Preoperative Rehabilitation on the Perioperative Complications in Patients with Chronic Obstructive Pulmonary Disease Eligible for Lung Cancer Surgery]

BACKGROUND

Chronic obstructive pulmonary disease (COPD) will reduce the cardiopulmonary function and increase perioperative risk. The aim of this study is to investigate the effect of preoperative short-term high intensity lung rehabilitation training on lung function and postoperative complications in patients with COPD who are eligible for lung cancer surgery.

METHODS

We analysis of 101 patients with COPD and a diagnosis of lung cancer, with 43 patients in pulmonary rehabilitation group and 58 patients in conventional group. The pulmonary function, postoperative pulmonary complications (PPCs) and length of stay (LOS) will be compared between the two groups, the lung function will be compared before and after the rehabilitation at the same time.

RESULTS

There were no significant difference between the two groups in general information, lung function before surgery, postoperative pulmonary infection [8 (18.6%) vs 17 (29.3%)], atelectasis [1 (2.3%) vs 1 (1.7%)], respiratory failure [1 (2.3%) vs 2 (3.4%)] and postoperative LOS [(8.93±3.78) d vs (9.62±3.98) d, P>0.05]. In the rehabilitation group, the FEV1 [(2.06±0.45) L vs (2.15±0.45) L, P<0.001] and PEF [(4.32±0.90) L/s vs (5.15±1.05) L/s, P<0.001) were higher, and PCO2 [(42.42±2.79) mmHg vs (41.58±2.98) mmHg, P=0.009] was lower after rehabilitation, significantly. The increase value of FEV1 in moderate to severe COPD group was higher than that of the mild COPD group after the rehabilitation [(0.16±0.05) L, 8.6% vs (0.06±0.05) L, 2.8%, P<0.001).

CONCLUSIONS

The short-term highly-intensity lung rehabilitation can improve lung function in lung cancer patients with COPD, and the improvement of pulmonary function in moderate to severe COPD patients is more obviously.

Enhanced recovery after pulmonary surgery

The concept of surgical recovery encompasses the entire perioperative phase of the patient, beginning with the preoperative baseline and culminating in the long-term rehabilitation of the patient in the post-operative phase. Enhanced recovery pathways (ERPs) aim to encompass all phase of the patient trajectory, including the preoperative, perioperative, and postoperative management of surgical patients. While significant literature exists on standardizing and optimizing the perioperative phase, standardizing the pre and post-operative phases remains a topic of debate. Furthermore, with regards to pulmonary surgery, the available data on enhanced recovery remains limited, with no consensus on which components to include within the ERP. The difficulty in identifying specific factors to include within a pathway is in part due to the lack of representative metrics of recovery. Secondly, the strength of ERPs usually lies in the agglomeration of multiple components rather than the individual components themselves. This review provides a brief review on current developments in ERPs in pulmonary surgery, emphasizing novel components in the pre and post-operative care of patients. Furthermore, we discuss the limitations of current metrics used to study recovery, and what steps can be taken to direct future studies that aim to enhance patient recovery after pulmonary surgery.

Implementing a thoracic enhanced recovery with ambulation after surgery program: key aspects and challenges

Enhanced recovery after surgery (ERAS) protocols aim to improve operative outcomes by focusing on perioperative care, including early mobilization, limitation of narcotics, and maintenance of fluid balance. We implemented a T-ERA^AS (Thoracic-Early Recovery with Ambulation After Surgery) protocol which focused on early ambulation, with the rationale that a patient's mobility may be a reproducible and measurable metric for their overall status-pain control, respiratory function, cardiac function, and patient satisfaction. We set a benchmark distance of 250 feet for our early ambulation goal and redefined "early" as within the first hour post extubation. We describe some of the major aspects to our program as well as some of the challenges and successes during our 8-year experience following the implementation of this program.

Exercise prehabilitation in elective intra-cavity surgery: A role within the ERAS pathway? A narrative review

The Enhanced Recovery after Surgery (ERAS) model integrates several elements of perioperative care into a standardised clinical pathway for surgical patients. ERAS programmes aim to reduce the rate of complications, improve surgical recovery, and limit postoperative length of hospital stay (LOHS). One area of growing interest that is not currently included within ERAS protocols is the use of exercise prehabilitation (PREHAB) interventions. PREHAB refers to the systematic process of improving functional capacity of the patient to withstand the upcoming physiological stress of surgery. A number of recent systematic reviews have examined the role of PREHAB prior to elective intra-cavity surgery. However, the results have been conflicting and a definitive conclusion has not been obtained. Furthermore, a summary of the research area focussing exclusively on the therapeutic potential of exercise prior to intra-cavity surgery is yet to be undertaken. Clarification is required to better inform perioperative care and advance the research field. Therefore, this "review of reviews" provides a critical overview of currently available evidence on the effect of exercise PREHAB in patients undergoing i) coronary artery bypass graft surgery (CABG), ii) lung resection surgery, and iii) gastrointestinal and colorectal surgery. We discuss the findings of systematic reviews and meta-analyses and supplement these with recently published clinical trials. This article summarises the research findings and identifies pertinent gaps in the research area that warrant further investigation. Finally, studies are conceptually synthesised to discuss the feasibility of PREHAB in clinical practice and its potential role within the ERAS pathway.

Impact of prehabilitation on morbidity and mortality after pulmonary lobectomy by minimally invasive surgery: a cohort study

Background

Thoracic surgery is currently the optimal treatment for non-small cell lung cancer (NSCLC). However, it may be responsible for numerous postoperative complications and is often used in patients with multi co morbidities. In recent years, the optimization of a patient's physical capacity before surgery has been the subject of several studies. The objective of this study was to determine whether participation in a prehabilitation program would improve outcomes after surgery and lower morbidity according to the Clavien-Dindo classification.

Methods

This retrospective cohort study was performed between 1st January 2014 and 31st January 2016 at Rouen University Hospital. All adult patients with NSCLC (IIIa or <) who had pulmonary lobectomy by minimally invasive surgery and cardiopulmonary exercise testing [CPET (VO2max ≤20 mL/min/kg)] were included.

Results

The cohort included 38 patients. Two groups were formed: one group with prehabilitation (n=19) and one group without prehabilitation (n=19). Four patients were not included leaving 34 patients for the final analysis. Most patients with a Clavien-Dindo grade of ≤2 had received prehabilitation compared to patients who had not received prehabilitation, respectively 17/19 vs. 8/15; P=0.0252. Patients who had received prehabilitation had fewer postoperative complications than patients who had not received prehabilitation, respectively 8/19 vs. 12/15; P=0.0382.

Conclusions

We have shown that prehabilitation has a positive impact on the occurrence and severity of postoperative complications after pulmonary lobectomy by minimally invasive surgery. Further studies conducted in larger populations are warranted to confirm these results.

Inspiratory muscle training is effective to reduce postoperative pulmonary complications and length of hospital stay: a systematic review and meta-analysis

PURPOSE

This study systematically review and meta-analyse the effectiveness of inspiratory muscle training (IMT) to reduce postoperative pulmonary complications (PPC) and length of hospital stay (LOS), both in the preoperative and/or postoperative periods of cardiac, pulmonary, and abdominal surgical patients. Sensitive analysis was performed to examine which patients benefit more from IMT according to methodological features (quality of studies and sample size), patient's characteristics (pulmonary risk stratification, age, and body mass index), type of surgery, period of training, and training protocols (training doses and level of supervision).

METHODS

The literature search was made in the electronic databases PubMed®, EBSCO, Web of Science^®, PEDro and Scopus^®. Only randomized controlled trials were included. Data extraction, quality assessment and meta-analysis were performed.

RESULTS

We included 17 randomized controlled trials in the systematic review, of which, 12 were included for the PPC meta-analysis and 11 for the LOS meta-analysis. IMT significantly reduced the risk of PPC (Risk Ratio (RR) = 0.50, 95%CI: 0.39, 0.64, I²=0.0%), and a decrease in LOS (Mean Difference = -1.41, 95%CI: -2.07, -0.75, I² = 0.0%).

CONCLUSION

IMT is effective to reduce PPC and LOS in patients undergoing surgery. Implications for Rehabilitation Physiotherapy interventions with inspiratory muscle training (IMT) are effective to reduce postoperative pulmonary complications (PPC) and length of hospital stay (LOS) after major surgery, and should start preoperatively. Rehabilitation with IMT is beneficial at all ages and risk levels, but older and high-risk patients benefit more, as well as pulmonary surgery patients. IMT is more effective if it is supervised, and prescription target at least two-week period, sessions with more than 15 minutes, with imposed load increment, and adding other exercise modes.