Development and external validation of preoperative clinical prediction models for postoperative outcomes including preoperative aerobic fitness in patients approaching elective colorectal cancer surgery.

INTRODUCTION: Preoperative aerobic fitness is associated with postoperative outcomes after elective colorectal cancer (CRC) surgery. This study aimed to develop and externally validate two clinical prediction models incorporating a practical test to assess preoperative aerobic fitness to distinguish between patients with and without an increased risk for 1) postoperative complications and 2) a prolonged time to in-hospital recovery of physical functioning after elective colorectal cancer (CRC) surgery. MATERIALS AND METHODS: Models were developed using prospective data from 256 patients and externally validated using prospective data of 291 patients. Postoperative complications were classified according to Clavien-Dindo. The modified Iowa level of assistance scale (mILAS) was used to determine time to postoperative in-hospital physical recovery. Aerobic fitness, age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, neoadjuvant treatment, surgical approach, tumour location, and preoperative haemoglobin level were potential predictors. Areas under the curve (AUC), calibration plots, and Hosmer-Lemeshow tests evaluated predictive performance. RESULTS: Aerobic fitness, sex, age, ASA, tumour location, and surgical approach were included in the final models. External validation of the model for complications and postoperative recovery presented moderate to fair discrimination (AUC 0.666 (0.598-0.733) and 0.722 (0.651-0.794), respectively) and good calibration. High sensitivity and high negative predictive values were observed in the lower predicted risk categories (<40 %). CONCLUSION: Both models identify patients with and without an increased risk of complications or a prolonged time to in-hospital physical recovery. They might be used for improving patient-tailored preoperative risk assessment and targeted and cost-effective application of prehabilitation interventions.

Identification of subgroups of patients with oesophageal cancer based on exercise intensity during prehabilitation.

PURPOSE: To identify subgroups of patients with oesophageal cancer based on exercise intensity during prehabilitation, and to investigate whether training outcomes varied between subgroups. MATERIALS AND METHODS: Data from a multicentre cohort study were used, involving participants following prehabilitation before oesophagectomy. Hierarchical cluster analysis was performed using four cluster variables (intensity of aerobic exercise, the Borg score during resistance exercise, intensity of physical activity, and degree of fatigue). Aerobic capacity and muscle strength were estimated before and after prehabilitation. RESULTS: In 64 participants, three clusters were identified based on exercise intensity. Cluster 1 (n = 23) was characterised by fatigue and physical inactivity, cluster 2 (n = 9) by a low training capacity, despite high physical activity levels, and cluster 3 (n = 32) by a high training capacity. Cluster 1 showed the greatest improvement in aerobic capacity (p = 0.37) and hand grip strength (p = 0.03) during prehabilitation compared with other clusters. CONCLUSIONS: This cluster analysis identified three subgroups with distinct patterns in exercise intensity during prehabilitation. Participants who were physically fit were able to train at high intensity. Fatigued participants trained at lower intensity but showed the greatest improvement. A small group of participants, despite being physically active, had a low training capacity and could be considered frail.

Implications for rehabilitationPatients with oesophageal cancer show different patterns of exercise intensity during prehabilitation, resulting in three distinct subgroups.Patients with a good level of physical fitness are able to train at high intensity and may require less intensive supervision during the programme.Fatigued patients are able to perform the training programme, having more room for improvement.A small group of frail patients seem to be at risk for overtraining and may require an adjusted training intensity.

The Association Between Preoperative Inspiratory Muscle Training Variables and Postoperative Pulmonary Complications in Subjects With Esophageal Cancer.

BACKGROUND: Preoperative inspiratory muscle training (IMT) is frequently used in patients waiting for major surgery to improve respiratory muscle function and to reduce the risk of postoperative pulmonary complications (PPCs). Currently, the mechanism of action of IMT in reducing PPCs is still unclear. Therefore, we investigated the associations between preoperative IMT variables and the occurrence of PPCs in patients with esophageal cancer. METHODS: A multi-center cohort study was conducted in subjects scheduled for esophagectomy, who followed IMT as part of a prehabilitation program. IMT variables included maximum inspiratory pressure (PImax) before and after IMT and IMT intensity variables including training load, frequency, and duration. Associations between PImax and IMT intensity variables and PPCs were analyzed using independent samples t tests and logistic regression analyses, corrected for age and pulmonary comorbidities and stratified for the occurrence of anastomotic leakages. RESULTS: Eighty-seven subjects were included (69 males; mean age 66.7 ± 7.3 y). A higher PImax (odds ratio 1.016, P = .07) or increase in PImax during IMT (odds ratio 1.020, P = .066) was not associated with a reduced risk of PPCs after esophagectomy. Intensity variables of IMT were also not associated (P ranging from .16 to .95) with PPCs after esophagectomy. Analyses stratified for the occurrence of anastomotic leakages showed no associations between IMT variables and PPCs. CONCLUSIONS: This study shows that an improvement in preoperative inspiratory muscle strength during IMT and training intensity of IMT were not associated with a reduced risk on PPCs after esophagectomy. Further research is needed to investigate other possible factors explaining the mechanism of action of preoperative IMT in patients undergoing major surgery, such as the awareness of patients related to respiratory muscle function and a diaphragmatic breathing pattern.

Effects of exercise during chemo- or radiotherapy on immune markers - a systematic review.

Introduction Patients with cancer receiving radio- or chemotherapy undergo many immunological stressors. Chronic regular exercise was shown to positively influence the immune system in several populations, while exercise overload may have negative effects. Exercise is currently recommended for all patients with cancer. However, knowledge regarding the effects of exercise on immune markers in patients undergoing chemo- or radiotherapy is limited. The aim of this study is to systematically review the effects of moderate and high intensity exercise interventions in patients with cancer during chemotherapy or radiotherapy, on immune markers. Methods For this review, a search was performed in PubMed and EMBASE, until March 2023. Methodological quality was assessed with the Pedro tool and best-evidence syntheses were performed both per immune marker and for the inflammatory profile. Results Methodological quality of the 15 included articles was rated fair to good. The majority of markers was unaltered, but observed effects included a suppressive effect of exercise during radiotherapy on some pro-inflammatory markers, a preserving effect of exercise during chemotherapy on NK cell degranulation and cytotoxicity, a protective effect on the decrease in thrombocytes during chemotherapy, and a positive effect of exercise during chemotherapy on IgA. Discussion/conclusion Although exercise only influenced a few markers, the results are promising. Exercise did not negatively influence immune markers, and some were positively affected since suppressed inflammation might have positive clinical implications. For future research, consensus is needed regarding a set of markers that are most responsive to exercise. Next, differential effects of training types and intensities on these markers should be further investigated, as well as their clinical implications.

Physical activity monitoring during hospital stay: a validation study.

PURPOSE: The primary aim of this study was to investigate the concurrent validity of the PAM AM400 accelerometer for measuring physical activity in usual care in hospitalized patients by comparing it with the ActiGraph wGT3X-BT accelerometer. MATERIALS AND METHODS: This was a prospective single centre observational study performed at the University Medical Centre Utrecht in The Netherlands. Patients admitted to different clinical wards were included. Intraclass Correlation Coefficients (ICCs) were computed using a two-way mixed model with random subjects. Additionally, Bland-Altman plots were made to visualize the level of agreement of the PAM with the ActiGraph. To test for proportional bias, a regression analysis was performed. RESULTS: In total 17 patients from different clinical wards were included in the analyses. The level of agreement between the PAM and ActiGraph was found strong with an ICC of 0.955. The Bland-Altman analyses showed a mean difference of 1.12 min between the two accelerometers and no proportional bias (p = 0.511). CONCLUSIONS: The PAM is a suitable movement sensor to validly measure the active minutes of hospitalized patients. Implementation of this device in daily care might be helpful to change the immobility culture in hospitals.IMPLICATIONS FOR REHABILITATIONPhysical inactivity is common during hospital admission and the main cause of loss of muscle mass and physical fitness.The PAM AM400 is a suitable movement sensor to validly measure the active minutes of hospitalized patients.Implementation of this device in daily care might be helpful to change the immobility culture in hospitals.

Impact of curative treatment on the physical fitness of patients with esophageal cancer: A systematic review and meta-analysis.

BACKGROUND: Esophageal cancer and curative treatment have a significant impact on the physical fitness of patients. Knowledge about the course of physical fitness during neoadjuvant therapy and esophagectomy is helpful to determine the needs for interventions during and after curative treatment. This study aims to review the current evidence on the impact of curative treatment on the physical fitness of patients with esophageal cancer. METHODS: A systematic literature search of PubMed, Embase, Cinahl and the Cochrane Library was conducted up to March 29, 2021. We included observational studies investigating the change of physical fitness (including exercise capacity, muscle strength, physical activity and activities of daily living) from pre-to post-neoadjuvant therapy and/or from pre-to post-esophagectomy. Quality of the studies was assessed and a meta-analysis was performed using standardized mean differences. RESULTS: Twenty-seven articles were included. After neoadjuvant therapy, physical fitness decreased significantly. In the first three months after surgery, physical fitness was also significantly decreased compared to preoperative values. Subgroup analysis showed a restore in exercise capacity three months after surgery in patients who followed an exercise program. Six months after surgery, there was limited evidence that exercise capacity restored to preoperative values. CONCLUSION: Curative treatment seems to result in a decrease of physical fitness in patients with esophageal cancer, up to three months postoperatively. Six months postoperatively, results were conflicting. In patients who followed a pre- or postoperative exercise program, the postoperative impact of curative treatment seems to be less.

A 4-week exercise and protein program improves muscle mass and physical functioning in older adults - A pilot study.

BACKGROUND: Prehabilitation might attenuate common surgery-induced losses in muscle mass and physical performance. Beneficial effects of physical exercise with protein supplementation have been reported in older adults, but typically after an intervention of at least 12 weeks. The time-window for pre-surgery training is often limited to around 30 days, and it is not known if it is possible to achieve comparable results in such a short time window. OBJECTIVES: The aim of this study was to pilot-test the effectiveness of a controlled four-week combined exercise and protein supplementation program on skeletal muscle-related outcomes in a Dutch older adult population. DESIGN: This study was a one-armed pilot trial. PARTICIPANTS: Seventeen older men and women, aged 55-75y, not scheduled for surgery. INTERVENTION: A 4-week intervention program consisting of a twice-weekly supervised resistance and high-intensity aerobic exercise training of 75 min, combined with daily protein supplementation (2 doses of 15.5 g/day at breakfast and lunch). MEASUREMENT: After two and four weeks, isometric quadriceps maximal voluntary contraction (MVC) was assessed via Biodex and quadriceps cross-sectional area (CSA) via magnetic resonance imaging. Other outcome measures were handgrip strength, chair rise time and maximal aerobic capacity (VO2-max), as assessed from a submaximal exercise test. RESULTS: Compliance to the supervised training sessions (99.3%) and the protein supplementation (97%) was very high. The 4-week exercise and protein program led to an increase in quadriceps CSA of 2.3 ± 0.7 cm2 (P = 0.008) in the dominant leg and 3.2 ± 0.7 cm2 (P < 0.001) in the non-dominant leg. Isometric quadriceps MVC increased in the dominant leg (Δ14 ± 4 Nm, P = 0.001) and in the non-dominant leg (Δ17 ± 5 Nm, P = 0.003). Chair rise test time improved with -3.8 ± 0.5 s (P < 0.0001), and VO2-max improved with 3.3 ± 1.1 ml/min/kg (P = 0.014). We observed no changes in body weight and handgrip strength. CONCLUSION: A 4-week exercise and protein intervention led to improvements in muscle-related outcomes in older adults with low levels of physical activity.

Feasibility of preoperative supervised home-based exercise in older adults undergoing colorectal cancer surgery - A randomized controlled design.

Preoperative physical exercise is emerging as a growing field of research globally. There are still challenges in recruiting vulnerable older people, and time constraints in preoperative cancer care to consider. We therefore evaluated the feasibility of short-term supervised home-based exercise in older people prior to colorectal cancer surgery. This feasibility study was conducted between September 2016 and June 2018. People ≥70 years scheduled for colorectal cancer surgery were recruited and randomized to an intervention group receiving supervised home-based physical exercise at a high level of estimated exertion or a standard care group following the standard preoperative path. The exercise (respiratory, strength, and aerobic) consisted of 2-3 supervised sessions a week in the participants' homes, for at least 2-3 weeks or until surgery, and a self-administered exercise program in between. The primary outcome was process feasibility, including aspects specifically related to recruitment rate, compliance to the intervention, and acceptability. The secondary outcome was scientific feasibility including treatment safety, description of dose level and response, and estimation of treatment results. Twenty-three participants were included (recruitment rate 35%). A median of 6 supervised sessions was conducted over a 17-day exercise period. Compliance with the supervised sessions was 97%, and participants found the intervention acceptable. Concerning the self-administered exercise, a median of 19 inspiratory muscle training, 6 functional strength, and 8.5 aerobic sessions were reported. Challenges reported by program instructors were time constraints and difficulties in achieving high exercise intensities on the Borg CR-10 scale. A statistically significant between-group difference was only found in inspiratory muscle strength, favoring the intervention group (p<0.01). A short-term preoperative supervised home-based physical exercise intervention can be conducted, with respect to compliance and acceptability, in older people with similar physical status as in this study prior to colorectal cancer surgery. However, modifications are warranted with respect to improving recruitment rates and achieving planned intensity levels prior to conducting a definitive trial.

Association Between Preoperative Vitamin D Status and Short-Term Physical Performance after Total Hip Arthroplasty: A Prospective Study.

BACKGROUND: Insufficient serum vitamin D concentrations (50-75 nmol/L) are prevalent in 40-65% of patients who require total hip arthroplasty (THA). This could impair physical recovery after surgery. This study investigated the association between preoperative vitamin D status and physical performance after THA. Additionally, postoperative changes in vitamin D concentrations were measured. METHODS: We included 87 patients scheduled for elective THA and aged ≥65 years. Three groups were recruited: patients classified as vitamin D deficient (< 50 nmol/L, n = 23), insufficient (50-75 nmol/L, n = 32), or sufficient (> 75 nmol/L, n = 32). Serum 25-hydroxyvitamin D3 (25[OH]D3) concentration and physical performance were measured perioperatively. Linear mixed models were used to examine differences between groups. RESULTS: Change in physical performance over time was not affected by preoperative vitamin D status. In contrast, for physical activity, both vitamin D (p = 0.021) and time (p < 0.001) effect was seen: from 80.2 ± 25.8 to 58.1 ± 17.8 min/day in the deficient group, 143.7 ± 19.8 to 92.9 ± 11.5 min/day in the insufficient group, and 108.1 ± 20.9 to 62.3 ± 12.9 min/day in the sufficient group. The Chair Stand Test, Timed Up and Go test, and 10-Meter Walking Test also improved significantly over time, but independent of vitamin D status. An increase in 25(OH)D3 concentration 6 weeks postoperatively was correlated with improved hip function (Pearson's r = -0.471, p = 0.018). Overall, serum 25(OH)D3 declined with 32% one day after surgery (p < 0.001), to nearly return to baseline values 6 weeks later in all groups. CONCLUSION: Vitamin D status did not appear to affect physical recovery after THA. The drop in vitamin D after surgery deserves further investigation, but could possibly be explained by hemodilution.

Personal meaning in relation to daily functioning of a patient in physical therapy practice: narratives of a patient, a family member, and physical therapist.

PURPOSE: To get insight into personal meaning of a person involved in a physical therapy intervention. METHODS: Mrs. A, a 76-year-old woman is referred to a physical therapist (PT) for assessment of functioning and training before total hip arthroplasty (THA). The patient, her daughter, and PT were asked to write a story about their daily life. Stories were analyzed according to the narrative scheme based on a method to find meaning in daily life, which consists of four phases: 1. Motivation; 2. Competences; 3. Performance; and 4. RESULTS: Mrs. A was mainly motivated by her will to do enjoyable social activities and stay independent. Although she tried her best to undertake activities (performance) that made her proud (evaluation), her pain and physical limitations were anti-competences that motivated her to attend healthcare. Although the PT seemed to be aware of personal participation goals, her main motivation was to improve and evaluate functions and activities. The daughter was motivated by good relationships and did not see herself as informal caregiver. CONCLUSIONS: The narrative method was a valuable tool to clarify motivations, competences, and values in the process of creating personal meaning related to functioning. This knowledge could help caregivers in applying patient-centered goal-setting and treatment on a participation level. Implications for rehabilitation Personal meaning of people's functioning within their daily context can be clarified from daily life stories. This case report demonstrates that motivations and goals may differ between patient and therapist; the PT seems to focus on improving and evaluating functions and activities, while the patient seems to focus her motivations and personal meaning on participation. This approach may help in patient-centered goal-setting at the level of activities and participation.

Contextual explanations for numeracy and literacy skill disparities between native and foreign-born adults in western countries.

Using new direct measures of numeracy and literacy skills among 85,875 adults in 17 Western countries, we find that foreign-born adults have lower mean skills than native-born adults of the same age (16 to 64) in all of the examined countries. The gaps are small, and vary substantially between countries. Multilevel models reveal that immigrant populations' demographic and socioeconomic characteristics, employment, and language proficiency explain about half of the cross-national variance of numeracy and literacy skills gaps. Differences in origin countries' average education level also account for variation in the size of the immigrant-native skills gap. The more protective labor markets in immigrant-receiving countries are, the less well immigrants are skilled in numeracy and literacy compared to natives. For those who migrate before their teens (the 1.5 generation), access to an education system that accommodates migrants' special needs is crucial. The 1 and 1.5 generation have smaller numeracy and literacy skills gaps in more ethnically diverse societies.

[Improving pre- and perioperative hospital care : Major elective surgery]. / Verbesserung des prä- und postoperativen Behandlungskonzepts : Große elektiv-chirurgische Eingriffe.

Surgery is aimed at improving a patient's health. However, surgery is plagued with a risk of negative consequences, such as perioperative complications and prolonged hospitalization. Also, achieving preoperative levels of physical functionality may be delayed. Above all, the "waiting" period before the operation and the period of hospitalisation endanger the state of health, especially in frail patients.The Better in Better out™ (BiBo™) strategy is aimed at reducing the risk of a complicated postoperative course through the optimisation and professionalisation of perioperative treatment strategies in a physiotherapy activating context. BiBo™ includes four steps towards optimising personalised health care in patients scheduled for elective surgery: 1) preoperative risk assessment, 2) preoperative patient education, 3) preoperative exercise therapy for high-risk patients (prehabilitation) and 4) postoperative mobilisation and functional exercise therapy.Preoperative screening is aimed at identifying frail, high-risk patients at an early stage, and advising these high-risk patients to participate in outpatient exercise training (prehabilitation) as soon as possible. By improving preoperative physical fitness, a patient is able to better withstand the impact of major surgery and this will lead to both a reduced risk of negative side effects and better short-term outcomes as a result. Besides prehabilitation, treatment culture and infrastructure should be inherently changing in such a way that patients stay as active as they can, socially, mentally and physically after discharge.

The Influence of Muscle Weakness on the Association Between Obesity and Inpatient Recovery From Total Hip Arthroplasty.

BACKGROUND: There is ongoing discussion about whether preoperative obesity is negatively associated with inpatient outcomes of total hip arthroplasty (THA). The aim was to investigate the interaction between obesity and muscle strength and the association with postoperative inpatient recovery after THA. METHODS: Preoperative obesity (body mass index [BMI] >30 kg/m2) and muscle weakness (hand grip strength <20 kg for woman and <30 kg for men) were measured about 6 weeks before THA. Patients with a BMI <18.5 kg/m2 were excluded. Outcomes were delayed inpatient recovery of activities (>2 days to reach independence of walking) and prolonged length of hospital stay (LOS, >4 days and/or discharge to extended rehabilitation). Univariate and multivariable regression analyses with the independent variables muscle weakness and obesity, and the interaction between obesity and muscle weakness, were performed and corrected for possible confounders. RESULTS: Two hundred and ninety-seven patients were included, 54 (18%) of whom were obese and 21 (7%) who also had muscle weakness. Obesity was not significantly associated with prolonged LOS (odds ratio [OR] 1.36, 95% confidence interval [CI] 0.75-2.47) or prolonged recovery of activities (OR 1.77, 95% CI 0.98-3.22), but the combination of obesity and weakness was significantly associated with prolonged LOS (OR 3.59, 95% CI 1.09-11.89) and prolonged recovery of activities (OR 6.21, 95% CI 1.64-23.65). CONCLUSION: Obesity is associated with inpatient recovery after THA only in patients with muscle weakness. The results of this study suggest that we should measure muscle strength in addition to BMI (or body composition) to identify patients at risk of prolonged LOS.

An increase in physical activity after colorectal cancer surgery is associated with improved recovery of physical functioning: a prospective cohort study.

BACKGROUND: The influence of physical activity on patient-reported recovery of physical functioning after colorectal cancer (CRC) surgery is unknown. Therefore, we studied recovery of physical functioning after hospital discharge by (a) a relative increase in physical activity level and (b) absolute activity levels before and after surgery. METHODS: We included 327 incident CRC patients (stages I-III) from a prospective observational study. Patients completed questionnaires that assessed physical functioning and moderate-to-vigorous physical activity shortly after diagnosis and 6 months later. Cox regression models were used to calculate prevalence ratios (PRs) of no recovery of physical functioning. All PRs were adjusted for age, sex, physical functioning before surgery, stage of disease, ostomy and body mass index. RESULTS: At 6 months post-diagnosis 54% of CRC patients had not recovered to pre-operative physical functioning. Patients who increased their activity by at least 60 min/week were 43% more likely to recover physical function (adjusted PR 0.57 95%CI 0.39-0.82), compared with those with stable activity levels. Higher post-surgery levels of physical activity were also positively associated with recovery (P for trend = 0.01). In contrast, activity level before surgery was not associated with recovery (P for trend = 0.24). CONCLUSIONS: At 6 month post-diagnosis, about half of CRC patients had not recovered to preoperative functioning. An increase in moderate-to-vigorous physical activity after CRC surgery was associated with enhanced recovery of physical functioning. This benefit was seen regardless of physical activity level before surgery. These associations provide evidence to further explore connections between physical activity and recovery from CRC surgery after discharge from the hospital.

Preoperative prediction of inpatient recovery of function after total hip arthroplasty using performance-based tests: a prospective cohort study.

PURPOSE: The aim of this study was to evaluate the value of conventional factors, the Risk Assessment and Predictor Tool (RAPT) and performance-based functional tests as predictors of delayed recovery after total hip arthroplasty (THA). METHOD: A prospective cohort study in a regional hospital in the Netherlands with 315 patients was attending for THA in 2012. The dependent variable recovery of function was assessed with the Modified Iowa Levels of Assistance scale. Delayed recovery was defined as taking more than 3 days to walk independently. Independent variables were age, sex, BMI, Charnley score, RAPT score and scores for four performance-based tests [2-minute walk test, timed up and go test (TUG), 10-meter walking test (10 mW) and hand grip strength]. RESULTS: Regression analysis with all variables identified older age (>70 years), Charnley score C, slow walking speed (10 mW >10.0 s) and poor functional mobility (TUG >10.5 s) as the best predictors of delayed recovery of function. This model (AUC 0.85, 95% CI 0.79-0.91) performed better than a model with conventional factors and RAPT scores, and significantly better (p = 0.04) than a model with only conventional factors (AUC 0.81, 95% CI 0.74-0.87). CONCLUSIONS: The combination of performance-based tests and conventional factors predicted inpatient functional recovery after THA. IMPLICATIONS FOR REHABILITATION: Two simple functional performance-based tests have a significant added value to a more conventional screening with age and comorbidities to predict recovery of functioning immediately after total hip surgery. Patients over 70 years old, with comorbidities, with a TUG score >10.5 s and a walking speed >1.0 m/s are at risk for delayed recovery of functioning. Those high risk patients need an accurate discharge plan and could benefit from targeted pre- and postoperative therapeutic exercise programs.

Merits of exercise therapy before and after major surgery.

PURPOSE OF REVIEW: Advances in medical care have led to an increasing elderly population. Elderly individuals should be able to participate in society as long as possible. However, with an increasing age their adaptive capacity gradually decreases, specially before and after major life events (like hospitalization and surgery) making them vulnerable to reduced functioning and societal participation. Therapeutic exercise before and after surgery might augment the postoperative outcomes by improving functional status and reducing the complication and mortality rate. RECENT FINDINGS: There is high quality evidence that preoperative exercise in patients scheduled for cardiovascular surgery is well tolerated and effective. Moreover, there is circumstantial evidence suggesting preoperative exercise for thoracic, abdominal and major joint replacement surgery is effective, provided that this is offered to the high-risk patients. Postoperative exercise should be initiated as soon as possible after surgery according to fast-track or enhanced recovery after surgery principles. SUMMARY: The perioperative exercise training protocol known under the name 'Better in, Better out' could be implemented in clinical care for the vulnerable group of patients scheduled for major elective surgery who are at risk for prolonged hospitalization, complications and/or death. Future research should aim to include this at-risk group, evaluate perioperative high-intensity exercise interventions and conduct adequately powered trials.

Preoperative home-based physical therapy versus usual care to improve functional health of frail older adults scheduled for elective total hip arthroplasty: a pilot randomized controlled trial.

OBJECTIVE: To investigate the feasibility and preliminary effectiveness of a home-based intensive exercise program to improve physical health of frail elderly patients scheduled for elective total hip arthroplasty (THA). DESIGN: Single-blind pilot randomized controlled trial. SETTING: Patients' homes and a general hospital in The Netherlands. PARTICIPANTS: Frail patients (N=30) older than 65 years. INTERVENTION: A preoperative, home-based program supervised by an experienced physical therapist to train functional activities and walking capacity. The control group received usual care consisting of 1 session of instructions. MAIN OUTCOME MEASURES: Feasibility was determined on the basis of adherence to treatment, patient satisfaction, adverse events, walking distance (measured with a pedometer), and intensity of exercise (evaluated with the Borg scale). Preliminary pre- and postoperative effectiveness was determined by the Timed Up & Go (TUG) test, 6-minute walk test (6MWT), Chair Rise Time, and self-reported measures of functions, activities, and participation. RESULTS: Patient satisfaction and adherence to the training were good (median=5 on a 5-point Likert scale) and no serious adverse events occurred. The Borg score during training was 14 (range, 13-16). Preoperative clinical relevant differences on the TUG test (2.9 s; 95% confidence interval [CI], -0.9 to 6.6) and significant differences on the 6MWT (41 m; 95% CI, 8 to 74) were found between groups. CONCLUSIONS: Intensive preoperative training at home is feasible for frail elderly patients waiting for THA and produces relevant changes in functional health. A larger multicenter randomized controlled trial is in progress to investigate the (cost-)effectiveness of preoperative training.

The effects of preoperative exercise therapy on postoperative outcome: a systematic review.

OBJECTIVE: To summarize the current evidence on the effects of preoperative exercise therapy in patients awaiting invasive surgery on postoperative complication rate and length of hospital stay. DATA SOURCES: A primary search of relevant key terms was conducted in the electronic databases of PubMed, EMBASE, PEDro and CINAHL. REVIEW METHODS: Studies were included if they were controlled trials evaluating the effects of preoperative exercise therapy on postoperative complication rate and length of hospital stay. The methodological quality of included studies was independently assessed by two reviewers using the PEDro scale. Statistical pooling was performed when studies were comparable in terms of patient population and outcome measures. Results were separately described if pooling was not possible. RESULTS: Twelve studies of patients undergoing joint replacement, cardiac or abdominal surgery were included. The PEDro scores ranged from 4 to 8 points. Preoperative exercise therapy consisting of inspiratory muscle training or exercise training prior to cardiac or abdominal surgery led to a shorter hospital stay and reduced postoperative complication rates. By contrast, length of hospital stay and complication rates of patients after joint replacement surgery were not significantly affected by preoperative exercise therapy consisting of strength and/or mobility training. CONCLUSION: Preoperative exercise therapy can be effective for reducing postoperative complication rates and length of hospital stay after cardiac or abdominal surgery. More research on the utility of preoperative exercise therapy and its long-term effects is needed as well as insight in the benefits of using risk models.