Commentary: Key Aspects of Multimodal Prehabilitation in Surgical Patients With Cancer. A Practical Approach to Integrating Resistance Exercise Programmes.

Surgical prehabilitation aims to optimise patients' physiological reserves to better withstand the stress of surgery, reduce the risk of postoperative complications, and promote a faster and optimal recovery. The purpose of this commentary is to outline the key aspects of prehabilitation before surgery for cancer which seem to impact its effectiveness and wider implementation. Particular attention is paid to the role and integration of resistance training programmes as a key component of multimodal prehabilitation for patients with cancer. We firstly analyse some of the barriers currently hindering the implementation of prehabilitation programmes in the National Health Service (United Kingdom). Later, we describe essential aspects of resistance training design, such as exercise modality and order execution, volume and intensity, rest periods between sets or exercises, and workout frequency. Furthermore, we propose a methodology to use the perception of effort to control patients' progression during a prehabilitation programme.

Cost Analysis of a Digital Multimodal Cancer Prehabilitation.

INTRODUCTION: There is growing evidence that prehabilitation programmes effectively improve the physical and psychological conditions of cancer patients awaiting treatment. During the pandemic, people with cancer were classed as vulnerable. To reduce risk to this population Kent and Medway Prehabilitation service transformed into a TeleHealth format. The aim of this study is to assess the impact on health-related quality of life (HRQoL) and the costs of a digital multimodal prehabilitation programme. METHODS: HRQoL was measured with the EQ-5D and quality-adjusted life years (QALYs) were calculated. Costs of the prehabilitation service and inpatient care were calculated. Comparisons were made between different levels of prehabilitation received. RESULTS: A sample of 192 individuals was included in the study Mean HRQoL improved from 69.53 at baseline to 85.71 post-rehabilitation, a 23% increase. For each additional week of prehabilitation care in cancer patients, the model predicts that the total QALYS increase by 0.02, when baseline utility is held constant. CONCLUSIONS: Prehabilitation is associated with improved HRQoL and QALYs. Our model of a multimodal digital prehabilitation program can be beneficial for patients and reduce costs for healthcare facilities even when the patients attend only a few sessions.

Understanding Patients' Experiences and Perspectives of Tele-Prehabilitation: A Qualitative Study to Inform Service Design and Delivery.

BACKGROUND: Tele-prehabilitation is a behaviour change intervention that facilities the modification of unhealthy lifestyle behaviours. Understanding patients' experiences of tele-prehabilitation provides important insights into service improvement. In this study, we aimed to describe our patients' perceptions of tele-prehabilitation and capture their capabilities, opportunities, and motivations to participate. This was a qualitative study to inform our service design and delivery. METHODS: Following purposive sampling, 22 qualitative semistructured interviews were conducted with patients in the community that had completed tele-prehabilitation. Interviews were recorded and transcribed. Deductive content analysis was used to map the identified themes against theoretical determinants of health behaviour change. RESULTS: We conducted 22 interviews. Our patients described their overall experience of tele-prehabilitation as positive and provided important insights that impacted their capabilities, opportunities, and motivations to engage with our service. Our team provided them the capabilities and self-efficacy to engage by personalising multimodal plans and setting goals. The remote delivery of our service was a recurring positive theme in providing flexibility and widening accessibility to participation. A missed opportunity was the potential for peer support through shared experiences with other patients. Patients showed greater motivation to participate for immediate perioperative benefit compared to long-term health gains. CONCLUSION: Patients' experiences and perspectives of tele-prehabilitation can be enhanced by incorporating the findings from this qualitative study into service redesign and delivery. We recommend: (1) applying holistic principles in care and goal-setting, (2) delivering a combination of home-based and in-centre programmes, and (3) engaging with patients at the start of their cancer journey when they are most motivated. In turn, this can result in more effective uptake, improve adherence to interventions, and greater satisfaction.

The Feasibility and Effects of a Telehealth-Delivered Home-Based Prehabilitation Program for Cancer Patients during the Pandemic.

Patients awaiting cancer treatment were classified as "vulnerable" and advised to shield to protect themselves from exposure to coronavirus during the pandemic. These measures can negatively impact patients. We sought to establish the feasibility and effects of a telehealth-delivered home-based prehabilitation program during the pandemic. Eligible patients were referred from multiple centers to a regional prehabilitation unit providing home-based prehabilitation. The enrolled patients received telehealth-delivered prehabilitation prior to surgery and/or during non-surgical cancer treatment, which included personalized training exercises, dietary advice, medical optimization therapies, and psychological support. The primary outcome was to investigate the feasibility of our program. The secondary outcome was to investigate the relationship between our program and patient-reported outcomes (PROs). The patients completed two questionnaires (the EQ-5D-3L and the FACIT-Fatigue Scale) pre- and post-intervention. A total of 182 patients were referred during the study period. Among the 139 (76%) patients that were enrolled, 100 patients completed the program, 24 patients have still to complete, and 15 have discontinued. A total of 66 patients were able to return completed questionnaires. These patients were recruited from colorectal, urology, breast, and cardiothoracic centers. The patients significantly improved their self-perceived health (p = 0.001), and fatigue (p = 0.000). Home-based prehabilitation is a feasible intervention. The PROs improved post-intervention.

The Feasibility of Prehabilitation as Part of the Breast Cancer Treatment Pathway.

BACKGROUND: There is compelling support for implementing prehabilitation to optimize perioperative risk factors and to improve postoperative outcomes. However, there is limited evidence studying the application of multimodal prehabilitation for patients with breast cancer. OBJECTIVE: To determine the feasibility of multimodal prehabilitation as part of the breast cancer treatment pathway. DESIGN: This was a prospective, cohort observational study. Breast cancer patients undergoing surgery were recruited. They were assigned to an intervention or control group according to patient preference. SETTING: UK prehabilitation center. PARTICIPANTS: A total of 75 patients were referred during the study period. Forty eight patients (64%) did not participate; 20 of those opted to be in the control group. Twenty four patients engaged with prehabilitation and returned completed questionnaires. In total, 44 patients were included in the analysis. INTERVENTIONS: The program consisted of supervised exercise, nutritional advice, smoking cessation, and psychosocial support. OUTCOME MEASURES: Feasibility was determined by the center's ability to deliver the program. This was measured by the number of patients who wanted to access the service, compared with those able to. Service uptake, patient satisfaction, and project costs were recorded. Patient-reported outcomes (PROs) and the use of healthcare resources were also evaluated. RESULTS: A total of 61 patients (81%) wanted to participate; 24 (32%) were able to partake and return questionnaires. Reasons for nonparticipation included surgery within weeks, full-time commitments, and transportation difficulties. A total of 25 (93%) prehabilitation patients recorded high satisfaction with the program. There was a significant reduction in anxiety among prehabilitation patients. There were no significant improvements in the other PROs. There were no changes to hospital length of stay, readmissions, and complications. CONCLUSIONS: Multimodal prehabilitation is a feasible intervention. Logistical challenges need to be addressed to improve engagement. These results are limited and would require a larger sample to confirm the findings. Work on a thorough cost-benefit analysis is also required.

Effects and feasibility of a prehabilitation programme incorporating a low-carbohydrate, high-fat dietary approach in patients with type 2 diabetes: A retrospective study.

BACKGROUND AND AIMS: We performed a retrospective study of diabetic patients undergoing a targeted multimodal prehabilitation programme to assess changes in their diabetic control and functional capacity prior to surgery. As part of the programme, patients were encouraged to follow a low-carbohydrate, high-fat (LCHF) dietary approach. We aimed to assess the feasibility and effects of this programme on our cohort of patients. METHODS: From 79 patients attending prehabilitation, 17 (13 males, age (median [interquartile range]): 71 [63-79] years) had Type 2 diabetes and none had Type 1. Patients had undergone a targeted multimodal prehabilitation programme prior to surgery, which comprised supervised exercise sessions (aerobic or resistance training), nutritional education (LCHF suggestion, correct protein intake, and avoidance of processed food), psychological support and medical optimization. Weight, body mass index (BMI), glycosylated haemoglobin (HbA1c), fasting glucose, and functional capacity were measured prior to and after prehabilitation. Data were compared with a Wilcoxon signed-rank test. RESULTS: There were significant improvements in HbA1c (P = 0.000), fasting glucose (P = 0.006), weight (P = 0.002), and BMI (P = 0.002). There were no significant improvements in functional capacity. CONCLUSIONS: We have shown that in the preoperative period, a targeted multimodal prehabilitation programme incorporating a LCHF diet improves diabetes control in patients with T2D awaiting elective surgery. Our approach is novel as a LCHF diet has not previously been utilized in patients with diabetes within this context. Prospective studies are required in the context of post-operative outcomes.

Validity and reliability of a novel optoelectronic device to measure movement velocity, force and power during the back squat exercise.

This study analysed the validity and reliability of a new optoelectronic device (Velowin) for the measurement of vertical displacement and velocity as well as to estimate force and mechanical power. Eleven trained males with Mean (SD) age = 27.4 (4.8) years, completed an incremental squat exercise test with 5 different loads (<30-90% of their 1-repetition maximum) while displacement and vertical velocity of the barbell were simultaneously measured using an integrated 3D system (3D motion capture system + force platform) and Velowin. Substantial to almost perfect correlation (concordance correlation coefficient = 0.75-0.96), root mean square error as coefficient of variation ±90% confidence interval ≤10% and good to excellent intraclass correlation coefficient = 0.84-0.99 were determined for all the variables. Passing and Bablock regression methods revealed no differences for average velocity. However, significant but consistent bias were determined for average or peak force and power while systematic and not proportional bias was found for displacement. In conclusion, Velowin, in holds of some potential advantages over traditionally used accelerometer or linear transducers, represents a valid and reliable alternative to monitor vertical displacement and velocity as well as to estimate average force and mechanical power during the squat exercise.