Would you take an exam without studying? Would you run a marathon without training? If not, why would you show up for surgery without physical preparation for a life-changing event? Few patients capitalize on the opportunity to improve the odds of a successful surgery and a speedy recovery. Recently, an explosion of medical research suggests cardiovascular training before surgery, or “prehab,”can make this happen. As operating room physicians, we observe that major elective surgery similarly stresses the body as running a long-distance race. We wonder why patients don’t train for their surgeries with the same diligence.
We intuitively know the fitter a patient is when they arrive for surgery, the better the odds are of a successful recovery. One well-known example of this is Supreme Court Justice Ruth Bader Ginsberg who has recovered from pancreatic surgery and recently thoracic surgery. A pilot study from the Veteran’s Affairs of Los Angeles showed that prehab can improve postoperative results in frail patients with a few weeks of exercise. Among the millions of elective surgeries performed each year in the United States, many have months between scheduling and the day of surgery. Patients can prehab during this time period, thus optimizing their physiology for the big event. Why don’t more physicians ask their patients to perform prehab? And why don’t more patients demand it?
Who should prehab?
We believe there is a type of prehab that would benefit any preoperative patient, but more research is needed to know how to dose training in the frailest of patients. Therefore, we do not suggest everyone goes out and starts training for a marathon. However, many surgeons use enhanced recovery after surgery protocol starting the day of surgery to assist their patients with early ambulation and rapid recovery. We believe almost any patient who is expected to walk the day after surgery, should be able to prehab at least as aerobically rigorously in the weeks leading up to surgery. Furthermore, if research continues to support prehab as a path to a better recovery, hospital systems may consider making a baseline level of activity before elective surgery a requirement. Gastric bypass surgery patients already must go through such a rigorous process prior to elective surgery.
Where should we prehab?
For prehab to succeed, preoperative patients must be placed into a system that helps them train appropriately and monitors their progress. There are three options: 1. traditional medicalized rehabilitation systems, 2. physical fitness networks and trainers, and 3. virtual prehab programs, complete with monitoring. While medical research finds some benefit to in-hospital exercise training programs compared to community interventions, prehab in a health care facility is likely not the most cost-effective option for potentially millions of new prehab patients. Moreover, few preoperative patients want to spend any more time than absolutely necessary in the health care system.
Today, many patients are looking for health care in convenient locations. Neighborhood gyms and training facilities (e.g., YMCA) feature established, highly-resourced and distributed networks that can prehab patients immediately with minimal programmatic modification. Personal trainers often have experience working with elderly, frail, and chronically injured individuals.
Many are superb motivators who can meet patients at their level of need, effectively becoming prehab champions. Financially, access to gyms or even trainers is less expensive than many other common expenditures in health care. When improved preoperative fitness inevitably improves postoperative recovery, the return on investment — for all parties — will be obvious.
There is also an increasing group of technology-savvy surgery patients who could train and be monitored through connected health devices like step counters and heart rate monitors. Hospitals could offer virtual training plans, complete with instructional videos. One can imagine Peloton or Mirror exercises, designed specifically for the surgical patient, prescribed by physicians and physical therapists! And the monitoring would not be passive: prehab champions could respond directly to patients with words of encouragement as patients reach milestones on the journey to surgery day.
Prehab for population health
Good research indicates that prehab can improve postoperative outcomes that are meaningful to patients. Patients may spend less time in the hospital, return to their regular life more rapidly, and have fewer complications. These benefits are exactly what any patient contemplating surgery wants. Furthermore, we know the perioperative period is a “teachable moment.” When patients prehab, and reap the benefits of prehab, they simultaneously create a healthy habit of physical fitness that will ideally continue after surgery. This alteration could result in legions of more active people improving population health.
A vision of the prehab future
In the near future, we expect elective surgery patients to have minimal but specific cardiovascular milestones to achieve before surgery. Hospital systems will partner with local gyms and deploy their own virtual training guides to facilitate large-scale prehab efforts. Connected health devices will track patients’ progress toward milestones. Virtual visits with prehab champions will motivate patients to meet and exceed their goals. Friends, family, co-workers, and colleagues will offer their encouragement across social media while viewing training goals, performance stats, and milestones. More data needs to be collected and analyzed before we can prescribe specific types and doses of exercises for all patients. But early research should lead patients and providers to create physical training regimens before surgery. Surgery is an athletic feat. Let’s treat it as such by having our patients train for it, set performance goals, reach milestones, give encouragement, and celebrate their improved odds to a speedy recovery come that pivotal day.
Nirav Kamdar and Matthew Meyer are anesthesiologists.
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