'Prehab' can help mitigate impact of delayed surgeries amid COVID-19: U of T expert

Hospitals in Ontario have been ramping down elective surgeries and other non-urgent activities in an effort to mobilize health workers in the fight against COVID-19.

The shift, although necessary to keep the health system from collapsing amid the province’s third wave of infections, has been especially difficult for patients who will not be receiving the treatments they were expecting. 

Yet, there may be steps patients can take to mitigate prolonged wait times for surgery – particularly for those patients with cancer, says Daniel Santa Mina, an assistant professor in the University of Toronto’s Faculty of Kinesiology & Physical Education (KPE).

In particular, Santa Mina – who studies the effects of health interventions prior to surgery aimed at improving surgical outcomes – cites the potential benefits of so-called “prehabilitation” for affected patients.

KPE’s Jelena Damjanovic recently spoke with Santa Mina about the strategy and how it can help.

What is prehabilitation? 

Prehabilitation is the optimization of health prior to a stressor, like surgery. It typically includes health behaviours or medical strategies that aim to improve our physical and mental well-being, which are important predictors of treatment outcomes. The fundamental concept of prehabilitation is that patients who are as healthy as they can be will have better treatment experiences – i.e. tolerance to surgery and recovery – than they would had they not invested in their health.

The current delay in surgeries is certainly not welcome news, but prehabilitation can offer health benefits and some relief in a difficult situation for health workers and patients alike.

How can prehabilitation assist people with cancer, specifically?

Much of the prehabilitation research has focused on people with cancer, given the challenging side effects of many surgeries and the requirements of additional treatment before or after surgery such as chemotherapy and radiation. The pre-operative period is also often fraught with stress and anxiety in anticipation of surgery, so ensuring that mental health is addressed during this time is particularly important. 

How can prehabilitation help with mental health?

Along with a mounting body of evidence that demonstrates the ability of exercise to reduce the risk of cancer and its recurrence, slow the growth of tumours and improve cancer-specific mortality, there is also evidence to show that exercise improves mental health by reducing anxiety, depression and negative moods. So, while prehabilitation’s main goal is to prevent or mitigate potential surgical complications, it can and should be used to manage physical and mental health before surgery.

What type of exercise is usually prescribed in prehabilitation?

There is no consensus on specific exercises that should be used for prehabilitation. However, it is widely appreciated that patients should do exercise that meets their existing exercise capacity, their preferences for exercise and availability of related exercise equipment – while paying attention to any pre-existing health conditions that could limit or interfere with exercise and, importantly, the type of surgery and its effect on local, regional and other body systems. 

In general, exercise prescriptions for or during prehabilitation are aimed at maximizing health gains and would include aerobic exercise and resistance training. We may also include common rehabilitation exercises in the pre-operative period that are known to improve very specific adverse effects for a given surgery, such as pelvic floor muscle exercises for prostate cancer surgery, breathing exercises for abdominal or thoracic cancer surgeries or shoulder exercises for breast cancer surgery. 

Are there things people can do on their own to improve their well-being as they wait for surgery?

Because prehabilitation refers to optimizing health prior to treatment, there are many things that someone waiting for surgery may be able to do on their own. Becoming more physically active and engaging in routine exercise are a great start. Similarly, a healthy diet that adheres to Health Canada’s Food Guide will support a more physically active lifestyle and also help ensure the body has the resources to manage the stress of treatments.

Finding ways to manage stress are also recommended. These may include meditation, mindfulness or yoga – and each have numerous free guided classes available online. Finally, for those who smoke, smoking cessation is a very important, albeit difficult health behaviour change. The smoker’s helpline is a free online resource that continues to operate throughout the pandemic. 

What professional support is available under the current circumstances for people looking to make these behaviour changes?

Making some of these behaviour changes may require some help. For example, if you’re not sure how to exercise safely or you’re really struggling with anxiety, you may need to see a health professional. It is important to know that health visits can be conducted virtually.

Also, while virtual appointments are recommended, patients are permitted to leave home under the current pandemic restriction to receive the services of regulated health professionals and for medical appointments, like kinesiologists, physiotherapists, dietitians, psychologists, etc.  Health services in these areas are available in many communities and may be covered by some health insurance plans.