Multimodal prehabilitation in patients undergoing colorectal cancer resection: The impact of supervised structured perioperative exercise on postoperative functional capacity

Exercise training has been shown to positively affect the maintenance of functional capacity and facilitate recovery from surgery. This thesis proposes that a supervised pre- operative exercise training program would encourage patient compliance, thus maximizing the opportunity to regain functional exercise capacity 4-weeks post-surgery. The supervised group (Group S) received 4 training sessions at the Montreal General Hospital exercise laboratory along with a home-based exercise program during the pre-surgical period and provided daily supervised exercise during the post-surgical hospital stay. The unsupervised group (Group U) received a 4-week home-based exercise program during the pre-surgical period and were not seen by a kinesiologist during the post-surgical in-hospital stay. The exercise programs (both pre and post-surgery) included individualized aerobic, resistance and flexibility exercises. Both groups continued to exercise until 4 weeks post-surgery, after which they returned to the laboratory for evaluation. The primary outcome was functional walking capacity, as assessed by the six-minute walk test (6MWT)

From Theory to Practice: An International Approach to Establishing Prehabilitation Programmes

PurposeThis article focuses on the following:*The importance of prehabilitation in people with cancer and the known and hypothesised benefits.*Exploration of the principles that can be used when developing services in the absence of a single accepted model of how these services could be established or configured.*Description of approaches and learning in the development and implementation of prehabilitation across three different countries: Canada, the Netherlands and the United Kingdom, based on the authors’ experiences and perspectives.Recent FindingsPractical tips and suggestions are shared by the authors to assist others when implementing prehabilitation programmes. These include experience from three different approaches with similar lessons.Important elements include the following: (i) starting with a small identified clinical group of patients to refine and test the delivery model and demonstrate proof of concept; (ii) systematic data collection with clearly identified target outcomes from the outset; (iii) collaboration with a wide range of stakeholders including those who will be designing, developing, delivering, funding and using the prehabilitation services; (iv) adapting the model to fit local situations; (v) project leaders who can bring together and motivate a team; (vi) recognition and acknowledgement of the value that each member of a diverse multidisciplinary team brings; (vii) involvement of the whole team in prehabilitation prescription including identification of patients’ levels of risk through appropriate assessment and need-based interventions; (viii) persistence and determination in the development of the business case for sustainable funding; (ix) working with patients ambassadors to develop and advocate for the case for support; and (x) working closely with commissioners of healthcare.SummaryPrinciples for the implementation of prehabilitation have been set out by sharing the experiences across three countries. These principles should be considered a framework for those wishing to design and develop prehabilitation services in their own areas to maximise success, effectiveness and sustainability

Maximizing patient adherence to prehabilitation:: what do the patients say?

Purpose Multimodal prehabilitation programs (exercise, nutrition, and anxiety reduction) have been shown to be successful for enhancing patients' physical function prior to surgery, although adherence remains a challenge. Given the short pre-operative period, maintaining adherence is critical to maximize program effectiveness. This study was designed to better understand patients' perspectives of prehabilitation and to identify factors related to program adherence.Methods A qualitative descriptive study was conducted based on 52 cancer patients enrolled in a prehabilitation program at the Montreal General Hospital, Montreal, Canada. Data was collected with a structured questionnaire designed to evaluate the program.Results Patients enjoyed their experience in prehabilitation, especially the exercise program and training sessions. The primary motivating factor for participation was to be physically prepared for the surgery. The most challenging exercise component was resistance training, while the most enjoyed was the aerobic training. Approximately 50% of patients were interested in group fitness classes as opposed to supervised individual training sessions for reasons related to social support. The preferred methods for exercise program delivery were home-based and one supervised exercise session per week. The biggest barrier to participation was related to transportation.Conclusions These findings highlight the need to make prehabilitation programs more patient-centered. This is critical when designing more effective therapeutic strategies tailored to meet patients' specific needs while overcoming program non-adherence.</p

Prehabilitation and acute postoperative physical activity in patients undergoing radical prostatectomy: a secondary analysis from an RCT

Abstract Background Physical activity via early mobilization after surgery is recommended to help reduce the risk of postoperative adverse effects and to improve recovery. We explored whether prehabilitation is associated with differences in physical activity during the postoperative inpatient stay and the week after discharge in men undergoing abdominal surgery. Methods This study was a pre-planned secondary analysis of a larger randomized controlled trial of home-based exercise prehabilitation versus control for men undergoing radical prostatectomy. Twenty-one participants in both the prehabilitation and control groups wore accelerometers from postoperative day 1 until 7 days after discharge. Mean physical activity (minutes) during postoperative day 1 (inpatient) and 1 week following hospital discharge (outpatient) were estimated using ANCOVA. Pearson’s correlation coefficients were conducted for mean in- an outpatient physical activity with length of stay and changes in 6-min walk test (6MWT) over the course of the prehabilitation period. Results Nineteen participants in each group provided usable accelerometry data for analysis. Inpatient physical activity of light or greater activity during postoperative day 1 for prehabilitation and control groups were 442.5 ± 40.2 and 324.0 ± 40.2 min, respectively (∆ = 117.5 ± 57.8 min, 95%CI [0.04, 235.0]). During the outpatient period, mean daily physical activity was 448.4 ± 31.2 and 491.42 ± 31.2 min for prehabilitation and control participants, respectively (∆ = 42.6 ± 44.9 min; 95% CI [− 134.0, 48.7]). There were no correlations between in- or outpatient physical activity and preoperative changes in 6MWT or length of stay. Conclusions Accelerometry-based measurement of physical activity in the acute postoperative period is feasible in older men undergoing abdominal surgery. Prehabilitation may be associated with increased inpatient physical activity; however, larger and longer studies are needed to elucidate any associated effects on clinical and patient outcomes. Trial registration Clinicaltrials.gov: NCT02036684 registered January 15, 2014

Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial

<p><b>Background:</b> Prehabilitation has been previously shown to be more effective in enhancing postoperative functional capacity than rehabilitation alone. The purpose of this study was to determine whether a weekly supervised exercise session could provide further benefit to our current prehabilition program, when comparing to standard post-surgical rehabilitation.</p> <p><b>Methods:</b> A parallel-arm single-blind randomized control trial was conducted in patients scheduled for non-metastatic colorectal cancer resection. Patients were assigned to either a once weekly supervised prehabilitation (PREHAB+, <i>n</i> = 41) or standard rehabilitation (REHAB, <i>n</i> = 39) program. Both multimodal programs were home-based program and consisted of moderate intensity aerobic and resistance exercise, nutrition counseling with daily whey protein supplementation and anxiety-reduction strategies. Perioperative care was standardized for both groups as per enhanced recovery after surgery (ERAS^®) guidelines. Functional exercise capacity, as determined by the 6-minute walk test distance (6MWD), was the primary outcome. Exercise quantity, intensity and energy expenditure was determined by the CHAMPS questionnaire.</p> <p><b>Results:</b> Both groups were comparable for baseline walking capacity (PREHAB+: 448 m [IQR 375–525] vs. REHAB: 461 m [419–556], <i>p</i>=.775) and included a similar proportion of patients who improved walking capacity (>20 m) during the preoperative period (PREHAB+: 54% vs. REHAB: 38%, <i>p</i> = .222). After surgery, changes in 6MWD were also similar in both groups. In PREHAB+, however, there was a significant association between physical activity energy expenditure and 6MWD (<i>p</i> < .01). Previously inactive patients were more likely to improve functional capacity due to PREHAB+ (OR 7.07 [95% CI 1.10–45.51]).</p> <p><b>Conclusions:</b> The addition of a weekly supervised exercise session to our current prehabilitation program did not further enhance postoperative walking capacity when compared to standard REHAB care. Sedentary patients, however, seemed more likely to benefit from PREHAB+. An association was found between energy spent in physical activity and 6MWD. This information is important to consider when designing cost-effective prehabilitation programs.</p

Prehabilitation for men undergoing radical prostatectomy: a multi-centre, pilot randomized controlled trial

Abstract Background An emerging field of research describes the role of pre operative health behaviours, known as prehabilitation. The preoperative period may be a more physically and emotionally salient time to introduce and foster chronic adherence to health behaviours, such as exercise, in patients compared to post-treatment during recovery. Moreover, physical and psychosocial improvements during the preoperative period may translate into an enhanced recovery trajectory with reduced operative complications and postoperative adverse effects. No studies have assessed prehabilitation for men with prostate cancer undergoing radical prostatectomy. Methods/Design This is a multi-centre, pilot randomized control trial conducted at two Canadian urban teaching hospitals. 100 men undergoing radical prostatectomy for prostate cancer with no contraindications to exercise will be recruited and randomized to the prehabiliation program or usual care. Prehabilitation participants will engage in a preoperative, individualized exercise program including pelvic floor muscle strengthening instructions and a healthy lifestyle guide for men with prostate cancer. These participants will be asked to engage in 60 minutes of home-based, unsupervised, moderate-intensity exercise on 3–4 days per week. Usual care participants will receive the same pelvic floor muscle strengthening instructions and healthy lifestyle guide only. We will assess the feasibility of conducting an adequately powered trial of the same design via recruitment rate, programmatic adherence/contamination, attrition, and safety. Estimates of intervention efficacy will be captured through measurements at baseline (4–8 weeks preoperatively), within 1 week prior to surgery, and postoperatively at 4, 12, and 26 weeks. Efficacy outcomes include: fatigue, quality of life, urinary incontinence, physical fitness, body composition, aerobic fitness, pain, and physical activity volume. Discussion The primary outcome of this study is to determine the feasibility of conducting a full-scale, randomized controlled trial of prehabilitation versus usual care and to estimate effect sizes that will inform sample size determinations for subsequent trials in this field. To our knowledge, this is the first study to examine a structured presurgical exercise program for men undergoing radical prostatectomy for prostate cancer. This trial will advance our understanding of strategies to efficiently and effectively use the preoperative period to optimize postoperative recovery. Trial registration Clinicaltrials.gov Identifier: NCT02036684

Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial

Importance: Colorectal surgery is associated with substantial morbidity rates and a lowered functional capacity. Optimization of the patient's condition in the weeks prior to surgery may attenuate these unfavorable sequelae. Objective: To determine whether multimodal prehabilitation before colorectal cancer surgery can reduce postoperative complications and enhance functional recovery. Design, setting, and participants: The PREHAB randomized clinical trial was an international, multicenter trial conducted in teaching hospitals with implemented enhanced recovery after surgery programs. Adult patients with nonmetastasized colorectal cancer were assessed for eligibility and randomized to either prehabilitation or standard care. Both arms received standard perioperative care. Patients were enrolled from June 2017 to December 2020, and follow-up was completed in December 2021. However, this trial was prematurely stopped due to the COVID-19 pandemic. Interventions: The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed. Main outcomes and measures: Comprehensive Complication Index (CCI) score, number of patients with CCI score more than 20, and improved walking capacity expressed as the 6-minute walking distance 4 weeks postoperatively. Results: In the intention-to-treat population of 251 participants (median [IQR] age, 69 [60-76] years; 138 [55%] male), 206 (82%) had tumors located in the colon and 234 (93%) underwent laparoscopic- or robotic-assisted surgery. The number of severe complications (CCI score &gt;20) was significantly lower favoring prehabilitation compared with standard care (21 of 123 [17.1%] vs 38 of 128 [29.7%]; odds ratio, 0.47 [95% CI, 0.26-0.87]; P = .02). Participants in prehabilitation encountered fewer medical complications (eg, respiratory) compared with participants receiving standard care (19 of 123 [15.4%] vs 35 of 128 [27.3%]; odds ratio, 0.48 [95% CI, 0.26-0.89]; P = .02). Four weeks after surgery, 6-minute walking distance did not differ significantly between groups when compared with baseline (mean difference prehabilitation vs standard care 15.6 m [95% CI, -1.4 to 32.6]; P = .07). Secondary parameters of functional capacity in the postoperative period generally favored prehabilitation compared with standard care. Conclusions and relevance: This PREHAB trial demonstrates the benefit of a multimodal prehabilitation program before colorectal cancer surgery as reflected by fewer severe and medical complications postoperatively and an optimized postoperative recovery compared with standard care. Trial registration: trialregister.nl Identifier: NTR5947