Having major surgery is like running a marathon – both challenges require training, physical conditioning and stamina, experts say. That's why doctors and hospitals are prescribing prehabilitation – basically rehabilitation performed before a surgical procedure, be it joint replacement, cardiac, transplant, colorectal or cancer surgery.
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The goal? To help patients get stronger, fitter and more functional ahead of treatment – chemotherapy and radiation included, says Dr. Julie Silver, a physician and researcher at Harvard Medical School and Spaulding Rehabilitation Hospital. Prehab can encompass exercise or physical therapy (on land or in water), dietary changes and smoking cessation. It can also include fortifying mental strength through psychological interventions, she explains.
While research hasn't definitively proven the perks of prehab, "that in no way implies that it isn't of tremendous value," says Dr. Jonathan Whiteson, vice chair for clinical operations and medical director of cardiac and pulmonary rehabilitation at Rusk Rehabilitation at NYU Langone Health. In Europe and Canada, where there are often lengthy waitlists for surgery, research shows prehab may lower the risk of complications, shorten hospital stays and boost outcomes. "The window of opportunity to conduct research is smaller in the U.S. because we don't have long waitlists" for surgery, he adds.
Nothing cookie cutter about it. There isn't a one-size-fits-all approach to prehab. It's tailored to individual needs and accounts for the specific challenges a particular patient might face after a given procedure, says Silver, author of "Before and After Cancer Treatment: Heal Faster, Better, Stronger." "It's not general wellness – everybody knows to eat right and exercise. These are specific, targeted approaches to facilitate certain outcomes," like averting bleeding or infection after surgery.
Indeed, a Spanish study published in 2018 showed that patients who did a personalized prehab program involving high-intensity endurance exercise training before undergoing elective major abdominal surgery had fewer post-op complications compared to those who received standard care, because of their increased aerobic capacity. In a review of nine studies, Canadian researchers found that patients undergoing colorectal surgery who did nutritional prehabilitation (with oral nutritional supplements) alone or combined with exercise decreased their hospital stay by two days.
Prehab comes in different formats, from group classes to one-on-one training to self-directed at-home exercises. Duration? Often two to six weeks. "We want patients to quit smoking at least four to six weeks before surgery because smoking can lead to lung infections and wound infections after surgery," says Dr. R. Matthew Walsh, Cleveland Clinic's chair of general surgery. "It takes a while for the effects of smoking to wear off." Prehab can also involve efforts to get diabetes, hypertension or other chronic conditions under control before surgery.
Sometimes, prehab means the difference between being cleared – or not – for a given treatment. For example, with lung cancer, the surgical-eligibility bar is set fairly high and some patients may be too sick or weak to qualify initially, Silver says. "If they get stronger with prehab, they might be transformed into surgical candidates," which may thereby improve their odds of survival. For those patients, says Silver, "That would be a really big game-changer."
Patients needing an organ transplant are often weak and frail. Prehabilitation can help them get strong enough to tolerate the surgery, Whiteson says. Depending on how frail they are, the prehab Rx may be dietary. "If patients are underweight and have lost muscle, we'll increase their protein and calorie intake and encourage them to have small, frequent meals and take a vitamin and mineral supplement," says Jeanette Hasse, transplant nutrition manager at Baylor University Medical Center in Dallas.
Joanna King, 66, was diagnosed with idiopathic pulmonary fibrosis in 2018 after developing severe shortness of breath. She was put on oxygen therapy and told she wouldn't survive without a lung transplant. But to even be considered for surgery, she had to get stronger. While on oxygen therapy, King began prehab at NYU Langone Health. It involved doing physical therapy, working with a psychologist and learning specific breathing techniques to boost oxygen levels and promote calmness.
Better outcomes. "The physical therapy built my strength, which made me feel good, and the psychologist helped me feel calm and confident," says King, a retired headhunter in New York City. "I went from being terrified to really looking forward to the surgery." In October 2018, King had a left lung transplant and no longer needs oxygen therapy. "I came out of the surgery really well."
With most sports medicine operations, prehab can set the stage for better outcomes, too. If someone is scheduled to have an ACL (the anterior cruciate ligament) reconstruction, a prehab regimen can improve range of motion, swelling and muscle activation in the knee before surgery, says Dr. Rachel M. Frank, assistant professor of orthopaedic surgery and director of the joint preservation program at the University of Colorado School of Medicine. "If you go in for surgery with an angry knee, your chances of having stiffness in the knee after surgery are greater, as are your chances of having a decreased functional outcome and a slower return to sport." A 2018 study found that patients with knee osteoarthritis who did a six-week home-based prehabilitation exercise program before undergoing total knee arthroplasty had greater improvements in pain and functionality up to six months after surgery, compared to those in a control group.
After Ellie Venafro, 45, tore her ACL while skiing in January 2019, her knee was so swollen she couldn't straighten her leg. She needed surgery, but "Dr. Frank didn't want to do [it] until I had almost full range of motion," says Venafro, a health care finance director. So she went to physical therapy once weekly and did twice-daily exercises at home to strengthen her leg muscles. "I'm a very avid exerciser, and I wanted to get back to it as soon as I could."
She had surgery in February and was thrilled with the results. "I'd heard horror stories about how long recovery could take and how much pain I might be in," she says. "My recovery was pretty remarkable: I immediately had more range of motion than is typical, and by the second week, I was already on the bike, which is where someone would usually be by the seventh week." Venafro is now hiking and running on the treadmill again.
Sometimes patients end up in better shape than before surgery, Silver says. "The earlier people get in for prehab, the better they function on the other side," adds physical therapist Melanie Gaeta, orthopedic program manager at the Center for Restorative Therapies at Mercy Medical Center in Baltimore. The ideal scenario: prehab plus traditional post-operative rehabilitation, Whiteson says.
Interest in prehab is growing. "It's a field, a trend, a movement that makes tremendous sense," Whiteson says. "There's no doubt that there's a benefit to getting stronger before elective surgery." Walsh agrees: "We're so geared up to enhance recovery after surgery. What we do before surgery can enhance recovery after surgery even more."