Effects of Prehabilitation on Post-OP Success

William Cote PT/s

2-24-16

Overview

• What is Prehabilitation?

• Prehabilitation focus

• Prehabilitation effects on invasive surgeries

• Limitations

• Future of Prehabilitation

• What can we do?

• Summary

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What is Prehabilitation?1

• Prehabilitation refers to physical therapy treatment in the pre-operative setting.1

• Goal is to reduce post-op complications and reduce costs.

• The concept is new and ever changing in recent years, due to many eye-catching studies.1

• Concept has been found helpful for patients preparing for:

• Joint replacements

• Cardiac/abdominal surgeries

• Cancer related therapy/surgeries

The Many Focuses of Prehabilitation

• Pre-operative strength training

• Inspiratory training

• Pre-operative education

• Anxiety-reducing strategies

• Increase patient sense of control

• Supplementation

http://www.litigationps.com/.a/6a01156e439be2970c01a73e06ada4970d-pi

Effect of prehab on elective cardiac surgery

• AHA reports total number of inpatient cardiovascular procedures increased 28% between 2000-2010 (total of 7,588,000).2

• Of total cardiac surgies, 400,000 were Coronary Artery Bypass Grafts (CABG).2

• Although post-op mortality numbers have been reduced, there is still signifiicant risk of pulmonary complications, which increases morbidity and mortality. 2,3

Prehab and effects w/ CABG

• Post-op CABG complications include, but are not limited to:

• Altered breathing patterns

• Decreased chest wall movement

• Decreased mucous clearance

• Hypoxia

• Limited walking ability

• Decreased respiratory muscle function

• Increased hospital stay

• Decreased QOL

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Prehab and Effects w/ CABG –Inspiratory Training

• Intervention group received inspiratory muscle training 7 days/ week x20min along with usual care (education, and cough support)

• Control group received only usual care3

• Control group insp. Muscle strength increased by 15%

• Intervention group increased by 36%.3

• Control group has higher incidence of atelectasis (6 pts) in comparisons to intervention group (2)

• Average hospital stay 2 days longer for the control.3

Prehab and Effects w/ CABG – Exercises & Education

• Control group received 3 hour pre-surgery assessment

• Intervention group pariticpated in education classess and exercise 2x/week x 4 weeks.4

• Exercise group based on interest and ability, to include: walking (8/8), cycling (2/8) and stretching (2/8).4

• Primary outcomes included walking distance (6 min walk test).4

• Secondary outcomes: Gait speed (5 meter speed test) and cardiac rehab attendence post-op 3 months.4

Prehab and effects w/ CABG – Exercises & education4

Outcome Control Group (n=7) Intervention group (n=8)

Walking distance (6 min walk test) (meters)

Unchanged 474 +/- 101 (at pre-op)487 +/- 106 (x3 months)

Gait speed (5 meter gait speed) (seconds)

Unchanged 4.0 +/- 0.7 (at pre-op)3.7 +/- 0.9 (x3 months)

Cardiac rehab attendence x3 months

43% of patients attended 100% of patients attended

Effects of Prehabilitation on joint replacements

• Observation cohort comparion study of 4,733 hip or knee replacement cases within Medicare hospital referral cluster.5

• Outcome measured was use of post-acute care services; with 77% of patients using these services, which include:

• Skilled Nursing Facilities

• Home health Agency

• Inpatient Rehab Facility

Effects of Prehabilitation on joint replacements

• Post-op acute care utilization decreased if prehabilitation was used

• only 52.4% of cohort using services.

• However, 79.7% of non-prehabilitation patients used post-acute services.5

• Overall, use of prehabiliation was associated with a significant 29% reduction in post-acute care services.5

• In turn, this equates to an estimated CMS payment reduction of approx $1,215 per patient. 5

Effects of Prehabilitation on Colorectal Resection for Cancer

• Research evaluated effects of prehabilitation on recovery of functional exercise capacity vs patients receiving rehabilitation status post resection.6

• Both groups pariticpated in home based intervention including:

• Mod level aerobic/resistance exercises

• Nutritional counseling

• Relaxation exercises

• initiated 4 weeks before surgery, or immediately after. 6

• Primary outcome measured was functional exercise capacity

• Using 6-min walk test.6

Effects of Prehabilitation on Colorectal Resection for Cancer

• Preoperative period: Patients in prehabilitation group significantly improved walking capacity by 25.2 meters;

• rehab group declined by 16.4 meters.6

• Four weeks after surgery: 50% of patients in both groups remained >20m below baseline distances.6

• 8 weeks after surgery:

• Patients in prehab were significantly above their baseline walking distances (+23.7 meters),

• Rehab group patients were significantly below baseline (-21.8 meters).6

Effects of prehabilitation on Colorectal Resection

for Cancer 5

• Image shows effects of prehabilitation vs rehabilitation

from baseline through 8 week post operation5

Effects of prehabilitation on invasive surgeries

• Research evaluating effects of prehab on patients undergoing invasive surgeries, in relation to postoperative complication rate and hospital stay.7

• Search of relevant conducted in electronic databases including PubMed, EMBASE, PEDro, and CINAHL.7

• Evaluated joint replacement, cardiac, and abdominal surgeries7

Effects of prehabilitation on invasive surgeries

• Use of prehabilitation prior to cardiac or abdominal surgery led to a shorter hospital stay and reduced postoperative complication rates.7

• Pulmonary complications are leading cause of postoperative morbidity after cardiac or abdominal surgery.7

• Main preoperative method use was inspiratory training, which targets respiratory muscle function, thus directly affecting pulmonary function, and reducing complications after cardiac/abdominal surgery.7

http://1.bp.blogspot.com/-o8q0L32YBM4/UFBiAOGZDOI/AAAAAAAADNU/PJvK81j323g/s1600/incentive.jpg

Effects of prehabilitation on invasive surgeries

• By contrast, length of stay and complication rates s/p joint replacement surgery were not significantly affected by preoperative exercise.7

• Common complication in patients undergoing joint replacement procedure is wound infection.7

• Preoperative exercises/mobility training may not directly influence postoperative incidence of wound infections.7

http://www.oxfordvalleypain.com/blog/wp-content/uploads/2015/11/Fitness-Walking.jpg

Limitations of Prehabilitation • Research to examine the impact of prehabiliation is in the beginning stages1

• More “good studies” necessary to help promote the field/increase use

• Many insurance companies will not fund prehabilitation, or will take from overall visits, thus reducing post-op rehabilitation access1

• Specific exercises for specific procedures

• Trial and error

• Lack of marketing/promotion

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Limitations of Prehabilitation

• One of largest limitations is lack of support from physicians, who remain skeptical of prehab’s benefits1

• According to 2013 Study from Cancer Journal for Clinicians, 55-90% of pts diagnosed with cancer may benefit from prehabilitation, yet only 5-20% of those are referred to PTs/OTs.

• Further collaboration would be beneficial to improve working relationships and increase referrals/use of prehabilitation.

The Future of Prehabilitation

• With increase in aging and baby boomers seeking to prolong active lifestyles, preoperative care will increase in demand as research grows.1

• Implementation of Comprehensive Care for Joint Replacement Model from the federal governement will give prehabiliation a major push.1

• Mandates bundling payment and quality measures for each episode of care.

• Idea is to encourage hospitals, physicians, and other health care providers to work together to improve quality and coordination of care.

The Future of Prehabilitation

Comprehensive Care for Joint Replacement Model

http://image.slidesharecdn.com/ccjr-overviewwebinar-slides72015-150720123312-lva1-app6892/95/webinars-comprehensive-care-for-joint-replacement-model-overview-2-638.jpg?cb=1437751166

The Future of Prehabilitation• APTA is set to launch an online resource center in order to help PTs:

• navigate through new programs

• to help compile data

• show physical therapy, specifically prehabilitations, benefits.

• With an increase in bundle style payments, the importance of prehabiliation and its cost savings are going to assume increased importance moving forward.1

What can we do?

• Educate patients that are candidates for elective surgery?

• Promote prehabilitation…

• To patients

• To other physical therapists/occupational therapists

• To physicians

• Continue research on benefits with larger and a wider variety of populations

Summary

• Prehabilitation has been proven to have beneficial implications on post-op success.

• While research may be limited, the focus on prehabilitation is a rapidly growing field.

• It is up to us as physical therapists to help prehabilitation reach its utmost potential

Questions?

References

1. Ries E. Prehabilitation: Better sooner and later. PT In Motion. February 2016.

2. Humphrey E, Malone D. Effectiveness of preoperative physical therapy for elective cardiac surgery. Phys Ther. 2015;95(1):160-166.

3. Hulzebos EHJ, Meeteran N, Buijs B, De Bie RA, Riviere AB, Helders P. Feasibility of preoperative inspiratory muscle training in patients undergoing coronary artery bypass surgery with a high risk of postoperative pulmonary complication: a randomized controlled pilot study. Clin Rehabil. 2006;20(1):949-959.

4. Sawatzky J, Kehler DS, Ready AE, et al. Prehabilitation program for elective coronary artery bypass graft surgery patients: a pilot randomized controlled study. Clin Rehabil. 2014;28(7): 648-657.

5. Snow R, Granata J, Ruhil A, Vogel K, McShane M, Wasielewski R. Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement. 2014;96(19):1-12.

6. Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilitation: A randomized control trial in patients undergoing colorectal resection for cancer. Anesthesilogy. 2014;121(5):937-947.

7. Valkenet K, De Port I, Dronkers JJ, et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil. 2011;25(2):99-111.