Colorectal CNS Royal Alexandra Hospital What is Prehabilitation - - PowerPoint PPT Presentation

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

• utcomes 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 2017

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  set achievable goals  don’t get disheartened  build up gradually  track progress  make it social  enjoy yourself  try new activities  make it a habit  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:

 lower risk for

complications

 adhere to ERAS  shorter pre-op fasting

times

 good pain control  eat and drink night of

surgery

 up to sit night of surgery  walking laps day 1 post op

Usually over weight or unfit:

 laparoscopic conversion to

• pen

 risk of aspiration  reduced mobility  wound issues  low physical activity levels:

cardio respiratory complications

 failed ERAS.

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