Postoperative exercise should be initiated as soon as possible after surgery according to fast-track or enhanced recovery after surgery principles.
Future research should aim to include this at-risk group, evaluate perioperative high-intensity exercise interventions and conduct adequately powered trials. The successes of society in terms of education, urbanization, industrialization and innovation, not in the least in healthcare, have led to an increasing elderly population [1].
This still expanding generation of the elderly should be able to participate in society for as long as possible. Major life events like hospitalization and surgery can further compromise their functional status and activities of daily living [8]. This decrease in adaptive capacity of vulnerable elderly can be reduced by recent medical innovations and can be reduced more or possibly even prevented by therapeutic physical exercise training and maintaining physical activity in the course of an event; enabling the elderly to remain independent and live independently for a longer period of time after the event [4 , 9 , 10].
In case of elective surgery, exercise therapy could be initiated preoperatively in patients at risk for unsatisfactory surgical outcomes [11] , and be continued during the early and late postoperative period [12] until maximal recovery of physical function and societal participation is achieved.
This article provides the latest insights and evidence into pre and postoperative therapeutic exercise training to counterbalance the detrimental effects of hospitalization combined with either cardiovascular, abdominal, thoracic, or orthopedic surgery. This bed rest leads to a marked and rapid loss of lower extremity strength, power and aerobic capacity [16] , particularly in those with distinct risk profiles [17]. Surgery is known to augment this muscle wasting due to surgical stress [18] , which may even lead to more serious or even life-threatening conditions as is the case with patients undergoing surgical manipulations close to the diaphragm.
Apart from decreased inpatient physical activity and temporary sedentary behavior, the so-called, surgical stress syndrome, is a physiological contributor to functional decline.
This surgical stress response includes a wide range of physiological effects that directly impair cardiopulmonary, muscle and neurological function [19] , and contribute to an accelerated loss of lean tissue [20]. We depicted these phenomena in Fig.
Thus, a physically healthy person has the capacity to cope with physiological stress including surgical stress and to restore the body's physiological balance, a process called allostasis [2]. Depiction of possible effects of surgery and hospitalization in older patients and the role of preoperative functional status [21]. After major surgery functional status thus dips immediately and substantially, with a recovery of functional status during the postoperative period [23 , 24].
The majority of patients demonstrate an adequate surgical stress response and most patients regain prehospitalization level of functioning [2 , 23]. However, patients with a poorer preoperative physical condition might not be able to respond to the detrimental effects of hospitalization and surgery, which may hamper postoperative recovery, increasing hospitalization times and operative mortality. Knowing the detrimental impact of surgical interventions it is important to determine whether the risk of surgery is personally acceptable for each individual patient.
Therefore, health professionals need to screen and monitor for known risk factors. They need to determine physical fitness and activity factors in each patient to ascertain whether and when surgery is an appropriate intervention, and identify patients who may need additional necessary preventive care.
Functional status can be improved by high-quality therapeutic exercise, even in the very old and frail [25] and even in a short timeframe like the waiting for surgery [26]. Therapeutic exercise training should be considered to improve perioperative outcomes and functional status [24].
Risk stratification enables one to identify patients who are eligible for preoperative training, to optimize their physical status prior to elective surgery, so that they can withstand the negative consequences of surgery and minimize decrease in their perioperative functional status. The latter could be amplified with timely mobilization and, again, training after surgery an intervention.
In the following paragraphs, we discuss the merits of screening for risks, preoperative and postoperative exercise therapy in the physically frail patients in respectively cardiovascular, thorax, abdominal and major joint replacement surgery. Undergoing cardiac surgery is a significant life event and has an important psychoemotional impact on patients and their families.
Most patients report fear and anxiety and many report that uncertainty about the future is more disturbing than their chest pain. The longer a patient stays on the waiting list for cardiac surgery, the more likely they are to reduce their leisure activities, causing them to experience anxiety, reduced physical and social functioning, poorer vitality and general health [27].
In cardiac surgery, short-term mortality is frequently used as a measure of performance, whereas postoperative pulmonary complications PPCs are recognized as being a major determinant of hospital costs and quality of life after heart surgery [28].
PPCs can lead to postoperative morbidity and mortality, increased use of medical resources, length of hospital stay and healthcare costs [29]. Evidence demonstrates that preoperative physical therapy reduces PPCs i. In particular, preoperative inspiratory muscle training has positive effects in patients with a high risk of developing PPCs awaiting cardiac surgery [31] , while its effects in relatively healthy patients are likely negligible [11].
Maximal inspiratory muscle strength is a clinically relevant indicator of respiratory fitness that can be improved by training the inspiratory muscle before surgery; thus improving the preoperative respiratory condition of patients. Feedback given to patients may improve their motivation, and thus contribute further to lower the risk of PPCs. In a literature review on the different techniques used in chest physiotherapy after cardiac surgery, there is no consensus regarding the superiority of one technique over the other [33].
Regarding the recovery of function, evidence suggests that postoperative fast-track mobilization reduces the time to extubation and shortens the length of stay in the ICU after cardiac surgery [34]. As in open heart surgery, successful postoperative recovery from abdominal and thoracic surgery also depends on the ability of patients to cope with impaired cardiopulmonary and respiratory muscle function. An insufficient adaptive capacity may compromise postoperative functional recovery, potentially leading to postoperative complications, death, and protracted and sometimes permanent loss of mobility [8].
Conventional risk factors in abdominal surgery are generally related to demographics, such as age and smoking habits, and comorbidities, such as diabetes, chronic obstructive pulmonary disease and heart disease [35]. More recently, the relationship between postoperative outcomes and measures of physical fitness and activity like cardiorespiratory fitness and muscle function was demonstrated [36 , 37].
For instance, cardiorespiratory fitness is a strong independent predictor of survival after lung surgery for nonsmall cell lung cancer [38]. Moreover, in older patients undergoing abdominal surgery, physical fitness and activity are significantly and strongly associated with the postoperative outcomes such as mortality, length of stay and recovery of functional. The addition of these variables to prediction models involving conventional factors significantly improved the prediction of mortality, discharge destination and length of stay [36].
Apart from a predictive factor, physical fitness is also a modifiable and treatable factor during the preoperative phase. If there is a cause—effect relationship with the postoperative course, patients will benefit from preoperative interventions to improve their physical fitness. Evidence is accumulating that inspiratory muscle training decreases the incidence of PPCs after abdominal and thoracic surgery [39].
Therefore, in order to determine the effectiveness of this intervention, it is recommended to include patients at high risk for postoperative complications. Personalized and well monitored and titrated high-intensity training is necessary to achieve improvements, given the often short time available before surgery [45].
Studies investigating early physical training demonstrated improvements on physical fitness and on disability measures at discharge and a reduction in the number of transfers to a nursing home [12 , 46]. Physical training is often part of a multi parallel or inter integrated disciplinary rehabilitation approach, known under the names as fast-track or enhanced recovery after surgery. These programs also include dietary guidance and adequate analgesia to enable physical activity.
The merits of these programs have been proven, demonstrating a decrease in the length of hospital stay and postoperative complications [47]. Elective major joint replacement is generally advocated as a highly successful operation for relieving symptoms in people suffering from hip or knee osteoarthritis. Such claims are often made from a medical and biomechanical perspective i. Hawker et al. Pre and postoperative exercise therapy might augment the postoperative functional recovery of patients undergoing total hip replacement THR or total knee replacement TKR.
To date, several reviews are available that systematically synthesized the literature on preoperative exercise in individuals awaiting major joint replacement; concluding that preoperative exercise has little worth on postoperative outcomes [49]. The inclusion of the fit elderly distorts results, as patients of higher age with comorbidities are the ones with a significant risk of disappointing surgery outcomes [48].
Therefore to understand and appreciate the true potential of preoperative therapeutic exercise, we need to evaluate studies that did include individuals with a higher risk for disappointing outcomes after surgery. To date two studies are available that investigated the merits of preoperative exercise in patients with an increased risk for delayed functional recovery or increased length of hospital stay in a typical Western care setting [52 , 53]. Topp et al.
They found that after 3 months the functional performance level and strength of the people in the preoperative exercise group was better restored than in the control group. Hansen et al. The previous study suggests that an adequate selection of high-risk patients before surgery is essential for the success of preoperative exercise in THR and TKR. Considering that preoperative exercise is fairly cheap, well tolerated and clinically relevant, it needs to be considered an intervention of choice in aiding the recovery after total joint replacement [54].
However, the effectiveness of postdischarge exercise is still under debate [55 , 56]. The latter is confirmed by the study of Pozzi et al. To do so, supervision by a trained physical therapist is essential. Low intensity, unsupervised exercise should be avoided. Instead, research should identify which aspects of preventive exercise training programmes [strength, an aerobic capacity or functional mobility] are appropriate and tolerable for individual or specific groups of patients [50].
High-intensity training is necessary to achieve improvements given the often short time available before surgery. Fortunately, frail and older patients can tolerate the programs [25]. There is high quality evidence that perioperative exercise in patients scheduled for cardiac surgery is well tolerated and effective. Moreover, there is circumstantial evidence suggesting the same for thorax, abdominal and major joint replacement surgery provided that this is offered to the high-risk patients.
Implementation should be guided by proper monitoring of the effects in the real-life context of the care system. Papers of particular interest, published within the annual period of review, have been highlighted as:. National Center for Biotechnology Information , U. Current Opinion in Anaesthesiology. Curr Opin Anaesthesiol. Published online Mar 6. Thomas J.
Hoogeboom , a Jaap J. Dronkers , b Erik H. Hulzebos , c and Nico L. Jaap J. Erik H. Nico L. Author information Copyright and License information Disclaimer. Correspondence to Thomas J.
The work cannot be changed in any way or used commercially. This article has been cited by other articles in PMC. Abstract Purpose of review Advances in medical care have led to an increasing elderly population. Recent findings There is high quality evidence that preoperative exercise in patients scheduled for cardiovascular surgery is well tolerated and effective. Keywords: exercise therapy, functional status, postoperative, preoperative, surgery. VT will be determined through the modified v-slope method, which determines the point of the change in slope of the relationship of VO 2 above which VCO 2 increases faster than VO 2 without hyperinflation [ 19 ].
These widely used objective measures of postoperative complications, overcome the known issues with standardising the definition of postoperative complications [ 4 ]. In addition, hospital and critical care LOS and postoperative mortality will be recorded.
The Clavien-Dindo classification score measures the most severe complication that occurs in the postoperative period. The tool is widely used due to its simplicity and reproducibility, its correlation with LOS, and the degrees of severity of complications also correlate with the perceptions of severity of medical staff and patients [ 25 ].
The POMS is a nine-domain tool that prospectively describes and records in-hospital postoperative complications following major surgery [ 26 ]. The CCI provides a summary of overall morbidity including the type, number and severity of each complication experienced during the postoperative period [ 25 ]. When compared to the Clavien-Dindo Classification the CCI demonstrates a superior ability to discriminate between patients with a different number and severity of complications.
The training stimulus associated with HIIT may lead to important improvements in secondary measures of physical performance including pulmonary function, ventilatory and peripheral muscle strength and functional capacity [ 27 ], which may in turn positively impact postoperative outcome. The following measures will be performed at Dx, T0 and T1. Self-reported functional recovery will be evaluated on POD Pulmonary function will be measured as the first step of the CPET and analysed as a secondary outcome.
Maximal inspiratory pressure PImax provides a non-invasive, simple measure of inspiratory muscle strength, particularly the diaphragm.
PImax will measured using a PowerBreathe K-series portable respiratory pressure metre. Patients will be measured at residual volume during a forceful inspiratory manoeuvre while resting in a seated position. All measures will be performed in triplicate with the best measure taken for data entry.
Preliminary analysis of the PHIIT trial participants has demonstrated a post-intervention increase in peak power output, suggesting some improvement in lower limb strength with the cycle ergometer HIIT protocol. In the proposed study, quadriceps muscle strength will be measured by 1 repetition maximum 1RM using a horizontal leg extension. The 1RM is defined as the highest load that can be lifted through full range of movement at one time.
A maximum of 5 trials to determine 1RM will be completed with a rest period of 2 minutes between each trial. This measure combines the results of gait speed, chair stand and balance tests.
A score lower than 10 indicates one or more mobility limitations. The IPAQ long form comprises four activity domains work, leisure, transportation and household which evaluates activity in metabolic equivalent MET -hours per week over the previous 7 days.
The questionnaire also quantifies average weekend and weekday sitting time. Data collected on POD30 will be collected via a telephone call with the participant. Patient perceived physical recovery at POD30 will be self-assessed using standardised classifications. The core questionnaire, the QLQ-C30 has been used in a wide range of cancer clinical trials [ 29 ]. It is supplemented by disease specific modules. Categories include functional scales, global health status and QOL scale, in addition to several single-item symptom measures.
If costs of hospital care are lower in the intervention group, and if QOL scores are better post-intervention, then the intervention will dominate ie, lower costs of hospital care, including the cost of the exercise programme, and better QOL of patients and no cost-effectiveness ratios can be calculated. Otherwise it will be possible to estimate the additional cost of any measured improvement in QOL post-intervention.
Similarly, if costs of care are lower in the intervention group but QOL is also lower, it will be possible to estimate cost-effectiveness ratios for this change. Interviews will be held with approximately 20 participants or until data saturation is reached. Compliance to the aerobic component will be documented by the achieved heart rates on the Polar Heart Rate Monitors, and the duration of aerobic exercise, and for resistance training, the weight, number of sets, and repetitions will be recorded.
During the supervised sessions compliance will be monitored by the supervising physiotherapist, whilst during homebased sessions participants will record their compliance in a home exercise diary.
These additional exercise adherence variables will include; permanent treatment discontinuation, treatment interruption, dose modification, early session termination, and pre-treatment intensity modification. Adherence variables are described fully in Table 1.
The costing of hospital stays, and interventions will be carried out based on activity data from hospital records, with unit costs taken from the standard estimated costs from the Healthcare Pricing Office. Programme implementation costs will be analysed in consideration of clinician salaries, overheads and equipment costs. Formal care costs will be extracted from medical charts and from the institutional database in consideration of preoperative characteristics, surgery type and postoperative recovery including complications.
Since the participants in the study are randomised to each arm, the comparison of costs of hospital stays will be reported as differences and the normal tests of significance. It is also important to assess if the intervention has longer term effects beyond hospital discharge. The destination at discharge, use of community health services from the time of discharge to the follow up outpatient appointment and EQ5D5L scores at the time of the follow up appointment will be collected for each participant.
This will allow the measurement of any effects of the intervention on the feasibility of the patient going home directly from hospital, and any difference in the need for community health services. The EQ5D5L scores at outpatient follow up will allow an assessment if any short-term difference persists and will assist in modelling the likely medium-term effect of the intervention on costs and QOL. Prior to baseline testing, all participants will require written medical approval confirming their suitability for participation.
All adverse events will be recorded, and serious adverse events will be reported to the research ethics committees. The primary response is the change in VO 2 peak from baseline T0 to post-intervention T1. It is anticipated that the active control group will not experience a change in fitness during this 2 week time period [ 16 ]. Moderate intensity exercise interventions have not been shown to significantly change preoperative aerobic capacity and functional capacity of patients due to undergo elective surgery [ 31 ].
A comparison of patient characteristics at baseline will be carried out for each arm. Summary statistics for continuous variables means and standard deviations or median and ranges as appropriate and categorical variables counts and proportions will be presented. Graphical summaries boxplots, case profile plots, labelled scattered plots will be used to compare the distribution s of each response variable and for patient characteristics between the arms.
A linear mixed model will be used to model the longitudinal change in the primary response between the groups, allowing for missing data under the assumption that data are missing at random and allowing for within subject correlations in the repeated measures across time. The model will adjust for the baseline response variable and other covariates as necessary. Data collection will take a semi-structured approach individual interviews following the intervention.
The discussion guide for the interviews will explore topics such as: the impact of the intervention on health, well-being, and activities of daily living, facilitators and barriers to preoperative exercise, and recommendations for future implementation of the programme.
Interviews will be digitally audio-recorded and transcribed verbatim for data analysis. A qualitative descriptive approach [ 32 ] will be taken to the analysis, with the aim of providing a substantial description of what the participants said, without drawing deep implications from the data.
A team of researchers will analyse all transcripts following an agreed process using nVivo 12 QSR International, Australia. Data monitoring will be provided by the trial steering committee, including overall project supervision, progress monitoring, advice on scientific credibility and ensuring the integrity and appropriate running of the project. The research team will make quarterly reports to the trial steering committee. Aggregate study results will be presented to participants and their families at an education symposium upon study completion.
Anonymised data will be made available on an open access repository. We will seek feedback on participant documentation, particularly the participant information leaflet and consent form, to ensure readability and clarity. In addition, a patient representative will be invited to speak at the education symposium in the final year of the project.
The PRE-HIIT RCT will examine the influence of pre-operative high intensity interval training programme on physiological outcomes and postoperative recovery and, through evaluation of health economics, the impact of the programme on hospital costs. There is a need for clinically feasible interventions that attenuate the impact of multiple therapeutic interventions, most particularly major oncological operations, and accelerate patient recovery.
Prehabilitation is likely to have its greatest impact in cancer populations who experience the greatest treatment morbidity, such as oesophageal and lung cancer. There is growing interest in the value of exercise prehabilitation to increase preoperative fitness above critical values in oncologic resections [ 15 ]. HIIT exercise training stimulates great improvements in cardiopulmonary fitness over short periods compared to continuous aerobic training and therefore may be ideally suited to exercise prehabilitation.
This mode of exercise prehabilitation may attenuate postoperative risk and improve postoperative recovery, thus improving patient quality of life and having considerable economic benefits for the healthcare system. Given the high unit cost of hospital days and procedures, the direct effects of the intervention on hospital costs and any evidence of differences in QOL which will be explored by the PRE-HIIT trial are of considerable interest.
The results of this study will inform current perioperative practice and will provide direction for future research.
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