Improving functional capacity and recovery:
Thoracic surgery
We identified two randomised-controlled trials (RCT) and one systematic review assessing the effects of exercise programmes on recovery and functional capacity post thoracic surgery (12-14).
66 patients undergoing lung lobectomy were randomised to either a daily supervised walking exercise programme or a control group. The programme consisted of 12 weeks of brisk walking beginning on the day following transfer to the regular ward along with weekly telephone calls until 12 weeks post discharge. Pulmonary and physical function measurements in the form of FVC% (at 3 months), FEV1% (at 3 & 6 months), and 6MWT scores (at 1, 3 and 6 months) were significantly better in the intervention cohort compared to controls (12).
Although exercise does appear to have a positive effect on such outcomes, there is variation in the prescribed intervention across studies (13). This is highlighted in a Cochrane systematic review of 8 RCTs exploring the benefits of an exercise programme following lung resection for non‐small cell lung cancer in 450 patients (14). The majority of the studies assessed the effects of combined aerobic and resistance training; one study assessed aerobic and inspiratory muscle training; and one study explored the effects of all the above plus balance training. The review concluded with moderate-to high-certainty that exercise capacity – assessed in the form of a maximal incremental exercise test or a 6MWT – and quadricep muscle force was greater in the intervention group (14).
Quality of Evidence:
Grade A (high quality). High quality systematic review and meta-analysis of RCTs.
Strength of Recommendation:
Grade 1. Strong recommendation for post-operative exercise in thoracic surgery.
Conclusion:
Although there is heterogeneity in the study interventions, there is high quality evidence that post-surgical exercise can improve functional capacity and recovery. Further research is needed to identify an optimal protocol.
References:
1. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292-8.
2. Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg. 2019;154(8):755-66.
3. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019;55(1):91-115.
4. Rogers LJ, Bleetman D, Messenger DE, Joshi NA, Wood L, Rasburn NJ, et al. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg. 2018;155(4):1843-52.
5. Medbery RL, Fernandez FG, Khullar OV. ERAS and patient reported outcomes in thoracic surgery: a review of current data. J Thorac Dis. 2019;11(Suppl 7):S976-s86.
6. Li S, Zhou K, Che G, Yang M, Su J, Shen C, et al. Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res. 2017;9:657-70.
7. Khandhar SJ, Schatz CL, Collins DT, Graling PR, Rosner CM, Mahajan AK, et al. Thoracic enhanced recovery with ambulation after surgery: a 6-year experience. Eur J Cardiothorac Surg. 2018;53(6):1192-8.
8. Castelino T, Fiore JF, Jr., Niculiseanu P, Landry T, Augustin B, Feldman LS. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: A systematic review. Surgery. 2016;159(4):991-1003.
9. Mainini C, Rebelo PF, Bardelli R, Kopliku B, Tenconi S, Costi S, et al. Perioperative physical exercise interventions for patients undergoing lung cancer surgery: What is the evidence? SAGE Open Med. 2016;4:2050312116673855.
10. Chen B, You X, Lin Y, Dong D, Xie X, Zheng X, et al. A systematic review and meta-analysis of the effects of early mobilization therapy in patients after cardiac surgery: A protocol for systematic review. Medicine (Baltimore). 2020;99(4):e18843.
11. Ramos Dos Santos PM, Aquaroni Ricci N, Aparecida Bordignon Suster É, de Moraes Paisani D, Dias Chiavegato L. Effects of early mobilisation in patients after cardiac surgery: a systematic review. Physiotherapy. 2017;103(1):1-12.
12. Chang NW, Lin KC, Lee SC, Chan JY, Lee YH, Wang KY. Effects of an early postoperative walking exercise programme on health status in lung cancer patients recovering from lung lobectomy. J Clin Nurs. 2014;23(23-24):3391-402.
13. Messaggi-Sartor M, Marco E, Martínez-Téllez E, Rodriguez-Fuster A, Palomares C, Chiarella S, et al. Combined aerobic exercise and high-intensity respiratory muscle training in patients surgically treated for non-small cell lung cancer: a pilot randomized clinical trial. Eur J Phys Rehabil Med. 2019;55(1):113-22.
14. Cavalheri V, Burtin C, Formico VR, Nonoyama ML, Jenkins S, Spruit MA, et al. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev. 2019;6(6):Cd009955.
GI surgery
Improving functional capacity and recovery:
A number of mixed quality papers looking at post-operative exercise on recovery and functional capacity were identified.
De Almeida el al., conducted a single-blinded RCT assessing the impact of early supervised twice daily post-operative exercises (such as core stability and orthostatic training, gait training, aerobic and resistance training) on the ability to walk unaided on the 5th day after major abdominal cancer surgery (13). Compared to standard postoperative care, a greater proportion of the patients achieved this primary outcome (p=0.01). Moreover, those in the early mobilization group also performed better than the usual care group on secondary outcomes, such as 6MWT, health-related quality of life, incidence, and intensity of postoperative fatigue (13). Similar improvements in recovery time – without an increase in complications, pain scores or re-admission – are seen in an RCT focussing on early mobilisation after laparoscopic colon surgery (14). These clear short-term benefits with regards to recovery time are emphasised in an RCT conducted by Le et al. (15). Recovery (based on a post-operative recovery profile questionnaire) was significantly (p=0.003) improved in 15 patients that undertook a daily walking programme following abdominal surgery compared to those that did not (15). Physical function was also improved at 1 month in the walking group (15).
While the quality of evidence is low, there also appear to be longer-term benefits from exercising post-colorectal surgery. Van Zupthen et al., conducted a prospective observational study to assess the relationship between post-operative physical activity and the recovery of physical function in patients that had undergone surgery for colorectal cancer (16). At 6 months, those patients who increased their levels of moderate to vigorous activity by at least 60 min/week were 43% more likely to recover physical function compared with those with stable activity levels (16). These benefits were seen regardless of age, stage of disease, BMI, or physical functioning before surgery. It is important to note that physical activity levels were measured using questionnaires.
While only a pilot study, 6 patients assigned to a mixed supervised/home-based exercise program for six months following laparoscopic colorectal surgery showed increased flexibility, strength of lower limbs and aerobic capacity compared to the control group at 3 months (17). This highlights the potential for improved longer-term outcomes with exercise following abdominal surgery; more insight is needed, however.
Quality of Evidence:
Grade B-C (moderate to low quality): Combination of small moderate quality RCTs and observational studies.
Strength of Recommendation:
Grade 2: Weak recommendation
Conclusion:
Although stronger quality evidence is required, there is sufficient evidence to suggest that early mobilisation and physical activity following gastrointestinal surgery can improve recovery times and functional capacity.
References:
1. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292-8.
2. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010;29(4):434-40.
3. Ni X, Jia D, Chen Y, Wang L, Suo J. Is the Enhanced Recovery After Surgery (ERAS) Program Effective and Safe in Laparoscopic Colorectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials. J Gastrointest Surg. 2019;23(7):1502-12.
4. Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg. 2005;92(11):1354-62.
5. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011;146(5):571-7.
6. Raue W, Haase O, Junghans T, Scharfenberg M, Müller JM, Schwenk W. ‘Fast-track’ multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation. Surg Endosc. 2004;18(10):1463-8.
7. Baird G, Maxson P, Wrobleski D, Luna BS. Fast-track colorectal surgery program reduces hospital length of stay. Clin Nurse Spec. 2010;24(4):202-8.
8. Ripollés-Melchor J, Ramírez-Rodríguez JM, Casans-Francés R, Aldecoa C, Abad-Motos A, Logroño-Egea M, et al. Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Colorectal Surgery: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study. JAMA Surg. 2019;154(8):725-36.
9. Ahn KY, Hur H, Kim DH, Min J, Jeong DH, Chu SH, et al. The effects of inpatient exercise therapy on the length of hospital stay in stages I-III colon cancer patients: randomized controlled trial. Int J Colorectal Dis. 2013;28(5):643-51.
10. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum. 2003;46(7):851-9.
11. Bhatt NR, Sheridan G, Connolly M, Kelly S, Gillis A, Conlon KC, et al. Postoperative exercise training is associated with reduced respiratory infection rates and early discharge: A case-control study. Surgeon. 2017;15(3):139-46.
12. Browning L, Denehy L, Scholes RL. The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Aust J Physiother. 2007;53(1):47-52.
13. de Almeida EPM, de Almeida JP, Landoni G, Galas F, Fukushima JT, Fominskiy E, et al. Early mobilization programme improves functional capacity after major abdominal cancer surgery: a randomized controlled trial. Br J Anaesth. 2017;119(5):900-7.
14. Lee TG, Kang SB, Kim DW, Hong S, Heo SC, Park KJ. Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial. Dis Colon Rectum. 2011;54(1):21-8.
15. Le H, Khankhanian P, Joshi N, Maa J, Crevensten H. Patients recovering from abdominal surgery who walked with volunteers had improved postoperative recovery profiles during their hospitalization. World J Surg. 2014;38(8):1961-5.
16. van Zutphen M, Winkels RM, van Duijnhoven FJ, van Harten-Gerritsen SA, Kok DE, van Duijvendijk P, et al. An increase in physical activity after colorectal cancer surgery is associated with improved recovery of physical functioning: a prospective cohort study. BMC Cancer. 2017;17(1):74.
17. Mascherini G, Ringressi MN, Castizo-Olier J, Badicu G, Irurtia A, Stefani L, et al. Preliminary Results of an Exercise Program After Laparoscopic Resective Colorectal Cancer Surgery in Non-Metastatic Adenocarcinoma: A Pilot Study of a Randomized Control Trial. Medicina (Kaunas). 2020;56(2).
Orthopaedic Surgery
Improving post-operative recovery and function
Despite the success of Total Knee Arthoplasty (TKA), patients often demonstrate functional, strength and mobility deficits long after surgery. These shortfalls could be related to absent or ineffective post-operative rehabilitation strategies, but there is a paucity and heterogeneity of evidence to conclude this (3-4). In 2003, the National Institute of Health declared that “there is no evidence supporting the generalised use of any specific pre-operative or post-operative rehabilitation interventions” for TKA (5).
Given the growing body of evidence highlighting the impact that different post-operative rehabilitation strategies can have on short and long-term function (6-7), Pozzi et al., conducted a systematic review of randomised controlled trials to determine the optimal rehabilitation strategies post TKA (3). Of the 19 RCTs included, 15 were ranked at least good using the PEDro classification. The majority of the studies excluded patients with co-morbidities or who suffered complications post-operatively.
The significant loss of quadricep muscle strength after a total knee replacement has a significant functional impact. In fact, quadriceps strength is the stronger predictor of functional performance following TKA (3,6,8). Unsurprisingly, compared to ‘usual care’, post-operative, exercise programs consisting of progressive strength protocols and intensive functional exercises resulted in improved functional outcomes at 12-months in terms of quadriceps strength, Timed Up and Go (TUG) and Stair Climbing Test (SCT) times and distance walked in the Six Minute Walk (6MW) test (3). The exercise program should be tailored to patient’s progress, and ideally supervised by a physiotherapist in an outpatient setting to optimise the long-term outcomes (3). Studies failed to clarify accurately, however, what ‘usual care’ consisted of.
A more recent systematic review of 18 RCTs of examined the effects of post-TKR rehabilitation and exercise* on a number of outcome measures including pain and functional performance, such as walking distance/speed and stair ascent/descent compared with controls receiving minimal physiotherapy (9). Short-term improvements in physical function were seen, albeit following a meta-analysis of few small studies (9). No significant longer-term benefits of physiotherapy or exercise intervention were identified; however, a lot of patients were lost to follow-up at 6 months (9). In contrast to the systematic review by Pozzi et al., there was no observed difference in physical function or pain outcomes between home-based or outpatient physiotherapy suggesting that focussing on a strategy that optimises patient adherence is more important.
Physiotherapist-directed rehabilitation following elective total hip replacement was found to have a positive impact on physical function in a systematic review of 5 RCTs (10). Despite the small effect size, patients with higher compliance to their exercise program saw greater improvements in function (10). There was no difference noted between unsupervised home-based or supervised outpatient-based rehabilitation.
*physiotherapy exercise and no provision; home and outpatient provision; pool and gym-based provision; walking skills and more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling.
Quality of Evidence:
Grade B (moderate quality)
Strength of Recommendation:
Grade 2: Weak recommendation
Conclusion:
Despite a lack of consistent outcome data, a progressive exercise program with a strength element could help improve post-operative recovery and function in patients undergoing hip or knee arthroplasty. Evidence suggests programs tailored to the individual could increase adherence.
References:
1. Masaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K. Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis. PLoS One. 2017;12(6):e0178295.
2. Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil. 2015;29(9):844-54.
3. Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877-92.
4. Sattler LN, Hing WA, Vertullo CJ. What is the evidence to support early supervised exercise therapy after primary total knee replacement? A systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1):42.
5. NIH Consensus Statement on total knee replacement December 8-10, 2003. J Bone Joint Surg Am. 2004;86(6):1328-35.
6. Petterson SC, Mizner RL, Stevens JE, Raisis L, Bodenstab A, Newcomb W, et al. Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort. Arthritis Rheum. 2009;61(2):174-83.
7. Bade MJ, Stevens-Lapsley JE. Early high-intensity rehabilitation following total knee arthroplasty improves outcomes. J Orthop Sports Phys Ther. 2011;41(12):932-41.
8. Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther. 2005;35(7):424-36.
9. Artz N, Elvers KT, Lowe CM, Sackley C, Jepson P, Beswick AD. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC Musculoskelet Disord. 2015;16:15.
10. Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. J Physiother. 2013;59(4):219-26.