Physical Activity Pre and Post Surgery

Benefits of Exercise Pre and Post Surgery[edit | edit source]

The effect of exercise on outcomes after surgery has been extensively studied in a number of populations. The most common populations studied are:

  • Post-hip replacement
  • Post-knee replacement
  • Post-cardiac surgery
  • Post-abdominal surgery
  • Other surgical groups such as colorectal, thoracic, post-cancer resection, vascular and urological.

Whilst the evidence is good in general terms, unfortunately, as yet there is no clear consensus on the specifics of exercise prescription pre-surgery[1].

Studies can be divided into those that look at the effect of interventions pre-operatively on post-surgical outcomes and those that look at the effect of different exercise interventions post-surgery.

What Are the General Benefits of Preoperative Exercise?[edit | edit source]

The evidence that if cardiorespiratory fitness (CRF) is measured preoperatively, it is predictive of complications in the postoperative period is compelling, with several studies demonstrating this across different types of surgeries[2][3][4][5][6][7] The measure of CRF also offers significant advantage when compared to age alone in predicting mortality after major surgery[5].

  • CRF is a significant independent predictor of length of stay in hospital with patients older than 75
  • A low CRF is associated with an average of 11 days longer in hospital and 2 days longer in critical care

Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. It also exerts beneficial effects on physical fitness and postoperative outcomes measures across various surgical fields, including cardiac surgery, orthopedic surgery, abdominal surgery, thoracic surgery, vascular surgery and urologic surgery[9]. In their scoping study, Pouwels et al (2016) conclude that more research is needed to focus on heterogeneous outcome measures, patient populations and guidelines for exercise regimes[9].

What Are the Benefits of Preoperative Exercise in Specific Populations?[edit | edit source]

Hip Replacement[edit | edit source]

In patients undergoing this surgery, significant improvements (small to moderate effect sizes) have been observed in pain, function, and length of stay with exercise interventions preoperatively. [10]

Knee Replacement[edit | edit source]

A 2014 systematic review (Chesham and Shanmugham) concluded that there is minimal evidence so far supporting education and exercise interventions pre-operatively, compared with no physiotherapy or usual care. Interventions reviewed in the 10 RCTs were preoperative exercise; combined exercise and education; combined exercise and acupuncture; neuromuscular electrical stimulation; and acupuncture versus exercise. Outcomes assessed were knee strength, ambulation, and pain. Good quality research into this is ongoing[11].

However Moyer et al (2017) in their systematic review and meta-analysis found small to moderate effect sizes for pre-rehabilitation in this population. Significant improvements were made in function, quadriceps strength and length of stay.[10]

Cardiac Surgery[edit | edit source]

A Cochrane review in 2012 found that evidence from small trials suggests that preoperative physical therapy, with an exercise component, for elective cardiac surgery patients reduces postoperative pulmonary complications and length of hospital stay. They concluded that there is a lack of evidence to effect changes to postoperative pneumothorax, or prolonged mechanical ventilation[12].

It has been known for some years that inspiratory muscle training provided pre-operatively reduces the risk of anaesthetic complications as well as reducing post-operative complications[13] as well as length of postoperative hospital stay and pulmonary function[14].

Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. A randomised control trial showed positive effects of active cyclic breathing technique and routine physiotherapy on arterial oxygenation, heart rate, and pain perception following Coronary Artery Bypass Graft (CABG) surgery[15]. A systematic review suggests that inspiratory muscle training is an effective post-operative treatment tool for patients undergoing cardiac surgery[16]. There is strong evidence that training improves inspiratory muscle strength, pulmonary function, and functional capacity and reduces patients' hospital stay.

Abdominal Surgery[edit | edit source]

O'Doherty et al (2013) in their systematic review conclude that pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. A meta-analysis and systematic review done in 2016 (Moran et al) concluded that more research was needed, but 'prehabilitation' consisting of inspiratory muscle training, aerobic exercise, and/or resistance training can decrease postoperative complications after intra-abdominal operations.[17]

Review suggests positive outcomes with preoperative exercises in bariatric surgery. However, further research concerning the exercise intervention mode, intensity, and timing before or after bariatric surgery to maximize cardiorespiratory fitness, physical function, and reducing cardiometabolic risk is required[18].

Other[edit | edit source]

Mixed Populations[edit | edit source]

A systematic review in 2010 found that preoperative exercise therapy is effective for reducing both postoperative complication rates and length of hospital stay after cardiac or abdominal surgery[19]. A Cochrane review in 2015 concluded that preoperative inspiratory muscle training reduced the incidence of postoperative pulmonary complications (such as actelectasis and pneumonia) and length of hospital stay compared with usual care in adults undergoing cardiac and major abdominal surgery[20].

Colorectal Surgery[edit | edit source]

A study on patients undergoing colorectal surgery found benefits from exercise programmes pre-operatively: improved physical function, peak exercise capacity, mental health and self-perceived health[21]

Cancer-resection surgery[edit | edit source]

A Cochrane review in 2017 found low quality evidence that preoperative exercise training may reduce some risks in those having lung resection surgery for early stage non-small cell lung cancer (NSCLC).[22]. These were- developing postoperative pulmonary complications, duration of intercostal catheter use, a reduced postoperative length of stay and improved exercise capacity and FVC post-operatively. [22]

What Are the Benefits of Post-Operative Exercise?[edit | edit source]

There is clear evidence for the following surgeries:

  • Spinal surgery - improved spinal mobility[23]
  • Total Hip and Knee Replacement surgery - earlier discharge[24]
  • Colorectal surgery - increased cardiovascular fitness[25]
  • Breast surgery - fewer side-effects[26]
  • In many surgeries: reduced risk of blood clots[27]
  • Cardiac surgery - inspiratory muscle training on length of postoperative hospital stay and pulmonary function [14]

Evidence regarding preoperative rehabilitation[edit | edit source]

A study made in London by National Institute for Health and Care Excellence ( NICE) in 2020 Jun relates : " Evidence from 8 studies reported on people who are scheduled for hip or knee replacement surgery. No evidence was found for people scheduled for shoulder replacement surgery. The evidence review found no clinically important difference between individualised preoperative rehabilitation programs and usual care through 2 quality of life outcomes, 5 PROMs outcomes and 2 pain outcomes (moderate to very low quality, range of n=36–109). Evidence indicated a clinically important benefit for individualised preoperative rehabilitation programs in terms of length of stay (4 studies, very low quality, n=531) and function (1 study, very low quality, n=33). No evidence was available for revision of joint replacement, depression, or disability."

You can find more information here. [28]

Contraindications to Exercise Pre/Post Surgery[edit | edit source]

In addition to the absolute contraindications (see the Exercise Physiology page), specific precautions will apply depending on the surgery. The treating team (Doctors, Nurses, Physiotherapists) will give the patient specific advice on this.

Resources[edit | edit source]

The Motivate2Move website, created by Wales Deanery, has a comprehensive section on surgery and exercise.

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 Doherty, AF, West, M, Jack, S and Grocott, MPW. Preoperative aerobic exercise training in elective intra-cavity surgery: a systematic review  Br J Anaesth (2013) 110 (5): 679-689
  2. Carlisle J, Swart M. (2007) Mid-term survival after abdominal aortic aneurysm surgery predicted by cardiopulmonary exercise testing. Br J Surg 94:966-9
  3. Datta D, Lahiri B. (2003) Preoperative evaluation of patients undergoing lung resection surgery. Chest 123:2096-103
  4. Hennis PJ, Meole PM,, Grocott MP. (2011) Cardiopulmonary exercise testing for the evaluation of perioperative risk in non-cardiopulmonary surgery. Postgrad Med J 87:550-7
  5. 5.0 5.1 Snowdon CP, Prentis JM, Anderson HL et al. (2010) Sub maximal cardiopulmonary exercise testing predicts complications and hospital length of stay in patients undergoing major elective surgery. Ann Surg 251: 535-41
  6. Wilson RJT, Davies S, Yates D, et al. (2010) Impaired functional capacity is associated with all-cause mortality after major elective intra-abdominal surgery. Br J Anaesth 105: 297-303
  7. West RJT, Lythgoe D, Barbara C, et al. (2014) Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study. Br J Anaesth 101:1166-72
  8. 8.0 8.1 8.2 Arthur, HM, Daniels, C et al. Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery. A randomized, controlled trial. ☀[/ Ann Intern Med.] 2000 Aug 15;133(4):253-6
  9. 9.0 9.1 [null Pouwels, Sjaak]; [null Hageman, David]; [null Gommans, Lindy N.M.]; [null Willigendael, Edith M.]; [null Nienhuijs, Simon W.]; [null Scheltinga, Marc R.]; [null Teijink, Joep A.W. Preoperative exercise therapy in surgical care: a scoping review. 2016.] J CLIN ANESTH 33: 476-490.
  10. 10.0 10.1 Moyer R, Ikert K, Long K, Marsh J. [null The Value of Preoperative Exercise and Education for Patients Undergoing Total Hip and Knee Arthroplasty: A SystematicReview and Meta-Analysis. 2017.] JBJS Rev. Dec; Vol. 5 (12), pp. e2.
  11. Ross Alexander Chesham & Sivaramkumar Shanmugam (2016) Does preoperative physiotherapy improve postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty? A systematic review, Physiotherapy Theory and Practice, 33:1, 9-30, DOI: 10.1080/09593985.2016.1230660
  12. Hulzebos EHJ, Smit Y, Helders PPJM, van Meeteren NLU. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD010118. DOI: 10.1002/14651858.CD010118.pub2.
  13. Hulzebos, EH, Helders, PJ, et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. ☀[/ JAMA.] 2006 Oct 18;296(15):1851-7
  14. 14.0 14.1 Gomes Neto M, Martinez BP, Reis HF, Carvalho VO. Pre-and postoperative inspiratory muscle training in patients undergoing cardiac surgery: systematic review and meta-analysis. Clinical rehabilitation. 2017 Apr;31(4):454-64.
  15. Derakhtanjani AS, Jaberi AA, Haydari S, Bonabi TN. Comparison the Effect of Active Cyclic Breathing Technique and Routine Chest Physiotherapy on Pain and Respiratory Parameters After Coronary Artery Graft Surgery: A Randomized Clinical Trial. Anesthesiology and Pain Medicine. 2019 Oct;9(5).
  16. Dsouza FV, Amaravadi SK, Samuel SR, Raghavan H, Ravishankar N. Effectiveness of Inspiratory Muscle Training on Respiratory Muscle Strength in Patients Undergoing Cardiac Surgeries: A Systematic Review With Meta-Analysis. Annals of Rehabilitation Medicine. 2021 Aug 30;45(4):264-73.
  17. Moran J, Guinan E, McCormick P, larkin J, Mocklet D, Hussey J, Moriartu J, Wilson F. [null Outcomes: The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: A systematic reviewand meta-analysis]. 2016 . [null Surgery]; 160(5):1189-1201
  18. Pouwels S, Sanches EE, Cagiltay E, Severin R, Philips SA. Perioperative Exercise Therapy in Bariatric Surgery: Improving Patient Outcomes. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2020 May 25;13:1813-23.
  19. Valkenet, K. et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clinical Rehabilitation, Volume: 25 issue: 2, page(s): 99-111 Article first published online: November 8, 2010;Issue published: February 1, 2011
  20. Katsura M, Kuriyama A, Takeshima T, Fukuhara S, Furukawa TA. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD010356. DOI: 10.1002/14651858.CD010356.pub2.
  21. Mayo, NE et al. Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery,  2011 Sep;150(3):505-14. doi: 10.1016/j.surg.2011.07.045
  22. 22.0 22.1 Cavalheri V, Granger C. Preoperative exercise training for patients with non-small cell lung cancer. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD012020. DOI: 10.1002/14651858.CD012020.pub2.
  23. McGregor, AH et al. Cochrane Review: Rehabilitation following surgery for lumbar spinal stenosis.
  24. Hansen, TB, Bredtoft, KH, Larson, K. Preoperative physical optimization in fast-track hip and knee arthroplasty. [/ Dan Med J.] 2012 Feb;59(2):A4381.
  25. Carli, F, et al. Randomized clinical trial of prehabilitation in colorectal surgery. [/ Br J Surg.] 2010 Aug;97(8):1187-97. doi: 10.1002/bjs.7102.
  26. Rebecca M. Speck & Kerry S. Courneya & Louise C. Mâsse & Sue Duval & Kathryn H. Schmitz An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv (2010) 4:87–100 DOI 10.1007/s11764-009-0110-5
  27. Partsch, Hugo MD Bed rest versus ambulation in the initial treatment of patients with proximal deep vein thrombosis <section> </section><section> Current Opinion in Pulmonary Medicine: [/ September 2002 - Volume 8 - Issue 5 - pp 389-393] </section>
  28. 28. Joint replacement (primary): hip, knee and shoulder, NICE Guideline, No. 157 , National Guideline Centre (UK), London: National Institute for Health and Care Excellence (NICE); 2020 Jun. ISBN-13: 978-1-4731-3722-6