Surgery can be a major shock to the system, causing multiple short and long-term effects. Besides trauma to the organs, surgery can result in lack of physical activity, loss of appetite and psychological distress. Interventions can help manage many of the immediate negative effects — such as pain, fatigue, loss of appetite and weakness — thereby allowing patients to recuperate faster and go home sooner. But the effects of surgery are felt far beyond the early convalescent period; patients may feel tired and experience memory loss for many weeks. Fatigue delays the return to usual daily functional activities (work, visiting friends and relatives, sports and leisure, shopping) and lowers quality of life.
Current research is exploring a multidisciplinary approach that encompasses exercise, nutritional and psychological strategies to better prepare patients for the challenges of surgery and recovery. Identifying and implementing ways of improving post-surgery physical and mental function and quality of life would be of great practical benefit to many patients to help them return to normal faster, regardless of what type of surgery they are dealing with.
Since men facing prostate cancer surgery are often older, more sedentary and prone to other diseases such as hypertension and diabetes, they might be ideal candidates for this innovative type of intervention.
Pre-op versus post-op
While efforts have been made to speed up recovery from surgery in the postoperative period, this might not actually be the best time to intervene. People who’ve just undergone major surgery may be tired and concerned about disturbing the healing process. They may be depressed and anxious as they await further treatment. Thus, they may not be interested in engaging in processes to shorten their convalescence. In contrast, people may be more receptive emotionally before their surgery, so this might be a better time to address potential postoperative problems.
Several programs have aimed at getting patients ready for surgery — through education, positive reinforcement and by making sure they’re medically fit — but few have been specifically developed to enhance functional and mental capacity. Poor physical performance and enduring anxiety before surgery have been shown to increase the risk of postoperative complications and prolong the time it takes to recover. With this in mind, some researchers have proposed a process called “prehabilitation,” which focuses not only on physical activity, but also on nutrition and psychological well-being.
Healthy body, relaxed mind
The evidence for the role of exercise in disease prevention is overwhelming. It has been shown to decrease the incidence of heart (coronary artery) disease, diabetes, stroke, some forms of cancer, and fractures in the elderly (due to improved balance and strength). Physical exercise increases aerobic capacity, helps the heart respond better to stress, improves the body’s use of insulin, increases lean body mass and allays anxiety. Exercise training, particularly in sports medicine, has been used to prevent specific injuries or facilitate recuperation.
On the other hand, the role of exercise prior to surgery has only recently attracted the interest of clinicians. Recent studies in patients undergoing heart, lung and abdominal surgery have indicated that prehabilitation exercise training may result in fewer postoperative complications, reduced disability, shortened length of hospital stay and improved quality of life in comparison with patients who are inactive.
Studies suggest that three to six weeks of regular exercise while waiting for surgery are sufficient to begin to show some changes in functional capacity. It’s also important to continue to exercise, although less vigorously, while recuperating. Daily brisk walking, cycling for 20 minutes and deep breathing exercises, together with weightlifting every other day, will help strengthen the limb and respiratory muscles. The intensity of training depends on the individual’s fitness, and can be increased gradually.
Besides exercise, other interventions that may have benefits include:
- nutritional strategies, i.e. restricting sugar and fat intake
- supplementation with vitamins and trace elements before and after surgery, to help the tissues utilize nutrients better
- omega-3 (e.g. from fatty fish, nuts, soy, ground flax seeds or supplements)
- relaxation and meditation techniques to relieve anxiety
Individualized care
Prehabilitation requires a multidisciplinary approach where the surgeon, anesthesiologist, nurse, physiotherapist/kinesiologist, psychologist and nutritionist work together to address the various issues related to the specific type of surgery. This individualized care starts before surgery and continues after, until the patient is back to full functional capacity. Although the advantages of this strategy have been demonstrated, more research needs to be done to discover what works best for different types of surgery and for individuals. Ultimately, the aim is to reduce the incidence of medical complications and the cost of surgical care, and facilitate the return to “normal.”
This holistic (mind/body) approach has so far been used only in a few patient groups. The structured program we offer at Multinnova Medical Centre is the first of its kind in Canada (for information, see www.multinnova.ca). It includes two pre-surgery visits, during which patients see a nutritionist, psychologist, kinesiologist or physiotherapist and physician. Patients follow a program for a minimum of three to four weeks, and their progress is evaluated during the second visit just before surgery. They are reassessed again three to four weeks after surgery and possibly at nine or 10 weeks.
The more patients we treat, the more information we accumulate on the usefulness of prehabilitation, and the more we are able to test various interventions aiming to accelerate postoperative recovery.
Dr. Francesco Carli is Professor of Anesthesia and a staff anesthesiologist at the McGill University Health Centre in Montreal, Québec. He is also Associate Medical Director of the multidisciplinary Multinnova Medical Centre (www.multinnova.ca), which offers individualized programs and follow-up for patients before and after surgery.
