Evidence base for exercise prehabilitation suggests favourable outcomes for patients undergoing surgery for non-small cell lung cancer despite being of low therapeutic quality: a systematic review and meta-analysis

[Prehabilitation and sport in oncology]

Numerous randomized controlled trials confirm the clinical importance of exercise therapy in the management of side effects of cancer treatment. Physically active cancer patients also have a better prognosis. Since it has been known that the physical performance level before surgery is a strong prognostic factor for the occurrence of perioperative complications, the focus of interest has also been on exercise therapy-based prehabilitation. Studies in this field show that even very short interventions (2-4 weeks) can achieve lower perioperative complication rates, particularly for pulmonary complications. Even if the evidence is still limited, it can be concluded that every patient should be offered exercise therapy prehabilitation in preparation for major pulmonary or gastrointestinal surgical interventions. However, there are so far hardly any treatment structures that make this currently possible.

[Prehabilitation and enhanced recovery after surgery protocols for head and neck cancer : Value and application of these concepts]

Prehabilitation is gaining traction in complex oncological interventions and treatments. This CME article is focused on the basic principles of prehabilitation. We discuss the objective evaluation of physical fitness and how to improve it by physio- and speech therapy. Thereafter, we explain how to judge nutritional status, especially in oncological patients, and discuss modes of nutritional supplementation. Finally, the enhanced recovery after surgery concept is briefly explained and its current value in head and neck cancer patients discussed.

The effect of multimodal prehabilitation on postoperative outcomes in lung cancer surgery

OBJECTIVE

Patients with lung cancer are often elderly, frail, and smokers with poor functional reserve, making them excellent candidates for multimodal prehabilitation to improve postoperative outcomes. Patients referred to the prehabilitation clinic are at an even higher surgical risk. This retrospective observational study aimed to compare the postoperative 30-day outcomes in lung cancer surgery among the propensity score-matched patients.

METHODS

Patients who underwent lung cancer surgery between August 2018 and January 2024 were accessed for eligibility. After exclusion, a 1:1 propensity score-matching analysis was performed based on the following baseline characteristics: respiratory disease, predicted length of stay based on American College of Surgeons National Surgical Quality Improvement Program, Duke Activity Status Index less than 34, tumor stage, and neoadjuvant therapy. Baseline characteristics, preoperative and intraoperative data, and postoperative outcomes were compared between the matched patients.

RESULTS

Among 1242 patients, 555 were selected for propensity score matching, resulting in 147 matched pairs in each group. The control group exhibited significantly higher rates of overall (65.3% vs 46.3%, P = .001) and major complications (27.9% vs 13.6%, P = .003). Patients who underwent multimodal prehabilitation had a significantly lower Comprehensive Complication Index (12.2 [0-26.2] vs 0 [0-20.9], P < .0001), reduced intensive care unit admission rates (8.2% vs 2.7%, P = .040), and lower readmission rates (14.3% vs 6.1%, P = .021).

CONCLUSIONS

Multimodal prehabilitation significantly reduced overall and major postoperative 30-day complications in lung cancer surgery. It also contributed to reducing the severity of complications. These findings suggest that multimodal prehabilitation may improve postoperative outcomes for patients with lung cancer.

Feasibility and clinical potential of exercise interventions during neoadjuvant chemoradiotherapy in patients with esophageal and rectal cancer

BACKGROUND

Exercise during neoadjuvant chemoradiotherapy (NCRT) has potential to mitigate treatment-related declines in physical fitness, and to improve clinical outcomes, including toxicity and tumor response. However, optimal frequency and timing of exercise remains to be determined. Therefore, this pilot trial aimed to assess feasibility of 2 different exercise interventions during NCRT in patients with esophageal and rectal cancer and to evaluate potential clinical effects.

METHODS

Patients were randomized into 1 of 3 study arms during NCRT: (a) 30-min aerobic exercise in-hospital within 1 h prior to each radiotherapy fraction (ExPR), (b) two 60-min supervised combined aerobic and resistance exercise sessions per week (AE+RE), and (c) usual care (UC). Feasibility was assessed by examining participation rate and exercise adherence. Intervention effects on physical fitness, health-related quality of life, treatment-related toxicity, and tumor response in patients with esophageal cancer were explored using regression analyses and 85% confidence intervals (85%CI).

RESULTS

Thirty-seven patients with esophageal cancer (participation rate: 45%) and 2 patients with rectal cancer (participation rate: 14%) were included. Median session attendance was 98% (interquartile range (IQR): 96-100) in the ExPR and 78% (IQR: 33-100) in the AE+RE group. We found clinically relevant benefits of exercise on maximal oxygen uptake (VO2max)(ExPR: β = 9.7 mL/kg/min, 85%CI: 6.9-12.6; AE+RE: β = 5.6 mL/kg/min, 85%CI: 2.6-8.5) and treatment-related toxicity (ExPR: β = -2.8, 85%CI: -5.4 to -0.2; AE+RE: β = -2.6, 85%CI: -5.3 to 0.0). Additionally, good tumor response was found in 70% in AE+RE and ExPR vs. 55% in UC (OR = 1.9, 85%CI: 0.5-7.7).

CONCLUSION

Starting prehabilitation during NCRT is feasible, can increase starting fitness of traditional pre-surgical programs, and has potential to improve clinical outcomes.

An Updated Systematic Review and Meta-Analysis of Unimodal Prehabilitation with Exercise Intervention to Enhance Postoperative Outcomes in Cancer Surgery

BACKGROUND

The objective of this systematic review and meta-analysis was to update the body of evidence on the efficacy of prehabilitation with exercise interventions, in reducing postoperative complications and length of hospital stay after cancer surgery.

METHODS

A comprehensive literature search was conducted on MEDLINE, Embase, The Cochrane Library, CINAHL, AMED, and PsycINFO to identify randomized controlled trials investigating the impact of prehabilitation with exercise interventions for patients undergoing cancer surgery. Primary and secondary outcomes assessed were postoperative complications and length of hospital stay, respectively. Risk of bias was evaluated using the Cochrane risk of bias tool, and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology was used to determine the strength of evidence. Relative risk and mean difference were calculated using random-effects meta-analysis.

RESULTS

In this updated review, 32 trials (n = 2304 participants) were identified, with 5 trials focused on patients undergoing surgery for genitourinary cancer (n = 422 participants), 9 for lower gastrointestinal cancer (n = 639 participants), 6 for upper gastrointestinal cancer (n = 526), and 11 for lung cancer (n = 717 participants). The majority of included trials exhibited some risk of bias. Evidence of low-to-moderate quality indicated that prehabilitation with preoperative exercise significantly reduced postoperative complication rates by approximately 50% and decreased the length of hospital stay by 2.5 days in patients undergoing lung resection. Preoperative exercise did not demonstrate effectiveness in reducing postoperative complications or length of hospital stay for other cancer populations.

CONCLUSIONS

Evidence supports the efficacy of prehabilitation with exercise in reducing postoperative complications and length of hospital stay in patients undergoing lung cancer surgery. Further research is warranted to establish the efficacy of unimodal prehabilitation with exercise in genitourinary, lower gastrointestinal, and upper gastrointestinal cancer populations having cancer surgery.

Multimodal Prehabilitation in Head and Neck Cancer Patients Undergoing Surgery: A Feasibility Study

BACKGROUND

Head and neck cancer (HNC) incidence is increasing, and surgery is frequently indicated as curative treatment. Unfortunately, complications and long-term functional impairment are common. Recent promising results of multimodal prehabilitation in colorectal cancer surgery show improved recovery and functional outcomes. The objective of this study is to assess the feasibility of multimodal prehabilitation, which is composed of high-intensity training, a protein-enriched diet, cessation of intoxications, mental support and speech support therapy, in HNC surgery.

METHODS

A feasibility study was conducted at a large teaching hospital, Northwest Clinics, Alkmaar, the Netherlands, between July 2022 and December 2023. The primary outcome was feasibility, defined as participation, dropout and adherence rate. The secondary outcome was functional capacity 6 weeks postoperatively.

RESULTS

The participation rate was 60% (30 of 50 patients), mainly limited due to the travel distance to the physiotherapist. A dropout rate of 7% was present, as two patients discontinued prehabilitation. Of the remaining 28 patients, 27 patients (96%) attended at least six sessions at the community physiotherapist practice. All functional tests increased by prehabilitation, with the 6-min walking test being significant (p ≤ 0.05). Six weeks postoperatively, all but steep ramp tests remained higher than baseline.

CONCLUSION

Feasibility of multimodal prehabilitation in HNC surgery patients in this study is limited by its participation rate of 60%. Addressing participation, a widespread network of oncologic physiotherapists or home-based multimodal prehabilitation by an app could possibly potentiate participation. More studies are needed to assess the optimal form of multimodal prehabilitation in this challenging population.

Efficacy of digital therapeutics for perioperative management in patients with lung cancer: a randomized controlled trial

BACKGROUND

Perioperative management and lung function recovery are vital for lung cancer patients. We conducted an open-label, single-center, noninferiority, randomized controlled trial in China to evaluate the efficacy of digital therapeutic (DTx)-assisted management vs. multidisciplinary management (MM) in the perioperative management of patients with lung cancer.

METHODS

From July 2022 to June 2023, 186 minimally invasive lung surgery patients were randomized, and 147 completed the study. The participants were randomly assigned a 1:1 ratio to receive DTx-assisted management (n = 72) or traditional MM (n = 75). The primary endpoint was the pulmonary function recovery rate measured by forced expiratory volume in the first second (FEV1%) 3 weeks after surgery, and the noninferiority margin was set to 4.8%. The secondary endpoints included hospital stay duration, 90-day unplanned readmission rate, symptom scores, patient management time, and patient satisfaction rate. Exploratory endpoints include factors influencing postoperative lung function recovery.

RESULTS

The lung function FEV1% recovery rate of the DTx group was not inferior to that of the MM group (87.18% ± 11.01% vs. 84.21% ± 11.75%). There were no significant differences between the two groups in terms of postoperative hospitalization duration or 90-day unplanned readmission rates. The patient management time in the DTx group was significantly shorter than that in the MM group (1.48 ± 3.22 min vs. 16.67 ± 6.41 min, P < 0.001). Patient symptom scores tended to decrease over time after discharge, and the 5 target symptoms included pain, coughing, shortness of breath, disturbed sleep, and fatigue. On the 7th day after discharge, the DTx group had a lower occurrence rate of the 5 target symptoms triggering the alert threshold compared to the MM group (P = 0.002). Patients with higher education levels achieved a better FEV1% recovery rate with DTx-assisted management (P = 0.021).

CONCLUSIONS

Compared with the MM group, the DTx group achieved noninferior results in all evaluated clinically meaningful endpoints but was significantly more efficient in perioperative management, providing an alternative digitalized management mode for patients with lung cancer surgery.

TRIAL REGISTRATION

ChiCTR2200064723.

Quality Analysis of YouTube-Based Exercise Programs for Typically Developing Children: Content Analysis

Background: Physical activities in childhood are important. However, a lack of exercise among children and adolescents is becoming a global reality. Moreover, following the coronavirus disease 2019 pandemic, the increase in time spent at home has led to qualitative changes, such as at-home exercises and the use of YouTube content. This study aimed to conduct qualitative assessments of YouTube-based exercise education programs, such as video content and exercise education programs. Methods: A Python-based (version 3.11.6) video data crawl of YouTube using the keywords "children + exercise", "kid + exercise", "child + physical activity", and "kid + physical activity" was conducted on 27 November 2023. Duplicate, non-English, outdated (over 5 years old), short (<60 s) or long (>30 min) videos, and irrelevant content were excluded. Basic video characteristics, video popularity metrics, and qualitative analyses (m-DISCERN, GQS, i-CONTENT, CONTENT, CERT) were collected and assessed. Results: Of the 2936 retrieved videos, 126 were selected. Approximately 10% of the videos were uploaded by health professionals, and most videos covered aerobic and muscle-strengthening exercises. A qualitative analysis of the video content showed moderate to high quality, while only a few videos satisfied the criteria of an effective exercise program, especially in terms of "Type and timing of outcome assessment", "Qualified supervisor", "Patient eligibility", "Adherence to the exercise program", and "Dosage parameters (frequency, intensity, time)". In the correlation analysis of video content and exercise program quality, only a few items showed a statistically significant correlation. Conclusions: YouTube exercise-related educational content targeting children may be inadequate and is not correlated with video popularity. Although an overall weak to moderate correlation was observed between the quality evaluation of exercise education and video content, the use of video quality assessment tools to evaluate exercise program quality was insufficient.

Exercise medicine for individuals diagnosed with Lung Cancer: A systematic review and meta-analysis of health outcomes

Consensus exists regarding the need to provide exercise interventions to individuals diagnosed with lung cancer (LC). Exercise interventions for this populations usually include multidisciplinary approaches, making the attempt to understand the effects of exercise a real challenge. Therefore, we designed a systematic review to identify the effects of exercise interventions among individuals with a LC diagnosis. Following the PRISMA guidelines, studies across 5 different databases were systematically screened. Eligible studies were randomised and non-randomised trials, including individuals with a LC diagnosis, administering exercise-only interventions. Three-level meta-analyses were performed for cardiorespiratory fitness, strength, physical function, anxiety, depression, and health-related quality of life. Differences between exercise types were also explored. The Cochrane Risk of Bias (RoB) II tool for randomised controlled trials and the RoB in non-randomised studies - of interventions were used to assess study quality. A total of 36,304 records were screened and 13 studies, including 547 LC survivors, were considered eligible. Randomised and non-randomised trials were mainly judged as "some concern" and at "serious" RoB, respectively. Meta-analyses reported significant improvements on physical function among exercise groups compared to control (ES = 0.62; 95 % CI: 0.10 to 1.15; p = 0.03), and no significant changes for all other variables. There is moderate evidence that exercise interventions appear to be an effective tool to improve physical function among individuals diagnosed with LC. Further studies are still needed to determine exercise prescription effectiveness on health outcomes, differences across exercise types and enhance individualized interventions.

Grading the evidence for physical activity and any outcome in cancer survivors: An Umbrella review of 740 meta-analytic associations

BACKGROUND

To contribute to the refinement of future physical activity (PA) guidelines, which have remained mostly generic until now, we performed an umbrella review of meta-analyses for PA in cancer survivors.

METHODS

Medline and Scopus databases were searched in January 2024 for systematic reviews and meta-analyses on the association/effect of any type of PA in every cancer type and for any studied outcome. Statistically significant meta-analyses were categorized into four evidence groups (strong, highly suggestive, suggestive, weak) using pre-established grading criteria.

RESULTS

A total of 102 publications reporting 740 meta-analytic associations were identified, including breast (n = 427), prostate (n = 104), hematological (n = 58), colorectal (n = 79) and lung (n = 54) cancer survivors. Overall, 401 (54 %) associations were nominally statistically significant, of which 16 were categorised as strong, 10 as highly suggestive, and 93 as suggestive evidence. In breast cancer, there was strong or highly suggestive evidence that post-diagnosis PA is associated with lower all-cause mortality, recurrence, cancer-related fatigue, depression, and higher mental health, body strength, aerobic capacity, and weight loss. In prostate cancer, strong evidence was identified for the positive association of PA with cardiovascular fitness, quality of life and fatigue amelioration. In colorectal cancer, strong and highly suggestive evidence supported the association of PA with lower all-cause mortality. In lung cancer, strong evidence supported the association of preoperative combination of breathing exercise and PA with reduced length of hospital stay.

CONCLUSION

This grading of the entirety of the available evidence can facilitate robust introduction of targeted exercise prescription in oncology care as standard practice.

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.

Evaluating the therapeutic quality of prehabilitation programmes in patients scheduled for colorectal surgery: A systematic review and meta-analysis

AIM

The aim of this work was to evaluate whether the therapeutic quality of exercise prehabilitation programmes is associated with their effectiveness to preoperatively improve aerobic fitness and reduce postoperative complications and length of hospital stay in patients scheduled for colorectal surgery.

METHOD

Three electronic databases (PubMed, Embase and CINAHL) were systematically searched (up to October 2023) for randomized controlled trials that investigated the effects of prehabilitation before colorectal resection. Methodological quality and therapeutic quality were assessed using, respectively, the Cochrane Risk of Bias 2 tool and the i-CONTENT tool. Studies were divided into four subgroups based on the estimated risk of bias and risk of ineffectiveness.

RESULTS

Fourteen studies were included, comprising 986 patients. Meta-analysis showed that, in general, prehabilitation improved preoperative aerobic fitness but did not improve postoperative outcomes. No differences were found between the four subgroups; however, only one study (7%) had a low risk of bias in combination with a low risk of ineffectiveness.

CONCLUSION

The fact that only one study had a low risk of bias in combination with a low risk of ineffectiveness precluded us from establishing an association between therapeutic quality and the effectiveness of prehabilitation on postoperative outcomes. The quality of future prehabilitation research with exercise interventions should be improved by using an assessment tool during the design phase of prehabilitation programmes.

Physical Prehabilitation for Older Patients with Cancer before Complex Medical-Surgical Interventions: An Umbrella Review

Prehabilitation has become a field of increasing interest over recent decades. However, few studies specifically investigated prehabilitation for older patients with cancer. The objective of this umbrella review was to summarize evidence on prehabilitation programs to identify the physical interventions that may be applied with benefit to older cancer patients who will undergo complex medical-surgical procedures. The protocol was registered in Prospero. Major databases, namely PubMed, Embase, CINAHL, Cochrane, Web of Science and Prospero, were searched until summer 2020 and a second search was performed until November 2023. All systematic reviews and meta-analyses were included, dealing with the major topic of prehabilitation for older patients with cancer diagnosis. Among 1425 records (633 until 2020, 792 until November 2023), 14 reviews were selected for inclusion. According to the AMSTAR-2 checklist, the median quality score was 11 (range: 5-12). Total duration of prehabilitation ranged from 1 to 5 weeks, session duration from 20 to 50 minutes, session frequency from 3 to 6 per week. Reported program modes were aerobic and resistance exercises. Concerning the outcome measures, the functional as well as the respiratory status was significantly affected. Quality of life did not benefit significantly, but showed a positive trend. The length of hospital stay was not significantly improved in the majority of the studies. In contrast, most systematic reviews reported significantly lower numbers of total postoperative complications. Functional recovery was enhanced in half of the found reviews. Prehabilitation is a growing field, notably also in reviews focussing on oncological care for elderly patients included in this umbrella review. Aerobic and resistance exercises are the core of the majority of the programs evaluated but their characteristics (total duration, frequency) are partly heterogeneous. Prehabilitation for older patients may also include other modalities of geriatric interventions like nutritional or psychological optimization.

Real-world study on the application of enhanced recovery after surgery protocol in video-assisted thoracoscopic day surgery for pulmonary nodule resection

OBJECTIVE

This study aims to evaluate the real-world effectiveness of applying different levels of Enhanced Recovery After Surgery (ERAS) guidelines to video-assisted thoracic day surgery (VATS). The goal is to determine the optimal degree of ERAS protocols and management requirements to improve postoperative recovery outcomes.

METHODS

It was designed as a single-centre, prospective pragmatic randomized controlled trial (PRCT), including patients who underwent VATS at the Day Surgery Center of West China Hospital, between January 2021 and November 2022. Patients were divided into Group A and Group B through convenience sampling to implement different levels of ERAS management protocols. Data collection included the baseline characteristics (gender, age, marital status, education level, BMI, PONV risk score, ASA classification), surgery-related indicators (type of surgery, pathological results, hospitalization costs, duration of surgery, intraoperative blood loss, intraoperative rehydration volume), postoperative recovery indicators (postoperative chest tube duration time, time to first postoperative ambulation and urination, postoperative complications, follow-up condition), pain-related indicators (pain threshold score, pain score at 6 h postoperatively, bedtime, and predischarge), psychological state indicators (anxiety level), Athens Insomnia Scale (AIS) scores, and social support scores. Propensity score matching (PSM) was utilized and statistical analyses were conducted using R version 4.4.1. Comparisons of categorical variables were performed using the χ² test, while comparisons of continuous variables were conducted using ANOVA or the Kruskal-Wallis rank-sum test. A significance level of α = 0.05 was set for statistical tests.

RESULT

A total of 340 patients were included, with 187 in Group A and 153 in Group B. After propensity score matching (PSM), there were 142 patients in Group A and 105 in Group B, with no significant baseline differences. Group A had a significantly higher proportion of chest tube removals within 24 h postoperatively (P < 0.001) and earlier mobilization (P < 0.001). Despite a higher pain threshold in Group A (P = 0.016), their postoperative pain scores were not higher than those in Group B. Additionally, Group A had a lower incidence of postoperative complications.

CONCLUSION

The more comprehensive ERAS protocol significantly improved postoperative recovery, confirming its value in day-case VATS and supporting its clinical adoption. However, the study has limitations; future research should focus on standardizing ERAS protocols and expanding their application to a broader patient population to validate these findings further.

TRAIL REGISTRATION

This study underwent review by the Ethics Committee of West China Hospital of Sichuan University under No. 2020 (1001). It has been officially registered with the China Clinical Trial Registry, TRN: ChiCTR2100051372 and registration date is Sept. 22, 2021.

Physiotherapy provided for patients undergoing thoracic surgery in Sweden - a national survey of practice

INTRODUCTION

Patients undergoing thoracic surgery commonly receive perioperative physio-therapy, typically consisting of education, mobilization, breathing exercises, and mobility exercises. To date, no study has described physiotherapy practice for patients undergoing thoracic surgery in Sweden.

PURPOSE

To investigate physiotherapy interventions for patients undergoing thoracic surgery in Sweden.

METHODS

All physiotherapists currently working in thoracic surgery units in Sweden (n = 8) were eligible to participate. A survey was e-mailed to the physiotherapists, to determine physiotherapy interventions offered to patients undergoing thoracoscopy or open thoracic surgery. Of 21 physiotherapists, 13 (62%) responded, representing seven hospitals.

RESULTS

Physiotherapists reported routinely providing preoperative education and postoperative treatment for all patients undergoing thoracic surgery. Breathing exercises and mobilization were usually initiated on the day of surgery or the first postoperative day. Common treatments were deep breathing exercises, with or without positive expiratory pressure, and airway clearance techniques. Upper limb and shoulder exercises were typically initiated on the first or second day after surgery. The most important factor reported to influence treatment choice was personal experience of the attending physiotherapist. No routine post-discharge rehabilitation was provided.

CONCLUSION

Physiotherapists in Sweden reported routinely treating patients scheduled for thoracic surgery, both pre and postoperatively. Prehabilitation or post-discharge rehabilitation was not routinely provided.

[Anatomical Lung Resection Following Neoadjuvant Chemoimmunotherapy: Technical Aspects and Case Reports]

Since the approval of neoadjuvant chemo-immunotherapy in Europe, treatment options for resectable stage II-III NSCLC have also significantly improved in clinical routine. Surgical excision of the tumour by anatomic lung resection still remains the most essential component of multimodal therapy. However, with the increasing use of the new treatment concepts in clinical routine, questions also arise regarding safety, adverse events and technical resectability following neoadjuvant chemo-immunotherapy. This review summarises the current data on perioperative safety following neoadjuvant chemo-immunotherapy and discusses aspects of surgical technique, the extent of resection and intraoperative challenges illustrated by clinical case reports.

Analysis of YouTube-Based Therapeutic Content for Children with Cerebral Palsy

BACKGROUND/OBJECTIVES

Cerebral palsy (CP) causes movement and posture challenges due to central nervous system damage, requiring lifelong management. During the COVID-19 pandemic, there was limited access to facility-based treatments, which increased the demand for home-based therapies and digital resources. We analyzed the qualitative and quantitative aspects of YouTube videos focusing on CP therapy for children.

METHODS

A total of 95 videos were evaluated for content quality using the modified DISCERN (mDISCERN) tool and Global Quality Scale (GQS). The therapeutic program efficacy was assessed via the International Consensus on Therapeutic Exercise and Training (i-CONTENT) tool, Consensus on Therapeutic Exercise Training (CONTENT) scale, and Consensus on Exercise Reporting Template (CERT), and popularity was measured by the video power index (VPI).

RESULTS

YouTube-based therapeutic videos for children with CP generally exhibit reliability in video content and effectiveness in therapeutic programming, and no correlations were found between video popularity and quality. However, the qualitative analysis reveals insufficient mention of uncertainty in the treatment principles within the video content as well as a lack of detailed treatment descriptions encompassing aspects such as intensity, frequency, timing, setting, outcome measurement during and post-treatment, and safety considerations within therapeutic programs. In particular, this tendency was consistent regardless of the uploader's expertise level and the classification of the neuromotor therapy type in contrast to that of the exercise type.

CONCLUSIONS

YouTube-based content for CP children still has significant limitations in how substantive viewers, such as caregivers, can acquire tailored information and apply practical information to their exercise and treatment programs.

Prehabilitation in Adults Undergoing Cancer Surgery: A Comprehensive Review on Rationale, Methodology, and Measures of Effectiveness

Cancer surgery places a significant burden on a patients' functional status and quality of life. In addition, cancer surgery is fraught with postoperative complications, themselves influenced by a patient's functional status. Prehabilitation is a unimodal or multimodal strategy that aims to increase a patient's functional capacity to reduce postoperative complications and improve postoperative recovery and quality of life. In most cases, it involves exercise, nutrition, and anxiety-reducing interventions. The impact of prehabilitation has been explored in several types of cancer surgery, most commonly colorectal and thoracic. Overall, the existing evidence suggests prehabilitation improves physiological outcomes (e.g., lean body mass, maximal oxygen consumption) as well as clinical outcomes (e.g., postoperative complications, quality of life). Notably, the benefit of prehabilitation is additional to that of enhanced recovery after surgery (ERAS) programs. While safe, prehabilitation programs require multidisciplinary coordination preoperatively. Despite the existence of numerous systematic reviews and meta-analyses, the certainty of evidence demonstrating the efficacy and safety of prehabilitation is low to moderate, principally due to significant methodological heterogeneity and small sample sizes. There is a need for more large-scale multicenter randomized controlled trials to draw strong clinical recommendations.

Cardio-oncology rehabilitation: are we ready?

Cardio-oncology rehabilitation (CORE) is not only an essential component of cancer rehabilitation but also a pillar of preventive cardio-oncology. Cardio-oncology rehabilitation is a comprehensive model based on a multitargeted approach and its efficacy has been widely documented; when compared with an 'exercise only' programme, comprehensive CORE demonstrates a better outcome. It involves nutritional counselling, psychological support, and cardiovascular (CV) risk assessment, and it is directed to a very demanding population with a heavy burden of CV diseases driven by physical inactivity, cancer therapy-induced metabolic derangements, and cancer therapy-related CV toxicities. Despite its usefulness, CORE is still underused in cancer patients and we are still at the dawning of remote models of rehabilitation (tele-rehabilitation). Not all CORE is created equally: a careful screening procedure to identify patients who will benefit the most from CORE and a multidisciplinary customized approach are mandatory to achieve a better outcome for cancer survivors throughout their cancer journey. The aim of this paper is to provide an updated review of CORE not only for cardiologists dealing with this peculiar population of patients but also for oncologists, primary care providers, patients, and caregivers. This multidisciplinary team should help cancer patients to maintain a healthy and active life before, during, and after cancer treatment, in order to improve quality of life and to fight health inequities.

Cost-effectiveness of prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO) versus usual care - Protocol for a health economic evaluation alongside a randomized controlled trial

BACKGROUND

Prehabilitation aims to improve patients' functional capacity before surgery to reduce perioperative complications, promote recovery and decrease probability of disability. The planned economic evaluation is performed alongside a large German multi-centre pragmatic, two-arm parallel-group, randomized controlled trial on prehabilitation for frail elderly patients before elective surgery compared to standard care (PRAEP-GO RCT). The aim is to determine the cost-effectiveness and cost-utility of prehabilitation for frail elderly before an elective surgery.

METHODS

The planned health economic evaluation comprises cost-effectiveness, and cost-utility analyses. Analyses are conducted in the German context from different perspectives including the payer perspective, i.e. the statutory health insurance, the societal perspective and the health care provider perspective. Data on outcomes and costs, are collected alongside the ongoing PRAEP-GO RCT. The trial population includes frail or pre-frail patients aged ≥70 years with planned elective surgery. The intervention consists of frailty screening (Fried phenotype), a shared decision-making conference determining modality (physiotherapy and unsupervised physical exercises, nutrition counselling, etc.) and setting (inpatient, day care, outpatient etc.) of a 3-week individual multimodal prehabilitation prior to surgery. The control group receives standard preoperative care. Costs include the intervention costs, the costs of the index hospital stay for surgery, and health care resources consumed during a 12-month follow-up. Clinical effectiveness outcomes included in the economic evaluation are the level of care dependency, the degree of disability as measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), quality-adjusted life years (QALY) derived from the EQ-5D-5L and the German utility set, and complications occurring during the index hospital stay. Each adopted perspective considers different types of costs and outcomes as outlined in the protocol. All analyses will feature Intention-To-Treat analysis. To explore methodological and parametric uncertainties, we will conduct probabilistic and deterministic sensitivity analyses. Subgroup analyses will be performed as secondary analyses.

DISCUSSION

The health economic evaluation will provide insights into the cost-effectiveness of prehabilitation in older frail populations, informing decision-making processes and contributing to the evidence base in this field. Potential limitation includes a highly heterogeneous trial population.

TRIAL REGISTRATION

PRAEP-GO RCT: NCT04418271; economic evaluation: OSF ( https://osf.io/ecm74 ).

Qualitative assessment of expectations on the content, form and way of delivery of a prehabilitation programme in patients with lung resection surgery - A Swiss tertiary centre experience

Objective

To assess the interest in a prehabilitation programme of patients awaiting lung resection and to identify expectations from such a programme.

Introduction

At present, in Switzerland, there are no multimodal clinical prehabilitation programmes for lung resection patients awaiting surgery.

Methods

Semi-structured face-to-face interviews were conducted with patients who have had or were awaiting lung resection at a Swiss tertiary centre. Thematic analysis was performed to identify common prespecified themes.

Results

Twenty-two patients (45.5% female, age 70.6 ± 16.6 years) were interviewed. Seventy-seven percent were interested in a prehabilitation programme. Sixty-two percent, 67% and 90% were interested in endurance, strength and respiratory training, respectively. Six patients (27%) were active smokers, of whom two (one-third) were interested in a smoking cessation programme. Seventy-six percent were interested in nutrition counselling and 90% in receiving education on risk factor management. Forty percent preferred centre-based training/counselling sessions, 20% preferred home-based training/counselling and 30% found both forms acceptable. Patients were willing to perform prehabilitation activities on 2.6 days/week for a total of 162 min/week. Participating in peer groups was desired by only 25%.

Conclusions

Patients with lung resection were highly interested in participating in prehabilitation, albeit only for a mean time cost of 2.7 h per week. Offering a prehabilitation programme with a combination of in-hospital group sessions and home-based training seems feasible.