Optimizing general health and well-being through ‘prehab’ can improve surgical outcomes

Studies show prehabilitation, or “prehab,” is associated with reduced complications, shorter hospital stays and less need for postoperative rehabilitation

Prehabilitation, or “prehab,” refers to optimizing general health and well-being before surgery to improve surgical outcomes.

Prehab takes a multidisciplinary approach, focusing on strength and aerobic exercises, nutrition, smoking cessation, alcohol reduction, and psychological factors such as mitigating stress, anxiety and depression.

The approach is primarily designed for patients who are at the highest risk for surgical complications as the result of age or other comorbidities. Prehab has been used with good results for knee and hip arthroplasty, and colorectal, cardiac and abdominal procedures.

Studies have shown prehab is associated with reduced postoperative mortality and complications, hospital length of stay, need for postoperative rehabilitation, cost and readmission rates. It also is associated with a more rapid return to baseline functional capacity.

In August 2020, Norton Neuroscience Institute started a prehab program for spinal surgery patients. We focused on two areas. First, patients received preoperative physical therapy to increase strength. Second, we educated patients about what to expect with a lumbar fusion, stressing the importance of early mobility postoperatively. Our experience with implementing a nurse-led rehabilitation program for patients undergoing spinal surgery at Norton Neuroscience Institute has been accepted for publication. (Shields LBE, Clark L, Reed J, Tichenor S. Implementing a nurse-led prehabilitation program for patients undergoing spinal surgery. Nursing. 2024. In press.)

Before starting the prehab program, we noted that not all patients were aware of the expectations of lumbar fusion surgery. Using uniform language to educate patients helped mentally prepare patients about their upcoming procedures in a consistent way.

In a pilot study of our prehab program, we selected patients who met at least one of four criteria: they were undergoing lumbar decompression or fusion, used an assistive device, were age 80 or older, or they lived alone.

A physical therapist was responsible for the education and physical therapy.

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All patients received prehab sessions with a physical therapist, either in person or remotely. Sessions were either a one-time visit or once a week until surgery. The preference was for patients to receive as many prehab visits as possible. All exercises recommended during prehab were safe to perform postoperatively, with restrictions in place.

As part of the education component, patients learned about postoperative considerations, including activity restrictions, pain medications, therapy needs, home and transfer safety, exercises, assistive devices and fall risks.

In our prehab program, smoking cessation was required prior to spine fusion. This was confirmed during preadmission testing. Patients also were told pain medications would not be given to them routinely after surgery. They would have to ask for them. This made patients more actively involved in their own health care.

Each patient’s prehab order was placed in Epic, and the initial prehab evaluation and all subsequent visits were tracked in Epic. Having this information logged helped the physical therapist at the initial postoperative evaluation. This information also benefited the care manager coordinating post-hospital needs.

In their first postoperative visit, patients were surveyed about their prehab experience. Of the 43 included in the pilot study, 77% said they “strongly agreed” that they would recommend prehab to others. The program also was favorably received by spine surgeons and nurses.

Since this successful pilot study, we have started expanding prehab to include more patients and over a longer period of time.

In addition to readying patients physically and mentally for surgery, prehab is empowering for patients, promoting autonomy, enhancing coping skills and improving stress management.

Christopher B. Shields, M.D., is a neurosurgeon and spine surgeon with Norton Leatherman Spine and Norton Neuroscience Institute.

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