Disease-specific impairment-based rehabilitation

Jennifer Baima, MDJennifer.Baima@umassmemorial.org

Nothing to disclose

• Colorectal– nutrition– delaying surgery worsens outcomes (absent

prehab)

• Lung – pulmonary function– delaying surgery may not worsen outcomes (non-

small cell)

• Prostate– urinary/ sexual function– May not need individualized program

• Breast– shoulder pain, weakness, and limited range of

motion • Head and neck

– swallowing dysfunction

Measuring Improvement

Timeline

colorectal prostate

head and necklung

Gastrointestinal prehabilitation

Reversing nutritional deficiencies and improving

compliance

West, M. A., et al. "Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study."

• 6 weeks of 3x weekly sessions on an exercise bike returns (cardiopulmonary) fitness to baseline levels after chemo

surgery

radiation

chemotherapy

Cho, Haruhiko, et al. "Matched Pair Analysis to Examine the Effects of a Planned Preoperative Exercise Program in Early Gastric Cancer Patients with Metabolic Syndrome to Reduce Operative Risk: The Adjuvant Exercise for General Elective Surgery (AEGES) Study Group."

• Matched pair analysis of 4 week preoperative exercise (aerobic, resistance, stretching) with no serious adverse events

• Decreased volume of visceral fat • Postoperative complications in 5.5%

vs 40.7%

Gillis, Chelsia, et al. "Prehabilitation versus Rehabilitation: A Randomized Control Trial in Patients Undergoing Colorectal Resection for Cancer."

• Trimodal intervention– dietician, kinesiologist, and psychologist

on home-based interventions

• RCT with two groups:– Prehab (38 patients) = 4 weeks before

and for 8 weeks post-op– Rehab (39 patients) = 8 weeks post-op

only

• Preop: improvement in 6 MWT by average of 25.2 m vs decline of 16.4 m in rehab group

• 4 weeks post: both groups < 20 m below baseline

• 8 weeks post: prehab group above baseline and rehab group below baseline

25.2 m increase preop offsets 21.8 m decline postop for a net gain

Gastrointestinal impairments

• Abdominal weakness

• Chest weakness/atelectasis

• Fatigue

Lung prehabilitation

improving pumonary functionand changing treatment

options

High prevalence of COPD (left) Total oxygen intake of muscles during

low level exercise

Other Respiratory Other Respiratory

• Prehab pilot vs incentive spirometry without IMT

• Warm up and cool down• 1. Upper limb- 15 reps per minute of

diagonal movements• 2. Lower limb- treadmill walking- 10min 1st

week, 20 min 2nd week, 30min 3rd week, 30 min 4th week

• 3. Inspiratory muscle training- inhaling through the mouth against pressure

Morano MT et al. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial.

Rodriguez-Larrad, Ana, et al. "Perioperative physiotherapy in patients undergoing lung cancer resection."

• 8 studies of 599 patients: two preoperative, four postoperative, and two that started preoperatively and continued

• Prognosis is related to preoperative performance on exercise testing

• Presurgical time period is most crucial in changing exercise performance

Timeline and heterogeneity

• 5 sessions per week for 4 weeks of aerobic exercise

• 14 sessions per week for one week of aerobic exercise

• 14-21 sessions per week of physical therapy for one week before surgery and until discharge

• 35 sessions per week of independent non-invasive pressure support ventilation for one week before surgery to three days after

Lung impairments• Cardiopulmonary

dysfunction• Respiratory

muscle weakness/ atelectasis

• Fatigue

Prostate prehabilitation

Preventing pelvic floor dysfunction and overcoming

changing hormones

Presentation Title 17

Bernardo-Filho, Mario, et al. "The Relevance of the Procedures Related to the Physiotherapy in the Interventions in Patients with Prostate Cancer: Short Review with Practice Approach."

• Physiotherapy is effective before and after treatment

• Urinary incontinence– Internal sphincter

deficiency – Bladder dysfunction

• Erectile dysfunction

April 18, 2023 Presentation Title 18

• Unique functions of pelvic floor muscles

• Biofeedback, electrotherapy, external vacuum devices

• 29%-97.5% rate of ED after radical prostatectomy

• Psychotherapy; sex therapy; oral, intraurethral, or intracavernosal pharmacologic agents; and surgery

April 18, 2023 Presentation Title 19

• Decrease of postoperative complications in patients who have undergone prehab

• Improvement not observed until exercises are done after surgery

• Taught and practiced for at least 3 weeks for UI and 3 months for ED

April 18, 2023 Presentation Title 20

• 50% undergo androgen deprivation

• Unlike male colorectal and lung cancer patients, do not change behavior at diagnosis

• 12 weeks of supervised football increases exercise compliance

• Access to professionals and accountability

April 18, 2023 Presentation Title 21

Bruun, D. M., et al. "“All boys and men can play football”: A qualitative investigation of recreational football in prostate cancer patients."

Genitourinary impairments

• Urinary dysfunction• Sexual dysfunction• Fatigue

Breast prehabilitation

Preventing shoulder problems and lymphedema

Sagen, Aase, et al. "Upper Limb Physical Function and Adverse Effects After Breast Cancer Surgery: A Prospective 2.5-Year Follow-Up Study and Preoperative Measures."

Type of surgery ALND SLNB

arm lymphedema(only affected side)

17% 3%

shoulder abduction-provoked pain

increase 6% decrease 50%

Grip strength reduction

12% 2%

Martins Da Silva RC, Rezende LF. Asessment of impact of late postoperative physical functional disabilities on quality of life in breast cancer survivors. Tumori 2014 Jan-

Feb: 100(1): 87-90 • 4-5 years after ALND• Limited ipsilateral

shoulder flexion, external rotation, and abduction range of motion

• Negative impact on functional capacity and global quality of life

• 28% had lymphedema

NIH Clinical Center Program

Springer BA et al. Preoperative assessment enables early diagnosis and recovery of shoulder function in patients with breast cancer. Breast Cancer Research and Treatment

26

Breast prehab study

• Prehabilitation intervention: 3 exercises– Codman’s exercise– Scapular squeezes– Reach for the pillow- 3 sets of 10 daily in the one to four

weeks prior to surgery

• Eval pain and range of motion before surgery, 1 month postoperative, and 3 months postoperative

Courneya, K. S., et al. "Subgroup effects in a randomised trial of different types and doses of exercise during breast cancer chemotherapy." British journal of cancer (2014).

• Metabolic vs “cancer” variables• Dose response: Elevated BMI

moderates the effect of exercise during chemotherapy in breast cancer, but self-reported exercise baseline does not– 25-30 minutes of aerobic– 50-60 minutes of aerobic– 50-60 minutes of aerobic and resistance

Cerulli, Claudia, et al. "Therapeutic Horseback Riding in Breast Cancer Survivors: A Pilot Study." The Journal of Alternative and Complementary Medicine 20.8 (2014): 623-629.

-10 of 20 women > 6 months after breast cancer treatment

-VO2 max, strength including shoulder press, and FACIT-F after 16 weeks of equine-assisted therapy

Breast Cancer Impairments

• Range of motion of shoulder

• Bone/ joint pain from aromatase inhib.

• Chemo-induced neuropathy

• Lymphedema• Sexuality

30

Head and neck cancer

Preventing swallowing and speech dysfunction

• 47 subtotal laryngectomy patients

• The average time to swallowing resumption was 27.76 days for the 25 patients who received ST only after surgery, and 16.38 for the 22 patients who underwent ST both before and after surgery.

Cavalot AL et al. The importance of preoperative swallowing therapyin subtotal laryngectomies. Otolaryngology–Head and Neck Surgery (2009) 140, 822-825

Impairments in HNC

Impairment Prevalence (%)

Ingestion 75

Articulation 67

Taste 66

Voice 61

Pain 59

Structure of head and neck 82%

Prehabilitation clinical trials and clinical care

Compliance– Accountability– Access to health care professionals– Able to do it