PREhabilitation – Preparing the Patient for Surgery
Priya Brahmbhatt1,2, RKin & Rachel Aitken1,2, RKin
1) Faculty of Kinesiology and Physical Education, University of Toronto;
2) Cancer Rehabilitation and Survivorship, Princess Margaret Cancer Centre
Preparing one’s body for the stresses of surgery through exercise is known as prehabilitation and has been widely shown to improve pre- and postoperative wellbeing1. Prehabilitation is important because physical fitness strongly predicts outcomes related to surgery2. Analogous to training before a marathon or another challenging sporting event, prehabilitation prepares patients for surgery and capitalizes on the waiting period between diagnosis and surgery – a time when patients may be in better health and able to invest in their health and postoperative wellbeing.
Several reviews of scientific studies report favourable outcomes for patients that train preoperatively compared to their sedentary counterparts. Compared to non-exercising controls, prehabilitation participants generally show significant improvements in physical and psychosocial wellbeing immediately prior to surgery3. Those who prehabilitate also experience lower postoperative complication rates and shorter hospital lengths of stay2-4 that may subsequently impact healthcare utilization costs. Prehabilitated patients also tend to have quicker recoveries to preoperative levels of health and better self-reported functional performance2.
Exercise-based prehabilitation interventions should include both whole-body conditioning and locoregional training of the areas susceptible to surgical injury. These modalities work in a complementary fashion to address the systemic deconditioning and local impairments or demands associated with surgical recovery, respectively. For instance, aerobic exercise is important given the relationship between cardiorespiratory fitness (e.g. VO2 peak or anaerobic threshold) and surgical outcomes such as functional capacity, pain, quality of life, hospital length of stay, and postoperative complications2,3. On the other hand, preparing tissues directly affected by surgery or required during recovery can ease the burden of post-operative rehabilitation. For example, training the contralateral limb or upper extremities to support assisted ambulation after a knee replacement; or, training the pelvic floor to sustain trauma incurred during prostate cancer surgery that often leads to urinary incontinence. Designing an appropriately tailored prehabilitation program requires a thorough understanding of the risks and stresses posed by the surgery, in alignment with postoperative rehabilitation paradigms and patient goals.
While most studies thus far have examined the role of exercise-based prehabilitation, a growing number of studies have explored a more holistic approach through the inclusion of psychological support, nutritional and smoking cessation counselling5,6. Furthermore, patients undergoing other forms of treatment, such as radiation or pharmacologic therapy, may also benefit from pretreatment conditioning; however, research in these areas remains nascent. Future research is needed to better understand whether prehabilitation can exploit a ‘teachable moment’ and lead to chronic health behaviour change to reduce the risk of other injuries or chronic disease.
Given the novelty of this field, more methodologically rigorous research is warranted as optimal training regimes, as well as program frameworks and implementation methods, remain unknown. Nevertheless, the sizeable body of literature on prehabilitation suggests that significant benefits can be obtained with preoperative exercise interventions. Development of appropriate programming specific to the unique needs of distinct patient populations is likely crucial to the success of the prehabilitation intervention. While prehabilitation programs have been shown to be safe, including for those awaiting intensive cardiac surgeries7, medical clearance may be necessary for higher risk populations.
1. Carli F, Zavorsky GS. Optimizing functional exercise capacity in the elderly surgical population. Current Opinion in Clinical Nutrition & Metabolic Care. 2005 Jan 1;8(1):23-32.
2. Moran J, Guinan E, McCormick P, Larkin J, Mockler D, Hussey J, Moriarty J, Wilson F. The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: a systematic review and meta-analysis. Surgery. 2016 Nov 30;160(5):1189-201.
3. 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 30;100(3):196-207.
4. Valkenet K, van de Port IG, Dronkers JJ, de Vries WR, Lindeman E, Backx FJ. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clinical rehabilitation. 2011 Feb;25(2):99-111.
5. Bolshinsky V, Li MH, Ismail H, Burbury K, Riedel B, Heriot A. Multimodal Prehabilitation Programs as a Bundle of Care in Gastrointestinal Cancer Surgery: A Systematic Review. Diseases of the Colon & Rectum. 2018 Jan 1;61(1):124-38.
6. Minnella EM, Awasthi R, Gillis C, Fiore JF, 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 31;160(4):1070-9.
7. 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. Clinical rehabilitation. 2014 Jul;28(7):648-57.