Prehabilitation before surgery
The application of systematic physical exercise to improve postoperative outcomes was first mentioned in the 1940s by the British Army in an attempt to improving the poor condition of the soldiers due to war, malnutrition and poor living habits.
More than 12,000 men went through the program in 1946, and 85% of those had improved remarkably in physical and intellectual capacities. However, it was not until the 1980s that the concept of prehabilitation regained interest.
This point of view article discusses best practice and relevant outcomes.
Physical activity is identified as the major component of all prehabilitation programs. Nevertheless, a clear conceptual model for treatment components and exercise progression is lacking.
More recently, there is increasing support for broader prehabilitation programs, where the core components are physical activity as well as nutritional care and psychological strategies. Prehabilitation has also been identified as a window of opportunity to change health behavior.
Specific exercise, such as pelvic floor muscle training before prostatectomy (a) or respiratory muscle training (b) before abdominal or cardiothoracic surgery have been implemented, with significant outcomes on long term incontinence (a), and preventing pulmonary complications, reduced time to extubation, reduced mortality and length of hospital stay (b).
For orthopaedic interventions, evidence for prehabilitation is the strongest for ACL ruptures, with a focus on reducing deficits in knee extension and quadriceps strength. Evidence for prehabilitation before total hip of knee arthroplasty as well as spinal surgery is less convincing.
Anxiety and fear about the outcome of surgery are commonly reported in patients, and an increasing number of prehabilitation programs therefore combine physical activity with psychological strategies.
The methodological quality of prehabilitation studies is found to be low. Exciting results are difficult to obtain with a one-size-fits-all program, or with small sample sizes.
In order to move forward, the field requires:
- Innovative thinking (i.e., Boden et al. showed how a single physiotherapy session before abdominal surgery can reduce pulmonary complications by half)
- Sound risk stratification (specifically targeting people with low physical function, sarcopenia or self-efficacy)
- Person-centered interventions (educational materials, multi-modal and lifestyle)
Additional training in behaviour change strategies would help facilitate this expanded role of physiotherapists.
Expert opinion by Liesbeth Raymakers
Prehabilitation may not be a new arena ? but we need to take action to disentangle the effectiveness of programs now applied in the clinical context.
Not everything we deem relevant is significantly effective. How could we better apply the skills we have in order to improve better health for patients planned for surgery?
> From: Lundberg et al., Phys Ther (2018) (Epub ahead of print). All rights reserved to the American Physical Therapy Association. Click here for the online summary.
