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Training for Better Surgical Outcomes: Hitting the gym before a procedure may reduce surgical risks and speed recovery.

Surgery is stressful on the body and mind. The degree of stress depends upon many factors, including the magnitude of the surgery, the preoperative condition of the patient, and the risk of postoperative complications. Of course, every surgical procedure carries with it some risk, however small. In older adults it's greater because as a group, statistically, older people have more chronic illnesses, take multiple medications, and tend to be in poorer physical condition--which negatively affects skeletal, muscular, circulatory, and respiratory systems, and thus impacts recovery from surgery.

But, even if you haven't seen the inside of a gym in long time, exercise before surgery can potentially improve your overall resilience--minimizing complications and facilitating recovery.

Prehab: Optimizing Physical Function Before Surgery

Prehabilitation (prehab) is the medical term for a pre-surgery exercise program intended to improve postsurgical outcomes, such as reducing the length of stay in the hospital, limiting the need for pain medications, and speeding overall recovery. For example, prior to knee or hip replacement, it's common for patients to spend several weeks strengthening the support muscles of the joints being replaced. According to studies, this approach helps patients recover joint function faster, potentially with less pain.

Prehab can also be helpful in other procedures, such as prior to chemotherapy, and before cardiovascular, esophagogastric, and abdominal surgeries.

A recent pilot study at UCLA and the VA of Greater Los Angeles demonstrated that older higher-risk veterans could benefit from a prehabilitation program.

"It was especially surprising to see how well it worked for one of our heart surgery patients," says Steven Castle, MD, an author of the study. "This was someone who was told he needed the surgery because he might have a heart attack. Often heart surgery patients become afraid to do anything and become deconditioned. But with supervision they can improve outcomes, if we get them moving."

Preparing Older High Risk Veterans

Gerofit is a gym that provides exercise and health promotion programs in VA hospitals nationwide (including the VA of Greater Los Angeles). It is designed for veterans age 65 and older who are at risk of functional decline because of deconditioning, chronic disease or limited mobility. The UCLA pilot study was conducted at a Gerofit gym to prepare high-risk veterans for major surgery. A total of nine patients ages 64 to 80 participated in the study. They completed an average of 18 prehab sessions. Five patients improved in two or more of the five fitness assessments completed.

At the beginning of the study, baseline fitness levels were assessed, after which patients received personalized exercise programs that required them to go to the gym one to three times a week. The fitness program included aerobic exercise, resistance training, and group exercise classes on flexibility, mobility, and balance. Patients were reassessed prior to surgery (usually after four to six weeks of exercise) and percentile ranks were compared to the baseline assessment.

Prior to surgery, patients' data were entered into a surgical risk calculator, which predicted that the group had a 15 percent chance of serious complication and 18 percent chance of any complication. The study participants beat those odds (there was only one minor complication). Seventy-seven percent of participants had a hospital length of stay that was equal to or shorter than predicted, and though the calculator estimated that 10 percent of patients would be readmitted, no patients in the study were readmitted within 30 days of discharge. Hospital read-missions are associated with inferior patient outcomes and higher costs.

Beyond Physical Preparation

In addition to physically preparing patients for surgery, the Gerofit prehab pilot study also included care coordination, helping patients understand procedures and surgical risks, and obtaining patient-centered data. The collected personal data were entered on the electronic health record so staff caring for the patient could review it and use it to facilitate relationship. For example, health-care workers learned about the patient's preferences for music, sleep/wake times, whether the patient had a pet or wanted pet therapy, and what the patient liked to be called.

Another novel aspect of the project included training patients how to use a spirometer.

"When you lie in bed your lungs collapse, which places you at risk for pneumonia," explains Dr. Castle. "Spirometers improve lung function, which is why they are at the hospital bedside after surgery. It takes some practice to use them correctly, however, so we trained our patients about a week before surgery. That has been really effective. It's a simple thing, but it worked really well."

Data collected from the Gerofit prehab pilot study enabled the researchers to obtain funding from the National Center for Patient Safety to become a Patient Safety Center of Inquiry. This distinction enables the team to expand the scope of future studies and to recruit more participants. Researchers want to reassess fitness outcomes at 30 days and 90 days after surgery to measure the trajectory of recovery.

What they learn in subsequent studies will fuel their ultimate goal--to implement a prehabilitation program for at-risk older veterans at VA health-care systems nationwide.

ASSESSING SENIOR FITNESS

The Senior Fitness Test is a scientifically validated protocol developed at Cal State Fullerton University by Roberta Rikli, PhD, and Jessie Jones, PhD. Clinicians use simple assessments to ascertain older adults' functional fitness levels. The tests include common activities, such as getting up from a chair, walking, lifting, bending, and stretching. Below is a summary of the tests.

* Arm Curl assesses upper body strength.

* Sit-to-Stand tests lower body strength (see example).

* Chair Sit and Reach measures lower body flexibility.

* Back Scratch tests upper body flexibility.

* 8-Foot Up and Go is an agility test.

* Walk Test or Step in Place is used to measure aerobic fitness.

30-Second Sit-to-Stand Chair Test

Sit in a sturdy, straight-back chair with no arm rests. Have a partner use a stopwatch (there is probably one embedded in your smart phone). When he or she says "Go," complete as many sit-and-stand repetitions as you can in 30 seconds. Don't use your hands to push off. Rise to a full stand, and then sit all the way down (no touch and rise).
30-Second Sit-to-Stand Chair Test Normal Range Scores

AGE     MEN     WOMEN

60-64   14-19   12-17
65-69   12-18   11-16
70-74   12-17   10-15
75-79   11-17   10-15
80-84   10-15    9-14
85-89    8-14    8-13
90-94    7-12    4-11
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Publication:Healthy Years
Date:Mar 1, 2019
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