By Glenda Arcilla Borreo, PT, MHSc, CLT, ACSM EP-C, CCET
In rehabilitation medicine, “optimal function” is at the core of practice. The Merriam-Webster’s dictionary defines the word “rehabilitate” as “to restore to a former capacity.”1 In general, the goals of rehabilitation can be classified as “restorative,” with the intent of returning to prior function, or “supportive” with the intent of achieving optimal function, if restoring prior level of function is not a possibility. There is another aspect of rehabilitation that is less known—one that is proactive, even pre-emptive. It is that aspect of rehabilitation that does not wait for loss of function, but anticipates and braces for what could possibly result in some loss of function.
Lately, the terms “prehabilitation” or “prehab” have made their way into the healthcare discourse. Although the term “prehab” may sound novel, the concept is not entirely new in rehabilitation. For example, preoperative rehab has been conducted in orthopedics prior to joint replacements, ligament reconstructions, tendon repairs, etc. Likewise, pulmonary rehab has been done prior to lung surgery and lung transplant. In sports rehab, athletes go through sport-specific performance training and pre-season training to prepare them for the specific demands of their sport, as well as to help prevent injuries during the season. These practices may not always have been referred to as “prehabilitation,” but the concepts behind these practices are quite similar. They are interventions used to prepare the body for a major physical and physiological stress, whether from invasive procedures such as surgery, or the physically demanding needs of sports. Prehabilitation is a concept that continues to develop even as it is utilized in more areas of medicine, and its benefits are becoming more recognized.
The modern concept of prehabilitation may have its initial development in orthopedic and cardiopulmonary rehabilitation. The early attention prehabilitation gained was mostly in the preoperative phase, particularly in orthopedic surgery and cardiopulmonary surgeries. Most of the prehabilitation interventions consist of exercise programs designed to improve baseline strength and endurance, training in activities of daily living, respiratory training, etc. Disability or loss of decline of function is usually thought of as a consequence of causes such as trauma or injury, a catastrophic pathology, or an insidious or acute disease. However, it can also result from the side effect of major medical treatments. Surgery is one example of a major treatment procedure that impacts physical function. Until recently, rehabilitation was mostly involved in postoperative care and recovery.
Benefits of Prehabilitation
It can be said there is a link between the benefits of prehabilitation and the deleterious effects of illness and inactivity. It is precisely these detrimental effects that prehabilitation is premised to potentially mitigate, if not prevent. It makes excellent sense in theory that conditioning the body prior to surgery or other physiologic and physical stresses will lead to more favorable outcomes. Other than the intensity and perhaps the mode of training, this concept is not very different from that of training and conditioning the athlete to maximize performance in a sport. In prehabilitation, the premise is “to improve the patient’s functional ability before encountering the stressor…the individual would be more likely to withstand the stress better…”2
It is reasonable to expect that a preconditioned individual will be able to return to baseline level sooner, hence a decrease in duration of dependent function.2 Based on the aforementioned premise of prehabilitation, it is expected to have a positive impact on musculoskeletal and physical function, cardiopulmonary function and aerobic capacity, pain, and psychological state. This will in turn facilitate and enhance recovery and perhaps even lessen the risk of complications. A decrease in the risk of complications will lead to a shorter hospital stay and, possibly, lower the chance of hospital readmission following discharge.
A literature review by Jack et al3 about prehabilitation and perioperative training concludes that studies show encouraging evidence that physical capacity, quality of life, and well-being are improved. Those studies, however, did not have a consistent pattern of exercise modality, intensity, or duration. A more recent systematic literature review by Santa Mina et al4 about the effect of total body prehabilitation on postoperative outcomes concludes that prehabilitation can result in improvement of physical function, and reduced hospital length of stay and postoperative pain. Both reviews strongly advocate conducting more research with adequately powered randomized controlled designs, as well as consistent use of outcome measurements.
Prehabilitation in Oncology
Prehabilitation continues to gain greater ground in areas other than orthopedics. Recently, it is finding its place in oncology rehabilitation. And rightfully so. As of January 2014, nearly 14.5 million Americans are cancer survivors.5 The National Cancer Institute defines “cancer survivorship” as the period of time from cancer diagnosis up until the end of life.6 Hence, an individual who has been diagnosed with cancer is considered a survivor whether he or she is undergoing active treatment, has completed treatment, or is in remission. With advances in early detection and treatment, the rate of surviving cancer continues to improve. From 2004 to 2010, the 5-year relative survival rate for all cancers has risen to 68%, compared to 49% in the years 1975 to 1977.5
Although the data is showing a positive trend, the unfortunate fact is that cancer remains a devastating diagnosis and a debilitating disease. Cancer and cancer treatments can negatively impact an individual’s physiologic function, functional capacity, cognitive abilities, emotional and psychosocial well-being, and economic status. The Institute of Medicine7 of the National Academies issued a comprehensive report with recommendations focusing on survivorship of adult cancers and guidelines for survivorship care. It is clear in this report that survivorship care spans across the continuum of cancer care from the time of diagnosis and onward. It is also evident that rehabilitation professionals have a crucial role along this care continuum. The focus is not only on quality of life, but equally important is reintegration into the community and society.
In addition to traditional rehabilitation in oncology, cancer prehabilitation is emerging as a critical component of survivorship care. Julie Silver, MD,8,9 a noted proponent of oncology prehab and assistant professor at Harvard Medical School, defines oncology prehabilitation as a process in the continuum of cancer care that: 1) should include physical and psychological assessments that establish a baseline functional level, identify impairments, and 2) provides targeted interventions that improve a patient’s health to reduce the incidence and severity of current and future impairments. Baseline assessment provides clinicians with an understanding of the patient’s current level of function.
It is likewise beneficial to know certain co-morbidities that can be addressed prior to beginning and during cancer treatment. Not very different from regular prehabilitation, cancer prehabilitation also aims to prepare the cancer survivor for the stressors of upcoming treatment. Prehabilitation interventions are designed to reduce the severity of anticipated side effects of treatments that may cause significant impairments.8 Prehabilitation can have a positive impact on the cancer patient’s ability to tolerate cancer treatments, thereby allowing continuous, uninterrupted treatments. Consequently, options of possible treatments are broadened if functional capacity can be maintained at a decent level.8
Exercise and Physical Activity in Cancer Prehabilitation
Physical activity is beneficial and, in fact, recommended for cancer survivors during and after cancer treatment. More evidence continues to support the important role of exercise in cancer prevention, control, progression-free survival, as well as cardiorespiratory fitness, muscular strength, and quality of life.10-14 Cancer survivors are encouraged to “be as physically active as their abilities and conditions allow,” with the explicit recommendation to “avoid inactivity.”12
In spite of advances in cancer treatments (surgery, chemotherapy, radiation, targeted therapy, etc), there remain unfavorable side effects that negatively impact physical strength, endurance, and function. Exercise has been shown to mitigate these side effects and therefore has an important role in the prehabilitation of cancer patients. Aerobic exercise such as walking, swimming, water exercises, biking, dancing, etc, can improve functional cardiopulmonary capacity and endurance. Resistance training using free weights, gym equipment, resistance bands, body weight, etc, can improve muscular strength and endurance, coordination, and increase muscle mass. Neuromuscular exercises such as plyometrics, sequential multijoint routines (eg, lunges with combined upper-body moves, squats combined with upper-body rowing, kickboxing moves, etc), some Pilates moves and yoga postures, to name a few, can improve balance, neuromuscular coordination, strength, and endurance.
Stretching exercises can improve motion and flexibility and should not be neglected, particularly because some treatments for cancer (eg, surgery, radiation therapy) can cause scar tissue proliferation. Stretching is also credited with mitigating the effects of delayed-onset muscle soreness that may develop following exercise. Exercise training and conditioning for the cancer patient must be tailored individually based on such factors as: cancer type; current and pretreatment functional status or aerobic fitness; current, past, or future treatments; anticipated trajectory of the disease; other medical comorbidities; and other pertinent issues.12 Progression or modification of the program is usually based on symptoms and patient response, but may also be influenced by a change in cancer treatment or a change in the patient’s medical and physical status.
There are also several considerations unique to the cancer patient such as the risk for pathologic fractures (bone metastases, myeloma, hormone management therapies, etc), risk for cardiovascular events (as a result of cardiotoxicity from some treatments), chemotherapy-induced peripheral neuropathy, lymphedema, musculoskeletal morbidities, etc, as a result of some treatments. These are just a few things that must be taken into account to formulate a safe exercise program for the cancer patient. The details of exercise recommendations and guidelines for cancer survivors are beyond the scope of this article. The reader is referred to guidelines issued by The American College of Sports Medicine12 as listed in the reference section and to the American Cancer Society and the National Comprehensive Cancer Network websites.
Cancer Prehabilitation: Going Beyond Exercise
Even as exercise is credited with benefits for cancer survivors, still a recent and the first-ever review of cancer prehabilitation favors an approach that goes beyond exercise and physical conditioning.8 In addition, another systematic review of literature concluded that “exercise may have beneficial effects on Health Related Quality of Life (HRQoL) and certain HRQoL domains, including cancer-specific concerns: body image / self-esteem, emotional well-being, sexuality, sleep disturbance, social functioning, anxiety, fatigue, and pain at varying follow-up periods.”15 This review cautioned the interpretation of results due to the risk of bias and heterogeneity of exercise programs and HRQoL measures. Nevertheless, the beneficial effects on certain domains of HRQoL (self-esteem, anxiety, fatigue, sleep disturbance, etc) must compel us to recognize that the impact of cancer goes beyond physical function.
As such, it behooves clinicians to appreciate cancer prehabilitation and rehabilitation as multidisciplinary programs that involve more than exercise and physical conditioning. A multidisciplinary approach takes into account the following aspects: physical (function, nutrition, safe mobility, symptoms, etc), psychological and behavioral (coping skills, stress management, smoking cessation, self-esteem, intimacy, etc), cognitive (“chemo brain,” memory loss, etc), psychosocial (community reintegration, faith, cultural leanings, etc), and even the financial (community support and resources available) impact.
More recent literature in oncology prehabilitation support and employ a multimodal model versus a unimodal one.8,14,16-20 The multimodal prehabilitation model utilized by the STAR Program (Survivorship Training and Rehabilitation) centers on the cancer survivor and includes the following components: general and targeted exercise, nutrition, stress reduction, and smoking cessation.21 The basic framework must be individualized to address the needs of the cancer survivor. The program advocates that each single intervention is a piece that fits the bigger puzzle to form a multimodal approach, focused on improving health outcomes.8, 21
As ideal as it may sound, the implementation of cancer prehabilitation has its own challenges. Typically, there is not much time between diagnosis and the beginning of treatment. Not because the situation is always deemed to be emergent, but primarily because treatment usually commences within a short period of time. Nevertheless, it is still beneficial to implement prehabilitation in spite of this challenge to perform baseline assessments. Other challenges include third-party payors and obtaining referrals from physicians. In both cases, demonstrating good outcome and appropriate and comprehensive documentation will be particularly helpful.21
Cancer-Specific Prehabilitation and Literature Support
In lung cancer patients, Tarumi et al17 instituted exercise, training in activities of daily living, respiratory and cough training, relaxation, and smoking cessation. The study found that prehabilitation resulted in improvement in pulmonary function during chemoradiotherapy with subsequent lung resection, even in smokers and those with pretreatment respiratory impairment. A multimodal version of pulmonary prehabilitation that continues into the treatment phase will be beneficial even for nonsurgical patients.
Another study involving patients with colorectal cancer also investigated the effect of the multimodal prehabilitation approach (exercise, nutrition counseling and supplementation, relaxation, and breathing strategies) prior to colorectal resection.16 The study found clinically meaningful changes in functional exercise capacity postoperatively (ie, recovery to or above baseline capacity). A review of literature on long-term outcomes in older colorectal cancer patients advocates thus, “focus of preoperative assessment needs to switch to long-term patient-centered outcomes such as quality of life, functional independence, and community reintegration.”22
Treatments for prostate cancer are known to possibly cause urinary and sexual dysfunction, and reduced physical function that, as a whole, can negatively impact health-related quality of life.20 There are patients who may have urinary and erectile dysfunction even prior to cancer treatment. The same is true for cyctectomy, cystoprostatectomy, and surgeries for gynecologic cancers. The preoperative phase is an opportune time to address impairments (that can worsen with treatment) before the treatment begins. Pelvic floor muscle training and behavioral interventions are usually beneficial. Jensen et al14 suggested the role for early rehabilitation in major uro-oncology surgery that may facilitate return to work.
For breast cancer, treatment usually involves one or a combination of surgery, chemotherapy, radiation, targeted therapy, and hormone-management therapy. Courneya et al23 found that “higher volume of aerobic (50 to 60 minutes) or combined aerobic and resistance training exercise is achievable and safe during breast cancer chemotherapy, and may manage declines in physical functioning and worsening symptoms better than standard volumes of 20 to 30 minutes aerobic exercise alone.”
A 2008 study of supervised exercise for breast cancer patients grouped participants based on cancer treatment (surgery alone, surgery and chemotherapy, surgery and radiation, combination of all three).24 It involved comprehensive screening and evaluation that determined the individualized exercise prescription for each participant. The authors found “improvement in cardiopulmonary function with concomitant reductions in fatigue regardless of cancer treatment,” and those who received a combination of all three treatments for cancer appeared to have the most benefit as a result of an individualized exercise intervention.24 Other areas that prehabilitation might address in a patient-specific manner and in addition to exercise are: nutrition, skin integrity and healing, lymphedema prevention, specialized garment needs, activities of daily living, stress management, body image and self-esteem, relationships and intimacy, etc.
Patients afflicted with head and neck cancers can present with disabling consequences of treatment. Surgery, radiation therapy, and chemotherapy are common treatments. Decreased range of motion, radiation dermatitis and fibrosis, oral mucositis, speech and swallowing dysfunction, and weight loss are a few of the physical effects of treatment. Prophylactic swallowing exercises have been shown to positively affect swallowing after chemotherapy and radiation therapy.25,26 Patients who undergo surgery (prior to radiation therapy or chemotherapy) with muscle and possibly lymph node dissection present with the additional challenges of decreased range of motion and risk for lymphedema. Ideally, these are some of the issues that prehabilitation can address before the patient transitions to the next treatment phase.
Hematologic cancers and their treatments also result in unwanted consequences that can be quite disabling. These cancers can be accompanied by severe anemia and thrombocytopenia in addition to extended lengths of cancer therapy. As such, overall strength, endurance, and function are negatively impacted, and consequently, so is quality of life. In a systematic review, the authors concluded that “physical exercise added to standard care can improve quality of life, especially physical functioning, depression, and fatigue.”27 An earlier review advocates that “for optimal outcomes, this vulnerable oncology population will need earlier and more comprehensive involvement of rehabilitation services.”28 Indeed, knowing the significant effects of major treatments (chemotherapy, radiation, stem cell transplant) justifies the need for prehabilitation and judicious monitoring throughout the continuum of treatment in this patient population.
From a general perspective, prehabilitation can be considered as the initial or preparatory phase of the rehabilitation process. Prehabilitation certainly has a significant role in the rehabilitation of oncology patients as they go through the continuum of cancer care. Comprehensive assessment of baseline functions (physical, psychosocial, cognitive) is essential to oncology prehabilitation. Identification of pretreatment impairments and comorbidities is necessary to shape a multimodal blend of individualized interventions that focuses on improving health outcomes. Although prehabilitation has been practiced in other areas in the past, it is crucial to stress the importance of initial assessment and identification of impairments.
This article mostly comments about physical rehabilitation interventions. With a multimodal approach, involvement of other allied health disciplines is essential. The cancer-specific prehabilitation examples cited in this article should not be interpreted as a review of literature, but rather, a portion of what is available in literature. It is also evident that there is a pressing need for extensive research in oncology prehabilitation. As rehab oncology clinicians, it is our hope that it becomes a part of standard cancer care in every institution. RM
Glenda Arcilla Borreo, PT, MHSc, CLT, ACSM EP-C, CCET, practices as a physical therapist in Oncology Rehabilitation at Cancer Treatment Centers of America at Midwestern Regional Medical Center in Zion, Ill, a suburb of Chicago. A physical therapist with more than 30 years of experience, she holds a master’s degree, and is certified in Survivorship Training and Rehabilitation (STAR Program) by Oncology Rehab Partners, Exercise Physiology by the American College of Sports Medicine, Cancer Exercise Trainer by the American College of Sports Medicine and American Cancer Society, and as a certified lymphedema therapist. For more information, contact [email protected]
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