Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

[App-based prehabilitation: implementation and adherence]

In recent years prehabilitation before oncological visceral surgery has become increasingly more in the clinical focus. The aim of prehabilitation is to significantly increase patient's physical and mental performance status through multimodal treatment resulting in a decrease of postoperative complications and faster rehabilitation. As prehabilitation requires a high level of personnel and economic resources in the healthcare system, app-based prehabilitation might be a suitable alternative. The currently available evidence shows a high patient adherence to app-based prehabilitation with an improvement of functional performance status; however, further studies with more patients especially from Germany are necessary to confirm the preliminary data and to become established in the clinical routine.

Effect of tailored, intensive prehabilitation for risky lifestyles before ventral hernia repair on postoperative outcomes, health, and costs - study protocol for a randomised controlled trial (STRONG-Hernia)

BACKGROUND

A substantial untapped potential for risk reduction may be fulfilled by applying intensive lifestyle interventions targeting the co-existing risky lifestyle factors Smoking, Nutrition (both malnutrition and obesity), risky Alcohol intake, and Physical inactivity (SNAP) before surgery. This trial will compare the effect of combined and individually tailored prehabilitation with standard care on postoperative outcomes, health, and cost-effectiveness in short and long term in participants undergoing ventral hernia repair. An interview study will be nested within the randomised trial.

METHODS

The study is a multicenter, parallel-group, superiority randomised clinical trial. A total of 400 adult participants undergoing ventral hernia repair with ≥1 SNAP factor will be allocated to the individually tailored STRONG programme or standard care. The STRONG programme is initiated at least four weeks prior to surgery and consists of six sessions. It is delivered as one session a week, approximately, and includes patient education, motivational, and pharmaceutical supports. The primary outcome is postoperative complications requiring treatment within 30 days. Secondary outcomes address other surgical outcomes, changes in lifestyle, health, and cost-effectiveness. Follow-up takes place after 6 weeks (the end of intervention), at surgery, and 30 days, 90 days, and 6 months after surgery, respectively. Long-term data on health and costs will be obtained from nationwide registries after two years. Eligible trial participants will be invited to a semi-structured interview study at baseline. Their reflections on the STRONG programme and the choice of participating in the trial or not will be explored.

DISCUSSION

Many patients have multiple SNAP factors adding to the risk of complications related to surgery. As these are modifiable, prehabilitation may be an area with great potential for risk reduction. Nevertheless, no well-acknowledged and evidence-based strategies exist in the preoperative period. The STRONG programme is tailored specifically to the individual patient's preidentified needs including up to all five common risky SNAP factors and may tap into the large unused potential for risk reduction. Overall, the study will add important new knowledge on the effect of individually tailored prehabilitation on complications and other important outcomes in elective surgery, and also clarify if this intervention will have long-lasting implications.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT06611462).

Prehabilitation in surgery - an update with a focus on nutrition

PURPOSE OF REVIEW

Since the introduction of the prehabilitation concept for optimizing functional capacity before surgery 20 years ago, evidence and interest has grown considerably. This review summarizes the recent evidence and proposes questions for prehabilitation with special regard to the nutritional component.

RECENT FINDINGS

Several meta-analyses of multimodal prehabilitation (exercise, nutrition, and psychological support) have been published recently. These reviews suggest that preoperative conditioning can improve functional capacity and reduce the complication rate for many patient groups (risk of bias: moderate to low). A prerequisite is the identification of high-risk patients using suitable screening and assessment tools. Additionally, there are currently no standardized, clear recommendations for the organization and implementation of prehabilitation programs. The programs vary greatly in duration, content, and outcome measurement. Although the preoperative nutrition interventions enhanced outcomes consistently, there was no clear evidence for which nutritional intervention should be applied to whom over consistent time frame four to six weeks (timeframe consistent with most prehabilitation programs).

SUMMARY

To advance our understanding of which prehabilitation interventions work best, how they work, and for whom they work best, additional low risk of bias and adequately powered trials are required. Nevertheless, our review presents evidence that prehabilitation should be offered before major surgery on a risk-stratified basis.

A multimodal prehabilitation class for Enhanced Recovery After Surgery: a pragmatic randomised type 1 hybrid effectiveness-implementation trial

BACKGROUND

Prehabilitation promotes postoperative recovery through preoperative optimisation; however, few studies have been conducted under real-world conditions. Our objective was to determine the extent to which a multimodal prehabilitation programme influenced intermediate and late recovery post-colorectal surgery in a type 1 effectiveness-implementation and randomised pragmatic trial. We hypothesised that a prehabilitation class, as part of an Enhanced Recovery After Surgery (ERAS) pathway, would reduce length of hospital stay (LOS).

METHODS

Adult male and female patients with colorectal disease requiring an elective primary resection at a single centre were randomised to the intervention or standard care group at least 2 weeks before surgery. All participants attended an ERAS class, which was extended to include prehabilitation components of nutrition education, supplements, walking with a smartwatch, functional exercises, and deep breathing in the intervention group. Effectiveness outcomes included LOS (primary) and 6-min walking distance (6MWD; secondary outcome) at 6 weeks post-surgery. Implementation outcomes included adherence to prescribed step count and nutrient intakes. Multivariable regression analyses were adjusted for age, sex, type of surgery, and COVID-19.

RESULTS

The study ended prematurely. In total, 110 patients were included. Two-thirds had cancer and mean prehabilitation duration was 17.2 (sd 5.5) days. LOS was not different between groups. Preoperative median step count did not differ between groups, but protein inadequacy (prevalence ratio: 0.59 [95% CI: 0.36-0.82]) decreased substantially with prehabilitation. After surgery, the mean difference in 6MWD was +38 m (95% CI: 9-67 m) for prehabilitation vs control, indicating earlier functional recovery.

CONCLUSIONS

A pragmatic prehabilitation programme did not influence length of hospital stay (underpowered because of early trial termination), but did reduce preoperative protein inadequacy (implementation outcome) and improve early functional recovery (secondary outcome).

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT04247776).

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).

Exploring prehabilitation interventions for patients with gynaecological cancer undergoing radiotherapy: A scoping review

PURPOSE

Radiotherapy imposes a significant physiological and psychological burden on gynaecological cancer patients. Prehabilitation is being increasingly used to prepare individuals for cancer treatment and improve their well-being and resilience. Whilst prehabilitation has demonstrated benefit for individuals undergoing cancer surgery, the structure, role and implementation of prehabilitation prior to radiotherapy are poorly defined and relatively unexplored. This scoping review aims to provide a comprehensive overview of the current literature regarding prehabilitation interventions for individuals with gynaecological cancer undergoing radiotherapy.

METHODS

This review was conducted following the gold-standard Joanna Briggs Institute guidelines for scoping reviews. Literature searches were completed in October 2024 across: the Allied and Complementary Medicine Database; British Nursing Index; Cumulative Index to Nursing and Allied Health Literature; Cochrane library (Controlled trials and systematic reviews); Embase; Medical Literature Analysis and Retrieval System Online; and the Psychological Information Database. Grey literature searches were conducted via Google Scholar, Overton.io, and Trip Pro Medical Database.

RESULTS

Ninety records met the inclusion criteria, pertaining to 56 studies. Cervical cancer was the most represented gynaecological cancer type across studies. A small number of multimodal prehabilitation studies were identified (n = 4). Studies evaluating unimodal interventions were more common, with nutritional interventions (n = 24) being the most frequent, followed by psychological (n = 22) and physical exercise (n = 6) interventions. There was considerable variation across studies in respect to intervention initiation, duration, delivery and outcome measures.

CONCLUSIONS

The physiological and psychological impacts of cancer diagnosis and treatment are closely entwined. Further development of multimodal prehabilitation to cohesively address these is an important area for future research. Studies evaluating exercise interventions are relatively unexplored in this patient population and the potential barriers to engagement must be considered. Future research should focus on complete and transparent reporting of interventions, with input from those with lived experience, and adopting a standardised set of outcome measures reported across all trials.

Prehabilitation: Are There Sex- and Gender-Specific Issues in Surgery Preparation?

BACKGROUND

Prehabilitation programs have advanced considerably; however, critical issues related to sex- and gender-specific factors remain largely unaddressed. Historically, research has been male-centered due to the underrepresentation of females in clinical trials, often attributed to concerns over hormonal variability. This focus has resulted in significant knowledge gaps and potential biases that impact effectiveness across sexes. We aim to highlight the need for integrating sex- and gender-specific considerations into prehabilitation to optimize surgical outcomes and promote equitable care for all patients.

SUMMARY

Both biological (sex-related) factors, such as differences in muscle mass, metabolism, and body composition, and social (gender-related) factors, such as caregiving roles and stress management, influence individuals' responses to presurgical preparation. A review of the existing literature reveals a scarcity of data on sex and gender differences in prehabilitation, highlighting a major barrier to designing equitable and effective programs. Evidence underscores that comprehensive prehabilitation approaches, integrating physical, nutritional, and psychological elements, must account for these differences to optimize recovery outcomes.

KEY MESSAGES

Sex- and gender-specific factors significantly shape patients' responses to prehabilitation and should be systematically incorporated into program design. The current lack of research on these differences limits the effectiveness of prehabilitation strategies, emphasizing the need for focused investigations. Addressing these gaps will facilitate the development of tailored, equitable prehabilitation programs that enhance presurgical care and improve recovery outcomes for all patients.

The inequalities and challenges of prehabilitation before cancer surgery: a narrative review

INTRODUCTION

Prehabilitation seeks to enhance functional capacity and preparedness before surgery with the aim of improving outcomes; it is generally based on exercise, diet and psychological interventions. While there is obvious appeal to this approach in terms of patient experience and resource use, the interventions are complex and the evidence base for prehabilitation before cancer surgery is heterogeneous. Prehabilitation requires patient understanding and motivation as well as commitment of resources. Programmes are challenging to design and implement, and can generate 'intervention-based inequalities' based on the capacity of patients to engage. We present a narrative review on the inequalities and challenges of prehabilitation before cancer surgery.

METHODS

We searched databases of peer-reviewed research to identify appropriate articles. We used the results in combination with iterative searches based on citation tracking, grey literature (e.g. patient information resources) and articles from personal libraries, to develop our discussion.

RESULTS

We describe the uncertainties in the evidence base for prehabilitation before cancer surgery, and the challenges and barriers for healthcare providers, systems and patients. Key findings include that prehabilitation is under-researched in many cancers and that people with lower health literacy, from minority ethnic groups and socio-economically disadvantaged backgrounds, are less likely to engage, despite often having worse peri-operative outcomes.

DISCUSSION

Prehabilitation must be implemented carefully to avoid widening inequalities. More research is needed, both in terms of the impact of interventions and to understand how prehabilitation should account for the social determinants of health.

Optimisation of the patient having oncological surgical through prehabilitation: a narrative review

INTRODUCTION

Prehabilitation aims to improve physiological reserve and psychological resilience, enabling patients to better tolerate the physiological stress of major surgery, thereby reducing the risk of complications and improving surgical outcomes. In this review, we provide an update of the development of prehabilitation in patients having cancer surgery.

METHODS

We searched databases of peer-reviewed research to identify appropriate papers. Keywords comprised 'prehabilitation', 'cancer surgery' and associated synonyms (prehab; pre-operative rehabilitation; cancer). The results were combined with articles identified by reviewing the references of key papers and the use of the grey literature to develop our discussion.

RESULTS

We detail the different elements of prehabilitation (exercise, nutrition, psychological support) relevant to patients with cancer undergoing surgery, focusing on the recent evidence base and ongoing challenges. Within this, we consider the role of behaviour change in enabling patients to undertake prehabilitation interventions and reflect on the different models of prehabilitation that have been utilised. Facilitators and barriers to implementation of prehabilitation are explored. Key findings include positioning prehabilitation as an integral part of the oncological surgical pathway which includes, but is discrete from, medical optimisation.

DISCUSSION

Prehabilitation has the potential to improve surgical outcomes for patients undergoing cancer surgery. Further evidence is needed to understand how and what we provide to patients as optimal exercise, nutrition and psychological interventions as part of their surgical care, and how we improve long-term lifestyle using behaviour change methodology. Digital technology offers the opportunity for scaling and greater personalisation of prehabilitation but needs to be deliberately fashioned to ensure equitable access.

Starting a surgical prehabilitation program: results from a pragmatic nonrandomized feasibility study

PURPOSE

We sought to assess the feasibility and estimate the effects on outcomes of a multimodal prehabilitation service implemented as an ancillary surgical service.

METHODS

We conducted a pragmatic, nonrandomized feasibility study of surgical prehabilitation. Patients were eligible if they were ≥ 18 yr of age, fluent in English, and referred by a health professional for prehabilitation. Participants received an individualized program of preoperative exercise, nutrition, psychological, and/or smoking cessation support. The primary outcome was operational feasibility, including referral volume, enrolment rate, prehabilitation window, engagement, completion rate, and safety. Secondary outcomes included surgical complications, length of hospital stay, readmission, quality of life, and physical and mental health. Qualitative data related to intervention feasibility and acceptability. We compared intervention participants with patients who were referred for, but declined, prehabilitation.

RESULTS

One hundred and sixteen patients were referred for prehabilitation. The mean age of referred patients was 71 yr and 55% were male. Over 90% of referrals were from surgical oncology, and the most common indication for referral was frailty (46%). Of the 116 referred patients, 83 consented to participate in the study. Patient-reported and objectively measured outcomes improved by a clinically important margin from baseline to presurgery, and returned to presurgery levels by 90 days postoperatively. Qualitative findings suggest that the prehabilitation intervention was well received.

CONCLUSION

Multimodal surgical prehabilitation is feasible as an integrated clinical service and may be effective for improving physical and psychological outcomes. Further evaluations of clinically integrated prehabilitation programs in Canada are needed to confirm these findings.

Head and Neck Cancer (HNC) Prehabilitation: Advantages and Limitations

Cancer prehabilitation is the process between the time of cancer diagnosis and the beginning of the active acute treatment; prehabilitation consists of various need-based interventions, e.g., physical activity, a nutritional program, and psychological support. It can be delivered as unimodal or multimodal interventions. Physical activity, including resistant exercise and aerobic activities, has to be tailored according to the patient's characteristics; nutritional support is aimed at preventing malnutrition and sarcopenia; while psychological intervention intercepts the patient's distress and supports specific intervention to address it. In addition, multimodal prehabilitation could have a potential impact on the immune system, globally reducing the inflammatory processes and, as a consequence, influencing cancer progression. However, many challenges are still to be addressed, foremost among them the feasibility of prehabilitation programs, the lack of adequate facilities for these programs' implementation, and the fact that not all prehabilitation interventions are reimbursed by the national health system.