‘Prehabilitation’ is slowly being recognized as valuable for success after a procedure
By Judith Graham for Next Avenue
A dozen years ago, at the age of 50, Lillie Shockney decided to have breast reconstruction surgery after two bouts of cancer and two mastectomies. The procedure called for removing a flap of skin and fat from her abdomen, used to rebuild her breasts.
Shockney knew a lot about breast cancer and the trials of recovery: she was (and still is) director of the breast center at Johns Hopkins’ Sidney Kimmel Cancer Center. Characteristically, this dynamic nurse didn’t want to stay in the hospital for any longer than absolutely necessary.
Taking action to prepare for surgery
So, Shockney contacted a physical therapist and asked for exercises that would strengthen her abdominal muscles before she went under the knife. “My hope was that that would result in my getting up and about sooner,” she said.
Over the next six weeks, Shockney lay on her back, lifted each leg 18 inches and held the position for 15 seconds — 30 times, twice a day. The effort paid off when she became the first Johns Hopkins patient to go home three days after the surgery, a day or two earlier than other patients.
Today, all women who undergo DIEP (Deep Inferior Epigastric Perforator) flap breast reconstruction at Johns Hopkins undergo a similar exercise regime — a form of rehabilitation-before-treatment, or prehabilitation.
Not a new idea
The principle behind prehabilitation is universally embraced by athletes, Shockney noted: Prepare for surgery by getting in good (or great) shape before you subject your body to significant stress, so you’re better able to endure that stress and minimize the potential for complications.
Orthopedists have incorporated prehabilitation into their practices for decades, with positive outcomes for people getting knee and hip replacements, among other procedures.
“We’ve learned that the steps you take before surgery are just as important as what happens during and after surgery,” said Dr. Howard Luks, an orthopedic surgeon who practices about 60 miles north of New York City.
He recommends that people getting knee replacements have five to six sessions with a physical therapist before surgery, during which they work on enhancing their strength and flexibility and learn how to use walkers or canes that might be needed during their recovery.
“Your range of motion before surgery is associated with your range of motion after,” said Luks. “And if your muscles are strong and used to being stressed, they’re going to do better after surgery as well.”
Preparing for cancer treatment
More recently, prehabilitation has begun to find a place in cancer centers for patients about to undergo surgery, chemotherapy or radiation therapy.
“Prehabilitation in cancer is really in the early stages,” with researchers trying to learn which interventions are most effective for patients, when therapies should be initiated and how long they should last, said Dr. Julie Silver, an associate professor at Harvard Medical School and founder of Oncology Rehab Partners, which disseminates model cancer prehabilitation and rehabilitation programs.
At McGill University, Dr. Francesco Carli, a professor of anesthesia, has shown that patients with colorectal cancer who follow a structured exercise program; add whey protein to their diet and learn stress reduction techniques before surgery return to the previous level of functioning far more quickly than patients who didn’t prepare for surgery by following this regimen.
Research supports benefits
About 80 percent of patients who participated in prehabilitation had returned to their before-surgery “normal” baseline two months after surgery, compared with 30 percent of patients who received usual post-surgery services, Carli and colleagues reported in 2014 in the journal Anesthesiology.
Today, all colorectal cancer patients at McGill are evaluated by a kinesiologist, who tailors recommended exercises to their personal circumstances; a nutritionist, who evaluates their diet and suggests needed supplements and a psychologist, who addresses the fear and anxiety that often precede major medical treatment.
Typically, home-based therapies are initiated a month or two in advance of surgery.
The interventions are especially important for older patients, who have often become inactive and lost muscle strength and physiological resilience, Carli noted. “Our recent findings show that elderly with low fitness are potentially benefiting the most and their functional capacity increases greatly compared to those who are already fit,” he wrote from overseas in an email exchange.
At Lahey Hospital and Medical Center in Burlington, Mass., patients with early stage lung cancer are undergoing a five-stage prehabilitation protocol: getting a nutrition assessment (with coaching to increase protein intake prior to surgery), being counseled to stop smoking (with smoking cessation aids disseminated, if necessary), having a psychological assessment (with people in distress referred for mental health counseling), undergoing a lung assessment (with pulmonary rehabilitation exercises recommended, as needed) and being advised to enhance general conditioning (by walking several times a week for increasingly long periods).
Responding to patients
“People ask all the time, ‘What can I do to prepare for surgery?’” said Dr. Andrea McKee, Lahey’s chair of radiation oncology. “Previously, we would have told them ‘nothing by mouth after midnight the night before surgery’ or ‘quit smoking.’ We didn’t do the kinds of comprehensive assessments and evaluations of patients that we’re doing now.”
Still, the evidence proving that prehabilitation interventions work is slim, and most hospitals don’t offer these services. Nor does insurance pay, in many cases.
Lahey is offering the services free to patients because it believes they’ll recover from surgery more readily, with fewer complications and potentially reduced costs, McKee said.
“What we’re doing makes a lot of sense intuitively, especially for older patients with multiple medical conditions who need to get through big surgeries safely,” said Silver, who’s working to expand prehabilitation services across the country. “But changing clinical care always takes time.”
Learning the hard way
Some patients have recognized the need for prehabilitation on their own. Barbara Charnes, 84, found herself in this position after an April 2015 surgery on her ankle left her bedridden, incontinent and deeply distressed.
Charnes, who lives in Denver, hadn’t known what to expect from the surgery, the first stage of an ankle replacement that called for another procedure. She hadn’t paid attention to her physical conditioning or emotional readiness beforehand, and doctors hadn’t discussed this with her.
It took almost a year for Charnes to recover before a second surgery to insert a new metal ankle in February 2016. This time, she found a therapist in advance so she could talk through concerns and have someone she could depend on for emotional support. Also, she got on a stationary bike months before the procedure, exercising for half an hour every day and gradually increasing the level of difficulty.
“I think for everyone my age, surgery is physically and emotionally daunting,” Ms. Charnes said, sitting in her sunlit study. “And I think it’s foolish not to prepare if, say, you’re not in very good shape. This time, I understood much better what was going to happen and I felt that I was really ready. And that made all the difference.”