'Prehab' before surgery speeds up patient recovery, review suggests
Christopher Wanczycki loved to ski and work up a sweat outdoors before his advanced cancer diagnosis. Such exercise may have actually helped shorten his recovery after surgery, according to the findings of a large review.
Wanczycki, 65, was told he had a five centimetre diameter tumour in May 2021. The Ottawa resident had aggressive radiation and chemotherapy to shrink the tumour in his rectum.
When his oncologist also recommended surgery, Wanczycki enrolled in a clinical trial at Ottawa Hospital to help him prepare.
The trial was centred on prehabilitation, or prehab — a program of exercise, enhanced nutrition, psychological support and cognitive training aimed at helping patients recover more quickly. The lengths of the program vary from weeks to months depending on the type of surgery.
"You need something to motivate you to get through it," Wanczycki said. "I looked at the prehab as something that I could use to kind of push me through the treatments and get me through the surgery as well."
A systematic review published in Wednesday's issue of the medical journal BMJ backs up Wanczycki's experience. Researchers examined data from a variety of studies and concluded prehab could reduce complications and hospital stays after surgery, as well as improve patients' quality of life.
Dr. Daniel McIsaac, the review's first author and an anesthesiologist and scientist at Ottawa Hospital, said seeing many patients struggle to recover after surgery throughout his career sparked his interest in using the time before surgery to help patients to get healthier before they arrive in the operating room.
McIsaac compared planned surgery to preparing to run a half marathon.
"Having surgery is stressful on your body, like going for a jog," McIsaac said. "If we're going to go out there and put someone's body under stress, then we should be providing them the tools to train and get ready."
Though prehab programs exist in some hospitals as part of research, the review's authors hope their findings will lead to broader adoption. To that end, an ongoing trial focused on virtual home-based prehab, is currently enrolling patients across Canada who have a planned surgery that requires at least one night in hospital.
Shortened hospital stays
For the review, McIsaac and his co-authors at Ottawa Hospital Research Institute, McGill University in Montreal and St. Michael's Hospital in Toronto analyzed data from 15,000 patients receiving planned surgeries.
The researchers looked at various forms of prehab, including exercise, eating more protein, psychological support and cognitive training as well as combinations of these.
Dr. Daniel McIsaac compared prehab for a patient's mind and body to training to run a half marathon. (Toni Choueiri/CBC)
They found a 40 to 50 per cent relative reduction in complications, meaning, for instance, that the risk fell from one in three patients having a complication to one in six patients.
What's more, there was a one-day reduction in the length of hospital stays, as well as improvements in walking after surgery, physical independence and other quality of life improvements that patients called meaningful, McIsaac said.
"It's not just the exercise, it's not just the protein, but it's also that psychosocial aspect of support that is going to help people to effectively get home sooner."
Check-in calls to keep up motivation
In Wanczycki's case, he lost 37 pounds during chemo and had little appetite. Walking was uncomfortable due to swelling and numbness in his legs and feet from chemo, he recalled.
Wanczycki's three month prehab program included weekly check-in calls with a research assistant who gradually showed him exercises and stretches to do at home at least three times a week, as well as written and video instructions.
"Every morning I would have to kind of motivate myself because I knew a call was coming," he said.
Wanczycki resumed cross-country skiing five weeks after his surgery. (Submitted by Christopher Wanczyck)
Celena Scheede-Bergdahl, a professor of kinesiology at McGill University, was not involved in the review, but said she sees high rates of participation in prehab at Montreal General Hospital's surgery program.
"We're capturing them in a teaching moment," Scheede-Bergdahl said. "Allowing them to … feel like they're doing something that can help their recovery and to help them through the surgical process, that really resonates with a lot of individuals."
She said it's difficult to tease out what elements of prehab have the most profound effects. For example, if a patient is anxious, they may need support to stick with a program to be able to see the benefits of physical exercise and nutrition.
McIsaac said the next step in their research is to tailor prehab, such as focusing on leg strength for someone having a knee replacement surgery or deep breathing before having part of a lung removed.
Older patients who are more frail may need to improve their nutrition before they can exercise, he noted. "In some ways, they're both the group that's hardest to get engaged in prehab, but also they may have the most benefit."
Christopher Wanczycki enjoys the outdoors at home in Ottawa and during this visit to Newfoundland in September 2022. (Submitted by Christopher Wanczycki)
For his part, Wanczycki encourages anyone with a cancer surgery scheduled to take advantage of prehab if possible.
Wanczycki's January 2022 surgery revealed a Stage 1 cancer growing near the tumour. Five weeks after his surgery to remove the tumour and the new cancer, he had returned to hitting the cross-country ski trails.
He credits his recovery to his prehab regime, which he says helped him gain weight and strength, allowing him to get back to spending time in the outdoors, including downhill skiing and successfully hiking Newfoundland and Labrador's Gros Morne Mountain with his wife.
