Prehabilitation for surgical patients: a systematic review protocol

Transcription

1 Prehabilitation for surgical patients: a systematic review protocol Cara Joyce Cabilan 1 Sonia Hines 1 Judy Munday 1 1. Nursing Research Centre, Mater Health Services; Nursing Research Centre, Mater Health Services; The Queensland Centre for Evidence Based Nursing and Midwifery: A Collaborating Centre of the Joanna Briggs Institute. Corresponding Author: Cara Joyce Cabilan, cara.cabilan@mater.org.au Review question/objective The objectives of this review are to identify the impact of prehabilitation on postoperative outcomes. More specifically, the objectives are to identify: Background the impact of prehabilitation on postoperative functional status; the impact of prehabilitation on postoperative healthcare utilization (HCU) such as readmission, and/or utilization of acute rehabilitation service; the impact of prehabilitation on postoperative health-related quality of life (HRQL); and the impact of prehabilitation on postoperative pain. Physical functional decline is very common after major surgery. It can lead to loss of independence of activities of daily living (ADLs), 1 such as walking, toileting, and home care activities; increased incidence of rehabilitation unit admission and nursing home placement for the elderly, 1,2 ; longer hospital stay; development of postoperative complications; poor health-related quality of life (HRQL); and morbidity. 3 Inactivity is well documented as one of the leading causes of physical functional decline. 4-6 Inactivity has been observed amongst all hospitalized individuals 7 regardless of their present condition. 2 Increased pain and anxiety about activity due to "fear of injury" 8,p.195 after surgery are amongst the contributing factors. 8 Individuals who experience physical functional decline have the tendency to enter a continuing cycle of added inactivity due to their limited physical capacity. 9 Prolonged inactivity may inhibit normal Page 112

2 functioning of major organ systems such as the cardiovascular system, cardiopulmonary system, and musculoskeletal system. 4 Every individual s functional ability (defined as ability to perform activities of daily living) 10 is dependent on the overall functioning of the major organ systems, 11,12 therefore a decline in one or more of the organ systems also means a decline of functional ability. For example, a reduction in aerobic capacity as well as ineffective ventilation and perfusion limit the individual s capacity to perform physical tasks such as functional walking 9 ; orthostatic hypotension and decreased muscle strength put the individual at a greater risk of falls and injury. 10,11,13 Preoperative physical functional status also contributes to postoperative physical functional decline. Evidence indicates that individuals who have limited physical fitness preoperatively have higher rates of morbidity and mortality during their hospital stay. 14 Conversely, individuals who have better preoperative physical fitness experience less postoperative pain and have better physical functional status postoperatively. 15 Increasing physical activity is the most effective intervention to counteract physical functional decline after surgery. Therapeutic exercise is a form of physical activity that has been known to improve physical fitness (defined as the capacity to carry out daily functional tasks). 9 Current evidence supports exercise rehabilitation to enhance physical fitness after surgery. 8,9 Exercise rehabilitation has been used widely as a beneficial and effective intervention to re-establish the individual s postoperative functional status 15 and independence. 16 Although these outcomes can be achieved through exercise rehabilitation, it has been argued that the body deconditions faster than it recovers. 4,13,17 For example, low-intensity exercises strengthen the muscles at only 6% per week while inactivity induces 10%-15% loss of muscle strength per week. 5 Hence re-attainment of muscle strength is only possible with prolonged intensive exercise rehabilitation. 8 It would therefore be reasonable to optimize functional status through preoperative rehabilitation or prehabilitation before surgery. Prehabilitation is defined as the process of enhancing functional capacity of the individual to enable him or her to withstand the stressor of inactivity. 11,p.268 Prehabilitation aims to maintain a normal level of functionality and achieve a quicker recovery of functional status during postoperative inactivity. 11,12,18 The theory of prehabilitation originated in sports medicine where athletes train intensively before a competition to prevent injuries. 12 In a medical context, prehabilitation is employed to prevent physical functional decline. Currently prehabilitation programs do not have standardized exercise protocols. 14 For example, the types of exercises and exercise duration, intensity and frequency vary across organizations, but generic prehabilitation programs include the following exercises: 3-5 minutes of warm-up exercises, 5 minutes of aerobics up to 2-3 times per week, 8 repetitions of strengthening exercises 2 days per week, 30-second flexibility exercises, and up to 5 repetitions of functional task training 2-3 times per week. 11,p.272 It is believed that prehabilitation training is proportionate to its impact on physical functional status, therefore longer and intensive prehabilitation training maximizes functional status. 12 Moreover, the length of prehabilitation training has also not yet been standardized but the duration of training commonly ranges from four to eight weeks. 3,19 The effectiveness of prehabilitation has been increasingly explored through clinical experiments and systematic reviews especially in orthopedic settings. A systematic review 19 indicated that prehabilitation does not enhance both observed and self-reported postoperative functioning in orthopedic patients. Moreover, another systematic review 3 that included cardiac surgery patients investigated the impact of prehabilitation on length of stay (LOS) and postoperative complications. This review indicated that Page 113

3 prehabilitation in the form of inspiratory muscle training in patients awaiting cardiac or abdominal surgery reduced postoperative pulmonary complications and hospital LOS, although the authors reported there was no significant effect of strengthening exercises for joint replacement therapy on LOS and postoperative complication rate. Both reviews 3,19 offer limited data on the impact of prehabilitation on physical functional status after surgery. In addition, the impact of prehabilitation on physical functional status in other surgical populations such as cardiac, colorectal, and thoracic surgeries has not yet been explored in a systematic review. Therefore, it is necessary to conduct this systematic review. Keywords Preoperative care; Surgery; Prehabilitation; preoperative rehabilitation; presurgical rehabilitation; preoperative exercise*; preoperative training; Exercise*; exercise training Inclusion criteria Types of participants This review will include studies that include adult patients (18 years and older) undergoing surgery in hospitals with the exception of day surgery patients. Types of intervention(s)/phenomena of interest This review will include any preoperative exercise interventions identified as a part of a prehabilitation program or preoperative exercises program in a study comparing it to usual care. Studies that compare the effectiveness of different prehabilitation programs such as home-based versus hospital-based prehabilitation, or aerobic exercise versus weight training will not be included in this review. Types of outcomes This review will explore the following postoperative outcomes: Primary outcomes: physical functional performance preferably measured by a validated tool such as the Timed Up and Go Test 20, 6-Minute Walk Test 21, Barthel Index 22, or Katz ADL. 23 Secondary outcomes: healthcare utilization in terms of readmission, admission to acute rehabilitation; HRQL; and postoperative pain. Types of studies This review will include any experimental study designs including randomized controlled trials, non-randomized controlled trials, and quasi-experimental studies from 1996 to April 2013; and will only include studies published in the English language due to limited funding support for translators. The dates were chosen based on the search results data obtained from the Medline Trend application. 24 Page 114

4 Search strategy The search strategy aims incorporates both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be manually searched for additional studies. The databases will be searched for published and unpublished studies from 1996 to April The databases to be searched for published studies include Australian New Zealand Clinical Trials Registry (ANZCTR), CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Eu Clinical Trials Register, MEDLINE, and PEDro. The search for unpublished studies will include ProQuest Dissertations and Thesis, OpenGrey, and Grey Literature Network Service. Then initial search terms to be used are: Preoperative care Surgery Prehabilitation OR preoperative rehabilitation OR presurgical rehabilitation OR preoperative exercise* OR preoperative training Exercise* OR exercise training Assessment of methodological quality Prior to retrieval, all studies will be assessed for relevance against the inclusion criteria using the Verification of Study Eligibility form (Appendix I) developed by reviewers based on the recommendations of the Cochrane Collaboration. 25 Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments for experimental studies (Appendix II) from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted from papers included in the review using the JBI data extraction tool for Experimental Studies modified for this review by the authors (Appendix III). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Page 115

5 Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and standard mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Where a certain demographic is suspected to impact on the effect of the intervention, a subgroup analyses will be used to explore heterogeneity due to age, type of intervention, or type of surgery. Studies are expected to have different follow-up times. Follow-up times will be categorized into different groups, for example <3 months, <6 months, <1 year or short-term, long-term to overcome problems of analysis due to variation in measurement points. Conflicts of interest None known. Acknowledgements We would like to thank Professor Anne M Chang for her input during the development of this protocol. Page 116

6 References 1 Sager MA, Franke T, Inouye SK, Landefeld CS, Morgan TM, Rudberg MA, Siebens H, Winograd CH. Functional outcomes of acute medical illness and hospitalization in older persons. Archives of Internal Medicine.1996; 156(6): Suesada MM, Martins MA, Carvalho CRF. Effect of Short-Term Hospitalization on Functional Capacity in Patients Not Restricted to Bed. American Journal of Physical Medicine & Rehabilitation.2007; 86(6): /PHM.0b013e31805b Valkenet K, van de Port, IG, Dronkers JJ, de Vries WR, Lindeman E, Backx FJ. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil.2011;25(2): Dean E. Bedrest and deconditioning. Journal of Neurologic Physical Therapy.1993;17(1):6. 5 Dittmer DK and Teasell R. Complications of immobilization and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Canadian Family Physician.1993;39: Teasell R and Dittmer DK. Complications of immobilization and bed rest. Part 2: Other complications. Canadian Family Physician.1993;39:1440-2, Callen BL, Mahoney JE, Grieves CB, Wells TJ, Enloe M. Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatric Nursing. 2004;25(4): Block AR, Gatchel RJ, Deardorff WW, Guyer, RD. The psychology of spine surgery Wittink H, Engelbert R, Takken, T. The dangers of inactivity; exercise and inactivity physiology for the manual therapist. Manual Therapy.2011;16(3): Killewich LA. Strategies to minimize postoperative deconditioning in elderly surgical patients. J Am Coll Surg.2006; 203(5): Topp R, Ditmyer M, King K, Doherty K, Hornyak III J. The effect of bed rest and potential of prehabilitation on patients in the intensive care unit. AACN Advanced Critical Care.2002;13(2): Ditmyer MM, Topp R, Pifer, M. Prehabilitation in preparation for orthopaedic surgery. Orthopaedic Nursing.2002;21(5): Creditor, MC. Hazards of Hospitalization of the Elderly. Annals of Internal Medicine.1993; 118(3): Jack S, West M, Grocott MPW. Perioperative exercise training in elderly subjects. Best Practice & Research Clinical Anaesthesiology.2011; 25(3): Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, Phillips C, Partridge AJ, Belisle, P, Fossel AH. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis & Rheumatism.1999;42(8): Kortebein P. Rehabilitation for hospital-associated deconditioning. Am J Phys Med Rehabil.2009; 88(1): Page 117

7 17 Siebens H. Deconditioning. Geriatric rehabilitation. Boston (MA): Little Brown.1990: Carli F and Zavorsky GS. Optimizing functional exercise capacity in the elderly surgical population. Current Opinion in Clinical Nutrition & Metabolic Care.2005;8(1): Hoogeboom TJ, Oosting E, Vriezekolk JE, Veenhof C, Siemonsma PC, de Bie RA, et al. Therapeutic Validity and Effectiveness of Preoperative Exercise on Functional Recovery after Joint Replacement: A Systematic Review and Meta-Analysis. PLoS ONE.2012;7(5): e Mathias S. Nayak US, Isaacs B. Balance in elderly patients: the" get-up and go" test. Arch Phys Med Rehabil.1986;67(6): Balke B. A SIMPLE FIELD TEST FOR THE ASSESSMENT OF PHYSICAL FITNESS. REP [Report]. Civil Aeromedical Research Institute (US).1963:1. 22 Mahoney FI. Functional evaluation: the Barthel index. Maryland state medical journal.1965; 14( ): Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. JAMA: The Journal of the American Medical Association.1963; 185(12): Corlan AD. Medline trend:automated yearly statistics of PubMed results for any query [cited ]; Available from: 25 Higgins, JPT; Deeks, JJ. Chapter 7:Selecting studies and collecting data. Cochrane Handbook for Systematic Reviews of Interventions Page 118

8 APPENDIX I: Verification of study eligibility STUDY DETAILS Verification of study eligibility 1 TYPE OF STUDY any experimental study designs including randomised YES NO EXCLUDE controlled trials, non-randomised controlled trials, and quasi-experimental studies TYPE OF PARTICIPANTS YES NO EXCLUDE adult patients (18 years and older) undergoing surgery in hospitals with the exception of day surgery patients TYPE OF INTERVENTIONS YES NO EXCLUDE any preoperative exercise interventions. TYPES OF OUTCOMES YES NO EXCLUDE Primary outcomes: physical functional performance Secondary outcomes: healthcare utilization in terms of readmission, admission to acute rehabilitation, health-related quality of life; and postoperative pain LANGUAGE YES NO EXCLUDE The study is in English YEAR YES NO EXCLUDE IF YOU ANSWERED YES TO ALL, PLEASE CONTINUE TO CRITICAL APPRAISAL. REVIEWER 1. Higgins JPT, Deeks JJ (editors). Chapter 7: Selecting studies and collecting data. In: Higgins JPT, Green S (editors), Cochrane Handbook for Systematic Reviews of Interventions. Version [updated March 2011]. The Cochrane Collaboration, Available from Page 119

9 Appendix II: Appraisal instruments MAStARI Appraisal instrument Page 120

10 Appendix III: Data extraction instruments Modified MAStARI data extraction instrument Modified JBI Data Extraction Form for Experimental Studies Study: Author/s: Journal: Year: Method: Setting: Type of Participants: No. of Participants in Intervention Group No. of Participants in Intervention Group Type/s of Interventions: Intervention Control Outcome Measures Outcome Description Scale/Measure Functional status HCU (in terms of ): HRQL Postoperative Pain Page 121

11 Results (Dichotomous Data) Outcome Intervention Number/total number Control Number/total number Results (Continuous Data) Outcome Intervention Mean and SD (number) Control Mean and SD (number) Author s conclusions: Reviewer s comments: Page 122