Keywords:
Prehabilitation, prehab, preoperative rehabilitation
Prehabilitation is a new term for preoperative rehabilitation
before major surgery [1]. Some authors use the short form '
Prehab',
though it is not so widely used. Prehabilitation involves
measures to improve the physical, physiological, metabolic and
psychosocial reserves in preparation for an elective surgery
[2]. This involves exercise, nutrition, education and
psychosocial interventions.
It has been found that even in the absence of complications,
there is significant reduction in functional capacity after
major abdominal surgery [3]. This may be more in frail elderly
individuals, which may take even months to revert to
preoperative levels and that too partially [4]. Impaired
functional capacity documented by preoperative cardiopulmonary
exercise testing as reduced oxygen uptake at anaerobic
threshold and elevated ventilatory equivalent for carbon
dioxide is associated with all cause mortality after major
abdominal surgery. Cardiopulmonary exercise testing can
identify high risk patients more than clinical risk factors
alone [5].
Earlier, the stress was on post operative rehabilitation to
improve recovery. But now the focus has shifted to
prehabilitation prior to scheduled surgery, which utilizes the
usual waiting period for surgery in most major centers. One of
the early reviews on prehabilitation found data on 275 elderly
patients undergoing abdominal or cardiac surgeries [6]. They
recommended a 3 month progressive exercise prehabilitation
program at 45-65% of maximum predicted heart rate along with
periodic high intensity interval training. Extra intake of
carbohydrate prior to exercise sessions and mixed protein and
carbohydrate intake shortly after the session were included.
Prehabilitation was found to reduce postoperative
complications and hospital stay, improved quality of life and
reduced decline in functional capacity.
Multimodal prehabilitation can involve nutritional counseling,
protein supplementation and anxiety reduction in addition to
exercise programs. A pilot study with one month trimodal
prehabilitation showed improved functional recovery [7].
Analysis of data from 185 participants with colorectal cancer
included in a pilot study and two randomized controlled trials
from 2010 to 2015 has been recently published [8]. Functional
capacity was assessed with six minute walk test and changes
before surgery, at four weeks and eight weeks after surgery
were determined. An increase in six minute walk distance of at
least 19 m was taken as clinically significant. Endurance
exercise training sessions of 20-30 minutes were given on
three days a week. Resistance exercise involving major muscle
groups was given two times per week. Sessions were preceded by
warm up sessions and concluded with cooling down activities.
Nutritional supplementation included total protien intake of
1.5 g/Kg/day. Prehabilitation was started 4 weeks prior and
continued for two months after surgery. Control group received
trimodal rehabilitation program after surgery and discharge
from the hospital. Significant improvement in preoperative
physical fitness was documented in the prehabilitation group.
There was a decrease in physical status at 4 weeks post
surgery in both groups, but reduction was significantly higher
in the control group. At eight weeks, the change in functional
capacity was significantly higher in the study group. No
adverse events were reported due to the multimodal
prehabilitation, though compliance with the program was lower
in the post operative period compared to preoperative period.
This data set did not show any difference in the length of
hospital stay or postoperative complications.
Patients with poor baseline walking capacity are the ones with
generally higher risk. But these are exactly the persons who
are more likely to benefit from prehabilation programs [9]. A
subgroup analysis of 106 participants included 36 patients
with a six minute walking test distance of less than 400 m and
70 who could walk over 400 m. Patients with lower baseline
fitness had greater improvement in functional walking capacity
with prehabilitation. At 4 weeks after surgery, those with
lower baseline fitness were more likely to have recovered to
their baseline walking distance than those with higher fitness
(74% vs 50%, P = 0.029). This is akin to the well known dictum
in medicine that any treatment intervention is likely to give
more benefit in those at higher risk.
All these data on benefits of prehabilitation have come from
abdominal surgeries. But the data on orthopedic surgery where
more number of studies have been conducted is a bit
disappointing. A recent systematic review identified 17
studies which met their quality criteria [10]. Of these 13
studies were in orthopedics, mainly knee or hip arthroplasty
for osteoarthritis. They found no evidence that
prehabilitation provides better function, pain relief or
quality of life in those who had arthroplasty for
osteoarthritis. But prehabilitation of more than 500 minutes
may reduce acute rehabilitation admissions after surgery. They
found that the evidence is insufficient to give
recommendations on benefits of prehabilitation in other
surgical groups.
Preliminary data on the feasibility of rehabiliation prior to
coronary artery bypass graft surgery has demonstrated that
none of the 15 patients developed cardiac symptoms during
study participation [11]. There was an increase in the six
minute walking distance and an improvement in the gait speed.
Enrollment in cardiac rehabilitation program three months
after surgery was also higher in the prehabiliation group
(100% vs 43% in the control group, p<0.05).
Though prehabilitation programs are generally risk free, being
conducted in well equipped centers with adequate preassessment
and a tailored program, a systematic review of 21 studies
noted two adverse events in 669 exercising participants [12].
To conclude, prehabilitation is certainly worth a trial if
time and resources permit, more so in certain abdominal
surgeries which can wait till prehabilitation is completed.
Larger well planned randomized studies are needed to place
prehabilitation in its actual perspective. Role of shorter
term prehabilitation has also to be assessed as adequate time
may not be available for prehabilitation in most scenarios.
References
1. Fleisher LA. The Value of Preoperative Assessment Before
Noncardiac Surgery in the Era of Value-Based Care.
Circulation. 2017;136:1769-1771.
2. Santa Mina D, Scheede-Bergdahl C, Gillis C, Carli F.
Optimization of surgical outcomes with prehabilitation. Appl
Physiol Nutr Metab. 2015 Sep;40(9):966-9.
3. Christensen T, Bendix T, Kehlet H. Fatigue and
cardiorespiratory function following abdominal surgery. Br J
Surg. 1982 Jul;69(7):417-9.
4. Lawrence VA, Hazuda HP, Cornell JE, Pederson T, Bradshaw
PT, Mulrow CD, Page CP. Functional independence after major
abdominal surgery in the elderly. J Am Coll Surg. 2004
Nov;199(5):762-72.
5. Wilson RJ, Davies S, Yates D, Redman J, Stone M. Impaired
functional capacity is associated with all-cause mortality
after major elective intra-abdominal surgery. Br J Anaesth.
2010 Sep;105(3):297-303.
6. Carli F, Zavorsky GS. Optimizing functional exercise
capacity in the elderly surgical population. Curr Opin Clin
Nutr Metab Care. 2005 Jan;8(1):23-32.
7. Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS,
Kaneva P, Augustin B, Wongyingsinn M, Gamsa A, Kim DJ,
Vassiliou MC, Feldman LS. Impact of a trimodal prehabilitation
program on functional recovery after colorectal cancer
surgery: a pilot study. Surg Endosc. 2013 Apr;27(4):1072-82.
8. Minnella EM, Bousquet-Dion G, Awasthi R, Scheede-Bergdahl
C, Carli F. Multimodal prehabilitation improves functional
capacity before and after colorectal surgery for cancer: a
five-year research experience. Acta Oncol. 2017
Feb;56(2):295-300.
9. Minnella EM, Awasthi R, Gillis C, Fiore JF Jr, Liberman AS,
Charlebois P, Stein B, Bousquet-Dion G, Feldman LS, Carli F.
Patients with poor baseline walking capacity are most likely
to improve their functional status with multimodal
prehabilitation. Surgery. 2016 Oct;160(4):1070-1079.
10. Cabilan CJ, Hines S, Munday J. The effectiveness of
prehabilitation or preoperative exercise for surgical
patients: a systematic review. JBI Database System Rev
Implement Rep. 2015 Jan;13(1):146-87.
11. Sawatzky JA, Kehler DS, Ready AE, Lerner N, Boreskie S,
Lamont D, Luchik D, Arora RC, Duhamel TA. Prehabilitation
program for elective coronary artery bypass graft surgery
patients: a pilot randomized controlled study. Clin Rehabil.
2014 Jul;28(7):648-57.
12. Santa Mina D, Clarke H, Ritvo P, Leung YW, Matthew AG,
Katz J, Trachtenberg J, Alibhai SM. Effect of total-body
prehabilitation on postoperative outcomes: a systematic review
and meta-analysis. Physiotherapy. 2014 Sep;100(3):196-207.