The Operating Theatre Journal - Journal - Page 15
Research Literature Table
Source
Sackett
Key
Level of
Findings
Purpose/Thesis
Article Type
Northgrave
Investigative –
RCT –
Level 2 –
Improvement
et al. (2020)
effects of novel
feasibility
feasibility so
in 3 of 5
prehab
no power
functional
intervention on
calculation
areas, length
Evidence
post op
recovery.
(HRQoL
secondaries)
of stay not
Utilises
improved –
reference
factors
material
considered.
from Chen
31 days to
and
initiate
Northgraves
treatment –
impact on
participation.
Chen et al.
4-week trimodal
Reanalysis
Level 2 – no
Improvement
(2017)
prehab preop
of x2 RCTs
power
in function –
intervention to
calculation
6MWT
improve or
and
results are
modify exercise
although re
an indicator.
behaviours
analysis it is
4 weeks -
only of x2
sufficient to
RCTs
modify
(HRQoL
secondaries and
behaviours.
functional
walking
Recall bias.
capacity)
Van
Multimodal
Prospective
Level 1 – a
Prospective
Rooijen et
prehab preop
RCT
prospective
but
al. (2019)
intervention –
RCT
discussion
does it enhance
and focus
post op
align to the 4
outcome.
weeks to
treatment
4-week
programme.
(HRQoL
secondaries)
pathway and
application of
6MWT and
similar.
Review of the Literature
A randomised controlled feasibility trial carried out by Northgrave
et al. (2020) investigates exercise based prehabilitation as a form
of preoperative intervention, implemented to increase individuals’
physiological reserve.
The aim is to enable a faster return of mobilisation and normal
functioning, reducing the likelihood of morbidity and resulting in
improved HRQoL postoperatively.
22 patients undergoing elective colorectal surgery were randomly split
into two groups with 11 participants respectively.
One group was allocated standardised care and the other group
received exercise prehabilitation focusing on 5 measurable exercise
tests, findings were then compared to ascertain any notable differences
between the sample. 11 patients received standardised care whilst 10
received prehabilitation, and 1 patient withdrew 2 days prior to surgery.
Conversely, the findings noted that those with standard care had a
shorter recovery stay than those who participated with prehabilitation.
The researchers discuss the likelihood that the small sample size and
external factors such as missing intervention sessions could play a part
in this conflicting result.
Some improvements were seen in 3 of the 5 tests, with notable mention
of the 6-minute walking test (6MWT), but no direct correlation to
improved postoperative outcomes were recorded.
The primary challenge identified in recruiting participants was the fasttrack pathway from diagnosis to treatment in those requiring colorectal
surgery, leading to insufficient time to take part or account for
potential pre booked arrangements or appointments. The researchers
have a set window of time to implement rehabilitation strategies,
current standards for target times in England are described as a wait
not to exceed 31 days, from decision to treat (DTT) with agreement of
treatment plan, to commencement of said plan (NHS England, 2017).
The researchers further highlight areas to be considered in planning
for a full and comprehensive trial in the future and how to ascertain a
wider and more consistent sample. Recommendations include a more
stringent participant recruitment process.
Similarly, Chen et al. (2017) steers the reanalysis of a 4-week
prehabilitation programme to enhance functional walking capacity and
the modification of behaviours related to exercise prior to surgery.
A cohort of 116 in total, 57 participants were assigned to prehabilitation
intervention while 59 participants were assigned to a matched time
control group. A control group is a method commonly used to monitor
the effect of a new treatment as it allows for clear identification of
statistical variation where an observable intervention is being measured
(Godby, 2020). However, in contrast a notable limitation of this study
was participants physical activity levels being self-reported allowing
recall bias to be prevalent. Recall bias can affect the focus, and in turn
the conclusion of a study or investigation (Althubaiti, 2016).
A baseline clinical assessment of physical reserve could be implemented
here to further strengthen the evidence and remove the potential for
inaccuracy.
The study concludes that 4 weeks is a limiting time frame, but still
suitable to successfully modify exercise behaviours. Results confirmed
that prehabilitation participation resulted in better functional walking
capacity and improved physical performance in comparison to
standard care participation. Although no direct link to post operative
improvements or outcomes are deduced or measured directly, the
researchers substantiate the positive impact of prehabilitation post
operatively in reducing morbidity and enhancing postoperative
recovery.
A prospective RCT conducted by Van Rooijen et al. (2019) includes
714 participants split evenly with group 1 receiving prehabilitation
and group 2 receiving standard care over a 4-week period. The study
considers nutritional, psychology and physiological preparation as
an essential factor in optimisation of patients undergoing colorectal
cancer surgery or resection.
This prospective study has a considerably larger participant cohort than
Northgraves et al. (2020) and Chen et al. (2017) due to the international
multi center approach employed. Although renowned as a gold standard
approach to research in health, an important consideration in larger
RCTs that has the potential to impact the results, is the variation due
to the nature of surgery and perioperative practices employed per case
(Ekhtiari et al, 2019).
The disparity may lie in many areas which impact post operative
recovery such as the surgeon performing the operation, surgical
technique and differing complex anatomy and physiology aligned to
the individual participants colorectal cancer. Still, with a clear study
population identified, a comprehensively designed prehabilitation
strategy and a well-defined measurement plan, combined with the
application of randomisation software, a credible RCT is delivered.
Northgraves et al. (2021), Chen et al. (2017) and Van Rooijen et al.
(2019) similarly illustrate, that effective prehabilitation with a
multimodal approach poses some benefit to colorectal cancer patients,
with improved physiological reserve, and increased functional capacity
demonstrated prior to undergoing surgical intervention pre operatively.
However, improvements in post operative outcomes still requires further
review, and although there is clear correlation to improved physiological
health with potential faster recovery of perioperative patients, there is
no definitive evidence at this time regarding multimodal prehabilitation
achieving this effectively or consistently.
Perhaps some limitations cannot be removed due the prevalence of
complexities in obtaining and maintaining a cohort, this is a naturally
occurring factor due to the nature of the disease and uncontrollable
external influences, exacerbated by a limited window of prehabilitation
time available for use.
Each study encompasses a psychosocial approach to their prehabilitation
intervention, by considering multimodal approaches to holistic health
improvement as opposed to a sole focus of one aspect.
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Issue 393
June
2023
15