The weeks leading up to a major surgery can be a time of uncertainty and worry for patients, many of whom anticipate the need for rehabilition to get back on their feet. But if patients improve their physical and mental health prior to surgery, a process called prehabilitation or prehab, they can reduce the risk of complications afterward.
The problem is that many patients, even when directed to change their diet, increase their physical activity and get plenty of sleep, fail to make significant changes before surgery.
A new study by Stanford Medicine researchers finds that a personalized prehab coaching program focused on nutrition, physical activity, cognitive training and mindfulness can motivate patients, enhance their immune system and result in fewer complications.
"Even though it's recommended by physicians, to actually have patients do it, and have compliance and adherence to these prehabilitation programs, is quite difficult," said Brice Gaudilliere , MD, PhD, professor of anesthesiology, perioperative and pain medicine, who is one of the senior authors of the study to publish Nov. 12 in JAMA Surgery.
The study suggests patients will prehabilitate more successfully if they have a little one-on-one help. Not only were the coached patients physically and mentally stronger right before surgery, their immune cells were in better shape to respond to injury and infections.
"It emphasizes how personalizing the prehab program enhances adherence, which results in a larger immune-modulatory effect and improves pre- and post-operative clinical outcomes," Gaudilliere said.
Training for surgery
For decades, physicians have been recommending ways to boost a patient's physical, nutritional and psychological condition before surgery.
That's because undergoing a major operation takes an extraordinary toll on the body, not unlike getting in the ring with Mike Tyson or running a marathon.
"You would never run a marathon without training for it," said Cindy Kin , MD, associate professor of surgery and a senior author of the study.
"You can think of prehab as a way to train — not just your physical resilience, but also your immunological, neurocognitive and psychological state, to really prepare for this major trauma of surgery," Gaudilliere said.
The true impact of prehabilition, however, has been difficult to gauge because the types of programs, the degree of personalization and guidance, as well as the patients and surgeries involved are so variable. Nor is there a good understanding of the biological mechanisms by which prehab confers its benefits.
Getting personal
The new study is a randomized controlled trial designed to compare a standard prehab program — like the ones many hospitals provide today — with a personalized prehab program that includes twice-weekly coaching. Because surgery triggers a powerful immune response that plays a central role in recovery (helping with infection control, wound healing and functional recovery), the researchers' main goal was to understand how prehabilitation programs influence a patient's immune system before surgery.
The participants were adult patients at Stanford Health Care who were, on average, four to five weeks away from a major surgery. Many were abdominal surgeries for cancer or gastrointestinal conditions.
The standard prehab group received a booklet with guidance on physical exercise, including strength and cardio exercises of different levels; nutritional recommendations based on a Mediterranean-style diet; stress reduction with a mindfulness technique; and cognitive training with a brain training app.
The personalized prehab group received one-on-one remote coaching sessions twice a week, one with a physical therapist who specialized in exercise, and the other with a physician, who focused on nutrition, cognition and behavioral strategies. Though the content was similar to the standard prehab program, the personalized version was tailored to an individual's abilities and progress.
Patients were given nutritional advice and recipes, for instance, based on photos and videos of what they had in their kitchen.
Out of 27 patients assigned standard prehab, 11 experienced moderate-to-severe post-operative complications within 30 days of surgery. Of the 27 patients assigned prehab with personalized coaching, four experienced moderate-to-severe post-operative complications.
Perhaps tellingly, the personalized prehab program was well received by patients, which translated into better adherence. They liked the convenience of the remote format and the human connection in a time of high stress.
"Patients really want a personalized program," Kin said. "They wanted us to have their data and use it to direct the prehab care they were receiving."
Profound changes
The patients took physical and cognitive tests before starting prehab and again before their surgery. Those in the personalized group improved significantly on every test of physical and cognitive fitness, whereas those in the standard group improved only on a test of walking distance.
Moreover, the researchers discovered immunological changes that parallelled these effects.
"When we started measuring how these interventions change a patient's immune system, that's when things got really exciting," Gaudilliere said.
Using sophisticated techniques, the researchers surveyed the immune cells from a patient's blood sample and evaluated the function of individual cells, even simulating the molecular conditions of surgery in a test tube to see their response. They observed profound changes in the personalized prehab group, including less over-reactivity in certain immune cells and a lower level of baseline inflammation.
"From prior studies, we know that people who get an infection after surgery are those who have an abnormally high innate immune response before surgery, so they're in an overly inflammatory state," Gaudilliere said. The heightened state can paradoxically result in a less efficient immune response to pathogens.
Personalized prehab also appeared to normalize adaptive immune responses in certain T cells that have been linked to post-surgical cognitive decline, which affects up to half of patients after major surgery, said Franck Verdonk, MD, PhD, a senior author of the paper and a former research fellow in Gaudilliere's lab.
Such significant changes to the immune system were surprising, the researchers said, especially as they resulted from a low-cost, non-pharmacological intervention that patients can do at home and has no side effects.
"It's a measurable effect that you would expect from a pharmacological intervention, honestly," Gaudilliere said.
"I think it's really impressive as a response," Verdonk said. "It's not so much work, and it has a huge impact."
A teaching moment
The researchers hope personalized prehab will become more widely available, but that will take time and resources. For now, the next step is to identify patients who would benefit the most from such intensive support, Kin said.
For those preparing for surgery on their own, she suggests starting with one tiny habit — any behavior that improves nutrition, exercise or sleep. "If I had to choose one thing, it would probably be exercise," she said.
When delivered effectively, prehab can transform a period of anxious waiting into an opportunity to inspire long-term change.
"It's a very powerful teaching moment when patients are facing an operation and they're fearful," Kin said. "To have something they can do at home to prepare and then have it actually work, I think that contributes to their ability to continue those healthy habits after surgery."
The lead authors of the study are Amelie Cambriel , MD, a postdoctoral scholar in anesthesiology, perioperative and pain medicine; Amy Tsai , MD, a resident in general surgery; and Benjamin Choisy, MD, a former visiting medical resident in the Gaudilliere lab.
A researcher from the Centre Hospitalier Universitaire de Brest in France contributed to the work.
The study received funding from the National Institutes of Health (grant 1R35GM137936); the Fondation des Gueules Cassées; the Philippe Foundation; the Société Française d'Anesthésie-Réanimation; the Stanford Department of Anesthesiology, Perioperative and Pain Medicine; the Stanford Center for Human Systems Immunology; and the Stanford Department of Surgery.
