Prehabilitation. Christine Alvero DPT, MBA Director of Rehab, Nutrition, Safe Patient Handling Moffitt Cancer Center

Size: px

Start display at page:

Download "Prehabilitation. Christine Alvero DPT, MBA Director of Rehab, Nutrition, Safe Patient Handling Moffitt Cancer Center"

Chloe Wilkerson
5 years ago
Views:

1 Prehabilitation Christine Alvero DPT, MBA Director of Rehab, Nutrition, Safe Patient Handling Moffitt Cancer Center

2 OVERVIEW Define prehabilitation Identify areas where prehab is used Identify components of prehab Benefits of prehab Multidisciplinary roles in prehab

3 What is Rehabilitation? A process of helping an individual achieve the highest level of function, independence, and quality of life. Physical therapy Occupational therapy Speech therapy Occurs when there are problems present

4 What is Prehabilitation? A process designed to improve a person s physical and psychological health in anticipation of an upcoming stressor. Occurs after diagnosis but before treatment Time when patients are more physically and emotionally salient Proactive versus reactive Intervention based programs to improve outcomes Prepares for stressors to include: Surgery Chemo Radiation Cardiac procedures

healthcare 5/6 top causes of death could be impacted by shift to wellness and

5 Why the shift? National strategy to change healthcare focus Away from sick care Towards healthcare 5/6 top causes of death could be impacted by shift to wellness and prevention Heart disease, cancer, stroke, COPD, diabetes Benefits of healthy individuals More productive Live independently longer Take fewer sick days

Classifications Physical Focus Early studies and prehab programs had small focus Emphasis on physical exercise and endurance programs only

6 Classifications Physical Focus Early studies and prehab programs had small focus Emphasis on physical exercise and endurance programs only Multi-modal approach Recent research (oncology focused) supports broader view Approach includes: Physical Psychological Nutrition Modifiable risk factors

7 Components Physical Focus Strengthening Endurance Balance, core Psychosocial Stress reduction Relaxation techniques Coping strategies Nutrition New nutritional needs during treatment Facts versus myths

8 Goals of Prehab LOWER Length of stay (LOS) Peri-operative complications Postoperative complications Re-admissions Physical impairments Recovery time Pain INCREASE Endurance capacity Cardiac reserve Respiratory function Quality of Life Outcomes Return-to-work Independence

9 History of Prehabilitation Began in the orthopedic population (joint replacements) Concepts used, term not 1946 military used prehab and found that 85% were able to pass recruitment exams after a 2 month prehab program Using a small window of opportunity to improve outcomes Pre-operative physical conditioning is an increasingly common strategy aimed at improving postoperative outcomes, including length of stay (LOS), functional capacity and per-operative complications.

10 Benefits Length of stay Pilot programs show 40% decrease in lung ca patients Pilot programs show 21% improvement in ambulation distance in lung ca patients Perioperative Complications Cardiac surgery patients had decreased incidence of post op atelectasis and pneumonia

11 Benefits QOL Self reports (questionnaires) show improved perception Post Operative Care 1-2 pre op sessions can decrease post op care by 29%

12 Pre-Op Usage Recent dx, surgery pending Generalized aerobic & strength program using ACSM guidelines Results: Improved cardiopulmonary fitness Improved muscle strength Aid in functional recovery post op Improved QOL 6 months later om/watch?v=dbddvj4 Om10

13 Pre-Op Usage Nutrition focus alone (GI surgeries) Use of oral supplements for 3-5 days prior to surgery Focus on certain supplements (argenine, omega 3 fatty acids, nucleotides) Beginning these supplements post op day 1 Post op results: Decreased infections (51%) Decreased complications Decreased length of stay (15%)

14 Pre-Op Usage MOFFITT EXPERIENCE Trialed with GI surgeon Expensive for patients No change in LOS noted No change in leaks No change in infection rate

15 Orthopedic Usage Prehab prior to joint replacements can decrease post op care by 30% ($1200 per patient) Education and exercise focus TKR Pre-op ROM is a predictor for outcomes Functional capacity prior Decreased pain post operatively Improved function at a more rapid pace Largest gap in function is 6 weeks post op

$patients have fractures or are at risk for fracture and are not appropriate for prehab Patients are frequently seen by PT preop for education$

16 Orthopedic Usage MOFFITT EXPERIENCE Barriers: Many of our patients are seen by ortho and then have surgery the following week Many of our patients have fractures or are at risk for fracture and are not appropriate for prehab Patients are frequently seen by PT preop for education purposes

Prehab in Oncology Lung Cancer May make patient eligible for surgery Maximize respiratory efficiency Smoking cessation if needed Results show:

17 Prehab in Oncology Lung Cancer May make patient eligible for surgery Maximize respiratory efficiency Smoking cessation if needed Results show: aerobic capacity, O2 sats post op hospital LOS, stress using progressive relaxation Often patients to not need further PT after discharge from hospital

18 Prehab in Oncology GU Cancer Pre radical prostatecomy Pelvic floor, low back, lower abdominal muscle strengthening program 4-6 weeks preop Results show: Significant difference in level of continence at 3 and 6 months post op Improved QOL scores with prehab

Prehab in Oncology Head and Neck Cancer Swallowing exercises Neck and shoulder ROM exercises Extensive education Smoking cessation if needed Results

19 Prehab in Oncology Head and Neck Cancer Swallowing exercises Neck and shoulder ROM exercises Extensive education Smoking cessation if needed Results from 2012 study Fast tracked healing/swallow function after chemoradiation Johns Hopkins Anecdotal evidence shows fewer problems with prehab in place

20 Prehab in Oncology Breast Ca UE strengthening to decrease post op frozen shoulder Stress management Psychological component of losing breast(s)

21 Prehab in Oncology Bone Marrow Transplant Exercise program pre-transplant, during, and post transplant 15% improvement in fatigue scores with exercise 28% deterioration in fatigue scores without exercise Depression scores were better with exercise

22 Prehab in Oncology MOFFITT EXPERIENCE Lung Cancer This is an area that we need to target GU Cancer Most referrals are post-op Currently investigating possibilities of offering a pre-op class H&N Cancer Currently seen by speech pre-op and pre-xrt Smoking cessation is offered

23 Prehab in Oncology MOFFITT EXPERIENCE Breast Cancer Currently investigating possibility of offering pre-op classes Currently participating in lymphedema clinic monthly Currently offering lymphedema screenings which take place pre-op and post-op BMT Exercise program begins day 1 of admission Many are seen before transplant when admitted for initial chemo Need to further explore pre-op screenings/exercise and nutrition programs

24 Standardized Programs Athletes Colleges use CSCS and Athletic Trainers Focus on muscle balance to prevent injury Established protocols which are sport dependent

25 Standardized Programs The Valley Hospital Focus is on pre-op orthopedics only using Athletic Trainers Multimodal approach Exercise Guided imagery and meditation Components Education Functional skills practice Exercise (strength and cardio) Audio programs for relaxation

26 Standardized Programs STAR New cancer dx Prevention/reduction of long term problems Protocols based upon published research Focus on early screenings and early interventions

27 Standardized Programs STAR Prehab Protocol Targeted therapy with PT, OT, or SP Smoking cessation Nutrition services Nurse navigation Integrated medicine/complementary therapy

28 Multi-Disciplinary Roles Nurse Navigator screening tools, suggesting referrals Providers recognition of early intervention Social Work anxiety, stress management Specialties smoking cessation, behavior modification

29 Multi-Disciplinary Roles PT increasing activity, building strength/endurance OT maintaining ind with ADL and IADL Speech swallowing difficulties Nutrition eating plans before, during, and after tx

30 Barriers to Prehab Challenge to patients and providers believing that patients need intervention Benefits extend past the physical into relationships, trust, etc Brief time period between dx and surgery/treatment Determining the correct setting Group classes Individual sessions

31 Barriers to Prehab Some patients believe that no problems = no needs Delay in surgery (2 weeks -8 weeks) Reimbursement varies Determining the correct providers Exercise specialists Athletic trainers Physical therapists

32 Creating a Prehab Program Clearly define prehab Designate a physician champion Address treatment delays Nurses are critical Determine your format In person Independent work for the patient

33 References Bruns, E.R., van den Heuvel, B., Buskens, C.J., Duijvendijk, Festen, S., Wassenaar, E.B., van der Zaag, E.S., Bemelman, W.A., van Munster, B.C. (2016). The effects of physical prehabilitation in elderly patients undergoing colorectal surgery: a systematic review. Colorectal Disease The Association of Coloproctology of Great Britain and Ireland, 18: O267-O277. Carli, F., Scheede-Bergdahl, C. (2015). Prehabilitation to enhance perioperative care. Anesthesiology Clin, 33; Coats, V., Maltais, F., Simard, S., et al. (2013). Feasibility and effectiveness of a home based exercise training program before lung resection surgery. Cancer Respir Journal. 20:2; Dunne, D., Jack, S., Jones, R., et al. (2016). Randomized clinical trial of prehabilitation before planned liver resection. British Journal Society. 103: Mina, D.S., Clarke, H., Ritvo, P., Leung, Y.W., Matthew, A.G., Katz, J., Trachtenberg, J., Alibhai, S.M.H. (2014). Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy, 100;

34 References Pirsch, Chris (2016). The Power of Prehabilitation. ONS Connect, The Official News Magazine of the Oncology Nursing Society. Pouwels, S., Fiddelaers, J.,Teijink, J., Woorst, J., Siebenga, J., Smeenk, F. (2015). Preoperative exercise therapy in lung surgery patients: a systematic review. Respiratory Medicine. 109; Sebio Garcia, R., Brange, M., Moolhuyzen, E., Granger, C., Denehy, L. (2016). Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interactive CardioVascular and Thoracic Surgery /icvts/ivw152. Silver, Julie (2014). Cancer prehabilitation: One step toward improved outcomes. Oncology Nurse Advisor.

35 References Tsimopoulou, I., Pasquali, S., Howard, R., et al. (2015). Psychological prehabilitation before cancer surgery: a systematic review. Annals of Surgical Oncology. 22; Valkenet, K., Trappenburg, J., Shippers, C., Wanders, L., Lemmons, L., Backx, F., Van Hillegersberg, R. (2016). Feasibility of exercise training in cancer patients scheduled for elective gastrointestinal surgery. Digestive Surgery. 33:

Not a Laughing Matter

Not a Laughing Matter How to Incorporate Pelvic Health Rehabilitation into your STAR program Nancy Corvigno MSPT PRPC Certified Star Clinician STAR Program at Griffin Hospital Survivorship Training and