Surgery puts enormous stress on the body. It puts patients at risk for complications, which can slow recovery. But taking time to get into optimal shape before elective surgery can vastly improve a patient's chances for a speedy recovery, says Katie Starr, Vivo chief scientific officer with the VA POSH (Perioperative Optimization of Senior Health) at the Durham VA Medical Center in Durham, North Carolina.
Essentially, the healthier a person is before surgery, the better equipped their bodies are to overcome the stress responses produced during surgery. But many people have compromised immune systems due to advanced age or a medical condition, making it more difficult for them to bounce back after surgery.
With a growing population of aging, obese and diabetic individuals — who have, in turn, created a greater demand for surgical services — the medical community has begun pursuing ways to improve patient outcomes following surgery.
One such approach is prehabilitation.
What Is Prehab?
Prehab is a new buzzword in patient care that takes a proactive approach using exercise and nutrition training to treat at-risk patients before they undergo elective surgery.
Most people are familiar with rehabilitation, the medical specialty that helps people regain lost body functions due to medical conditions or injury. For example, people who have undergone hip replacement surgery usually require extensive rebab to help them rebuild muscle strength and regain function and mobility.
Prehab is like rehab before surgery, but it strives to get the body to its maximum health potential before surgery so that the patient can quickly heal and return to normal activities. Like rehab, though, prehab takes time. Cardiovascular improvements can be seen in as little as three weeks. But four to eight weeks of prehab before surgery is necessary for patients to see strength gain.
Where Does Prehab Come From?
In 1997, in an effort to improve postoperative outcomes of patients, a group of general physicians from Europe developed Enhanced Recovery After Surgery (ERAS). The method employs practices designed to reduce a patient's hospital stay, complication rates, recovery period and economic costs.
Through the years, the protocol has evolved to include practices such as patient and family education, pain management and nutrition recommendations. It also involves optimizing patients' health before surgery — the keystone of prehabilitation.
"What we want to do with prehab is bump somebody's baseline from where they started so that we can delay and reduce the loss and impact [caused by surgery] so that they will be able to recover sooner," Starr says.
How Does Prehab Work?
The type of surgery and the patient's needs dictate the type of prehabilitation needed. Here are some examples of how prehabilitation works:
Muscular strength: Prehab is often used in patients undergoing joint replacement surgery to build muscle mass in order to support the body and provide mobility as the affected area recovers. For example, an 84-year-old man was prehabilitated before knee replacement surgery to strengthen his upper body. The prehab focused on his arm strength so he could lift himself in and out of chairs and his bed until his could apply pressure on his rebuilt knee.
Cardiorespiratory: "Cardiorespiratory muscles are extremely important when it comes to intubation during anesthesia. The impact on the lungs is very big," Starr says. Smokers and people with poor lung volume or cardio-respiratory fitness are at greater risk for infection, pneumonia or aspiration — "all are things that will cause long-term, postoperative complications and reduced ability to heal from surgery."
Prehab for patients undergoing a lobectomy or having a portion of their lung removed may focus on building aerobic capacity in addition to strength training.
Nutritional: Nutrition impacts how quickly the body heals from the stress of surgery, which is why being nutritionally fit before undergoing surgery is imperative to a good recovery, Starr says.
Many conditions can adversely impact nutrition. As we age, our bodies go through physiological and metabolic changes that result in a loss of muscle mass and renal function, which affect hydration and fluid status — "important factors in regard to surgery because of the stress response," Starr says.
Surgical stress also boosts blood sugar levels in the body, posing risks for patients who are not nutritionally fit. For example, surgery puts diabetic patients at risk for complications, including wound site infections and longer recovery.
Cancer and cancer treatments can also affect a person's ability to eat food or absorb nutrients, which can lead to malnutrition.
"Just like with function and cardiorespiratory and physical function, we know that nutritional status is going to decline in the hospital setting," Starr says. "We want to make sure we do everything we can on the front end to help mitigate that on the back end."
Who Is Prehab For?
While anyone would benefit from getting in optimal health before elective surgery, prehab is intended for patient populations who are more vulnerable to surgical stress response, including:
- the elderly
- anyone with multiple health conditions such as Type 2 diabetes
- patients with cancer at any age, particularly those who have undergone chemotherapy or radiation
Healthier people in better physical shape are less likely to see much gain with prehab, Starr says. But those who are unfit stand to see "amazing gains" from achieving optimal health before surgery.
"With older adults, independence is one of the most important things. They want to remain independent and they want to remain in their homes. If they want to do that, we've got to be sure that we optimize the muscles before going into surgery, and that includes both prehab and nutrition," Starr says. "That's what we're trying to do: Reduce the insult caused by surgery and get them home and back active and back to their baseline as soon as possible."
Does Prehab Work?
Studies on the effectiveness of prehabilitation vary.
One meta-analysis of several studies of adults undergoing knee or hip replacement for osteoarthritis found that pre-surgical exercise had no significant post-surgery benefit on function, quality of life and pain. However, they did find that prehab may reduce admission to rehabilitation in this population.
A 2019 pilot study from the Veteran's Affairs of Los Angeles published in The Journal for Healthcare Quality found that prehab improved postoperative results in more than half of older, frail veterans. Furthermore, postoperative outcomes, including complications, 30-day mortality and 30-day readmissions, were better than predicted based on the National Surgical Quality Improvement Program Surgical Risk Calculator.
Bottom line, there is enough evidence to support the benefits of prehabilitation that the American College of Surgeons has launched a program called Strong for Surgery focused on identifying and evaluating evidence-based practices aimed at optimizing the health of patients before they go under the knife.