By definition, prehabilitation involves interventions aimed at improving patients’ health prior to an anticipated upcoming physiologic stressor so that they are better able to withstand that stress. Many decades ago, prehabilitation emerged as a way to prepare soldiers for battle in World War II. A study published in 1946 in The British Medical Journal entitled Prehabilitation, Rehabilitation and Revocation in the Army described an experiment in which “good food, lodging, hygiene, and recreation combined with controlled physical training and education” for a period of approximately two months were found to improve the health ratings of 85% of the 12,000 men who participated. The report stated that the participants’ outlook on life also improved, and that these physical and psychological changes were “astonishingly easy” to accomplish. Modern day military training continues to use prehabilitation-type interventions.
Although the coronoavirus pandemic is not a literal war, many people will have to “fight” a future infection, and what science has taught us since the British military study was published could be vital in helping affected patients to survive. Crucial to understanding why prehabilitation may be particularly valuable during a pandemic is to recognize that strategies that might help slow the spread of disease and perhaps reduce its overall incidence (i.e., social distancing and sheltering in place), could have the unintentional and harmful effect of decreased physical activity and contribute to cardiopulmonary deconditioning. In particular, the elderly, who are most vulnerable to pulmonary complications from coronavirus, may exhibit a decrease in their baseline cardiac and pulmonary fitness that could substantially impact their outcomes and increase morbidity and mortality.
Prehabilitation has not yet been evaluated in the setting of an infectious pandemic disease. However, there is currently a window of opportunity that exists, whereby physicians can recommend a best practices approach (based on the evidence base to date in other diagnostic conditions) and advise patients and the public about how to maintain and optimize their baseline fitness and nutritional health in the midst of the coronavirus pandemic. Notably, best practice prehabilitation recommendations can be followed while simultaneously adhering to social distancing and sheltering in place; these are not mutually exclusive and can be done together to optimize someone’s health and keep everyone as safe as possible.
In pre-surgical protocols, best practices prehabilitation is multimodal (versus unimodal as “exercise only”) and involves a combination of exercise, nutrition, smoking cessation, and stress reduction. Regarding exercise, there is a large body of research that shows that muscle wasting and cardiopulmonary deconditioning occurs rapidly during reduction in physical activity (e.g., bedrest). Thus, an important goal is to encourage people to remain at least at their baseline activity level in order to avoid losing muscle strength and decreasing cardiopulmonary conditioning.
Importantly, small changes in cardiopulmonary fitness may have a large impact on patients who are medically frail, including elderly patients with multiple co-morbidities. As such, prehabilitation may have the greatest positive effect on those who are most vulnerable. A 2019 report in the journal Current Opinion in Anesthesiology stated, “Identifying high-risk patients at the earliest possible stage and increasing their physiological reserve prior to surgery is a promising approach that seems to result in remarkable improvements for older patients.” All healthcare professionals should follow established exercise guidelines when giving advice about increasing activity levels. In older individuals or those who are medically frail, a cautious approach is warranted and exercise recommendations should be carefully individualized and tailored to ensure safety and efficacy.
Nutrition plays an essential, though often underappreciated, role in prehabilitation. Protein supplementation in prehabilitation has been studied, particularly in the context of increased exercise (recalling that in sports medicine, an increase in training and protein intake are routinely recommended together). Furthermore, there are numerous studies that show relationships with improved glycemic control correlating with reduced post-operative infection rates in people with diabetes. Thus, glycemic control has also been proposed as a key consideration in prehabilitation protocols. Finally, medical advice and education about smoking cessation and reducing stress can be useful, and benefits are easily appreciated in overall improvements in pulmonary capacity and function.
While the benefits of exercise and nutrition in prehabilitation are readily appreciated and incorporated in generic prehabilitation protocols prior to surgery, their application to optimization of health during infectious pandemic disease are also relevant. However, once someone becomes symptomatic and/or is diagnosed with coronavirus, then the types of interventions recommended for prehabilitation may no longer be appropriate. Since most people who develop pulmonary complications from coronavirus will survive, it is also worthwhile considering who will benefit from conventional rehabilitation interventions post-infection.
As telemedicine becomes widely adopted during this pandemic, it is worth mentioning that prehabilitation interventions may be delivered by using this technology, and further optimized with the aid of wearable devices and newer innovations that will continue to feature in 21st century medicine. A recent study of patients who underwent total knee arthroplasty found that a telemedicine prehabilitation intervention significantly decreased hospital length of stay compared to the control group. In this study, the protocol included advice on exercise, nutrition, home safety, reducing medical risks, and pain management skills. Another recent report showed that at-home prehabilitation is feasible. This small study (n=14) was published in the American Journal of Physical Medicine and Rehabilitation and found that the majority of older, frail participants (median age 79 years) followed the exercises and prepared the recipes in a Fit4SurgeryTV at home programme for approximately one month. The application of such prehabilitation telemedicine strategies in the context of infectious pandemic diseases are even more applicable in settings where direct contact is less desirable. Thus, the combination of telemedicine with prehabilitation for infectious disease may prove to be symbiotic and very beneficial entities in future medicine.
For people who remain at risk for coronavirus infection, now is a good time to consider prehabilitation and the types of interventions that have been proven to improve health prior to an upcoming physiologic stress. Knowledge is power, and there is no better time than a pandemic to empower our patients and the public with information that could decrease morbidity and mortality.
Julie K. Silver is an Associate Professor and Associate Chair of the Department of Physical Medicine at Harvard Medical School. Dr. Silver is on the medical staff at Massachusetts General, Brigham and Women’s, and Spaulding Rehabilitation Hospitals. Twitter: @JulieSilverMD
Competing interests: JS reports no disclosures.