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There has been a lot of hype surrounding an article recently published in the Sunday Times which puts “prehabilitation” on a pedestal in the context of cancer surgery. It highlights the importance of getting ‘fit’ for major surgery in exchange for benefits that include reduced risks and better surgical outcomes.
Prehabilitation, for those of you who are relatively new to the term, is a proactive approach to preparing people for surgery that enables the patient to become an active participant in their own care. Unlike rehabilitation, which is a reactive model of care, prehabilitation is a strategy to begin the rehabilitation process before surgery. It is an opportunity to tackle the management of a number of risk factors such as anaemia and malnutrition which may have an adverse effect on functional capacity and ultimately on postoperative outcomes and recovery.
The concept is comparable to marathon training: it is based on the principle that structured and sustained exercise over a period of weeks leads to improved cardiovascular, respiratory, and muscular conditioning which in turn is associated with fewer postoperative complications and a quicker recovery with an earlier restoration of strength. In short, training for major surgery enables people to better withstand the stress response that accompanies an operation, which would otherwise leave an unfit person physically vulnerable.
Patients comment frequently on how prehabilitation can be beneficial. They feedback on how it gives them confidence and makes them feel like they can contribute to their own outcome. Healthcare professionals start to see the changes too. Anaesthetists are now calling on prehabilitation schemes to become a ‘national priority’ in order to get patients fitter before operations. Anaesthetists are not just involved in providing anaesthesia for surgery, they are the key players in preoperative assessment for patients and most importantly the quantification of risk. They are acutely aware of the impact smoking, obesity, frailty, poor nutrition and anxiety has on post-operative outcomes and the role prehabilitation has played in mitigating this risk.
Long waiting lists for hospital beds have traditionally been viewed negatively, causing distress and anxiety for many, however evidence has started to reveal that by using this time to optimise fitness through prehabilitation, the wait could be worthwhile.
Prehabilitation in its traditional sense has focused primarily on exercise prescription and has been rolling for some years now. What is really starting to gain momentum is the interdisciplinary approach to preoperative optimisation in cancer patients. This approach looks at the person as an individual, and goes beyond addressing just physical function.
Returning to our marathon analogy, training for sport does not just involve physical preparation. It includes a certain amount of mental preparation and confidence building to maintain a positive attitude. It also requires a certain level of self-motivation to achieve success.
Similarly, prehabilitation programmes are beginning to acknowledge the multidimensional aspects of preoperative preparation to include nutritional, psychological, and behavioural interventions in addition to exercise. Exercise when prescribed in a healthcare setting, can be a complex intervention. Initiation and adherence to a programme is determined by behavioural, psychological, physiological, environmental, and social factors. A thorough understanding of all these factors is critical to the success of exercise-based prehabilitation programmes. In a similar way, smoking cessation and weight loss in obesity can be quite complex to achieve and require a certain level of understanding from the healthcare team; such goals are not always easy to achieve and being told to ‘quit now’ or ‘eat less, move more’ is not always helpful. First unpicking what social, psychological or behavioural barriers exist may be important in achieving sustained change and therefore long-term success.
Restoring function and getting back to normal daily life is most likely a priority for every cancer patient faced with major surgery. Prehabilitation should be seen as an opportunity to turn one’s life around, to take control back and to do everything in one’s power to ensure quicker recovery and better quality of life. The proof is now out there – and results speak for themselves.
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