Jenny McDonald Colorectal CNS Royal Alexandra Hospital
What is Prehabilitation
Athletic Definition ‘A form of strength training to prevent injuries before actual occurrence’ Surgical definition ‘ the process of enhancing the functional capacity of the individual to enable him or her withstand a stressful event’ Grocott et al Can J Anaesthesia 2015
Prehabilitation ‘‘Prehabilitation is defined as ‘’process on the cancer continuum of care that occurs between the time of diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identify impairments and provide interventions that promote physical and psychological health to reduce the incidence and /or severity of future impairments.’’ Silver et al . CA Cancer J Clin, 2013.
Evidence for promoting physical activity in cancer patients?
• Prehab is feasible in CRC patients • first RCT • 112 recruited • straight to surgery group • bike/ strengthening group vs. walking/ breathing group • no serious adverse events • walking/ breathing group increased walking capacity Carli F et al BJS 2010
‘Cohort study of 139 CRC patients multimodal prehabilitation may improve patients preoperative status, which may be associated with improved outcomes of the operation, recovery, and adherence to further cancer treatment and rehabilitation.’ Stefanus van Rooijen et al Journal Acta Oncologica 2017
Prehabilitation verses Rehabilitation
Prehab may have potential to reduce post -op complications recent meta-analysis 9 RCTs included intra-abdominal operations reduction in all types post-op complications no accompanying length of stay reduction Moran J et al Surgery 2016
Prehab is feasible in post neo adjuvant chemo DXT rectal cancer patients. • 39 recruited • reduction in fitness after NACRT • standard care versus supervised aerobic exercise (3 times weekly) • non-randomized • no serious adverse events • only intervention group returned to baseline levels prior to surgery West MA et al BJA 2015
Local evidence that low exercise levels are influencing our surgical outcome 200 elective colorectal patients 2014-15 within ERAS programme assessed lifestyle factors: physical activity , BMI, alcohol, smoking low pre operative physical activity 5 times increase in complications and 3 times longer hospital stay McLennan et al 2017
Colorectal cancer patients undergoing curative surgery 2011-2012 in GG&C 75% overweight/ obese 10.6% smokers 13.1% excess alcohol 8.5% could not climb 2 flights of stairs Over weight and physically restricted patients had poorer long term survival . Alexander et al Colorectal Disease In press 2016
Prehab is feasible in neo adjuvant colorectal cancer • the REx Trial: The feasibility of performing a walking intervention in patients undergoing treatment for rectal cancer • multi-centre RCT in West of Scotland • telephone guided walking programme during NACRT • feasibility primary aim • Mean duration of walking group 14.2 weeks • No serious adverse events Moug SJ et al 2 017
Walking Group 6 week pilot walking group October 2015 in conjunction with Community Activity Officer East Renfrewshire Council and Ms Moug Colorectal Surgeon. 19 patients invited, 10 agreed plus one partner of patient GP informed of patients participation.
Walking Group All participants given a pedometer and an activity chart On completion of programme questionnaires issued Over all positive feedback ‘happy to take part’ ‘ would have liked longer than 6 weeks’ ‘well looked after’
Addressing Barriers
Patient Body image issues, stoma , wounds , lethargy Educating Staff Financial implications Maintaining Change with Teachable Moments
Patient
involve the patient in decision making introduce lifestyle change at first consultation early referral to MacMillan “Move More” set achievable goals agreed with the patient what do they feel they can achieve: walking, swimming, local gym involve spouse and family
Physical Activity moderate intensity exercise walking/ cycling household chores gardening swimming dancing World Cancer Research Fund
Top Tips for lifestyle change think about benefits make it social set achievable goals enjoy yourself don’t get disheartened try new activities build up gradually make it a habit track progress reward yourself MacMillan Cancer Support
Body Image
refer to MacMillan “Move More” small classes for patients with cancer, with trained instructors gentle movement class / walking/ circuits class / home participants attends 12 “Move More” sessions patients are signposted to on-going local activities and supported for 12 months.
Staff
education and involvement of all members of colorectal team introduce discussion in pre operative setting ERAS programme documentation records patients activity progress
Colorectal CNS pivotal to success nurse led clinic allows regular contact with patient ideal setting to encourage and support progress easy referral system to Allied Health professionals and community partners
Financial
Walking It is free no need to buy equipment, lace up shoes and warm clothing walking: with friends, the dog join local walking group: “Paths for all”
Maintaining Change with Teachable Moments
‘An opportunity arising between a patient and a health professional during consultation to mention and encourage change.’ Lee A Scottish Cancer Prevention Network 2015 Clinician-patient interaction may be central to the creation of teachable moments for health behaviour change’. Lawson PJ, Flocke SA Patient Education Counselling 2009.
patient centred approach collaboration all members of multi disciplinary team reinforce message at each consultation close links with primary care, local and national support groups raise awareness of teachable moments with staff inclusion of lifestyle factors in follow up review
Conclusion
Rationale for Prehabilitation at local level REx study 2017 Walking group feedback MacMillan Move More Renfrewshire involvement
Prehabilitation No Prehabilitation Usually fitter patients: Usually over weight or unfit: lower risk for laparoscopic conversion to complications open adhere to ERAS risk of aspiration shorter pre-op fasting reduced mobility times wound issues good pain control low physical activity levels: eat and drink night of cardio respiratory surgery complications up to sit night of surgery failed ERAS. walking laps day 1 post op
Growing evidence suggests Prehab is feasible: • during neo adjuvant chemo/ DXT and after NACRT • straight to surgery colorectal populations • low adverse events recorded Need further high quality evidence: • optimal intervention and adherence • post-operative outcomes influenced • high-risk patients/ older adult/ frailty/ mobility • quality of life improvements/ cancer specific survival
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