Elective surgeries have been markedly reduced or even halted altogether in countries affected by the covid-19 pandemic, the scale of which is unprecedented in modern medicine. The pandemic will negatively affect many individuals’ health due to reductions in physical activity, suboptimal diets, increased substance use, decreased control of co-morbid conditions, and deterioration in mental health.¹ Predictably, some patients waiting for surgery will experience a decline in their health from pre-pandemic baseline—potentially affecting surgical risk.² Thus, there is a window of opportunity to consider greater implementation of surgical prehabilitation.³

Patients awaiting elective surgery can be grossly subdivided into two groups: (1) No history of covid-19 infection or (2) recovered from proven, suspected, or presumed covid-19 infection. For Group 1 patients who were not infected with covid-19, physical distancing recommendations may lead to reduction in physical activity. This is due to home confinement, closure of community gyms, cancellation of group exercise classes, and restriction (or prohibition) of access to public facilities, such as local and state parks and high school tracks. Although the effects of deconditioning would not be as profound in this group, these effects on baseline health can predictably increase surgical morbidity and mortality. These effects also likely impact medically frail patients disproportionately,⁴ who have decreased access to healthcare professionals, reduced control of their chronic medical conditions, and possibly less availability of medications due to shortages or high costs.  

Patient status in Group 2 who are post-covid-19 infection, can range from asymptomatic to more serious long term effects. However, even those who experience mild to moderate symptoms may have a decline in physical activity due to the effects of bedrest and convalescence. Patients with more serious complications are often hospitalised, some requiring mechanical ventilation, hemodialysis, parenteral or enteral nutrition, and/or extracorporeal membrane oxygenation. The effects of immobilisation are deleterious and result in rapid deconditioning.⁵ On average, the reported loss of total skeletal muscle mass, as measured by numerous studies in various ways, is conservatively estimated at approximately 0.5-6% daily.⁵ Skeletal muscle loss with bedrest is most pronounced in the first few days with a slower rate as time progresses, and the elderly experience greater loss. There is also a decline in strength of around 1% per day, although this varies depending on the method of measurement.⁵ Studies among adults from young to old have found an approximate 1% decline in VO2 max per day. Importantly, patients with these deteriorations in physiologic function that occur over a period of days take weeks to recover, and may only fully recover with targeted rehabilitation interventions. Post-covid patients who were in the intensive care unit (ICU) may have more serious sequelae due to additional complications and often will not return to baseline, even with rehabilitation. Although younger patients may be more easily able to maintain their baseline health status than older and medically frail individuals, small increases in activity in frail patients tend to have a larger impact on fitness.⁶

To put frailty into context, a recent study by Shinall and colleagues described surgical risk in medically frail patients via a novel frailty stress score applied to a large cohort in the Veterans Administration Surgical Quality Improvement Program.⁷ Citing a commonly used metric (1% mortality) to describe high risk patients, the authors noted significantly higher mortality rates in patients who were classified as frail. Additionally, the 30-day mortality rate for frail patients who underwent the lowest-stress surgical procedures (e.g., cystoscopy) was 1.6%, and 5.1% for moderate-stress procedures (e.g., laparoscopic cholecystectomy). Comparatively, the very frail group had a 30-day rate of 10.3% for lowest-stress procedures and 18.7% for moderate stress procedures, respectively. Mortality rates increased for frail and very frail patients at 90 and 180 days, and peaked at 43% for very frail patients at 180 days after moderate-stress procedures. This study highlighted the powerful effect of surgical physiologic stress in medically frail patients, and the potential benefit from prehabilitation as a helpful preoperative intervention.

Prehabilitation

Prehabilitation dates back many decades, and a modern definition describes it as “physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments”.⁸ Studies use either a single intervention (unimodal) or combination of interventions (multimodal) that typically focus on physical activity, nutritional optimisation, and stress and/or substance use reduction. 

Reports suggest that prehabilitation improves patient outcomes and may be cost-effective.⁹ A study by Mouch and colleagues found that a home-based multimodal Michigan state-wide prehabilitation program (walking, nutrition education, smoking cessation, and psychological preparation) resulted in participants (n=523) having shorter length of stay and lower total episode Medicare payments compared to controls (n=1,046).¹⁰ In a home-based total knee arthroplasty telemedicine trial, researchers found that a multimodal intervention was effective with significantly shorter length of stay, and more favourable discharge disposition status; 77.2% of patients were discharged home without assistance, and fewer were discharged to a subacute nursing facility.¹¹

Prehabilitation generally begins a few weeks prior to an elective surgery and complements perioperative enhanced recovery protocols. Unimodal prehabilitation protocols often involve a diet or exercise intervention, and published studies support that either one of these alone are beneficial. However, multimodal prehabilitation may be superior and perhaps safer, as caution is warranted when increasing activity in the absence of nutritional support.² While the majority of nutritional programs incorporate protein increases prior to upcoming stressors, other dietary interventions include glycemic control and supplementation for vitamin, mineral, or trace element deficiencies.³

Smoking cessation is becoming a mainstay of multimodal prehabilitation protocols because of improvements in pulmonary fitness and reduced surgical wound infection rates. It is important to be aware that during the covid-19 pandemic, increases in substance use are anticipated (e.g. alcohol), which may adversely impact baseline health status. Interventions to combat emotional stress and improve sleep quality are also incorporated into multimodal prehabilitation protocols, and this may be particularly important during and after the pandemic when there may already be an increased demand for mental health services.

There is a potential path forward for surgical prehabilitation that can be implemented strategically:

1. Make a list of all patients who are waiting for surgery and include a tracking system of who becomes covid-positive and recovers. 
2. Work rapidly and cooperatively with rehabilitation medicine physicians and other clinicians at local institutions with expertise in prehabilitation to set up a system to address the needs of patients while they are at home awaiting surgery (e.g. telemedicine visits can facilitate¹²). 
3. Introduce to these patients a program of multimodal prehabilitation¹³ that is supported by the current body of research and feasible at home under the current circumstances. 
4. Consider evaluating patients with online validated tools and questionnaires to determine adherence to suggested prehabilitation protocols prior to surgical intervention. 
5. Refer readily to rehabilitation professionals postoperatively in anticipation of patients benefiting from additional support during the foreseeable future. 
6. Track outcomes and assess the benefits of prehabilitation and rehabilitation interventions.

Prehabilitation may influence surgical morbidity and mortality during and even after the pandemic. Now is the time to prepare patients for the physiologic stress of an anticipated future operation. 

Julie K. Silver, MD, Department of Physical Medicine & Rehabilitation, Massachusetts General Hospital, Brigham and Women’s Hospital, Spaulding Rehabilitation Hospital, Boston, MA, USA @JulieSilverMD

Naomi M. Sell, MD, MHS, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA @NaomiSellMD

Sareh Parangi, MD, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA @SarehParangiMD

Motaz Qadan, MD, PhD, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA @MotazQadan

Competing interests: the authors report no conflicts of interest related to this report, and Drs. Silver, Sell, and Qadan disclose they are investigators in clinical trial research on pancreatic cancer prehabilitation.

 

1. Silver JK. Prehabilitation could save lives in a pandemic. Br Med J. 2020; Apr 6;369:m1386. doi: 10.1136/bmj.m1386.
2. Silver JK. Prehabilitation may help mitigate an increase in COVID-19 peri-pandemic surgical morbidity and mortality. Am J Phys Med Rehabil. 2020; Apr 21  doi: 10.1097/PHM.0000000000001452. [Epub ahead of print].
3. Scheede-Bergdahl C, Minnella EM, Carli F. Multi-modal prehabilitation: addressing the why, when, what, how, who and where next? Anaesthesia. 2019 Jan;74 Suppl 1:20-26. doi: 10.1111/anae.14505.
4. Sell NM, Qadan M, Silver JK. Implications of preoperative patient frailty on stratified postoperative mortality. JAMA Surg. 2020;  2020 Apr 22. doi: 10.1001/jamasurg.2020.0430. [Epub ahead of print].
5. Kortebein P. Physical inactivity: physiologic impairments and related clinical conditions. In: Frontera, Walter R., et al. Delisa’s Physical medicine and rehabilitation: principles and practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2019.
6. Minnella EM, Awasthi R, Gillis C, et al. Patients with poor baseline walking capacity are most likely to improve their functional status with multimodal prehabilitation. Surgery. 2016;160(4):1070–1079.
7. Shinall MC Jr, Arya S, Youk A, et al. Association of preoperative patient frailty and operative stress with postoperative mortality  JAMA Surg. 2019;155(1):e194620. [Epub ahead of  print].
8. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA Cancer J Clin. 2013; 63(5):295-317.
9. Howard R, Yin YS, McCandless L, et al. Taking control of your surgery: impact of a prehabilitation program on major abdominal surgery. J Am Coll Surg. 2019 Jan;228(1):72-80.
10. Mouch CA, Kenney BC, Lorch S, et al. Statewide prehabilitation rrogram and episode payment in medicare beneficiaries. J Am Coll Surg. 2020;230(3):306–313.e6.
11. Chughtai M, Shah NV, Sultan AA, et al. The role of prehabilitation with a telerehabilitation system prior to total knee arthroplasty. Ann Transl Med. 2019 Feb;7(4):68.
12. Verduzco-Gutierrez M, Bean AC, Tenforde AS, et al. How to conduct an outpatient telemedicine rehabilitation or prehabilitation visit. PM R. 2020; Apr 15. doi: 10.1002/pmrj.12380. [Epub ahead of  print].
13. Sell NA, Silver JK, Rando S, et al.  Prehabilitation telemedicine in neoadjuvant surgical oncology patients during the novel COVID-19 coronavirus pandemic. Ann Surg. 2020. [Epub ahead of  print].