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Fig. 6.2 Case 1 summary timeline
L. Edbrooke etal.
of 30/58 indicated reduced exercise capacity. At the prehabilitation consultation the perioperative physician (anaesthetist) initiated referrals to the allied health preha­bilitation team and for a cardiopulmonary exercise test (CPET) to further assess his exercise capacity and risk of postoperative complications. The prehabilitation team provide holistic and co-ordinated care with regular multidisciplinary team meetings including clinicians from anaesthetics, surgery, nursing and allied health. The aim of these meetings is to ensure consistent messaging, common goals and a clear understanding of progress.
Allied health screening and initial assessment ndings, outlined in detail in Table6.2, included reduced physical function and adequate nutrition. Mr. D ini­tially met criteria for referral to exercise and nutrition services, due to the high­risk surgical procedure planned with neoadjuvant treatment. Using the International Physical Activity Questionnaire —Short Form (IPAQ-SF), Mr. D self-reported being physically inactive and highly sedentary since retiring. He struggled to set goals and engage in prehabilitation treatment sessions during this period. Mr. D reported the main barriers to participation were nausea and dizzi­ness, which were side effects of the neoadjuvant treatment he was receiving. He was offered daily, supervised, centre- based exercise sessions (aerobic and resis­tance training), but often failed to attend scheduled exercise and nutrition appointments.
Mr. D performed his initial CPET a 2weeks later during neoadjuvant treatment. Due to his low body weight CPET VO
and AT were not reective of his true
2 peak
exercise capacity (Table6.2). After adjusting for body surface area, CPET perfor­mance indicated Mr. D was at high risk of postoperative pulmonary complications. Following completion of neoadjuvant treatment repeat CPET ndings indicated that Mr. D was not t for surgery, he was deconditioned and was losing weight. The
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Table 6.2
Mr. D’s screening and assessment ndings, treatment, and progress
Screening Measures and Findings
Exercise AKPS 70/100 (cares for self, unable to carry on normal activity or do active
work); IPAQ-SF—not meeting PA guidelines
Nutrition
1/5 (not at risk of malnutrition)
(MST) Psychology
(PHQ-4)
Baseline
2/12 (not experiencing anxiety or depression)
Post-neoadjuvant Rx
7/12 (moderate), clinical notes documented anxiety
Assessment measures and ndings
CPET During-neoadjuvant Rx (initial)
VO
=18.3mL/kg/min
2 peak
AT=14.7mL/kg/min VO
/ BSA=585mL (normative
2 peak
750)
Exercise During-neoadjuvant Rx (initial)
6MWT (metres)=447 30s STS (chair stands)=16 handgrip strength (kg)=25 (right),
Post-prehab
VO
=20.3mL/kg/min
2 peak
AT=14.0mL/kg/min VO
/ BSA=643mL (normative
2 peak
750)
Post-prehab
6MWT (metres)=560 30s STS (chair stands)=19 handgrip strength (kg)=unchanged
20 (left)
Nutrition During-neoadjuvant Rx (initial)
PG-SGA=6A (adequately nourished) Weight (kg)=52.0
Post-neoadjuvant Rx
PG-SGA=10A Weight (kg)=46.0
Post-prehab
PG-SGA=6A weight
(kg)=51.5 Nutrition=poor appetite, mild nausea, mild oesophagitis
Psychology Post-neoadjuvant Rx (initial)
FTA due to inpatient admission 1/52 later: PHQ-9=9/27 (mild)
Post-prehab
PHQ-9=3/27 (minimal)
GAD-7=7/21 (mild) GAD-7=14/21 (moderate). Fear of dying, anxious aboutsurgical risks and potential forprolonged recovery. Sleep improved with medication.
Treatment and progress Exercise 2months post-neoadjuvant Rx
(initial)
F: 2–3/week, supervised I: Moderate-intensity (aerobic: 70% Watts of initial CPET AT; resistance: 80% of 10RM, 8 reps×2 sets) T: Aerobic: 30s intervals (stationary cycle); resistance: UL/LL free weights, body weight Aerobic:2×5 min;resistance:10min Home walking: x2/week, 10min,
Progression (1-month later)
F: 2–3/week, supervised
I: High-intensity (aerobic: 85% Watts
most recent CPET AT; resistance: 80%
most recent 10RM, 12 reps×3 sets)
T: Aerobic: 90s interval (stationary
cycle); resistance:
UL/LL free weight, body weight
Aerobic: 3×5 min;resist.:10min
Home walking: x4/week, 20min,
moderate (Borg 4/10) moderate (Borg 3/10)
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Table 6.2 (continued)
Nutrition 2months post-neoadjuvant Rx
(initial)
Education protein/ energy needs, nutrition impact symptoms (dietary modications and medication)
Psychology Five sessions over 3.5months
Relaxation training (breathing exercises) Activating supports and identication of barriers to this Behavioural activation and avoidance of distress; goal setting; Discussionregarding physical barriers to exercise (pain and continence) Education about exercise (that it will increase fatigue) Anxiety management and psycho-education in context of fears Education regarding further support postoperatively if required
AKPS Australia-modied Karnofsky performance status, AT anaerobic threshold, BSA body sur­face area, CPET cardiopulmonary exercise test, Exercise (F frequency, I intensity, T type, T time); FTA failed to attend, GAD-7 generalised anxiety disorder-7 item, IPAQ-SF international physical activity questionnaire-short form, LL lower limb, NIS nutritionimpact symptoms, NGT gastric tube, PG-SGA patient generated-subjective global assessment, PHQ-9 patient health ques­tionnaire- 9 item, RM repetition maximum, Rx treatment, UL upper limb, VO uptake, 6MWT 6-min walk test, 30s STS 30-s sit-to-stand
Progress
Fortnightly/weekly reviews (increased
frequency as NIS worsened)—Oral
supplements, NGT feeding for poor
intake
L. Edbrooke etal.
naso-
peak oxygen
2 peak
perioperative physician recommended a further 6weeks of prehabilitation aiming to improve his nutritional and functional status. Mr. D was referred and commenced treatment with the prehabilitation psychologist and commenced engaging during nutrition sessions. With care from the multidisciplinary team Mr. D’s symptoms improved. Over several weeks of treatment and with regular communication at mul­tidisciplinary team meetings, the psychologist was able to unpack motivational issues and highlight the burden his symptoms were having. He worked with the dietician on strategies to improve his nausea. As his symptom burden lessened, Mr. D was able to attend the centre for supervised face to face exercise three times a week. Following prehabilitation his weight had increased and CPET and 6MWT results indicated signicant and clinically important improvements in his exercise capacity (Table6.2).
Three-months post diagnosis Mr. D underwent the planned surgery (oesophagec­tomy), his postoperative course was uncomplicated and followed the standard ERAS postoperative pathway which included enteral feeding via a jejunostomy on days 3–6 and respiratory physiotherapy and early mobilisation which commenced on the day of surgery [53]. Mr. D was discharged home after 7days. Follow-up, short-term outpatient review with the dietician was planned due to expected swal­lowing difculties associated with the surgical procedure.
Case 2—Ms. S
Ms. S is a 75-year-old woman who works part time in human resources for an edu­cational organisation. Her past medical history includes osteoporosis, hypertension, and removal of bilateral cataracts. Although living alone, Ms. S has a supportive partner. She has not been active or able to eat well over the last few months due to fatigue, more frequent bowel, diarrhoea-like movements (causing anal discomfort)
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Fig. 6.3 Case 2 summary timeline
93
and abdominal discomfort, but prior to that she enjoyed bushwalking and cycling and did this for 30min 2–3 times per week.
Ms. S was referred for investigation due to her symptoms and an MRI scan and biopsy provided a diagnosis of stage II rectal cancer. Following surgical consulta­tion and discussion at a multidisciplinary team meeting, Ms. S’s treatment plan was to commence neoadjuvant chemotherapy, uorouracil, with radiation prior to abdominoperineal resection (APR). Ms. S was referred to the allied health team for prehabilitation. Her prehabilitation timeline is shown in Fig.6.3. Ms. S was screened 3days after referral and booked in for allied health assessments the following week. Due to the high-risk procedure, Ms. S was eligible to be assessed by exercise, nutri­tion, and psychology disciplines. She declined a psychology assessment stating that she felt she was managing well currently and had a good network of social supports. Details of screening and assessment are provided in Table6.3. During screening her clinician-rated Clinical Frailty Scale (CFS) score was 3 ‘managing well’. This is dened as patients whose medical problems are well controlled but who are not active regularly beyond walking to complete daily tasks.
Ms. S’s nutrition assessment indicated that she was at risk of malnutrition and she was given education regarding how to achieve a diet that was high in protein and energy. Given her previous enjoyment of cycling, the goal she set during her initial exercise assessment was to commence unsupervised aerobic training on her home exercise bike. She was also prescribed resistance training exercises to maintain her
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Table 6.3
Ms. S’s screening and assessment ndings, treatment, and progress
Screening Measures and Findings
[Exercise] AKPS 90/100; DASI 34.95 Nutrition MST=3/5 (at risk malnutrition)
Weight 65kg; weight loss 5kg (7.1%) previous 6/12months
Psychology PHQ-4 baseline=0/12
Assessment measures and ndings
During-neoadjuvant Rx Post-prehab
CPET VO
=19.8mL/kg/min
2 peak
AT=12.5mL/kg/min VO
/ BSA=731mL
2 peak
Exercise 6MWT (metres)=530
30s STS (chair stands)=14 handgrip (kg)=18 (right), 18 (left); CFS =3 IPAQ—Below PA guidelines
Nutrition PG-SGA=15B (malnourished) poor
appetite; weight=65.0kg
VO
=19.8mL/kg/min
2 peak
AT=16.0mLl/kg/min VO
/BSA=743mL
2 peak
6MWT (metres)=567 30s STS (chair stands)=16 handgrip (kg)=20 (right), 18(left); CFS =1 IPAQ—Meeting PA guidelines
PG-SGA=7A (adequate) Poor appetite, mild nausea, oesophagitis; weight=59.0
Treatment and progress
Exercise Initial (during neoadjuvant Rx)
Education (effects exercise, treatment vs. exercise capacity, safe exercising) Goal setting Home exercise: Aerobic—Stationary cycle, walking 20 min×7days; moderate intensity (Borg 3) Resistance×3days/week (step up, squats,
Progression
Fortnightly telehealth reviews— Compliant with home walking, minimal bike or RT initially, then improved. Was educated, self­progressed resistance exercises maintaining Borg 3–4 (3 sets×12
reps with 8kg on discharge) calf raise, bicep curl, shoulder raise, kickback); from 10RM, 2 sets×10 reps with 4kg; Borg 3
Nutrition Single in-person session following initial assessment, set goals to muscle mass/
weight maintenance –high energy-high protein diet, and oral nutrition supplements pre-op
Abbreviations: AKPS Australia-modied Karnofsky Performance Status, AT anaerobic threshold,
SA body surface area, CPET cardiopulmonary exercise test, DASI duke activity status index, IPAQ-SF international physical activity questionnaire-short form, PG-SGA
patient generated-
subjective global assessment, RM repetition maximum, RT resistance training, Rx treatment, VO
peak oxygen uptake, 6MWT 6-min walk test; 30s STS 30-s sit-to-stand
peak
2
skeletal muscle mass and a home-walking programme. Ms. S was reviewed by her physiotherapist fortnightly via telehealth. She completed three cycles of chemo­therapy prior to surgery and reported moderate levels of fatigue and mild nausea as the main side effects. She found walking outside was the most effective strategy to control her symptoms. Because of this, she was initially adherent only to her pre­scribed walking programme. Some discomfort associated with sitting on the exer­cise bike and boredom with resistance training impacted her adherence. Behaviour change techniques utilised during telehealth sessions included action planning, bar­rier identication/problem solving, and social support [54]. The physiotherapist
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provided further education to Ms. S regarding the importance of resistance training, not only for maintaining function, but also for her ability to recover post-surgery and re-commence chemotherapy. Ms. S’s partner modied her exercise bike seat to improve comfort. With greater adherence, Ms. S began to notice improvements in her strength which made her more motivated to continue her exercise sessions.
Eight weeks after referral Ms. S was admitted to hospital and underwent an abdominoperineal resection. Her postoperative management followed ERAS guide­lines including respiratory physiotherapy and early mobilisation and return to a high-protein diet (supported with oral nutrition supplements) within 24h of surgery [55, 56]. She was discharged home after 8days, returning for a further three cycles of chemotherapy. Since discharge, she has continued with her strength training exercises twice a week and has gradually built up her home walking programme with support from her partner. She is scheduled to commence an outpatient rehabili­tation programme in 2weeks’ time to help her return to her previous level of tness and commence a graduated return to work plan.
Conclusions andFuture Directions
Despite the growing research outputs and gradual implementation of prehabilitation in abdominal surgery, there are many different avenues of research still needed to improve efcacy and implementation to inuence patient outcomes. Prehabilitation guidelines are required in the next 2years to standardise interventions and outcome variables further. Figure6.4 summarises areas for future research in prehabilitation for colorectal and other surgical patient populations. There are many groups inter­nationally currently working on these research priorities.
Acknowledgements The authors would like to thank Dr. Christina Prickett, Ms. Jess Crowe and Ms. Anna Beaumont for their assistance with the development of the rst case study.
Fig. 6.4 Diagrammatic representation of the areas for future research in prehabilitation
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