Prehabilitation May Benefit Adults Preparing for Surgery

Exercise and nutritional prehabilitation, as well as multicomponent interventions that include exercise, are associated with lower complication rates and possible improvements in other outcomes among patients preparing for surgery, a new systematic review suggested.

Researchers found that exercise was associated with a 50% reduced risk for complications, compared with usual care, and nutritional support was associated with a 38% reduced risk. Combined exercise, nutritional, and psychosocial support was associated with a 36% reduced risk.

“On one hand, our findings are common sense,” study author Daniel McIsaac, MD, leader of the Aging Innovation in Perioperative Medicine and Surgery Research Group at the University of Ottawa, Ottawa, Ontario, Canada, told Medscape Medical News. In most health settings, “being more active and eating better are associated with better outcomes,” he said. “On the other hand, I was surprised to see the size of some of the benefits.”

The other surprising finding, he added, “was how the inclusion of psychosocial support was so useful for decreasing length of stay. Looking back, this does make sense, as discharge after surgery is a complex process, so having good psychosocial support before surgery likely makes preparing for getting home easier.”

The study was published online on January 22 in the BMJ.

Exercise Key

The researchers searched the literature published through October 2023 to estimate the relative efficacy of individual prehabilitation components (eg, exercise, nutrition, cognitive, and psychosocial) and combinations of these components on postsurgical outcomes among adult patients. The outcomes included length of stay, health-related quality of life, and physical recovery.

A total of 186 randomized controlled trials with 15,684 participants (mean age, 62 years; 45% women) were included in the review. The certainty of evidence for all comparisons across all outcomes was generally low to very low because of trial-level risk for bias and imprecision. But results for exercise and nutritional prehabilitation were robust after trials with a high risk for bias were excluded.

Exercise alone (odds ratio [OR], 0.50), nutrition alone (OR, 0.62), and combined exercise, nutrition, plus psychosocial prehabilitation (OR, 0.64) were most likely to reduce the risk for complications compared with usual care.

Regarding length of stay, combined exercise and psychosocial support was associated with 2.44 fewer days in the hospital, whereas combined exercise and nutritional support was associated with 1.22 fewer days. Individually, exercise and nutrition were associated with 0.93 and 0.99 fewer days, respectively.

Compared with usual care, a combination of exercise, nutrition, and psychosocial prehabilitation was most likely to improve health-related quality of life (mean difference on Short Form-36 physical component scale, 3.48) and physical recovery (mean difference in meters on the 6-minute walk test, 43).

Overall, exercise and nutrition were the individual components most likely to improve all critical outcomes.

“Even though this study combined data from 186 studies that included over 15,000 patients, the results are still preliminary,” McIsaac cautioned. “This is because most of the studies we pooled together were small, conducted at a single hospital, and used approaches to prehab that were resource-intensive and likely would not scale across healthcare systems.”

Furthermore, he said, “While the preponderance of data suggest that prehab is safe for patients, including when delivered at home, for people who are new to exercise or haven’t been active in a while, caution is warranted, and good nutrition should be in place to support the added demands of exercise.”

Rather than viewing prehabilitation as an individual activity that patients must choose to do themselves, he added, “We need to look at prehab as a health system intervention and make sure that we positively support patients in prehab through safe, effective, and feasible programs.”

‘Minimal’ Risks

Michael Englesbe, MD, professor of surgery and director of the Michigan Surgical and Health Optimization Program and the Michigan Surgical Quality Collaborative in Ann Arbor, commented on the study for Medscape Medical News. “The study is rigorous and basically draws the conclusion that the data for prehabilitation are consistently positive for patients, but the robustness of the overall evidence is lacking.”

Nevertheless, he said, “Considering the relatively small downside of doing it, it seems like a common-sense approach to improve clinical outcomes for patients having major surgery.

“The risks of the intervention are minimal…And even if not effective, it is probably just good for human beings to do these activities before surgery or, for that matter, every day,” said Englesbe, who was not involved in the current study. He led an earlier study showing that participation in a prehabilitation program in Michigan was associated with a shorter length of stay and lower total episode payments after an operation.

“Rigorous trials would require a good bit of financial backing, and I’m not really sure it would be feasible or necessary,” he noted. “In my experience, more and more advanced health systems are incorporating prehab into preoperative care.

“Exercise, nutrition, and efforts to promote positive psychology should be components of a good program,” he affirmed. “It comes down to feasibility. What can patients do, and what can health systems implement? Flexible programs are going to be better, as they increase compliance.”

The study was supported by a grant from the Canadian Institutes of Health Research. McIsaac and Englesbe declared no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.