13Perioperative exercise training in elderly subjects
Introduction
The benefits of activity and exercise across a broad spectrum of medical conditions are widely recognised for both the general population1, 2 and, specifically, amongst the elderly.3 Recently, the association between physical fitness and outcome following major surgery has been harnessed in the use of cardiopulmonary-exercise-derived variables as a means of predicting risk, and thereby guiding management, in patients undergoing major surgery.4 However, the benefits of exercise training before, or immediately after surgery, are less well explored, particularly in older patients. There is a nascent literature in this area suggesting that, notwithstanding the time constraints imposed by the surgical timetable, exercise training may provide benefit in this patient group. In the context of surgery, training interventions can be divided into preoperative training or ‘prehabilitation’”, defined as ‘the process of enhancing the functional capacity of the individual to enable him or her to withstand a stressful event’,5, 6 and postoperative training or ‘rehabilitation’, defined as ‘a treatment or treatments designed to facilitate the process of recovery from injury, illness and disease’7 Here, we review the published literature relating to exercise training around the time of major surgery with particular focus on older patients. We concentrate on randomised controlled trials, systematic reviews and meta-analyses and attempt to address several key questions: Can pre- and postoperative exercise training improve fitness? Does any improvement in fitness translate into an improvement in outcome? Do older patients benefit from this approach? What are the key elements of perioperative training interventions – modality, frequency, duration, intensity and pattern?
Section snippets
Activity, exercise and ageing
Inactivity increases with age. Although it is reported that a large percentage of the general population undertake some form of daily activity, it is thought that only 30% of those aged over 65 years achieve this goal.8 This lack of adherence to the published recommendations for regular exercise in an ageing population is of concern because of the implications for long-term health.8 Regular exercise has long been considered a therapeutic modality; however, the benefits of physical exercise were
Exercise and outcome following major surgery
Surgical intervention has almost doubled in both men and women aged over 75 years in the last two decades24 and there is significant mortality and morbidity in this age group.25 Since the first observations by Older and colleagues that low fitness levels were associated with an increased mortality rate in elderly patients following general surgery,26 many studies have replicated this observation. Whilst the predictive utility of exercise-testing-derived variables remains a subject of
Effect of preoperative inspiratory muscle training on postoperative complications after cardiac or major vascular surgery
Four randomised controlled studies used inspiratory muscle training (IMT) as the intervention in high-risk elderly patients prior to AAA surgery45 or coronary artery bypass grafting (CABG).46, 47, 49 The authors advocate the use of this form of training as they hypothesise that respiratory muscle weakness following surgery may lead to postoperative morbidity and predominately pulmonary complications. The idea underpinning the use of resistive training in the elderly is that there is progressive
Effect of preoperative physical training on postoperative outcomes after hip and knee replacement surgery
Seven studies used physical training prior to hip56, 72 or knee replacement50, 51, 52, 53 surgery. One study included both hip and knee replacement populations.54 Outcome measurements included surgical specific questionnaires, generic HRQL and well-being questionnaires and physical activity and motion. In four out of the seven studies, length of hospital stay was also a study endpoint. These studies used different treatment modalities; which included leg and upper extremity strengthening,
Discussion
This article has summarised the current literature on perioperative exercise training, with particular focus on systematic reviews, meta-analysis and randomised controlled trials. The main findings are that there is no consistent pattern of exercise modality, intensity or duration. Most of these studies used HRQL, fitness levels and fatigue as primary outcome measurements. Only a minority of studies used clinically important surgical outcomes (e.g., morbidity or mortality) as a primary
Conclusion/Summary
The implementation of a pre-surgical exercise programme termed ‘prehabilitation’ to improve patient fitness levels, functional capacity, quality of life and reduced mortality and morbidity is an attractive concept. There are few high-quality clinical trials in this area, and the evidence base in elderly patients is particularly limited. The overall summary in both prehabilitation and postoperative rehabilitation studies is that there is encouraging emerging data that exercise training leads to
Funding
None.
Conflict of interest
None.
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2021, Annals of Physical and Rehabilitation MedicineFrom preoperative assessment to preoperative optimization of frail older patiens
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2019, Anesthesiology ClinicsCitation Excerpt :Multimodal prehabilitation programs typically address 2 or more of 3 primary components: exercise, nutritional interventions, and cognitive-behavioral interventions (Fig. 2).2,26 First published in 1993 by Older and colleagues,37 the association of low preoperative fitness levels with higher morbidity and mortality after major surgery has been validated by several publications.12,30,38,39 This consideration is important for older adults because more than 60% of individuals more than 65 years of age do not meet recommended daily activity guidelines.32
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