Prehabilitation and Rehabilitation in Colorectal Surgery

High risk

Low risk

Surgical factors

Upper abdominal surgery

Lower abdominal surgery

Open surgery

Laparoscopic surgery

Prolonged surgery (>3–4 h)

Short surgical duration (<3–4 h)

Vertical or oblique incisions

Horizontal incisions

Age >65 years old

Age <65 years old

Smoker

Non-smoker

Pre-existing respiratory diseases

No active or ongoing respiratory diseases

Chronic bronchitis

Chronic obstructive pulmonary diseases

Pre-existing metabolic diseases

Minimal systemic co-morbidities

Diabetes

Renal diseases

Liver cirrhosis and failure

Malnutrition status

Good nutritional status and optimisation

Anaemia

Sarcopenia

Psycho-emotional factors

Positive mental and emotional preparation and outlook

Depression

Anxiety

7.2.1 Low-Risk Patients with Less Rehabilitation Needs

Patients who are younger, have fewer medical co-morbidities and/or are not undergoing major colorectal procedures will likely have minimal risks of postoperative chest complications and are unlikely to have significant decrease in physical capacity. For this low-risk group, traditional levels of physiotherapy may more than suffice. In fact, with sufficient pain management and encouragement from the doctors and nurses to resume normal activities, physiotherapy may not be indicated.

7.2.2 High-Risk Patients with More Rehabilitation Needs

Patients who are older, have multiple medical co-morbidities, have had a prior period of deconditioning due to curtailment or reduction of physical function, have undergone neo-adjuvant chemo- or radiotherapy, or will be undergoing surgical procedures that are prolonged or open (especially upper abdominal incisions) would have considerable higher risk of postoperative chest complications (Fujita and Sakurai 1995; Fearon et al. 2012) prolonged immobility, and poorer long-term functional outcomes. In essence, these factors appear to point towards patients who are frail. Mayo and colleagues (2012) found that patients who deteriorated during the prehabilitation phase were also more likely to have complications after surgery. These patients tended to be older (>75 years old) and more anxious.

Postoperative physiotherapy, which includes peri-operative education, has been part of standard care for patients undergoing abdominal surgery, especially for patients who are at higher risk of postoperative chest complications. For a selected group of higher-risk patients who are at risk of slower recovery, a period of a few weeks of prehabilitation for physical conditioning and boosting of the immune system via the reduction of surgical/illness-associated anxiety may reduce this risk. It is generally perceived that establishing rapport and improving the patient’s understanding before their surgery can also promote postoperative compliance to rehabilitation.

7.3 Prehabilitation

Prehabilitation aims to improve the physical and functional capacity of an individual through increasing the individual’s buffering capacity to withstand and recover from surgical stress. How does one do prehabilitation for colorectal surgery? Does it improve patient outcomes? Which patient group should have prehabilitation? Evidence in this area is limited but certainly emerging in the area of physiotherapy and surgery.

7.3.1 Is Prehabilitation Effective? Does It Improve Postsurgical Outcomes?

Prehabilitation has more commonly been performed in patients undergoing orthopaedic surgeries, such as periods of strengthening before total knee replacements (TKRs) and laminectomies. Prehabilitation for TKRs and laminectomies has consistently demonstrated the ability of patients with existing joint problems to improve in strength, pain, and function with a 4–8 week aerobic conditioning and strengthening programme prior to surgery (Mckay et al. 2012; Nielsen et al. 2010; Topp et al. 2009). Improvements in aerobic capacity and strength also had positive effects on functional outcomes in patients who have undergone a period of prehabilitation when compared to the control group (Topp et al. 2009). However, improvements in physical function did not necessarily result in improvements in postoperative complications, pain scores or quality of life.

With respect to colorectal discipline, there is a growing amount of evidence suggesting the beneficial role of prehabilitation in improving surgical outcomes. Carli et al. (2009) conducted a pilot study, which compared an exercise group who did under a cycling and strengthening programme with a control group who were asked to walk daily and do some breathing exercises. In this study, the control group performed better in the 6 min walk test preoperatively and at follow-up. Poorer compliance of the participants of the exercise group (~16 %) to the cycling and strengthening programme than the walking programme was cited as a possible reason for the observation. In a follow-up study, Mayo et al. (2012) found improvements in postoperative walking distances in 33 %, no changes in 38 % and actual deterioration in 29 % of the prehabilitation group. In the same paper, it was mentioned that improved functional exercise capacity prior to surgery improved postoperative recovery. Li et al. (2013) further supported the role of prehabilitation by establishing that prehabilitation intervention was found to be a significant predictor of a positive change in functional capacity when comparing preoperative and postoperative states. Kim et al. (2009) used prehabilitation with a 4-week duration for patients who were at high risk of poor bowel resection outcome. In this study, an exercise compliance of ~74 % was achieved and results indicate that the patients in the prehabilitation group achieved significant improvements in the 6MWT postoperatively. Apart from possible improvements in postoperative functional capacity, prehabilitation was also found to have positive impact on reducing anxiety and depression (Li et al. 2013; Mayo et al. 2012). Overall, there appears to be more research emerging which supports the effectiveness of prehabilitation in improving postoperative outcomes.

7.3.2 How Should Prehabilitation Be Designed?

Prehabilitation protocols in colorectal surgical populations are not well established and have variability in various studies, when compared to those in other specialist areas, such as orthopaedic surgeries (refer Table 7.2).

Table 7.2

Summary of prehabilitation protocols

Authors	Subject demographics	Intervention/control details	Outcome measures
Dimeo et al. (1998)	n = 5 (4 females, 1 male)	Prehabilitation	Conducted pre-post intervention
	Age: 18–55 years old	Frequency: weekdays	Treadmill stress test with continuous ECG monitoring
	Surgery: cancer ± chemotherapy	Intensity: corresponding to a lactate concentration of 3 ± 0.5 mmol L⁻¹	Walking distance per training session (m)
		Type: treadmill walking
		Duration: 6 weeks
		Monitoring: supervised, location not indicated
Kim et al. (2009)	n = 21	Prehabilitation	Conducted before and after intervention
	Exercise group: 14 (5 females, 9 males)	Frequency: daily	VO₂max test
	Control: 7 (3 females, 4 males)	Intensity: progressive from 40 to 65 % HRR, RPE 11–16	6MWT
	Age:	Duration: 20–30 min
	Exercise group: average 55 years old	Type: cycling on ergometer
	Control: average 65 years old	Total duration of intervention: 4 weeks
	Surgery: bowel resection surgery	Monitoring: supervised, home based
Li et al. (2013)	n = 108	Prehabilitation	1 week (preoperation) and 4 and 8 weeks (post operation)
	Exercise group: 54 (32 females, 22 males)	Frequency: three times a week	6MWT
	Control group:	Intensity: moderate aerobic (50 % MHR), volitional fatigue for strengthening	CHAMPS questionnaire
	64 (35 females, 29 males)	Duration: 30 mins aerobic	SF-36
	Age:	Type: aerobic exercises (walking or other machines) + strengthening using callisthenics or resistance bands	Emotional health
	Exercise group: 67.4 ± 11 years old	Total duration of intervention: dependent on surgery lead time; median of 33 days	Complication rate
	Control group: 66.4 ± 12 years old	Monitoring: unsupervised, home based
	Surgery:
	Elective surgery for primary colorectal cancer
Dronkers et al. (2010)	n = 42	Prehabilitation	Timed “up and go”
	Exercise group: 22 (7 females, 15 males)	Frequency: twice/week	Chair rise time
	Control group: 20 (4 females, 16 males)	Intensity:	Maximal inspiratory pressure
	Age: > 60 years old	Maximum of one set of 8–15 rm, consistent with 60–80 % of the one-repetition maximum for resistance training	Physical activity questionnaire
	Surgery: elective abdominal oncological surgery	55–75 % of maximal heart rate or perceived exertion between 11 and 13 on the Borg Scale for aerobic training	Maximal aerobic capacity
		Duration :60 min consisting of 20–30 mins of aerobic training	Quality of life
		Type: warm-up, lower limb extensor resistance training, inspiratory muscle training, aerobic training, functional activities training, cool-down	Fatigue
		Total duration of intervention: 2–4 weeks
		Monitoring:
		Exercise group; supervised in outpatient setting
		Control: Unsupervised, home based
Carli et al. (2010); Mayo et al. (2012)	Exercise group 1: n = 58	Prehabilitation	Conducted preoperative baseline measure and postoperatively between 2 weeks and 4 months
	Exercise group 2:	Group 1: bike/strengthening	VO₂max
	n = 54	Frequency: strength training at 3 times/week; aerobic 5 times/week	6MWT
	Age: 63 subjects <65 years old	Intensity: aerobic initially 50 % of MHR with gradual increase at 10 %/week; strengthening at 8RM	Hospital Anxiety and Depression Scale (HADS)
	Surgeries: 85 open; 17 laparoscopic; all upper abdominal	Duration:30 min aerobic; 10–15 min strengthening
		Type: cycling and upper/lower limb strengthening
		Group 2: walking/breathing
		Frequency: daily
		Duration: minimum of 30 min
		Prehab duration: mean of 52 days (22–60 days)
		Monitoring: unsupervised, home based, with weekly monitoring via phone calls

7.3.2.1 Frequency

Most studies asked their prehabilitation patients to exercise for two to three times a week. A few studies have used a frequency of five times a week.

7.3.2.2 Intensity

Studies have used a range of intensities from 50 to 70 % of MHR or RPE of 11–13 for aerobic exercises. Prescriptions were consistent with the general guidelines by the American College of Sports Medicine (ACSM). Interestingly, Carli et al.’s (2010) and Mayo et al.’s (2012) low-intensity exercise groups had also demonstrated benefits from baseline. In fact, the low-intensity exercise groups had performed better in the 6MWT during both the prehabilitation and rehabilitation phase, and the finding was attributed to increased compliance to the regime than a higher intensity one. For the strengthening component, exercise prescription for strengthening has been varied, ranging from 8 to 10 RM to volitional fatigue. No studies had evaluated the effect of their exercise prescription for strengthening with strength-specific outcome measures.

Only gold members can continue reading. Log In or Register to continue