Across Canada, people engage in regular physical activity. They may do so to look better, or to sleep better, or maybe to manage a long-standing health condition. The reasons to be active are as varied as the individuals themselves, but I’d like to highlight one reason that may not have occurred to you.
The stronger, fitter and more independent you are, the more likely you are to survive and successfully recover from an injury or surgery.
Researchers have known for some time that your physical function (the ability to do things for yourself) before surgery is an important predictor of your health and physical function after surgery and even your survival.1 While that may seem like common sense, being able to point to scientific evidence that supports the notion is a powerful thing.
It has also led to the concept of “prehabilitation.”
What is prehabilitation?
Many people are familiar with rehabilitation, the intentional use of exercise and activities after injury, illness or surgery to regain strength and function. Prehabilitation is similar, in that it uses exercise and activities to improve functional abilities; however, it is completed before surgery, with the goals of decreasing length of hospital stay, speeding recovery of physical abilities and the return to “normal” activities, and reducing complications from surgery.2
People can wait weeks and even months for elective surgery,3 making this period a golden opportunity to optimize physical fitness and function4 instead of having it be a period of inactivity that leads to further decline, deconditioning and debility.3
Length of stay is a constant concern of governments and hospital staff, so it’s easy to see why the promise of prehabilitation is popular with them. But length of stay is an important consideration for people waiting for, or undergoing surgery as well. After all, if every total joint replacement patient had a one day reduction in their length of stay, the capacity to perform more total joint surgeries would increase significantly, and that would help to decrease wait times to surgery. What’s more, the risk of developing a hospital acquired infection increases the longer you stay in hospital, so reducing hospital length of stay is also important for patients.
Who can benefit?
It’s not just total joint replacement patients who can benefit from prehabilitation, nor is it just about length of stay. Researchers have found that prehabilitation is safe and effective for people undergoing heart,4,5 lung1,6 or abdominal surgery.1,5 Benefits have included:1,2,4,5,8
Improved strength immediately prior to surgery
Improved physical ability immediately following surgery
Fewer complications from surgery
Improved quality of life
Participating in prehabilitation is also thought to help establish an exercise habit and has been found to improve participation with exercises after surgery (as in the case of people undergoing heart surgery).4 Since exercise after surgery is important for long-term recovery and longevity, any effort to improve participation is important.
To have the greatest effect, prehabilitation should be targeted to those people who are most likely to benefit, especially those who are weak or deconditioned prior to surgery.3,7 The program should be tailored to the needs of the patient, rather than “one size fits all.”3,7 Most importantly it needs to be challenging enough to result in a training effect.3,7
Prehabilitation programs should include:
For weak/affected limbs (as in the case of total joint replacement surgery)
To strengthen the non-surgical limbs in preparation for increased demands that may be encountered following surgery
To increase general fitness and exercise capacity
Prehabilitation can also be used to anticipate and prevent injury. For instance, a person with previous knee pain may wish to get prehabiliation before or during training for a fun run or marathon.
Does it actually work?
The research regarding the impact of prehabilitation is mixed, particularly for people awaiting total joint replacement. There are also many explanations for why the research results are inconsistent, including questions regarding the way the studied exercise program was designed (the intensity, compliance to, and appropriateness)7 and the size of the studied group.3 It is fair to say that more research is needed to help identify the best approach to prehabilitation and what to include in a prehabilitation program.
However, the potential benefits of improved outcomes, and reduced mortality rates far outweigh any risks and provide compelling reasons to pursue prehabilitation while waiting for surgery. As one researcher noted, no patients demonstrated a decline in function as a consequence of participating in a prehabilitation program.2
As already mentioned, there is consensus that prehabilitation exercises need to be tailored to the individual patient’s needs and challenging enough to provide a benefit.3,7 It has also been suggested that the people who are most likely to benefit are the ones who are most at risk of post-surgery problems, in other words, those who are not very physically active to begin with.3,7 Starting an exercise program can be challenging at the best of times, but even more so under those circumstances.
If you or someone you care about is awaiting surgery and is considering prehabilitation, the support and guidance of a physiotherapist is essential. They can design a program to address your health and current abilities, and set you up for success in both the pre- and post-surgery period.
Pouwels S, Stokmans FA, Willigendael EM, Nienhuijs SW, Rosman C, van Ramshorst B, Teijink JAW. Preoperative exercise therapy for elective major abdominal surgery: A systematic review. International Journal of Surgery 2014; 12:134-140
Santa Mina D, Clarke H, Ritvo P, Leung YW, Matthew AG, Katz J, Trachtenberg J, Alibhai SMH. Effect of total-body prehabilitation on postoperative outcomes: A systematic review and meta-analysis. Physiotherapy 2014; 100: 196-207.
Gill SD, McBurney H. Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials. Archives of Physical Medicine and Rehabilitation 2013; 94:164-176.
Arthur HM, Daniels C, McKelvie R, Hirsch J, Rush B. Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery. Annals of Internal Medicine 2000; 133:253-262
Valkenet K, van de Port IGL, Dronkers J, de Vries WR, Lindeman E, Backx FJG. The effects of preoperative exercise therapy on postoperative outcome: A systematic review. Clinical Rehabilitation 2011; 25:99-111
Jones LW, Peddle CJ, Eves ND, Haykowsky MJ, Courneya KS, Mackey JR, Joy AA, Kumar V, Winton TW, Reiman T. Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions. Cancer 2007; 110(3): 590-598.
Hoogeboom TJ, Oosting E, Vriezekolk JE, Veenhof C, Siemonsma PC, de Bie RA, and den Ende CHM, van Meeteren NLU. Therapeutic validity and effectiveness of preoperative exercise on functional recovery after joint replacement: A systematic review and meta-analysis. PLoS ONE 2012; 7(5): e38031
Rooks DS, Huang J, Bierbaum BE, Bolus SA, Rubano J, Connolly CE, Alpert S, Iversen MD, Katz JN. Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis & Rheumatism 2006; 55(5):700-708.