Clinical Value of Prehabilitation: A look at the science & evidence
By MEND Science Board Member, Sheraz Syed, PT, Cert MDT
In this article
What is Prehab?
Prehabilitation is defined as a process of improving the health status and functional capability of a patient prior to surgery in order to improve post-surgical outcomes. With an aging population that is at greater risk of surgical complications and slowed recovery, it has become increasingly critical to utilize multimodal strategies to further minimise surgical complications and improve recovery. This article looks at the evidence supporting prehabilitation as an approach to enhance outcomes.
Aging Population & Growth in Surgeries
The United States is undergoing a historical demographic transformation with ten thousand Americans reaching the age of 65 daily. According to the US Census bureau, this demographic — the baby boomers will more than double, from roughly 46 million today, to more than 98 million by 2060.
This staggering statistic requires policy makers and healthcare providers to reevaluate our preparedness for the unprecedented challenges to produce more efficiencies in our global health delivery systems.
An aging population will need more medical care including more invasive surgeries. Surgeries such as joint replacements, which are rising dramatically and expected to increase to roughly 2 million annually in the next few years from just a few hundred thousand just a few years ago.
Prevalence & Cost of Complications
Surgery related complications can create enormous stress and hardship for the ill person and greatly increased costs for the healthcare system. A number of studies have looked at the prevalence of surgical complications and the associated payer costs. For example, researchers at the University of Michigan Health System identified an overall complication rate of 14.5% with a mean hospital cost that was 119% higher at ~$36K for patients with complications versus $16K for those without. A study by the VA showed a 12.9% complication rate with an adjusted average increase in costs of $11.6K.
The nature of complications varies from less serious things like nausea to much more serious like infection, pain and bleeding. Prevention is the key and many complications can be linked to a person’s health status prior to surgery. For example, a number of studies have linked a person’s nutritional status to outcomes and yet upwards of 50% of patients go into surgery undernourished or malnourished.
Path of Surgery
The path to an elective surgery can contain many difficulties for both patients and clinicians. It is a lengthy, daunting process for the patient, while delays and cancellations can be extremely costly for the healthcare provider. In the US, access to care can vary depending on socioeconomic status and geography and the average wait time to see a physician is 24 days. By the time the tests are scheduled, results come in and a decision is made to perform a surgery, months can pass.
Elective surgeries during COVID-19 period of been postponed and will be rescheduled. If social distancing practices remain in place for a prolonged period of time, the wait times for patients will certainly increase.
Another looming long-term factors is the anticipated increase in the volume of surgeries and continuing shortages in hospital capacity and staff. Another factor that will contribute to increases in waiting time and an opportunity to optimize and ready the patient for surgery.
Optimizing the Patient
Deconditioning and atrophy during this time spent waiting, due to inactivity, can increase risk. Conversely, the time spent waiting presents an important opportunity to employ focused programs to address a person’s readiness and health for surgery. A prehabilitation model can help improve functional capacity to the best of a patient’s ability, improve nutritional status and help to manage the pressure and challenges of the surgery.
Does prehabilitation actually work? What’s the state of the evidence?
There is mounting clinical evidence supporting the implementation of a multi-model prehabilitation model, neatly summarized by one study as “Better in, Better out.”
The Michigan Health System, mentioned earlier, had patients participate in a three-pronged prehabilitation program including physical activity, nutrition counseling and healthy eating as well as the necessary mental preparation for the surgery. As a result, these patients spent significantly less time in the hospital and were more likely to go home after their surgery rather than to any kind of acute care or rehab facility. This study demonstrated clearly that not only were the patient’s surgical outcome improved, but also costs were reduced for both the providers and payors. Equally, the simplicity of this kind of program offers low barriers simplifying implementation across a range of practice settings from the large hospital system to medical offices.
The independent components of the multi-model rehabilitation program have also been extensively studied across populations with promising results. For example, in the case of exercise, one recent study of pre-operative physical therapy for patients having a total hip replacement saw significant improvements in pain, function and length of stay. Another study on total knee patients also showed statistically significant results in Knee and Function scores between the treatment group and the control. A systematic review and meta-analysis published in Journal of Bone and Joint Surgery suggest mild to moderate overall effects with significant improvements in TKA function, quadricep strength and length of stay and THA pain, function and length of stay.
In the case of mental preparation, studies have demonstrated important differences in patient outcomes. For example, at the University of Massachusetts Medical School, researchers saw that patients can help to determine how well they tolerate the recovery process and the degree of functional improvement they gain after surgery based on their mental approach before, during and after surgery.
Finally, the case for nutrition has been firmly established as a number of studies have looked at the high prevalence rates of malnutrition in hospital patients as well as the efficacy and safety of perioperative nutrition intervention strategies. With this in mind, MEND Repair & Recover and MEND Joint Replacement were designed to optimize healing from surgery.
Multi-model approach with nutrition, exercise, rest and relaxation
Most importantly, “this multi-model approach to prehabilitation ensures that the patient is an active participant in their surgery therefore, improving their surgical outcomes and reducing costs” says Dr. Englesbe, co-author of the Michigan Health System study. “Patient empowerment is the ‘secret sauce’ and we hope to harness it even more.”