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This feasibility study explored the effects of a 4-week prehab program on patients undergoing major abdominal surgery. The program included personalized diet plans, phone-based psychological counselling and interviews, and aerobic, strength, and breathing exercises either performed at home or in a clinic. Patients (N=60) showed good adherence to the program and it appeared to be safe. There was no comparative control group, so efficacy was tested by comparing patient measures before and after completion of the program. Prehab boosted walking capacity by about 9%, with the frailest patients seeing a 13% increase. Quality of life improved, along with reduced anxiety and depression levels. As the authors state, a good starting point for future larger controlled studies.
Prehabilitation before major abdominal surgery: Evaluation of the impact of a perioperative clinical pathway, a pilot study
2022
Scand J Surg
Pilot Study
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This cohort study of colorectal cancer patients examined the effects of a ~4 week prehabilitation program (N=76) on various clinical outcomes compared to standard care (N=351). In the prehab program, patients received nutritional guidance, protein supplementation, treatment for smoking or alcohol use or anemia. They also exercised twice per week with a physiotherapist at a high intensity, and four times per week at a low intensity from home. Both groups received an Enhanced Recovery After Surgery program. Adherence to the prehab program was very high (90%). A significantly lower rate of complications was seen in the prehab group (26%) compared to the standard care group (40%). The prehab group also stayed for less time in the hospital, and had a lower rate of unplanned readmissions (5% vs 16% for standard care).
A multimodal prehabilitation program in high-risk patients undergoing elective resection for colorectal cancer: A retrospective cohort study
2021
European Journal of Surgical Oncology
Observational Study
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This was one of the first studies to add cognitive training as a component of a comprehensive prehab program. The effects on cognitive and functional abilities for older patients awaiting major non-cardiac surgery were then investigated. For ~2 weeks before surgery, patients engaged in adaptive, tablet-based brain-training games designed to target key cognitive functions. They were also guided through a resistance exercise routine with a physiotherapist. Despite only moderate adherence rates to the program, the 17 prehab patients trended towards an improvement in cognition, but not functional abilities, compared to the 8 control patients who only received standard health counselling. This was a pilot trial with limited size, much more research with a larger number of patients is required to understand the optimal dose, type, and duration of brain training as well as treatment effects.
A randomised pilot trial of combined cognitive and physical exercise prehabilitation to improve outcomes in surgical patients
2021
British Journal of Anaesthesia
Pilot Study
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In this study, patients 60 years and older awaiting major surgery were randomly assigned to a cognitive prehabilitation group. They were asked to complete 10 hours (minimum) of brain training games using the Luminosity tablet app before surgery. Among those who completed some training, the rate of delirium was significantly lower (13.2%) compared to those in the control group (23%). Some patients found the program challenging, with four completing no training at all.
Effect of Cognitive Prehabilitation on the Incidence of Postoperative Delirium Among Older Adults Undergoing Major Noncardiac Surgery: The Neurobics Randomized Clinical Trial
2021
JAMA Surgery
RCT
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This study tested a 4-week prehab program in 9 older adults preparing for colorectal surgery. The program included supervised hospital-based strength and aerobic exercise sessions and freshly prepared protein-rich meals designed to meet daily nutritional needs. Recruitment was challenging due to high anticipated demands of the program. However, of those who did participate, adherence was high. Patients reported that the meals and training were acceptable, and no adverse effects were observed. The program led to small improvements in handgrip strength and exercise capacity. While recruitment was challenging, the study shows that such personalized multimodal prehab is feasible and could help patients improve their physical condition before surgery.
Feasibility and Efficiency of the BEFORE (Better Exercise and Food, Better Recovery) Prehabilitation Program
2021
Nutrients
Pilot Study
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This is a secondary analysis of pooled data from four other trials - three being RCT's. They examined how a multimodal prehab program could impact functional outcomes following colorectal cancer surgery in patients with or without pre-diabetes. Pre-diabetic (N=121) and non-diabetic (N=90) patients were allocated to either a prehab or usual care group. For four weeks, the prehab patients engaged in high-intensity cycling and resistance training with a kinesiologist, received a personalised diet program with protein supplements, and learned strategies to reduce anxiety. After four weeks of prehab training, both pre- and non-diabetic patients improved their functional walking capacity compared to the control group. Notably, the beneficial effects of prehab training on functional outcomes was more prominent in pre-diabetic patients. Patients with diabetes (type 1 or 2) were not studied.
Functional capacity of prediabetic patients: effect of multimodal prehabilitation in patients undergoing colorectal cancer resection
2021
Acta Oncologica
Secondary Analysis
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This study investigated how a multimodal prehab program impacted postoperative outcomes in elderly patients undergoing major abdominal surgery. All patients followed an Enhanced Recovery After Surgery (ERAS) protocol, which included early postop movement and rehabilitation. In addition to this, the prehab group (N=335) received nutritional assessment, optimised diet plans, and nutritional supplement drinks. They were given personalised exercise programs encompassing aerobic, strength, and balance training, to be completed at home or in the hospital clinic. Moreover, they received detailed counselling about physical therapy benefits, post-surgery expectations, and pain, fear, and anxiety management. Compared to the standard care group (N=256), prehab patients could move around longer post-surgery, with 55% participating in physical therapy vs. 43% in the standard care group. Prehab patients were also more likely to adhere to post-op adjuvant chemotherapy treatment, which the authors suggest may be from increased mental fortitude.
Multimodal prehabilitation before major abdominal surgery: A retrospective study
2021
Annals of the Academy of Medicine of Singapore
Observational Study
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This study looked at a four-week prehab program for colorectal cancer patients. The program included at-home exercises, advice on eating more protein, and mindfulness resources. Patients in the prehab group (N=119) had slightly improved physical, nutritional, and mental health measures compared to a historical population that did not receive the intervention (N=530). The prehab group had fewer complications (11.5%) compared to the standard care group (13.2%), and their hospital stay was also shorter (4 days compared to 6).
A single-center prospective observational study on the effect of trimodal prehabilitation in colorectal surgery
2020
Cirugía Española
Observational Study
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This study in frail, colorectal cancer patients, compared prehabilitation training (for 4 weeks before surgery) to rehabilitation (for 4 weeks after postoperative discharge) on various outcomes. Both groups (each N=55) received a nutritional assessment with diet guidance and protein supplementation, as well as coping strategies to manage psychological symptoms. They tried to complete moderate-intensity exercise daily, and resistance training 4x per week done at home and with a trained kinesiologist. No significant results were found on any of the outcome measures. As expected, the program adherence was much lower if done after surgery. Of note, the trial was conducted in a centre with a well established enhanced recovery program and the surgeries were predominantly minimally invasive.
Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer: A Randomized Clinical Trial
2020
JAMA Surgery
RCT
Feasibility of a novel exercise prehabilitation programme in patients scheduled for elective colorectal surgery: a feasibility randomised controlled trial
2020
Supportive Care in Cancer
Pilot Study
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This research group conducted a previous study that showed lower delirium rates in patients after a multimodal prehab program. This follow-up study tested if their prehab program had an effect on 1-year mortality for patients aged 70+ undergoing elective abdominal aortic aneurysm or colorectal cancer surgery. They found 1-year mortality unaffected by prehab training. However, the presence of delirium after surgery led to increased 1-year mortality rates as well as reduced functional performance. The previous results they observed (protection against delirium by doing prehab) could not be translated into protection from death by doing prehab, even though delirium is an independent risk factor for mortality. They attribute this to the small sample size.
These results indicate that delirium can have severe negative consequences on health and function following surgery, and, while more research is needed, prehab may help to mitigate these changes.
Long-term outcomes of major abdominal surgery and postoperative delirium after multimodal prehabilitation of older patients
2020
Surgery Today
Observational Study
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Aiming to determine the feasibility of a cognitive training program on postoperative delirium and cognitive decline, this study enrolled 45 patients aged 60-90 years old scheduled for elective cardiac surgery. Patients were instructed to train twice a day for 15 minutes from ~10 days before surgery until 4 weeks after surgery on the tablet-based Luminosity application. The results indicate substantial interest for cognitive training but low levels of adherence. Adherence rates were highest before surgery (39%), dropping to 9% immediately after surgery (not surprising), and to 19% after leaving the hospital. Patients enjoyed the program and felt that their thinking had improved despite no significant effect of training on delirium incidence or cognitive decline compared to those receiving usual care. Remember, this was a small feasibility trial not large enough to detect differences in clinical outcomes.
Prevention of Early Postoperative Decline: A Randomized, Controlled Feasibility Trial of Perioperative Cognitive Training
2020
Anesthesia & Analgesia
Pilot Study
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This study examined the feasibility and functional outcomes of a 4-week exercise-based prehab program for bladder cancer patients awaiting surgery. The program progressed in difficulty and included both aerobic and resistance exercise, abdominal and back strengthening, and assisted stretching. The sessions were completed three times per week with an exercise physiologist. 41/51 (80%) of patients completed 70% or more of the exercise program. The exercise program enhanced functional walking capacity by roughly 18 metres across the group, and also increased submaximal exercise test performance. Patients also indicated improvements in their self-reported quality of life which was sustained 3 months following surgery. Overall, this study portrays the benefits of an exercise-based prehab program for both functional outcomes and quality of life for bladder cancer patients awaiting surgery.
The Feasibility and Impact of a Presurgical Exercise Intervention Program (Prehabilitation) for Patients Undergoing Cystectomy for Bladder Cancer
2020
The Canadian Journal of Urology
Pilot Study
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In this secondary analysis from 3 previous studies, the effects of a prehab program on the functional abilities of elderly colorectal cancer patients with different baseline psychological symptoms were compared. It was found that patients with pre-existing symptoms of depression had lower functional capacity and walking abilities prior to surgery compared to patients with anxiety symptoms or no mental health symptoms. Patients with depressive symptoms also improved their functional abilities and walking performance to a larger extent with a prehabilitation program.
Depression and functional status in colorectal cancer patients awaiting surgery: Impact of a multimodal prehabilitation program
2019
Health Psychology
Secondary Analysis
Fit4SurgeryTV At-home Prehabilitation for Frail Older Patients Planned for Colorectal Cancer Surgery: A Pilot Study
2019
American Journal of Physical Medicine & Rehabilitation
Pilot Study
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This pilot study investigated whether 20 minutes of computerized cognitive training for one week before surgery is (1) feasible for patients and (2) could reduce delirium and cognitive difficulties following surgery. Patients initially expressed enthusiasm for participating, but then reality hit. In the training group, only 17% of patients were able to complete the prescribed 7 days of training, and 48% opted out of training once they got home. Many dropped out due to technological issues, time commitment, or feeling overwhelmed.
There were no significant differences in delirium incidence or cognitive performance between groups. This is not surprising given the low rates of program adherence. Barriers to participation need to be addressed in future studies and the authors suggest a longer timeframe with supervision may help.
Home-based Cognitive Prehabilitation in Older Surgical Patients: A Feasibility Study
2019
Journal of Neurosurgical Anesthesiology
Pilot Study
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This large-scale study examined the effects of a multimodal prehab program on delirium rates and other outcomes. Compared to 360 patients receiving standard care, 267 patients received at-home aerobic, resistance, and breathing exercise programming as well as nutritional advice and support for an average of 39 days pre-op. They found that the prehab group had significantly lower rates of delirium after surgery (8.2% vs. 11.7%). There were no differences in hospital length of stay, complication rates, or 30-day mortality.
Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study
2019
PLOS One
Observational Study
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In this secondary analysis of a previous RCT from this group, the 3- and 6-month postoperative effects as well as the overall costs of an exercise prehabilitation program were examined. In addition to the immediate post-op improvements in exercise capacity, which potentially helped reduce post-op complications, physical activity levels and exercise capacity remained higher in the prehab group at 3 and 6 months post-op compared to standard care. The prehab group also showed lower rates of 30 day hospital readmissions (3%) compared with usual care (18%).
The average cost of the prehab program was 389 euros (in 2017), primarily from exercise testing protocols. Importantly, incorporating the prehab program did not significantly increase the overall healthcare costs, as savings after surgery offset the cost of the program. These findings suggest that prehabilitation programs can enhance recovery without increasing healthcare costs. It did not demonstrate cost savings however.
Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial
2019
British Journal of Anaesthesia
Secondary Analysis
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This feasibility RCT was designed to inform a larger multi-centred RCT. The study investigated the impact of a walking program before, during and after neoadjuvant chemoradiotherapy in rectal cancer patients. The prehab group (N=24) engaged in 13-17 weeks of progressive walking, with regular telephone support to enhance step goals. Post-training, the prehab group showed slight improvements in functional walking test performance compared to the usual care group (N=24), but this was not statistically significant. Both groups exhibited reduced daily step counts after surgery as expected.
Prehabilitation is feasible in patients with rectal cancer undergoing neoadjuvant chemoradiotherapy and may minimize physical deterioration: results from the REx trial
2019
Colorectal Disease
Pilot Study
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