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Benefits of Exercise Pre and Post Surgery

The effect of exercise on outcomes after surgery has been extensively studied in a number of populations. The most common populations studied are

• Those post- hip replacement
• Those post- knee replacement
• Those post- cardiac surgery
• Those post- abdominal surgery
• Other surgical groups such as colorectal, thoracic, post- cancer resection, vascular and urological

Whilst the evidence is good in general terms, unfortunately, as yet there is no clear consensus on the specifics of exercise prescription pre-surgery^[1].

Studies can be divided into those that look at the effect of interventions pre-operatively on post- surgical outcomes and those that look at the effect of different exercise interventions post- surgery.

What Are the General Benefits of Preoperative Exercise?

The evidence that if cardiorespiratory fitness (CRF) is measured preoperatively, it is predictive of complications in the postoperative period is compelling, with several studies demonstrating this across different types of surgeries^{[2][3][4][5][6][7]} The measure of CRF also offers significant advantage when compared to age alone in predicting mortality after major surgery^[5].

• CRF is a significant independent predictor of length of stay in hospital with patients older than 75
• A low CRF is associated with an average of 11 days longer in hospital and 2 days longer in critical care

Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital^[8][1]. It also exerts beneficial effects on physical fitness and postoperative outcomes measures across various surgical fields.including cardiac surgery, orthopedic surgery, abdominal surgery, thoracic surgery, vascular surgery and urologic surgery^[9]. In their scoping study, Pouwels et al (2016) conclude that more research is needed to focus on heterogeneous outcome measures, patient populations and guidelines for exercise regimes^[9].

What Are the Benefits of Preoperative Exercise in Specific Populations?

Hip Replacement

In patients undergoing this surgery, significant improvements (small to moderate effect sizes) have been observed in pain, function, and length of stay with exercise interventions preoperatively. ^[10]

Knee Replacement

A 2014 systematic review (Chesham and Shanmugham) concluded that there is minimal evidence so far supporting education and exercise interventions pre-operatively, compared with no physiotherapy or usual care. Interventions reviewed in the 10 RCTs were preoperative exercise; combined exercise and education; combined exercise and acupuncture; neuromuscular electrical stimulation; and acupuncture versus exercise. Outcomes assessed were knee strength, ambulation, and pain. Good quality research into this is ongoing^[11].

However Moyer et al (2017) in their systematic review and meta analysis found small to moderate effect sizes for pre-rehabilitation in this population. Significant improvements were made in function, quadriceps strength and length of stay.^[10]

Cardiac Surgery

A Cochrane review in 2012 found that evidence from small trials suggests that preoperative physical therapy, with an exercise component, for elective cardiac surgery patients reduces postoperative pulmonary complications and length of hospital stay. They concluded that there is a lack of evidence to effect changes to postoperative pneumothorax, or prolonged mechanical ventilation^[12].

It has been known for some years that inspiratory muscle training provided pre-operatively reduces the risk of anaesthetic complications as well as reducing post-operative complications^[13] as well as length of postoperative hospital stay and pulmonary function^[14].

Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital^[8][1].

Abdominal Surgery

O’Doherty et al (2013) in their systematic review conclude that pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital^[8][1]. A meta-analysis and systematic review done in 2016 (Moran et al) concluded that more research was needed, but ‘prehabilitation’ consisting of inspiratory muscle training, aerobic exercise, and/or resistance training can decrease postoperative complications after intra-abdominal operations.^[15]

Other

Mixed Populations

A systematic review in 2010 found that preoperative exercise therapy is effective for reducing both postoperative complication rates and length of hospital stay after cardiac or abdominal surgery^[16]. A Cochrane review in 2015 concluded that preoperative inspiratory muscle training reduced the incidence of postoperative pulmonary complications (such as actelectasis and pneumonia) and length of hospital stay compared with usual care in adults undergoing cardiac and major abdominal surgery^[17].

Colorectal Surgery

A study on patients undergoing colorectal surgery found benefits from exercise programmes pre-operatively: improved physical function, peak exercise capacity, mental health and self-perceived health^[18]

Cancer-resection surgery

A Cochrane review in 2017 found low quality evidence that preoperative exercise training may reduce some risks in those having lung resection surgery for early stage non-small cell lung cancer (NSCLC).^[19]. These were- developing postoperative pulmonary complications, duration of intercostal catheter use, a reduced postoperative length of stay and improved exercise capacity and FVC post-operatively. ^[19]

What Are the Benefits of Post-Operative Exercise?

There is clear evidence for the following surgeries:

• Spinal surgery – improved spinal mobility^[20]
• Total Hip and Knee Replacement surgery – earlier discharge^[21]
• Colorectal surgery – increased cardiovascular fitness^[22]
• Breast surgery – fewer side-effects^[23]
• In many surgeries: reduced risk of blood clots^[24]
• Cardiac surgery – inspiratory muscle training on length of postoperative hospital stay and pulmonary function ^[14]

Contraindications to Exercise Pre/Post Surgery

In addition to the absolute contraindications (see the Exercise Physiology page), specific precautions will apply depending on the surgery. The treating team ( Doctors, Nurses, Physiotherapists) will give the patient specific advice on this.

Resources

The References

1. ↑ 1.0^1.11.21.3 Doherty, AF, West, M, Jack, S and Grocott, MPW.

   ↑ Carlisle J, Swart M. (2007) ↑ Datta D, Lahiri B. (2003) ↑ Hennis PJ, Meole PM,, Grocott MP. (2011) ↑ 5.0^5.1 Snowdon CP, Prentis JM, Anderson HL et al. (2010) ↑ Wilson RJT, Davies S, Yates D, et al. (2010) ↑ West RJT, Lythgoe D, Barbara C, et al. (2014) Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study. Br J Anaesth 101:1166-72

2. ↑ ^8.08.18.2 Arthur, HM, Daniels, C et al.

   ↑ 9.0^9.1 [null Pouwels, Sjaak]; [null Hageman, David]; [null Gommans, Lindy N.M.]; [null Willigendael, Edith M.]; [null Nienhuijs, Simon W.]; [null Scheltinga, Marc R.]; [null Teijink, Joep A.W. Preoperative exercise therapy in surgical care: a scoping review. 2016.] J CLIN ANESTH 33: 476-490.

3. ↑ ^10.010.1 Moyer R, Ikert K, Long K, Marsh J. [null The Value of Preoperative Exercise and Education for Patients Undergoing Total Hip and Knee Arthroplasty: A SystematicReview and Meta-Analysis. 2017.] JBJS Rev. Dec; Vol. 5 (12), pp. e2.
4. ↑ Ross Alexander Chesham & Sivaramkumar Shanmugam (2016) Does preoperative physiotherapy improve postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty? A systematic review, Physiotherapy Theory and Practice, 33:1, 9-30, DOI: 10.1080/09593985.2016.1230660
5. ↑ Hulzebos EHJ, Smit Y, Helders PPJM, van Meeteren NLU. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD010118. DOI: 10.1002/14651858.CD010118.pub2.
6. ↑ Hulzebos, EH, Helders, PJ, et al.

   ↑ 14.0^14.1 Gomes Neto M, Martinez BP, Reis HF, Carvalho VO. Pre-and postoperative inspiratory muscle training in patients undergoing cardiac surgery: systematic review and meta-analysis. Clinical rehabilitation. 2017 Apr;31(4):454-64.

7. ↑ Moran J, Guinan E, McCormick P, larkin J, Mocklet D, Hussey J, Moriartu J, Wilson F. [null Outcomes: The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: A systematic reviewand meta-analysis]. 2016 . [null Surgery]; 160(5):1189-1201
8. ↑ Valkenet, K. et al.

   ↑ Katsura M, Kuriyama A, Takeshima T, Fukuhara S, Furukawa TA. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD010356. DOI: 10.1002/14651858.CD010356.pub2.

9. ↑ Mayo, NE et al.

   ↑ 19.0^19.1 Cavalheri V, Granger C. Preoperative exercise training for patients with non-small cell lung cancer. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD012020. DOI: 10.1002/14651858.CD012020.pub2.

10. ↑ McGregor, AH et al.
    Cochrane Review:

    ↑ Hansen, TB, Bredtoft, KH, Larson, K.

    ↑ Carli, F, et al.

    ↑ Rebecca M. Speck & Kerry S. Courneya & Louise C. Mâsse & Sue Duval & Kathryn H. Schmitz

    ↑ Partsch, Hugo MD

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