Improving functional capacity and cardiopulmonary fitness
Evidence Summary
Abdominal surgery
There were five randomised controlled trials which provided high to moderate quality evidence demonstrating improvement in the 6-meter walking distance (6MWD) in patients who underwent prehabilitation when compared to control/comparator groups (4-5, 8-9, 11). Of these, three incorporated exercise prehabilitation as part of a trimodal strategy, including nutritional and psychological prehabilitation (4, 8, 11). There was also a mixture of both aerobic and resistance training (4,8-9, 11).
Three studies assessed cardiopulmonary fitness using peak VO2 using only exercise as a unimodal prehabilitation strategy. Two studies used aerobic exercises with cycling and one study used combined aerobic with resistance training. In all studies, there was significant change with improvement in cardiopulmonary fitness within the prehabilitation period (1,5,9). One high quality randomised controlled trial compared subjects undergoing a supervised 30-minute interval aerobic exercise, on a cycle ergometer as a unimodal prehabilitation strategy, against control subjects undergoing standard pre-operative care. The study demonstrated an improvement in VO2 at anaerobic threshold of 1⋅5ml per kg per min (P =0⋅023), as well as an improvement in VO2 at peak exercise (2⋅0ml per kg per min) (P =0⋅047), oxygen pulse at anaerobic threshold (0⋅9ml/beat) (P =0⋅050) and a higher peak work rate (P=0⋅005) compared with values in the standard care arm (1).
Five randomised controlled trials of mostly moderate quality reported on functional capacity as measured by the 6MWD. Four of these demonstrated a significant improvement in the 6MWD over the pre-operative prehabilitation period in subjects who underwent prehabilitation when compared with control/comparator subjects (4-5,8-9), whilst one study demonstrated an improvement with no statistically significant change (11). One trial studied prehabilitation as part of a trimodal strategy, with an unsupervised exercise regime that included 20 min of aerobic exercise followed by 20 min of resistance exercise three times per week. It demonstrated that subjects in prehabilitation group experienced a significantly greater baseline to time of surgery change in 6MWD compared to control subjects (+23.7 ± 6.9 vs. −5.4 ± 6.2 m, t (df) = 3.105 (111), P = 0.002) (8).
Three studies assessed post-operative functional change in the 6MWD, with all groups demonstrating a marked deterioration in functional capacity in the post-operative period (4, 9, 11). However, despite improvements in functional walking distances at 4 weeks post-operatively, there were no demonstrable differences identified between control and prehabilitation groups identified (4, 11). The same two RCTs went on to assess post-operative functional capacity at 8 weeks, with one RCT demonstrated subjects in the prehabilitation group (incorporating trimodal prehabilitation which included 50 minutes of home-based, unsupervised exercises for at least 3 days per week, alternating between aerobic and resistance training) were on average above baseline, while those in the rehabilitation group remained below baseline (+23.4 m [SD, 54.8] vs. −21.8 m [SD, 80.7], adjusted P = 0.010)( 4).
Quality of Evidence
Grade B. Mostly randomised controlled trial of moderate quality considering study limitations.
Strength of recommendation
Grade 2. Weak recommendation. Clinical heterogeneity across studies require recommendations are personalised.
Conclusion
Exercise can be recommended to improve functional capacity, particularly within the pre-operative period (from baseline to the time of surgery) for patients undergoing major abdominal surgery for bowel or liver cancer. The evidence is suggestive of a quicker return to functional capacity following surgery. Further evidence is required to determine if exercise is best administered as part of a multimodal strategy. The vast variation in exercise regimes may require a personalised approach to prehabilitation.
References
1. Dunne DF, Jack S, Jones RP, et al. Randomized clinical trial of prehabilitation before planned liver resection. The British journal of surgery 2016;103(5):504-12. doi: 10.1002/bjs.10096
2. Heger P, Probst P, Wiskemann J, et al. A Systematic Review and Meta-analysis of Physical Exercise Prehabilitation in Major Abdominal Surgery (PROSPERO 2017 CRD42017080366). Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2020;24(6):1375-85. doi: 10.1007/s11605-019-04287-w
3. Yamana I, Takeno S, Hashimoto T, et al. Randomized Controlled Study to Evaluate the Efficacy of a Preoperative Respiratory Rehabilitation Program to Prevent Postoperative Pulmonary Complications after Esophagectomy. Digestive surgery 2015;32(5):331-7. doi: 10.1159/000434758 [published Online First: 2015/07/18]
4. Gillis C, Li C, Lee L, et al. Prehabilitation versus REHABILITATIONA randomized control trial in patients undergoing colorectal resection for cancer. The Journal of the American Society of Anesthesiologists 2014;121(5):937-47.
5. KIm DJ MN, Carli F, Montgomery DL, Zavorsky GS. Responsive Measures to Prehabilitation in Patients Undergoing Bowel Resection Surgery. Tohoku J Exp Med 2009;217(2):109-15.
6. Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol 2018;44(7):919-26. doi: 10.1016/j.ejso.2018.04.016
7. Hijazi Y, Gondal U, Aziz O. A systematic review of prehabilitation programs in abdominal cancer surgery. International journal of surgery (London, England) 2017;39:156-62. doi: 10.1016/j.ijsu.2017.01.111
8. Chen BP, Awasthi R, Sweet SN, et al. Four-week prehabilitation program is sufficient to modify exercise behaviors and improve preoperative functional walking capacity in patients with colorectal cancer. Support Care Cancer 2017;25(1):33-40. doi: 10.1007/s00520-016-3379-8
9. Carli F, Charlebois P, Stein B, et al. Randomized clinical trial of prehabilitation in colorectal surgery. The British journal of surgery 2010;97(8):1187-97. doi: 10.1002/bjs.7102
10. Bruns ER, van den Heuvel B, Buskens CJ, et al. The effects of physical prehabilitation in elderly patients undergoing colorectal surgery: a systematic review. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2016;18(8):O267-77. doi: 10.1111/codi.13429
11. Bousquet-Dion G, Awasthi R, Loiselle SE, et al. Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial. Acta Oncol 2018;57(6):849-59. doi: 10.1080/0284186X.2017.1423180
Thoracic Surgery
Improved Cardiopulmonary Fitness
A 2019 Cochrane review of exercise training for advanced lung cancer identified six RCTs involving 221 participants. The authors noted 4 studies that demonstrated an increase in exercise capacity (measured by 6 minute walk distance) and health related quality of life, but cited high risk of bias and poor quality of evidence (10). Another systematic review focusing on non-small cell lung cancer comprising 10 RCTs with 676 participants identified improvements in walking endurance and peak exercise capacity in those undergoing pre-operative exercise interventions (including aerobic, strength, multi-modal and inspiratory muscle training) (11)
Jones et al provided a cycle-based intervention to 25 suspected lung cancer patients – 18 had repeated 6-minute walking distances and cardiopulmonary exercise testing following intervention (but pre-operatively) demonstrating an increase in 6MWD of 40m, and of VO2peak by 2.4ml/kg/min (12). Similar benefits to aerobic function were demonstrated by Licker et al following pre-operative high intensity interval training (13).
Quality of Evidence
Grade A – There appears to be a large heterogeneity amongst studies, and the ideal exercise intervention is difficult to ascertain.
Strength of Recommendation
2 – weak recommendation
References
1. Sanchez-Lorente D, Navarro-Ripoll R, Guzman R, Moises J, Gimeno E, Boada M, et al. Prehabilitation in thoracic surgery. J Thorac Dis [Internet]. 2018 Aug;10(Suppl 22):S2593–600. Available from: https://pubmed.ncbi.nlm.nih.gov/30345096
2. Stanzani F, Paisani D de M, Oliveira A de, Souza RC de, Perfeito JAJ, Faresin SM. Morbidity, mortality, and categorization of the risk of perioperative complications in lung cancer patients. J Bras Pneumol [Internet]. 2014;40(1):21–9. Available from: https://pubmed.ncbi.nlm.nih.gov/24626266
3. Crandall K, Maguire R, Campbell A, Kearney N. Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): A systematic review. Surg Oncol [Internet]. 2014;23(1):17–30. Available from: http://www.sciencedirect.com/science/article/pii/S0960740414000024
4. Sebio Garcia R, Yáñez Brage MI, Giménez Moolhuyzen E, Granger CL, Denehy L. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg [Internet]. 2016 Sep 1;23(3):486–97. Available from: https://doi.org/10.1093/icvts/ivw152
5. Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev. 2012;
6. Gomes Neto M, Martinez BP, Reis HFC, Carvalho VO. Pre- and postoperative inspiratory muscle training in patients undergoing cardiac surgery: systematic review and meta-analysis. Clin Rehabil [Internet]. 2016 May 6;31(4):454–64. Available from: https://doi.org/10.1177/0269215516648754
7. Chen X, Hou L, Zhang Y, Liu X, Shao B, Yuan B, et al. The effects of five days of intensive preoperative inspiratory muscle training on postoperative complications and outcome in patients having cardiac surgery: a randomized controlled trial. Clin Rehabil [Internet]. 2019 Feb 6;33(5):913–22. Available from: https://doi.org/10.1177/0269215519828212
8. Kendall F, Oliveira J, Peleteiro B, Pinho P, Bastos PT. Inspiratory muscle training is effective to reduce postoperative pulmonary complications and length of hospital stay: a systematic review and meta-analysis. Disabil Rehabil [Internet]. 2018 Apr 10;40(8):864–82. Available from: https://doi.org/10.1080/09638288.2016.1277396
9. Boujibar F, Bonnevie T, Debeaumont D, Bubenheim M, Cuvellier A, Peillon C, et al. Impact of prehabilitation on morbidity and mortality after pulmonary lobectomy by minimally invasive surgery: a cohort study. J Thorac Dis [Internet]. 2018 Apr;10(4):2240–8. Available from: https://pubmed.ncbi.nlm.nih.gov/29850128
10. Peddle-McIntyre CJ, Singh F, Thomas R, Newton RU, Galvão DA, Cavalheri V. Exercise training for advanced lung cancer. Cochrane database Syst Rev [Internet]. 2019 Feb 11;2(2):CD012685–CD012685. Available from: https://pubmed.ncbi.nlm.nih.gov/30741408
11. Rosero ID, Ramírez-Vélez R, Lucia A, Martínez-Velilla N, Santos-Lozano A, Valenzuela PL, et al. Systematic Review and Meta-Analysis of Randomized, Controlled Trials on Preoperative Physical Exercise Interventions in Patients with Non-Small-Cell Lung Cancer. Cancers (Basel) [Internet]. 2019 Jul 5;11(7):944. Available from: https://pubmed.ncbi.nlm.nih.gov/31284372
12. Jones LW, Peddle CJ, Eves ND, Haykowsky MJ, Courneya KS, Mackey JR, et al. Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions. Cancer [Internet]. 2007 Aug 1;110(3):590–8. Available from: https://doi.org/10.1002/cncr.22830
13. Licker M, Karenovics W, Diaper J, Frésard I, Triponez F, Ellenberger C, et al. Short-Term Preoperative High-Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial. J Thorac Oncol [Internet]. 2017 Feb 1;12(2):323–33. Available from: https://doi.org/10.1016/j.jtho.2016.09.125