Prehabilitation

Christine Alvero DPT, MBA Director of Rehab, Nutrition, Safe Patient Handling

Moffitt Cancer Center

OVERVIEW • Define prehabilitation • Identify areas where prehab is used • Identify components of prehab • Benefits of prehab • Multidisciplinary roles in prehab

What is Rehabilitation?

• A process of helping an individual achieve the highest level of function, independence, and quality of life.

• Physical therapy • Occupational therapy • Speech therapy • Occurs when there are problems present

What is Prehabilitation?

• A process designed to improve a person’s physical and psychological health in anticipation of an upcoming stressor.

• Occurs after diagnosis but before treatment • Time when patients are more physically and emotionally

salient • Proactive versus reactive • Intervention based programs to improve outcomes • Prepares for stressors to include:

– Surgery – Chemo – Radiation – Cardiac procedures

Why the shift?

• National strategy to change healthcare focus – Away from “sick care” – Towards “healthcare”

• 5/6 top causes of death could be impacted by shift to wellness and prevention – Heart disease, cancer, stroke, COPD, diabetes

• Benefits of healthy individuals – More productive – Live independently longer – Take fewer sick days

Classifications

• Physical Focus – Early studies and prehab programs had small focus – Emphasis on physical exercise and endurance

programs only

• Multi-modal approach – Recent research (oncology focused) supports broader

view – Approach includes:

• Physical • Psychological • Nutrition • Modifiable risk factors

Components • Physical Focus

– Strengthening – Endurance – Balance, core

• Psychosocial

– Stress reduction – Relaxation techniques – Coping strategies

• Nutrition

– New nutritional needs during treatment – Facts versus myths

Goals of Prehab

• LOWER – Length of stay (LOS) – Peri-operative

complications – Postoperative

complications – Re-admissions – Physical impairments – Recovery time – Pain

• INCREASE – Endurance capacity – Cardiac reserve – Respiratory function – Quality of Life – Outcomes – Return-to-work – Independence

History of Prehabilitation • Began in the orthopedic population (joint replacements)

– Concepts used, term not

• 1946 – military used prehab and found that 85% were able to pass recruitment exams after a 2 month prehab program

• Using a small “window of opportunity” to improve outcomes

• “Pre-operative physical conditioning is an increasingly

common strategy aimed at improving postoperative outcomes, including length of stay (LOS), functional capacity and per-operative complications.”

Benefits

• Length of stay – Pilot programs show 40% decrease in lung ca patients – Pilot programs show 21% improvement in ambulation

distance in lung ca patients

• Perioperative Complications – Cardiac surgery patients had decreased incidence of

post op atelectasis and pneumonia

Benefits

• QOL – Self reports (questionnaires) show improved perception

• Post Operative Care

– 1-2 pre op sessions can decrease post op care by 29%

Pre-Op Usage • Recent dx, surgery pending

• Generalized aerobic & strength

program using ACSM guidelines

• Results: – Improved cardiopulmonary

fitness – Improved muscle strength – Aid in functional recovery post op – Improved QOL 6 months later

https://www.youtube.com/watch?v=DbddvJ4Om10

Pre-Op Usage • Nutrition focus alone (GI surgeries)

• Use of oral supplements for 3-5 days

prior to surgery – Focus on certain supplements (argenine,

omega 3 fatty acids, nucleotides) – Beginning these supplements post op

day 1

• Post op results:

– Decreased infections (51%) – Decreased complications – Decreased length of stay (15%)

Pre-Op Usage MOFFITT EXPERIENCE • Trialed with GI surgeon

– Expensive for patients – No change in LOS noted – No change in leaks – No change in infection rate

Orthopedic Usage

• Prehab prior to joint replacements can decrease post op care by 30% ($1200 per patient)

• Education and exercise focus

• TKR – Pre-op ROM is a predictor for outcomes – Functional capacity prior – Decreased pain post operatively – Improved function at a more rapid pace

• Largest gap in function is 6 weeks post op

https://www.youtube.com/watch?v=uenIAZzx26k

Orthopedic Usage

MOFFITT EXPERIENCE • Barriers:

– Many of our patients are seen by ortho and then have surgery the following week

– Many of our patients have fractures or are at risk for fracture and are not appropriate for prehab

– Patients are frequently seen by PT pre-op for education purposes

Prehab in Oncology • Lung Cancer

– May make patient eligible for surgery – Maximize respiratory efficiency – Smoking cessation if needed

Results show:

• ↑ aerobic capacity, O2 sats post op • ↓ hospital LOS, stress using progressive relaxation • Often patients to not need further PT after discharge

from hospital

Prehab in Oncology • GU Cancer

– Pre radical prostatecomy – Pelvic floor, low back, lower abdominal muscle

strengthening program – 4-6 weeks preop

Results show: • Significant difference in level of continence at 3

and 6 months post op • Improved QOL scores with prehab

Prehab in Oncology • Head and Neck Cancer

– Swallowing exercises – Neck and shoulder ROM exercises – Extensive education – Smoking cessation if needed

Results from 2012 study

• “Fast tracked” healing/swallow function after chemoradiation

Johns Hopkins • Anecdotal evidence shows fewer problems with prehab in

place

Prehab in Oncology • Breast Ca

– UE strengthening to decrease post op frozen shoulder

– Stress management – Psychological component of losing

breast(s) https://www.youtube.com/watch?v=k-X_MpclygE

https://www.youtube.com/watch?v=wGejGU67LGU

Prehab in Oncology • Bone Marrow Transplant

– Exercise program pre-transplant, during, and post transplant

– 15% improvement in fatigue scores with exercise – 28% deterioration in fatigue scores without exercise – Depression scores were better with exercise

Prehab in Oncology MOFFITT EXPERIENCE • Lung Cancer

– This is an area that we need to target

• GU Cancer

– Most referrals are post-op – Currently investigating possibilities of offering a pre-op class

• H&N Cancer

– Currently seen by speech pre-op and pre-XRT – Smoking cessation is offered

Prehab in Oncology MOFFITT EXPERIENCE • Breast Cancer

– Currently investigating possibility of offering pre-op classes – Currently participating in lymphedema clinic monthly – Currently offering lymphedema screenings which take place pre-op

and post-op

• BMT – Exercise program begins day 1 of admission – Many are seen before transplant when admitted for initial

chemo – Need to further explore pre-op screenings/exercise and

nutrition programs

Standardized Programs Athletes

• Colleges use CSCS and Athletic Trainers

• Focus on muscle balance to

prevent injury

• Established protocols which are sport dependent

Standardized Programs The Valley Hospital

• Focus is on pre-op orthopedics only – using Athletic Trainers • Multimodal approach

– Exercise – Guided imagery and meditation

• Components

– Education – Functional skills practice – Exercise (strength and cardio) – Audio programs for relaxation

Standardized Programs STAR

• New cancer dx

• Prevention/reduction of long term problems

• Protocols based upon published research

• Focus on early screenings and early interventions

Standardized Programs STAR – Prehab Protocol

• Targeted therapy with PT, OT, or SP

• Smoking cessation

• Nutrition services

• Nurse navigation

• Integrated medicine/complementary therapy

Multi-Disciplinary Roles • Nurse Navigator – screening tools, suggesting referrals

• Providers – recognition of early intervention

• Social Work – anxiety, stress management

• Specialties – smoking cessation, behavior modification

Multi-Disciplinary Roles • PT – increasing activity, building strength/endurance

• OT – maintaining ind with ADL and IADL

• Speech – swallowing difficulties

• Nutrition – eating plans before, during, and after tx

Barriers to Prehab

• Challenge to patients and providers believing that patients need intervention

• Benefits extend past the physical into relationships, trust, etc

• Brief time period between dx and surgery/treatment

• Determining the correct setting – Group classes – Individual sessions

Barriers to Prehab

• Some patients believe that no problems = no needs

• Delay in surgery (2 weeks -8 weeks)

• Reimbursement varies

• Determining the correct providers – Exercise specialists – Athletic trainers – Physical therapists

Creating a Prehab Program • Clearly define prehab

• Designate a physician champion

• Address treatment delays

• Nurses are critical

• Determine your format

– In person – Independent work for the patient

References • Bruns, E.R., van den Heuvel, B., Buskens, C.J., Duijvendijk, Festen, S., Wassenaar,

E.B., van der Zaag, E.S., Bemelman, W.A., van Munster, B.C. (2016). The effects of physical prehabilitation in elderly patients undergoing colorectal surgery: a systematic review. Colorectal Disease The Association of Coloproctology of Great Britain and Ireland, 18: O267-O277.

• Carli, F., Scheede-Bergdahl, C. (2015). Prehabilitation to enhance perioperative care.

Anesthesiology Clin, 33; 17-33. • Coats, V., Maltais, F., Simard, S., et al. (2013). Feasibility and effectiveness of a

home based exercise training program before lung resection surgery. Cancer Respir Journal. 20:2; 10-16.

• Dunne, D., Jack, S., Jones, R., et al. (2016). Randomized clinical trial of

prehabilitation before planned liver resection. British Journal Society. 103:504-512. • Mina, D.S., Clarke, H., Ritvo, P., Leung, Y.W., Matthew, A.G., Katz, J., Trachtenberg,

J., Alibhai, S.M.H. (2014). Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy, 100; 196-207.

References • Pirsch, Chris (2016). The Power of Prehabilitation. ONS Connect, The

Official News Magazine of the Oncology Nursing Society. http://connect.ons.org/issue/may-2016/up-front/the-power-of-prehabilitation

• Pouwels, S., Fiddelaers, J.,Teijink, J., Woorst, J., Siebenga, J., Smeenk, F.

(2015). Preoperative exercise therapy in lung surgery patients: a systematic review. Respiratory Medicine. 109; 1495-1504.

• Sebio Garcia, R., Brange, M., Moolhuyzen, E., Granger, C., Denehy, L. (2016). Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interactive CardioVascular and Thoracic Surgery. 10.1093/icvts/ivw152.

• Silver, Julie (2014). Cancer prehabilitation: One step toward improved

outcomes. Oncology Nurse Advisor. http://www.oncologynurseadvisor.com/side-effect-management/cancer-prehabilitation-one-step-toward-improved-outcomes/article/381594/

References • Tsimopoulou, I., Pasquali, S., Howard, R., et al. (2015). Psychological

prehabilitation before cancer surgery: a systematic review. Annals of Surgical Oncology. 22; 4117-4123.

• Valkenet, K., Trappenburg, J., Shippers, C., Wanders, L., Lemmons, L., Backx,

F., Van Hillegersberg, R. (2016). Feasibility of exercise training in cancer patients scheduled for elective gastrointestinal surgery. Digestive Surgery. 33:439-447.