JBI Database of Systematic Reviews & Implementation Reports
2015;13(1) 146 - 187
The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review CJ Cabilan, RN, BN
1
Sonia Hines, RN, Cert IV TAE, BN, Grad Dip Ed (Tertiary & Adult), MAppSci (Research) Judy Munday, RN, DipEd (Nurs), BA (Hons)
1
1
1. Nursing Research Centre, Mater Health Services; Nursing Research Centre, Mater Health Services; the Queensland Centre for Evidence Based Nursing and Midwifery: a Collaborating Centre of the Joanna Briggs Institute
Corresponding author: CJ Cabilan
[email protected]
Executive summary Background Major surgery can induce functional decline and pain, which can also have negative implications on health care utilization and quality of life. Prehabilitation is the process of optimizing physical functionality preoperatively to enable the individual to maintain a normal level of function during and after surgery. Prehabilitation training can be a combination of aerobic exercises, strength training, and functional task training to suit individual needs. Objectives To evaluate the impact of prehabilitation on physical functional status, health care utilization, quality of life, and pain after surgery. Inclusion criteria Types of participants Studies of adult surgical patients, excluding day surgery patients. Types of interventions Any preoperative exercise interventions identified in the study as part of a prehabilitation or preoperative exercise program, versus usual care.
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-2015-1885 Page 146
JBI Database of Systematic Reviews & Implementation Reports
2015;13(1) 146 - 187
Types of studies Randomized controlled trials. Types of outcomes Functional status, health care utilization, quality of life and pain. Search strategy Published (CINAHL, CENTRAL, EMBASE, MEDLINE, PEDro) and unpublished studies between 1996 and March 2013 were searched extensively. Methodological quality All studies were assessed independently by two reviewers for relevance, eligibility and methodological quality. Data collection Data from included papers were extracted using a modified data extraction tool. Data synthesis Where possible, study results were pooled in statistical meta-analysis. Alternatively, results are presented in narrative and table form. Results A total of 3167 citations were identified; after removal of duplicates, assessment for relevance and eligibility, 33 studies underwent critical appraisal. Seventeen studies met the quality criteria and were included in quantitative synthesis. Thirteen studies were conducted in orthopedics (mainly knee or hip arthroplasty for osteoarthritis), one in colorectal, two in cardiac and one in upper gastrointestinal/hepatobiliary. Function, pain and quality of life were quantified according to prehabilitation dose and postoperative months. Prehabilitation, at any dose, did not demonstrate benefits in objective and self-reported function at any of the postoperative time points. Prehabilitation did not demonstrate benefits in quality of life or pain; however, there was significant evidence that prehabilitation doses of more than 500 minutes reduced the need for postoperative rehabilitation, but no significant reduction was found in readmissions or nursing home placement. Conclusions Results from this review reveal that prehabilitation has no significant postoperative benefits in function, quality of life and pain in patients who have had knee or hip arthroplasty for osteoarthritis; however, there is evidence that prehabilitation may reduce admission to rehabilitation in this population. The evidence on postoperative benefits of prehabilitation in other surgical populations is limited; however, preliminary evidence does not demonstrate better outcomes.
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-2015-1885 Page 147
JBI Database of Systematic Reviews & Implementation Reports
2015;13(1) 146 - 187
Implications for practice There is no evidence that prehabilitation provides benefits in function, pain or quality of life in patients who have had arthroplasty for osteoarthritis; however prehabilitation doses of more than 500 minutes might reduce acute rehabilitation admissions. The evidence is insufficient to provide recommendations on the benefits of prehabilitation in other surgical populations. Implications for research Future prehabilitation studies are not recommended in patients with osteoarthritis for whom arthroplasty is planned. However, should prehabilitation be tested in other surgical populations, programs must consider patient suitability, setting, delivery of intervention and clinical effectiveness. It is also recommended that the exercises prescribed should be maintained and adhered to after surgery. Most importantly, prehabilitation studies must have adequately powered sample sizes. Keywords Preoperative care; surgery; prehabilitation; preoperative rehabilitation; presurgical rehabilitation; preoperative exercise; preoperative training; exercise; exercise training
Background Physical functional decline is very common after major surgery. It can lead to loss of independence of 1
activities of daily living, such as walking, toileting, and home care activities; increased incidence of rehabilitation unit admission and nursing home placement for the elderly
1, 2
; longer hospital length of stay
(LOS); development of postoperative complications; poor health-related quality of life (QOL); and morbidity.
3
Inactivity is well documented as one of the leading causes of physical functional decline. 7
4-6
Inactivity has
2
been observed amongst all hospitalized individuals regardless of their present condition. Increased pain and anxiety about activity due to "fear of injury"
8(p.195)
after surgery are amongst the contributing factors.
8
Individuals who experience physical functional decline have the tendency to enter a continuing cycle of 9
added inactivity due to their limited physical capacity. Prolonged inactivity may inhibit normal functioning of major organ systems such as the cardiovascular system, cardiopulmonary system and musculoskeletal 4
system. Every individual’s functional ability (defined as ability to perform activities of daily living) dependent on the overall functioning of the major organ systems
10
is
11,12
, therefore a decline in one or more of
the organ systems also means a decline of functional ability. For example, a reduction in aerobic capacity as well as ineffective ventilation and perfusion limit the individual’s capacity to perform physical tasks 9
such as functional walking ; orthostatic hypotension and decreased muscle strength put the individual at a greater risk of falls and injury.
10,12,13
Preoperative physical functional status also contributes to postoperative physical functional decline. Evidence indicates that individuals who have limited physical fitness preoperatively have higher rates of morbidity and mortality during their hospital stay.
14
Conversely, individuals who have better preoperative
physical fitness experience less postoperative pain and have better physical functional status postoperatively.
15
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Increasing physical activity is the most effective intervention to counteract physical functional decline after surgery. Therapeutic exercise is a form of physical activity that has been known to improve physical 9
fitness (defined as the capacity to carry out daily functional tasks). Current evidence supports exercise rehabilitation to enhance physical fitness after surgery.
8,9
Exercise rehabilitation has been used widely as
a beneficial and effective intervention to re-establish the individual’s postoperative functional status independence.
16
15
and
Although these outcomes can be achieved through exercise rehabilitation, it has been
argued that the body deconditions faster than it recovers.
4,13,17
For example, low-intensity exercises
strengthen the muscles at only 6% per week while inactivity induces 10%-15% loss of muscle strength 6
per week. Hence re-attainment of muscle strength is only possible with prolonged intensive exercise rehabilitation.
8
It would therefore be reasonable to optimize functional status through preoperative rehabilitation or prehabilitation (prehab) before surgery. Prehab is defined as the “process of enhancing functional capacity of the individual to enable him or her to withstand the stressor of inactivity”.
12(p.268)
Prehab aims
to maintain a normal level of functionality and achieve a quicker recovery of functional status during postoperative inactivity.
11,12,18
The theory of prehab originated in sports medicine where athletes train
intensively before a competition to prevent injuries.
11
In a medical context, prehab is employed to prevent
physical functional decline. Currently prehab programs do not have standardized exercise protocols.
14
For
example, the types of exercise and exercise duration intensity and frequency vary across organizations, but generic prehabilitation programs include the following exercises: three to five minutes of warm-up exercise, five minutes of aerobics up to two to three times per week, eight repetitions of strengthening exercise two days per week, 30-second flexibility exercise, and up to five repetitions of functional task training two to three times per week.
12(p.272)
It is believed that prehab training is proportionate to its impact
on physical functional status; therefore longer and intensive prehab training maximizes functional status.
11
Moreover, the length of prehab training has also not yet been standardized but the duration of training commonly ranges from four to eight weeks.
3,19
The effectiveness of prehab in terms of functional status, postoperative complications and hospital LOS has been increasingly explored through clinical experiments and systematic reviews especially in orthopedic settings. A systematic review indicated that prehab did not enhance either objective or selfreported postoperative functioning in patients who have had total knee arthroplasty (TKA) or total hip arthroplasty (THA) for osteoarthritis.
19
Another systematic review in the same population also showed that
prehab had not demonstrated effectiveness in terms of reduction of postoperative complications and 3
LOS. However, in cardiac patients who have had coronary artery bypass graft (CABG) or abdominal aortic aneurysm, prehab in the form of inspiratory muscle training showed significant reductions in postoperative pulmonary complications, and LOS. Both reviews
3,19
3
offer limited data on the impact of prehabilitation on physical functional status in other
surgical populations such as cardiac, colorectal and thoracic surgeries. Additionally, the effectiveness of prehab in terms of health care utilization (HCU), QOL and pain in these surgical populations has not yet been explored in a systematic review. Therefore, it was necessary to conduct this systematic review. The objectives, inclusion criteria and methods of analysis for this review were specified in advance and documented in a protocol.
20
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Definitions Gait Speed – a measure of walking speed; measures the amount of time (seconds) taken to walk on 60m level ground.
21
Six-minute Walk Test (6MWT) – measures distance covered in 6 minutes; used to measure functional walking capacity.
22
Timed-Up-and-Go (TUG) – measures functional mobility, strength, balance and agility; amount of time (seconds) an individual takes from sitting, 6-metre return walk to the chair, and back to sitting position.
22
Iowa Level of Assistance Scale (ILAS) –measures function in TKA and THA patients according to the level of assistance (independent, supervised, minimal assistance, moderate assistance, maximal assistance, failed to achieve and not tested) in the following tasks: get out of bed, stand up from bed, walking, and climb up and down three steps. It is scored 0 to 50, with a higher score indicating lower functional ability.
23,24
Functional Independence Measure (FIM) –assesses a person’s ability to perform activities of daily living such as self-care, toileting, mobility and transfers, and cognitive assessment. It is scored 18 to 126 and can be categorized as: complete dependence (18), moderate dependence (19 to 60), mild dependence (61 to 103), independence (104 to 126).
25
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) – is a measure for joint pain, stiffness, and physical function in osteoarthritis. Pain is measured in a scale of 0 to 20 point, stiffness is measured from 0 to 8 scale, and function is measured from 0 to 68 scale. Higher scores indicate poor status.
21,26,27
Short-Form Health Survey 36 (SF-36) – is a measure of general health status or QOL. The scale measures eight domains: physical functioning, role limitation (physical), social functioning, bodily pain, general mental health, role limitation (emotional), vitality and general health.
28
These can be also
categorized into two: physical QOL (summary of physical functioning, role (physical), bodily pain and general health), and mental QOL (summary of social functioning, mental health, role (emotional), vitality.
26,29,30
Higher scores in individual domains or in summary scores indicate better QOL.
Visual Analogue Scale (VAS) – is a measure of pain. Scoring is usually from 0 to 10 or 0 to 100, no pain to worst pain.
31
Objectives The objectives of this systematic review were to synthesize the best available evidence on the effectiveness of prehab in adults on the following postoperative outcomes: physical functional status, HCU, QOL and pain.
Inclusion criteria Types of participants We included studies of adult patients (18 years and older) undergoing surgery in hospitals with the exception of day surgery patients.
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2015;13(1) 146 - 187
Types of intervention(s) This review considered any preoperative exercise interventions identified in the study as part of a prehab or preoperative exercise program, versus usual care. We excluded studies that compared the effectiveness of different types of preoperative exercise, for example, aerobics versus strength training. Types of outcomes Primary outcome: For the purpose of this review, functional status referred to the whole physical functional capacity or performance necessary to attend to the basic activities of daily living or perform routine roles.
32
Therefore, individual physiologic functions such as range of motion, muscle strength or
exercise capacity were not included. Functional status was measured by the ability to perform a functional task such as mobility or activities of daily living. Secondary outcomes: HCU was measured by the number of admissions to acute rehabilitation, readmission or nursing home placement. QOL measures are detailed in the results section. Pain was measured as part of the WOMAC scale
21,26,27
or VAS.
31
Types of studies Experimental study designs (e.g. randomized controlled trials [RCTs], non-randomized trials and quasiexperimental design) published from 1996 to March 2013 were eligible for inclusion. The dates were chosen based on the search results data obtained from the Medline Trend application.
33
Due to limited
funding support for translators, this review was limited to include only English language studies.
Search strategy The databases were searched for published and unpublished studies from 1996 to March 2013. Published studies were searched in the following databases: CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, and PEDro. Unpublished studies were searched for in OpenGrey, and ProQuest Dissertations and Theses. Additional studies were searched in the following trials registries: Australian New Zealand Clinical Trials Registry (ANZCTR), ClinicalTrials.gov and EU Clinical Trials Register. We initially used the following terms: Preoperative care Surgery Prehabilitation OR preoperative rehabilitation OR presurgical rehabilitation OR preoperative exercise* OR preoperative training Exercise* OR exercise training The final search terms used for each database are outlined in Appendix I.
Method of the review Initially, all identified studies were assessed independently by two reviewers (CC and SH) for relevance based on the title and abstract. Subsequently, the full-text versions of all potentially relevant studies were
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independently verified for study eligibility based on our inclusion criteria (i.e. experimental study, participants of ≥18 years of age, preoperative exercise interventions, outcome of interest, English language, and published between 1996 – March 2013) using the Verification of Study Eligibility form (Appendix II). Further, the references of all studies included in the verification process were also searched for additional studies. After the verification process, the selected studies underwent critical appraisal using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBIMAStARI) for experimental studies. Disagreements between the two reviewers (CC and SH) were resolved through discussion, and the third reviewer (JM).
Data collection Mean and standard deviation were extracted for functional status, QOL and pain’ and proportions were obtained for HCU using the modified JBI data extraction form for experimental studies (Appendix III). Where standard error (SE) was reported instead of standard deviation (SD), SD was calculated using this 34 formula: 𝑆𝐷 = 𝑆𝐸 × √𝑁 when necessary for pooling of results. Costing data for HCU were not extracted because this was not an outcome of interest in this review. Where studies had three treatment arms, only data from prehab and usual care groups were extracted. groups, results are presented in narrative form.
23,35
Where a study had two prehab
36
Data synthesis Where possible, study results were pooled in statistical meta-analysis using Review Manager 5.2 software.
37
Effect sizes were expressed as standard mean difference (SMD) for functional status, QOL
and pain; and odds ratio (OR) for HCU and their respective 95% confidence intervals (CI). Heterogeneity 2 of pooled studies was assessed using the I statistic and its accompanying p value. Results of the studies that could not be included in the meta-analysis are presented in narrative form. In the narrative, results are presented as mean (SD), mean (SE), or median (interquartile range or IQR) and their accompanying p values as reported in the studies.
Results Description of studies The search and study selection process is summarized in Figure 1. The search identified 3167 potentially relevant citations from published literature, unpublished literature and trial registries. After duplicates (n=107) were removed, 2953 citations were screened for potential eligibility by the two reviewers (CC and SH) based on the title and abstract. After the screening process, 2871 citations were excluded and 189 citations were retrieved and went through to the Verification of Study Eligibility
34
process.
Thirty-three studies met eligibility criteria and went through critical appraisal using JBI-MAStARI for experimental studies. Seventeen studies
21,23,25-27,29,30,35,36,38-45
met quality criteria and were therefore
included in the quantitative synthesis. Details of the included studies and their population characteristics are detailed in Appendix IV. Of the 17 RCTs, 13 studies were conducted in the orthopedic setting: 21,23,27,29,35,36,41,44,45
TKA,
26,40,43,44
THA,
and spinal surgery.
42
The TKA and THA studies were conducted in
patients with osteoarthritis. The remaining studies were conducted in the following settings: colorectal
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-2015-1885 Page 152
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surgery,
39
cardiac for participants awaiting coronary artery bypass graft,
gastrointestinal/hepatobiliary surgery.
2015;13(1) 146 - 187 30,38
and upper
25
61 CENTRAL 299 CINAHL 761 EMBASE 41 MEDLINE 174 PEDro 591 ClinicalTrials.gov 11 EU Clinical Trials Registry 569 ANZCTR 45 OpenGrey 615 ProQuest Dissertations and Theses
3167 citations identified through database searching
107 duplicates removed
3060 citations after duplicates remove
2871 citations excluded
189 citations through to verification
156 studies excluded: 3=not the target population, 3=not in English,
of study eligibility
63= not experimental study design, 87=not the intervention/outcome of interest 33 studies through to critical appraisal 16 excluded, did not meet quality criteria
17 studies included in quantitative synthesis
Figure 1: Study flow diagram
46
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Methodological quality Studies that met the eligibility criteria were subsequently appraised for methodological quality (Table 1). Disagreements regarding results of the critical appraisal were resolved with discussion and involvement of the third reviewer (JM). The methodological quality of the included studies was acceptable; however, blinding of participants was not explicit in all of the studies. A total of 16 studies were excluded: 13 studies did not meet quality criteria
47-59
and three studies had
limited information on allocation, blinding and randomization (authors were contacted to supply needed information but no responses were received).
60-62
Details of the excluded studies are presented in
Appendix V.
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Table 1: Critical appraisal of studies 1) Was the
2) Were
3) Was
4) Were
5) Were
6) Were the
7) Were
8) Were
9) Were
10) Was
assignment
participants
allocation
the
those
control and
groups
outcomes
outcomes
appropriate
to
blinded to
to
outcomes
assessing
treatment
treated
measured
measured
statistical
treatment
treatment
treatment
of people
outcomes
groups
identically
in the
in a
analysis
groups truly
allocation?
groups
who
blind to
comparable
other than
same way
reliable
used?
concealed
withdrew
the
at entry?
for the
for all
way?
from the
described
treatment
named
groups?
allocator?
and
allocation
intervention
included
?
s?
random?
FINAL
in the analysis Arthur et al.
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
INC
al.
No
Uc
Uc
Yes
Uc
Yes
Yes
Yes
Yes
Yes
EXC
et
Yes
No
Uc
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
Brown (2010)
Uc
No
No
No
No
Yes
Yes
Yes
Yes
Yes
EXC
Brown et al.
Uc
No
No
No
No
Uc
Yes
Yes
Yes
Yes
EXC
Yes
No
No
No
Uc
Yes
Yes
Yes
Yes
Yes
INC
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
EXC
Yes
Uc
Uc
Yes
Uc
Yes
Yes
Yes
Yes
Yes
INC
(2000) Back
et
(2008) Beaupre al. (2004)
(2012) Carli
et
al.
(2010) Carver et al. (2011) D'Lima et al.
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(1996) Evgeniadis et
Yes
Uc
Uc
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
Yes
No
Uc
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
Uc
Uc
Uc
No
Uc
Yes
Yes
Yes
Yes
Uc
EXC
Yes
Uc
Uc
No
Yes
No
Yes
Yes
Yes
Uc
EXC
Yes
No
Uc
Yes
No
Yes
Yes
Yes
Yes
Yes
INC
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
No
No
No
Uc
Uc
Yes
Yes
Yes
Yes
Yes
INC
Yes
No
Uc
Uc
Yes
Yes
Yes
Yes
Uc
Yes
EXC
No
No
No
No
Yes
Yes
Yes
Yes
Uc
Yes
EXC
Uc
Uc
Uc
Uc
Uc
Uc
Yes
Yes
Yes
Yes
EXC
Uc
Uc
Uc
No
Uc
Uc
Yes
Yes
Yes
Uc
EXC
Yes
No
Yes
Yes
Yes
Uc
Yes
Yes
Yes
Yes
INC
al. (2009) Ferrara et al. (2008) Gilbey et al. (2003) Gocen et al. (2004) Gstoettner et al. (2011) Hoogeboom et al. (2010) Huang et al. (2012) Jarvis et al. (2005) Keays et al. (2006) McGregor et al. (2004) McKay et al. (2012) Mitchell et al. (2005)
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Nielsen et al.
2015;13(1) 146 - 187
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
Uc
No
No
Uc
No
No
Yes
Yes
Uc
Yes
EXC
Yes
No
Uc
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
Yes
No
Uc
Yes
No
Yes
Yes
Yes
Yes
Yes
INC
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
EXC
Yes
No
Uc
No
No
Yes
Yes
Yes
Yes
Yes
INC
Uc
No
Uc
No
Uc
Yes
Yes
Yes
Yes
Yes
EXC
al.
Uc
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
Vukomanovic
Uc
No
Uc
No
Uc
Yes
Yes
Yes
Yes
Yes
EXC
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
Uc
EXC
Uc
No
No
Uc
No
Yes
Yes
Yes
Yes
Yes
EXC
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
INC
(2010) Oosting et al. (2012) Rodgers
et
al. (1998) Rooks et al. (2006) Rosenfeldt et al. (2011) Saey
(not
published) Soares et al. (2013) Swank et al. (2011) Topp
et
(2009)
et al. (2008) Walther et al. (2010) Wang et al. (2002) Williamson et
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al. (2007) INC = included; EXC = excluded; Uc = unclear
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Findings of the review Studies had different postoperative follow-up time points and prehab doses; therefore we decided to categorize our results for each outcome into: 1 month (POM1), 3 months (POM3), 6 months (POM6), and 12 months (POM12); and total prehab minutes: 60-
51
58
per
week Exercises: Progressive
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strengthening
exercises
and resistance training, and education Mitchell
et al
RCT
UK
2005
Self-reported function QOL Pain
Duration: ?≥ 8 weeks
Usual care
57
57
Frequency: minimum of
70.0
70.6
(7.2)
(8.2)
65
69
(8)
(8)
70.0(
69.6
8.79)
(10)
63.2
52.6
?
?
50
57
35.7
33.9
(9.2)
(6.5)
32.8
32.7
(5.68
(6.45
)
)
3 1-hour sessions per week Exercises: Knee flexion and
extension
techniques, gait training, and functional training. Duration: 6 weeks Rooks
et
al
RCT
USA
2006 (TKA)
Objective and selfreported function Healthcare utilization QOL Pain
Preoperative
Frequency: x3 30 to 60minute
sessions
per
15
education about falls and
injury
risk
+
telephone follow-up
week Exercises:
14
Progressive
and personalized water and
land-based
exercises, cardiovascular training, strength training, and flexibility exercises Williamson al 2007
et
Threegroup RCT
UK
Objective and selfreported function Pain
Duration: 6 weeks Frequency: one 60-min
Usual
care
exercise advise
with
60
61
52
54
sessions per week Exercises: Static
quadriceps
contractions, inner range
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quadriceps contractions, straight leg raises, sit-tostands,
stair
climbing,
calf stretches, Theraband resisted knee extensions, wobble
board
balance
training,
knee
flexion/extension on
gym
sitting
ball,
and
freestanding
peddle
revolutions. Evgeniadis
et
al 2009
Three-
Greece
Objective function QOL
group
Duration: 3 weeks
Usual care
18
20
Frequency: ?
67.1
69.4
(4.4)
(1.9)
83
70
RCT Exercises:
Warm-up,
34.7
33.4
3
6
(5.29
(4.71
)
)
32.1
32.0
6
0
(5.87
(6.09
)
)
27.4
28.2
strengthening exercises, resistance training, and cool-down Topp et al 2009
RCT
USA
Objective function
Duration:
Pain
Frequency: week
4
weeks
Usual care
26
28
x3 per
sessions
supervised/two
64.1(
63.5(
7.05)
6.68)
?
?
(one self-
directed with log-book) Exercises: resistance training, step training, and walking Gstoettner et al 2011
RCT
Austria
Objective and selfreported function Pain
Duration: 6 weeks Frequency:
one
Usual care 45-
minute session per week Exercises:
18
20
72.8
66.9(
(65-
61-
78)
75)
89
70
Warm-up,
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2015;13(1) 146 - 187
stretching, balance and strengthening
exercises
+daily
exercise
instructions Huang
et
al
RCT
Taiwan
Pain
2012
Duration: 4 weeks
Usual care
126
117
Frequency: 40 minutes
69.8
70.5(
(7.2)
7.4)
63.8
63.0
2(9.0
8(6.8
1)
9)
77
75(5)
69.8
73.5
27.1(
27.2
4.0)
(4.5)
daily Exercises: straight leg raising, ankle
knee
setting,
pumping,
hip
abduction
with
resistance,
and
strengthening exercise
Orthopedics – THA Ferrara
et
al
RCT
Italy
2008
Self-reported function QOL Pain
Duration: 4 weeks Frequency: minute
x5
sessions
Usual care
11
12
60per
63
58
?
?
70
63.6
26.0(
27.4
week Exercises: Strength and flexibility training
Hoogeboom et al 2010
RCT
Netherlands
Objective function
Duration: 3-6 weeks Frequency:
x2
Usual care 60-
10
11
(3)
minute per week Exercises:
Warm-up,
strengthening exercises, 20-30
minutes
aerobic
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-20151885 Page 182
2.6)
(4.2)
JBI Database of Systematic Reviews & Implementation Reports exercise,
2015;13(1) 146 - 187 functional
training Rooks
et
al
RCT
USA
2006 (THA)
Objective and selfreported function Healthcare utilization QOL Pain
Duration: 6 weeks
Preoperative
Frequency: x3 30 to 60minute
sessions
per
25
24
education about falls and
injury
risk
65
59
(11)
(7)
76.9(
75.0(
6.3)
6.3)
48(3
52(2
1-
3-
80)*
88)*
63
52
28.4
30.3
(5.3)
(9.1)
28.6
27.8
(5.6)
(4.2)
25
26
(21–
(17–
33)
33)
+
telephone follow-up
week Exercises:
Progressive
and personalized water and
land-based
exercises, cardiovascular training, strength training, and flexibility exercises Oosting et al
RCT
Netherlands
2012
Objective and selfreported function QOL Pain
Duration: 3-6 weeks
Usual care
14
12
Frequency: supervised – x2
93
67
30-minute sessions
per week; self-training – x4 30-minute sessions Exercises: activity
functional
training,
and
functional walking
Orthopedics - spinal surgery Nielsen 2010
et
al
RCT
Denmark
Objective and selfreported function QOL Pain
Duration: 6-8 weeks
Usual care
Frequency: 30 minutes per day
28
32
61
59
Exercises: strengthening exercises
and
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-20151885 Page 183
JBI Database of Systematic Reviews & Implementation Reports
2015;13(1) 146 - 187
cardiovascular conditioning
Cardiac - CABG Arthur
et
al
RCT
Canada
QOL
2000
Duration: >8 weeks Frequency: minute
x2
Usual care
123
123
90-
61.8(
63.8(
8.4)
7.8)
62.5(
68
12.2
17.1
?
?
22
30
?
?
supervised
sessions per week Exercises: with
Warm-up
ROM,
stretching,
aerobics (minimum of 30 minutes), cool-down and stretching + preoperative teaching Rosenfeldt et al 2011
RCT
Australia
QOL
Duration: 2 weeks Frequency:
x2
Usual care 60-
minute exercise sessions per
week,
and
30-60
60
57
5968.5)
(5877)*
*
minutes of exercises at home Exercises: exercises treadmill
aerobic e.g.
bicycle,
walking,
and
arm ergometry + mental stress reduction
Colorectal
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-20151885 Page 184
JBI Database of Systematic Reviews & Implementation Reports Carli et al 2010
RCT
Canada
Objective function
2015;13(1) 146 - 187
Duration: 3-6 weeks Frequency:
3.5
Walking
hours
breathing
and
58
54
exercises
61(1
60(1
6)
5)
58.6
57
28(6)
27(5)
58.5
55.0
(51.3
(49.3
50
44
23.6
24.2
(19.7
(21.3
–
–
–
–
63.5*
64.3)
25.9)
28.4)
)
*
recommendation
per week Exercises:
cycling,
weight-training
Upper GI/Hepatobiliary Soares
et
al
RCT
2013
Brazil
Objective function
Duration: 2-3 weeks Frequency: minute
Usual care
x2
50-
sessions
per
week Exercises: Trunk muscle upper extremity
16
stretching,
rotation,
breathing,
16
Deep
respiratory
training,
active
and
lower exercises,
walking, and relaxation. P = Prehabilitation group
TKA = total knee replacement
CABG = coronary artery bypass graft
Median(IQR)*
UC = Usual care
THA = total hip replacement
QOL = quality of life
? = unspecified
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-20151885 Page 185
JBI Database of Systematic Reviews & Implementation Reports
2015;13(1) 146 - 187
Appendix V: Summary of excluded studies 1. Bäck M, Wennerblom B, Wittboldt S, Cider A. Effects of high frequency exercise in patients before and after elective percutaneous coronary intervention. Eur J Cardiovasc Nurs. 2008:307-313 Reason for exclusion: Did not meet quality criteria. 2. Brown, K. Comparing pre- and post-surgical self-efficacy behavior changes by introducing prehabilitation exercise [PhD thesis]. University of Louisville: Kentucky; 2010. Reason for exclusion: Did not meet quality criteria. 3. Brown K, Topp R, Brosky J, Lajoie A. Prehabilitation and quality of life three months after total knee arthroplasty: a pilot study. Percept Motor Skill. 2012;115(3): 765-774. Reason for exclusion: Did not meet quality criteria. 4. Carver T, Mayo N, Andersen R, Zavorsky G. Pilot investigation to evaluate changes in exercise capacity following a prehabilitation intervention among seriously obese patients awaiting bariatric surgery. Canadian Journal of Diabetes 2011;35 (2):149. Reason for exclusion: Limited data presented in abstract – no response from author. 5. Gilbey H, Ackland T, Wang A, Morton A, Trouchet T, Tapper J. Exercise improves early functional recovery after total hip arthroplasty. Clin Orthop Relat R. 2003;408:193-200. Reason for exclusion: Unclear methodology 6. Gocen Z, Sen A, Unver B, Karatosun, Gunal I.The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial. Clin Rehabil. 2004;18(4): 353-358. Reason for exclusion: Poor reporting 7. Jarvis S, Hallam T, Lujic S, Abbott K, Vancaillie T. Peri-operative physiotherapy improves outcomes for women undergoing incontinence and or prolapse surgery: results of a randomised controlled trial. Aust Nz J Obstet Gyn. 2005;45(4):300-303. Reason for exclusion: Did not meet quality criteria. 8. Keays S, Bullock-Saxton, Newcombe P, Bullock M. The effectiveness of a pre-operative home-based physiotherapy programme for chronic anterior cruciate ligament deficiency [corrected] [published erratum appears in Phys Res Int. 2006;12(3):195]. Phys Res Int. 2006;11(4): 204-218. Reason for exclusion: Did not meet quality criteria. 9. McGregor A, Rylands H, Owen A, Dore C, Hughes S. Does preoperative hip rehabilitation advice improve recovery and patient satisfaction? J Arthroplasty. 2004;19(4):464-468.Reason for exclusion: The methods of allocation and randomization were unclear; baseline data of participants not reported. 10. McKay C, Prapavessis H, Doherty T. The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study. PM and R. 2012;4(9): 647-656. Reason for exclusion: Did not meet quality criteria.
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-2015-1885 Page 186
JBI Database of Systematic Reviews & Implementation Reports
2015;13(1) 146 - 187
11. Rodgers J, Garvin K, Walker C, Morford D, Urban J, Berdard J. Preoperative physical therapy in primary total knee arthroplasty. J Arthroplasty. 1998;13(4): 414-421. Reason for exclusion: Did not meet quality criteria. 12. Saey, D. Feasibility of a short home-based rehabilitation program for cancer patients waiting for lung resection surgery. http://ClinicalTrials.gov/show/NCT01667237 Reason for exclusion: Limited data presented – no response from author. 13. Swank A, Kachelman J, Bibeau W, Quesada P, Nyland J, Malkani A, Topp R. Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis. J Strength Cond Res. 2011;25(2): 318-325. Reason for exclusion: Did not meet quality criteria. 14. Vukomanovic A, Popovic Z, Durovic, Krstic L. The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty. Vojnosanitetski Pregled. 2008;65(4):291-297. Reason for exclusion: The methods of allocation and randomization were unclear. 15. Walther C, Fiess A, Moebius-Winkler S, Linke A, Erbs S, Schuler G, Walther T. Preoperative exercise training is associated with less peri- and postoperative adverse events but similar long term outcome in patients with stable coronary artery disease. European Journal of Cardiovascular Prevention and Rehabilitation. 2010; 17: S59-S60. Reason for exclusion: Limited data presented in abstract – no response from author. 16. Wang A, Gilbey H, Ackland T. Perioperative exercise programs improve early return of ambulatory function after total hip arthroplasty: a randomized, controlled trial. Reason for exclusion: Did not meet quality criteria.
Am
J
Phys
Med
Rehabil.
2002;
81(11):
801-806.
Cabilan et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review © the authors 2015 doi: 10.11124/jbisrir-2015-1885 Page 187