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Perioperative exercise training in elderly subjects

https://doi.org/10.1016/j.bpa.2011.07.003Get rights and content

The association between physical fitness and outcome following major surgery is well described – less fit patients having a higher incidence of perioperative morbidity and mortality. This has led to the idea of physical training (exercise training) as a perioperative intervention with the aim of improving postoperative outcome. Studies have started to explore both preoperative training (prehabilitation) and postoperative training (rehabilitation). We have reviewed the current literature regarding the use of prehabilitation and rehabilitation in relation to major surgery in elderly patients. We have focussed particularly on randomised controlled trials, systematic reviews and meta-analyses. There is currently a paucity of high-quality clinical trials in this area, and the evidence base in elderly patients is particularly limited. The review indicated that prehabilitation can improve objectively measured fitness in the short time available prior to major surgery. Furthermore, for several general surgical procedures, prehabilitation using inspiratory muscle training may reduce the risk of some specific complications (e.g., pulmonary complications and predominately atelectasis), but it is unclear whether this translates into an improvement in overall surgical outcome. There is clear evidence that rehabilitation is of benefit to patients following cancer diagnoses, in terms of physical activity, fatigue and health-related quality of life. However, it is uncertain whether this improved physical function translates into increased survival and delayed disease recurrence. Prehabilitation using continuous or interval training has been shown to improve fitness but the impact on surgical outcomes remains ill defined. Taken together, these findings are encouraging and support the notion that pre- and postoperative exercise training may be of benefit to patients. There is an urgent need for adequately powered randomised control studies addressing appropriate clinical outcomes in this field.

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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