Healthy Living: February 11, 2020
Last month, I had a scheduled shoulder surgery and knew the recovery would be rough. Motivated by my age and a need to return to work as quickly as possible, I determined to prepare myself the best I could. I had long hours up to the day of my surgery that wouldn't change but I went to bed early whenever possible, took the stairs at work, and used a free short exercise app most days. I got in the occasional swim (my favorite) and treadmill walk when possible. I cut out alcohol and paid closer attention to my diet. Most importantly, I told my husband about it and he was extremely supportive. Ironically, while recovering, I stumbled on an article about "pre-habilitation" which described what I had unofficially done.
Pre-habilitation is the concept of preparing for a major surgical event. Let's face it, surgery is no fun for anybody. But more than that it is a great stress to the body that can have major complications. These increase with the magnitude of surgery as well as the health of the person having it. For example, one study cited that greater than half of patients over 60 years of age who had abdominal surgery had decreased function six months after; even more sobering a "significant proportion" were unable to return to independent living. Patients who have complications within 30 days of surgery have decreased survival and even without complications permanently decreased function and decreased quality-of-life is not rare.
Obviously, those of us who undergo surgery do so because we need it and hope our lives will be better for it. Efforts to control or minimize surgical risk has thus far focused on honing surgical and anesthesia techniques as well as early recovery efforts which primarily occur in the hospital and in the immediate postoperative period. This is all incredibly valuable and makes sense. You basically want to "stack the cards" in your favor for avoiding problems after a procedure.
Prehabilitation helps on the front end by getting patients ready for surgery. One article described preparing for surgery as one would prepare for a marathon and it encompasses more than being in good shape. Prehabilitation includes exercise, nutrition, and psychological wellness/stress reduction. It improves cardiovascular, pulmonary, and muscular health and has been associated with decreased complication rates and increased early function. A study looking at Medicare recipients in Michigan showed that patients who participated in such a program had decreased length of stay in the hospital and decreased medical costs.
This seems like good common sense but there are certainly challenges. One of the most obvious is time. Often there is little of it before it is determined a surgery is needed and it is then performed. However, what time there is can be helpful. Multiple prehabilitation articles study cancer patients, for whom the time between diagnosis and surgery is often two weeks or more. When there is time before surgery, issues such as anemia, diabetes, smoking cessation, and excessive alcohol consumption can be addressed as well as instituting the prehabilitation triad of increased exercise, good nutrition, and stress management. Challenges are always present when trying to change behaviors and individual environmental (Maine in winter) and social issues factor into a patient's ability to institute change. Still, prehabilitation can be very empowering as it offers patients some control over their outcome; something I think most surgical patients feel they have little of. Though I can't definitively prove it made a difference in my recovery (which is going very well) I felt good going into my surgery and I'm sure it didn't hurt!
1. Pre-assessment and Pre-optimization of the Surgical Patient,
Das and Blightman, Dig Med Res 2019;2:30
2. Statewide Prehabilitation Program and Episode Payment in Medicare Beneficiaries
Mouch et al, Journal of American College of Surgeons 12/2019
3. Prehabilitation:preparing patientsfor surgery
Blyth and Moorthy, BMJ 2017
4. Framework for Prehabilitation Services
Bates, West and Jack, British Journal of Surgery 2020