Prehabilitation: high-quality evidence is still required

Changing the narrative for exercise-based prehabilitation: Evidence-informed and shared decision making when discussing the need for a total knee arthroplasty with patients

Objective

To examine a novel application of exercise-based prehabilitation in severe knee osteoarthritis-termed "pre-evaluation exercise"-focused on supporting surgical decision-making and adherence to clinical guidelines, rather than attempting to enhance post-operative recovery.

Design

This narrative review discusses the usage of exercise in the clinical decision process for total knee arthroplasty (TKA). It synthesizes data from studies on exercise-based prehabilitation, covering patient selection, implementation, and its effects on surgical choices. Emphasis is placed on multi-disciplinary coordination within an Enhanced Recovery After Surgery (ERAS) framework.

Results

Evidence suggests that pre-evaluation exercise can improve symptom management and may lead to delayed or reduced surgical intervention. This approach shows significant potential in reducing the rate of TKA surgeries among patients with severe knee osteoarthritis by improving physical conditioning, addressing symptom variability, and enhancing informed, patient-centered surgical decisions.

Conclusions

Pre-evaluation exercise in knee osteoarthritis is a viable strategy that complements existing ERAS initiatives by facilitating guideline-conformant surgical decision-making. Incorporating this into pre-surgical care pathways can foster improved patient-related outcomes and healthcare resource optimization.

New Approaches to the Treatment of Severe Obesity-Prehabilitation as the Key to Success

PURPOSE OF REVIEW

Bariatric surgery (BS) has emerged as a crucial and effective treatment for severe obesity (SO), providing significant and sustained weight loss and improving comorbidities. Optimizing perioperative careparticularly through structured prehabilitation is crucial for improving surgical outcomes and long-term weight management. This review examines the role of prehabilitation, nutrition, psychological support, physical activity, and pharmacologic treatment in improving the effectiveness of BS.

RECENT FINDINGS

Despite the benefits of prehabilitation, there are significant differences in the way it is implemented in different healthcare centers. Protocols vary widely in terms of duration, components and intensity, leading to inconsistencies in patient preparation and postoperative recovery. Many patients still do not receive multidisciplinary support from dietitians, psychologists or physiotherapists prior to surgery, which can affect long-term outcomes. Barriers to effective prehabilitation include a lack of standardized guidelines, insufficient healthcare resources and limited patient adherence due to lack of awareness, low motivation or logistical constraints. Despite its proven benefits, structured prehabilitation lasting at least 3-6 months is not available to all patients, as access remains unequal and suboptimal in many healthcare settings. Prehabilitation is an important but underutilized component of BS preparation. Standardizing protocols and ensuring multidisciplinary, patient-centered support are essential to maximizing surgical benefit. Overcoming barriers such as healthcare system limitations, patient motivation and knowledge gaps is critical to integrating prehabilitation into routine bariatric care. This review emphasizes the need for evidence-based, multimodal prehabilitation strategies to improve perioperative care and long-term outcomes for BS patients.

Home-based prehabilitation: a systematic review and meta-analysis of randomised trials

BACKGROUND

Prehabilitation aims to enhance preoperative functional capacity through exercise, nutrition, and psychological programs. Home-based prehabilitation represents an alternative to hospital prehabilitation, with the advantage of not utilising hospital resources. This review aims to evaluate adherence and clinical effectiveness of home-based prehabilitation.

METHODS

We searched PubMed, Cochrane, and Embase up to October 1, 2024 for randomised controlled trials comparing home-based prehabilitation with standard care. The primary outcome was the proportion of patients with postoperative complications. Secondary outcomes included protocol adherence, and 6-min walking test. We used risk ratios (RR) and mean differences to summarise the results. The risk of bias was assessed using RoB 2 tool.

RESULTS

We included 29 randomised trials for a total of 3508 patients. Median adherence to home-based prehabilitation programs was 82%. Home-based prehabilitation reduced the proportion of patients with postoperative complications (508/1322 [38.4%] vs 578/1335 [43.3%], risk ratio 0.84, 95% confidence interval [CI] 0.72-0.98, P=0.02, I2=44%, low certainty). After home-based prehabilitation, 6-min walking test performance was better compared with control (MD 28.2 m (95% CI 9.5-46.9; P<0.01, I2=48). Preoperative depression (MD -0.65, 95% CI -0.87 to -0.43; P<0.001, I2=0%), postoperative anxiety (MD -0.50, 95% CI -0.75 to -0.25; P<0.001, I2=0%, low certainty) and length of hospital stays (MD -0.32 days, 95% CI -0.61 to -0.03; P=0.03, I2=45%, low certainty) were lower with home-based prehabilitation.

CONCLUSIONS

Home-based prehabilitation reduced the proportion of patients with postoperative complications, but with low certainty of evidence. It also improved preoperative functional capacity, reduced hospital stays, depression and anxiety scores, with good adherence to the intervention.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42024591208).

Patient Education on Exercise Prehabilitation Among Patients Receiving Neoadjuvant Therapy for Cancer Surgery in China: A Mixed-Methods Study

Background/Objectives: Patients undergoing neoadjuvant therapy have ample time to engage in exercise prehabilitation. This study aimed to describe the current status, facilitators, and barriers of exercise prehabilitation among this population. Methods: This sequential explanatory mixed-methods evaluation was conducted at a general tertiary hospital in Beijing. It included a quantitative survey of patients who received neoadjuvant therapy before cancer surgery and qualitative semi-structured interviews with both patients and physicians. Thematic analysis was conducted using the Capability, Opportunity, and Motivation Behavior model. Results: A total of 269 patients participated in the survey, with a completion rate of 99.6%. Only 52.6% and 1.1% of patients met the standards for aerobic and muscle-strengthening activities, respectively. Fewer than 40% of patients reported learning about exercise prehabilitation from physicians. Patients' knowledge was associated with meeting aerobic activity standards after adjusting for confounders (Level 1: odds ratio [OR] of 2.06, 95% confidence interval [CI] of 1.02-4.22; Level 2: OR of 2.56, 95% CI of 1.25-5.36). In total, 28 participants were interviewed. Facilitators of patient education on exercise prehabilitation included the surgeon's ability to gain trust and patients' prior commitment to exercise. Barriers included physicians' lack of awareness of exercise benefits, insufficient knowledge or time for patient education, concerns about patients' exercise ability, lack of referrals to rehabilitation clinics, challenges in follow-up, conflicts with cultural beliefs, and inadequate insurance coverage. Conclusions: This study revealed a lack of physician-led patient education on exercise prehabilitation. Efforts are needed to enhance physician education, implement collaborative clinics, and provide remote supervision.

Cognitive prehabilitation for older adults undergoing elective surgery: a systematic review and narrative synthesis

Background

Perioperative cognitive maintenance and protection in older adults is an important patient safety imperative. In addition to foundational care, one area of growing interest is integrating cognitive prehabilitation into the surgical trajectory. This review aimed to evaluate the effectiveness and safety of cognitive prehabilitation on cognitive functional capacity and postoperative cognitive outcomes among older adults undergoing elective surgery.

Methods

The MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO, PEDro, CBM, CNKI, WANFANG, and VIP databases were systematically searched up to September 5, 2024, to identify randomized controlled trials published for English or Chinese. Two authors independently completed the study selection process, data extraction process and methodological quality assessment. The Patient, Intervention, Comparison, Outcome, Study design framework was used to construct the search strategy. The predefined primary outcomes of interest included the incidence of postoperative delirium (POD) and the incidence of delayed neurocognitive recovery (dNCR). The quality of the studies was evaluated by the PEDro scale. Owing to the small number of trials and clinical and methodological diversity, a narrative synthesis was undertaken in accordance with the Synthesis Without Meta-analysis guidelines. This study was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system.

Results

Six studies were analysed. These trials involved 645 total participants, with 316 in the intervention group (mean age, 66.0-73.8 years; 38.4-77.8% male) and 329 in the comparator group (mean age, 67.5-72.6 years; 31.8-88.9% male). The effects of preoperative cognitive training on reducing the incidence of dNCR, the incidence of POD, the length of hospital stay and the incidence of postsurgical complications as well as improving postoperative global cognitive function and activities of daily living are quite uncertain. The results of this study should be interpreted with caution owing to the limited number of trials and low to very low certainty of evidence.

Conclusion

Current evidence on the effectiveness and safety of cognitive prehabilitation on cognitive and noncognitive outcomes in older patients undergoing elective surgery is limited and unclear.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277191, Identifier CRD42021277191.

Exploring the acceptability of and adherence to prehabilitation and rehabilitation in patients undergoing major abdominal surgery: A systematic review and meta-analysis

BACKGROUND AND AIMS

Prehabilitation combines exercise, nutritional, and psychological interventions administered before surgery to improve patient outcomes. This comprehensive review and meta-analysis examined the feasibility, adherence, and effectiveness of prehabilitation in frail, high-risk individuals undergoing major abdominal surgery.

METHODS

We searched the Cochrane Central Register of Controlled Trials, Web of Science, MEDLINE, Embase, and Cumulative Index to Nursing & Allied Health Literature (CINAHL) databases to identify relevant studies evaluating prehabilitation programs published between 2010 and 2023, either as observational studies or randomized clinical trials (RCTs).

RESULTS

The 23 articles (13 RCTs and 10 observational studies) included 1849 older male and female patients aged 68.7 ± 7.2 years. Nineteen of the included studies reported on adherence to prehabilitation programmes, which was generally good (>75%) over different models, settings, and durations. Factors such as patients' desire for expedited surgery, self-assessment of fitness, personal and professional obligations, health issues, holidays, and advancement of surgery dates negatively affected adherence to prehabilitation programmes. When compared with rehabilitation or standard pre- and post-surgical care, prehabilitation was associated with a 25%, albeit not statistically significant reduction in postoperative complications, according to data from 14 studies reporting on postoperative complications (OR 0.75, 95% CI 0.48 to 1.17, P = 0.43; I2 = 65%). Prehabilitation has been found to improve the 6-min walk test significantly by 29.4 m (MD +29.4 m, 95% CI 5.6 to 53.3, P = 0.02; I2 = 39%), compared with rehabilitation or standard pre- and post-surgical care.

CONCLUSION

Prehabilitation was acceptable to patients, with good adherence, and improved physical function.

Prehabilitation before general surgery: Worth the effort?

Prehabilitation, or interventions before surgery aimed at improving preoperative health and postoperative outcomes, has various forms. Although it may confer benefit to patients undergoing general surgery, this is not certain. Furthermore, although it may yield a net monetary gain, it is also likely to require substantial monetary and non-monetary investment. The impact of prehabilitation is highly variable and dependent on multiple factors. Physical function and pulmonary outcomes are likely to be improved by most forms of prehabilitation involving physical and multimodal exercise programmes. However, other surgical outcomes have demonstrated mixed results from prehabilitation. Within this issue, the measures used for evaluating baseline patient biopsychosocial health are important, and collecting sufficient data to accurately inform patient-centred prehabilitation programmes is only possible through thorough clinical and laboratory investigation and synthesised metrics such as cardiopulmonary exercise testing. Although a multimodal approach to prehabilitation is the current gold standard, societal factors may affect engagement with programmes that require a significant in-person activity. However, this is weighed against the substantial financial and non-financial investment that accompanies many programmes. The overall effectiveness and optimal mode of intervention across the discipline of general surgery remains unclear, and further research is needed to prove prehabilitation's full worth.

Patients' and carers' views on research priorities in prehabilitation for cancer surgery

INTRODUCTION

The views of patients and carers are important for the development of research priorities. This study aimed to determine and compare the top research priorities of cancer patients and carers with those of multidisciplinary clinicians with expertise in prehabilitation.

MATERIALS AND METHODS

This cross-sectional study surveyed patients recovering from cancer surgery at a major tertiary hospital in Sydney, Australia, and/or their carers between March and July 2023. Consenting patients and carers were provided a list of research priorities according to clinicians with expertise in prehabilitation, as determined in a recent International Delphi study. Participants were asked to rate the importance of each research priority using a 5-item Likert scale (ranging from 1 = very high research priority to 5 = very low research priority).

RESULTS

A total of 101 patients and 50 carers participated in this study. Four areas were identified as research priorities, achieving consensus of highest importance (> 70% rated as "high" or "very high" priority) by patients, carers, and clinical experts. These were "optimal composition of prehabilitation programs" (77% vs. 82% vs. 88%), "effect of prehabilitation on surgical outcomes" (85% vs. 90% vs. 95%), "effect of prehabilitation on functional outcomes" (83% vs. 86% vs. 79%), and "effect of prehabilitation on patient reported outcomes" (78% vs. 84% vs. 79%). Priorities that did not reach consensus of high importance by patients despite reaching consensus of highest importance by experts included "identifying populations most likely to benefit from prehabilitation" (70% vs. 76% vs. 90%) and "defining prehabilitation core outcome measures" (66% vs. 74% vs. 87%). "Prehabilitation during neoadjuvant therapies" reached consensus of high importance by patients but not by experts or carers (81% vs. 68% vs. 69%).

CONCLUSION

This study delineated the primary prehabilitation research priorities as determined by patients and carers, against those previously identified by clinicians with expertise in prehabilitation. It is recommended that subsequent high-quality research and resource allocation be directed towards these highlighted areas of importance.

Exploring the need for reconsideration of trial design in perioperative outcomes research: a narrative review

"Enhanced recovery after surgery" is a multimodal effort to control perioperative pathophysiology and improve outcome. However, despite advances in perioperative care, postoperative complications and the need for hospitalisation and prolonged recovery continue to be challenging. This is further complicated by procedure-specific and patient-associated risk factors, given the increase in the number of elderly and frail patients with multiple comorbidities undergoing surgery. This paper is a critical assessment of current methodology for trials in perioperative medicine. We make a plea to reconsider the design of future interventional trials to improve surgical outcome, based upon studies of potentially effective interventions, but often without improvements in recovery. The complexity of perioperative pathophysiology necessitates a procedure- and patient-specific approach whenever outcome is assessed or interventions are planned. With improved understanding of perioperative pathophysiology, the way to improve outcomes looks promising, provided that knowledge and established enhanced recovery programmes are integrated in trial design.

Funding

None.

The impact of prehabilitation on outcomes in frail and high-risk patients undergoing major abdominal surgery: A systematic review and meta-analysis

BACKGROUND & AIMS

Prehabilitation comprises multidisciplinary preoperative interventions including exercise, nutritional optimisation and psychological preparation aimed at improving surgical outcomes. The aim of this systematic review and meta-analysis was to determine the impact of prehabilitation on postoperative outcomes in frail and high-risk patients undergoing major abdominal surgery.

METHODS

Embase, Medline, CINAHAL and Cochrane databases were searched from January 2010 to January 2023 for randomised clinical trials (RCTs) and observational studies evaluating unimodal (exercise) or multimodal prehabilitation programmes. Meta-analysis was limited to length of stay (primary end point), severe postoperative complications (Clavien-Dindo Classification ≥ Grade 3) and the 6-minute walk test (6MWT). The analysis was performed using RevMan v5.4 software.

RESULTS

Sixteen studies (6 RCTs, 10 observational) reporting on 3339 patients (1468 prehabilitation group, 1871 control group) were included. The median (interquartile range) age was 74.0 (71.0-78.4) years. Multimodal prehabilitation was applied in fifteen studies and unimodal in one. Meta-analysis of nine studies showed a reduction in hospital length of stay (weighted mean difference -1.07 days, 95 % CI -1.60 to -0.53 days, P < 0.0001, I2 = 19 %). Ten studies addressed severe complications and a meta-analysis suggested a decline in occurrence by up to 44 % (odds ratio 0.56, 95 % CI 0.37 to 0.82, P < 0.004, I2 = 51 %). Four studies provided data on preoperative 6MWT. The pooled weighted mean difference was 40.1 m (95 % CI 32.7 to 47.6 m, P < 0.00001, I2 = 24 %), favouring prehabilitation.

CONCLUSION

Given the significant impact on shortening length of stay and reducing severe complications, prehabilitation should be encouraged in frail, older and high-risk adult patients undergoing major abdominal surgery.

Potential for using simulated altitude as a means of prehabilitation: a physiology study

The current pandemic of surgical complications necessitates urgent and pragmatic innovation to reduce postoperative morbidity and mortality, which are associated with poor pre-operative fitness and anaemia. Exercise prehabilitation is a compelling strategy, but it has proven difficult to establish that it improves outcomes either in isolation or as part of a multimodal approach. Simulated altitude exposure improves performance in athletes and offers a novel potential means of improving cardiorespiratory and metabolic fitness and alleviating anaemia within the prehabilitation window. We aimed to provide an initial physiological foundation for 'altitude prehabilitation' by determining the physiological effects of one week of simulated altitude (FI O2 15%, equivalent to approximately 2438 m (8000 ft)) in older sedentary volunteers. The study used a randomised, double-blind, sham-controlled crossover design. Eight participants spent counterbalanced normoxic and hypoxic weeks in a residential hypoxia facility and underwent repeated cardiopulmonary exercise tests. Mean (SD) age of participants was 64 (7) y and they were unfit, with mean (SD) baseline anaerobic threshold 12 (2) ml.kg-1 .min-1 and mean (SD) peak V̇O2 15 (3) ml.kg-1 .min-1 . Hypoxia was mild (mean (SD) Sp O2 93 (2) %, p < 0.001) and well-tolerated. Despite some indication of greater peak exercise capacity following hypoxia, overall there was no effect of simulated altitude on anaerobic threshold or peak V̇O2 . However, hypoxia induced a substantial increase in mean (SD) haemoglobin of 1.5 (2.7) g.dl-1 (13% increase, p = 0.028). This study has established the concept and feasibility of 'altitude prehabilitation' and demonstrated specific potential for improving haematological fitness. Physiologically, there is value in exploring a possible role for simulated altitude in pre-operative optimisation.

Post-Cancer Treatment Reflections by Patients Concerning the Provisions and Support Required for a Prehabilitation Programme

BACKGROUND

Evidence suggests that physical fitness interventions, mental health support and nutritional advice before surgery (prehabilitation) could reduce hospital stay and improve quality of life of patients with cancer. In this study we captured the opinions of a group of patients with cancer undergoing these interventions after treatment to discover what a prehabilitation programme should encompass.

METHODS

Patients from the Cancer and Rehabilitation Exercise (CARE) programme based in Nottingham took part in a 26-point online questionnaire about the design of prehabilitation programmes.

RESULTS

The questionnaire was completed over a 2-week period in December 2021 by 54 patients from the CARE programme. Their responses were as follows: 44 (81.5%) participants would have participated in prehabilitation had it been available to them and 28 (51.9%) ranked physical exercise as the most important component. Forty (74.1%) participants believed the counselling aspect of prehabilitation would have contributed to a successful outcome and 35 (64.8%) thought dietary advice would have benefitted them before surgery. Thirty-one (57.4%) participants preferred the programme to take place in a fitness centre, rather than at home or hospital and 43 (79.6%) would have liked to have known about prehabilitation from their doctor at the time of diagnosis.

CONCLUSIONS

Patients are interested in prehabilitation to become more physically fit and mentally prepared for surgery. They expressed the need for a focus on physical exercise, counselling to improve mental health and personalised nutritional advice. Tailoring a prehabilitation programme, with input from patients, could contribute to improving patient outcomes following cancer treatments.

Prevention and treatment of noncognitive complications

Patients aged 65 and older are the fastest growing segment in the population of many countries. Based on evolving demographics showing increasing life expectancies, it is expected that there will be a concurrent rise in the demand for a large variety of surgical and anesthesia services. Surgery offers definitive management of many age-related diseases and provides symptom-relieving (morbidity) and life-extending (mortality) benefits. However, elderly adult surgical patients, especially the frail ones, often require a different level of care than younger patients during the perioperative period. As many have chronic illnesses and acquired deconditioning and functional decline, older patients are prone to develop untoward outcomes such as postoperative complications and loss of independence. This manuscript focuses on the holistic quality person-centered care, supported by a wide stakeholder team of health-care workers, ensuring fidelity to comprehensive geriatric assessment and optimization services where possible, offering a systematic approach to early health risk assessment and risk modification in the perioperative period, with the ultimate goal of reducing postoperative complications and health-care costs. The "comprehensive geriatric assessment and optimization" cost-effective approach builds on robust evidence with older people more likely to be alive, a shorter length of hospital stay due to fewer postoperative medical complications, and improved rates of return to usual residence. Prehabilitation programs are delivered focusing on primary (through counseling) and secondary prevention (through screening) with an aim to improve fitness for surgery, by evaluating functional capacity, nutritional and psychological health, prompting interventions, targeting physical exercise, lifestyle and nutritional advice, and psychological support.

Recommendations on the use of prehabilitation, i.e. comprehensive preparation of the patient for surgery

Prehabilitation is a comprehensive preparation of a patient for primarily surgical treatments. Its aim is to improve the patient'sgeneral condition so as to reduce the risk of complications and ensure the fastest possible recovery to full health. Thebasic components of prehabilitation include: improvement of nutritional status, appropriate exercises to improve functioning,psychological support, and help in eliminating addictions. Other important aspects of prehabilitation are: increasinghemoglobin levels in patients with anemia, achieving good glycemic control in patients with diabetes, treatment or stabilizationof any concurrent disorders, or specialist treatment associated with a specific procedure (endoprostheses, ostomyprocedure). This article organizes and outlines the indications for prehabilitation, its scope, duration, and the method to conductit. Experts of various specialties related to prehabilitation agree that it should be an element of surgery preparationwhenever possible, especially in patients with co-existing medical conditions who have been qualified for major procedures.Prehabilitation should be carried out by interdisciplinary teams, including family physicians and various specialists in thetreatment of comorbidities. Prehabilitation requires urgent systemic and reimbursement solutions.

Preoperative frailty screening, assessment and management

PURPOSE OF REVIEW

To highlight the importance of frailty assessment in thoracic surgery patients.

RECENT FINDINGS

Frailty results from an accelerated loss of functional reserve associated with ageing and leads to increased vulnerability following surgery. It is a complex and multidimensional syndrome involving physiological and psychosocial systems. Frailty is a separate entity from comorbidities and disabilities. Frailty is associated with an increased risk of complications and a higher mortality rate after thoracic surgery. Patients can easily be screened for frailty and frail patients can benefit from further assessment of all areas of frailty secondarily. Prehabilitation and rehabilitation can help limit frailty-related complications after thoracic surgery.

SUMMARY

Frailty should be part of the routine preoperative evaluation for thoracic surgery. Frailty must be considered in assessing eligibility for surgery and in planning prehabilitation and rehabilitation if necessary.