This Form of Cancer Care Can Improve Your Physical & Mental Wellbeing
September 20th, 2015 by Holly Cornish
You’ve heard of rehabilitation but I bet you’ve never heard of prehabilitation. Prehab takes place in the period of time between a diagnosis of cancer and the start of acute treatment, especially surgery.
The basic idea is that even moderately improving your physical — and psychological — fitness before surgery can give you a better outcome and a faster recovery time.
It’s starting to catch on as way to possibly reduce health problems related to treatment, enhance a patient’s physical and mental wellbeing, and even improve chances of survival.
Here’s what happens when you go through prehab. . .
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Proven Benefits in Cardiac and Orthopedic Surgery
Prehabilitation is not a new concept. In fact, the British Medical Journal published an article in 1946 showing how it had been used successfully to turn substandard military recruits into regular soldiers.
The program included education, recreation, physical training, nutritious food, hygiene and lodging.
In more recent times, prehabilitation has been used to help patients who elect to go into an intensive care unit (ICU). The lack of activity in an ICU poses a significant health risk, degrading the capacity of the cardiovascular and musculo-skeletal systems.
As part of a prehab program, the patient engages several times a week in activities like walking, aerobics, flexibility, strength training and functional tasks such as sitting and rising from a chair. Getting in better shape helps patients withstand the ordeal and improves outcomes.
Prehabilitation has been used mainly before coronary artery bypass and orthopedic surgery.
In heart bypasses, a combination of physical and psychological counseling has been shown to reduce depression, improve physical functioning before surgery, shorten hospital stay and improve quality of life in the months following surgery.
In one study of those about to undergo orthopedic surgery, 35 patients had prehabilitation while 36 had usual care. The prehab patients experienced increased leg strength and functional task abilities following total knee replacement, in comparison to the usual care group.
Individual case studies in patients undergoing knee replacement have seen better function, increased knee strength and less post-operative pain.
Other benefits from studies in orthopedic care include faster post-surgery recovery, shorter hospital stays and reduced hospital costs.
Prehabilitation applied to lung cancer
With benefits like these, you would expected prehab to have a positive effect in cancer therapy, too.
In 1980, Dr Herbert Dietz, a surgeon at New York Memorial Hospital who spent two years studying cancer care, suggested that prehabilitation for those at high risk of surgery had the potential to reduce morbidity and mortality in cancer patients.
Although prehab for cancer patients has not been well researched, the studies that have been performed demonstrate improved outcomes.
The most well-studied so far has been cancer of the lung.
In 1997 a study looked at pulmonary prehabilitation. This consisted of slow deep breaths and breathing exercises to strengthen the respiratory muscles. These took place in the two weeks before surgery as well as three months after. The result was a significant increase in lung function.
The authors suggested that presurgery training could allow patients with severe illness, not considered suitable for surgery, to become candidates for treatment.
More recently, 22 lung cancer patients who also suffered chronic obstructive pulmonary disease (COPD) undertook pre- and postoperative exercise routines.
Their regimens included breathing, coughing instruction to loosen, dislodge and clear secretions, as well as daily walking. They were compared to 60 similar patients who only received physiotherapy following surgery.
The exercise group had a much improved outcome and a 28% shorter hospital stay.
Another study involving similar patients made use of a stationary bicycle with trunk and upper body strength training. The researchers reported significant improvements in the maximum rate of oxygen consumption, demonstrating better lung capacity.
In 2007, an Italian study consisted of eight lung cancer and COPD patients who could not be considered for surgical removal of one or more lobes because of poor lung function.
These patients took part in an intense three-hours-a-day, five-days-a-week training program that lasted a month. It included education, smoking cessation, aerobics and breathing exercises.
The prehab program resulted in such a significant improvement in lung function that the patients were able to undergo surgery.
Prehabilitation in prostate, breast and colorectal cancer
As research into prehabilitation evolved, doctors started to look for opportunities to use it beyond lung function.
A review of eleven trials found that pelvic floor muscle training before surgery to remove the prostate saw a more rapid return to urinary continence, compared to control groups who did not undergo training.
Although Dr. Dietz recommended prehabilitation for mastectomy to increase range of shoulder motion for example, only anecdotal evidence and a single case study are available.
Since fatigue, muscle wasting, reduced functional ability and poorer quality of life are associated with breast cancer surgery and chemotherapy, a 42-year-old patient started aerobic training one week before surgery and throughout chemotherapy. She suffered less fatigue and improved in five out of seven functional measures.
77 patients received either four weeks of prehabilitation or eight weeks of rehabilitation before and after colorectal cancer surgery. The program consisted of aerobic exercise, resistance training, relaxation, nutritional counseling and protein supplements. They were evaluated by rating their performance on a six minute walk test.
Two months after surgery, 84% of the prehab group had recovered to or surpassed their starting point measurements, compared to only 62% of the rehab group. Several other measures were also superior in the prehab group, leading the authors to conclude that, “Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.”
Improvements in mental health
It’s not just physical health that improves with prehabilitation exercises. Psychological health also gets better.
Those who started exercising a week before chemotherapy had reduced levels of anxiety and depression, better mental health, and greater vitality and quality of life compared to those that didn’t exercise.
Direct psychosocial interventions also show benefits.
159 men scheduled for prostate surgery who had presurgery stress management suffered less mood disturbance and better immune function after surgery compared to the standard care group.
Goals of cancer prehabilitation
Improvements in physical and psychological functioning and outcomes, treatment options and compliance, occupational function and quality of life.
Reductions in treatment-related impairments, time to recovery, length of hospital stay, home care therapy, rehabilitation outpatient visits, hospital readmission, risk of cancer and co-morbidity recurrence, direct and indirect healthcare costs, disability and mortality.
And yet in spite of the evidence — admittedly somewhat limited — not everybody is convinced.
According to Catherine Alfano, vice president of survivorship at the American Cancer Society, “There are some rehabilitation physicians who don’t believe in prehab, they feel like the science isn’t there yet.”
However, according to Julie Silver, Department of Physical Medicine and Rehabilitation, Harvard Medical School,
“…what used to pass for good care is no longer good enough.
“With the focus squarely on improving every aspect of oncology care, offering evidence-based prehabilitation care by well-trained nurses who are tracking and reporting outcomes makes sense.
“After all, prehabilitation can impact outcomes including health-related quality of life, return to work, and physical function. As people begin to understand the role of prehabilitation in improving outcomes, there will be an increasing demand for these services—by doctors and patients alike.”
Our last issue looked at something that’s on a lot of people’s minds lately: gluten. Are that many people really gluten-sensitive, or is it just a fad? If you missed this article, it’s running again just below.