Diseasespecific impairmentbased rehabilitation Jennifer Baima MD Jennifer Baimaumassmemorial

Disease-specific impairment-based rehabilitation Jennifer Baima, MD Jennifer. Baima@umassmemorial. org Nothing to disclose

• Colorectal – nutrition – delaying surgery worsens outcomes (absent prehab) • Lung – pulmonary function – delaying surgery may not worsen outcomes (non-small cell) • Prostate – urinary/ sexual function – May not need individualized program • Breast – shoulder pain, weakness, and limited range of motion • Head and neck – swallowing dysfunction

Measuring Improvement Timeline colorectal prostate lung head and neck

Gastrointestinal prehabilitation Reversing nutritional deficiencies and improving compliance

West, M. A. , et al. "Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. " • 6 weeks of 3 x weekly sessions on an exercise bike returns (cardiopulmonary) fitness to baseline levels after chemo surgery chemotherapy radiation

Cho, Haruhiko, et al. "Matched Pair Analysis to Examine the Effects of a Planned Preoperative Exercise Program in Early Gastric Cancer Patients with Metabolic Syndrome to Reduce Operative Risk: The Adjuvant Exercise for General Elective Surgery (AEGES) Study Group. " • Matched pair analysis of 4 week preoperative exercise (aerobic, resistance, stretching) with no serious adverse events • Decreased volume of visceral fat • Postoperative complications in 5. 5% vs 40. 7%

Gillis, Chelsia, et al. "Prehabilitation versus Rehabilitation: A Randomized Control Trial in Patients Undergoing Colorectal Resection for Cancer. " • Trimodal intervention – dietician, kinesiologist, and psychologist on home-based interventions • RCT with two groups: – Prehab (38 patients) = 4 weeks before and for 8 weeks post-op – Rehab (39 patients) = 8 weeks post-op only

• Preop: improvement in 6 MWT by average of 25. 2 m vs decline of 16. 4 m in rehab group • 4 weeks post: both groups < 20 m below baseline • 8 weeks post: prehab group above baseline and rehab group below baseline

25. 2 m increase preop offsets 21. 8 m decline postop for a net gain

Gastrointestinal impairments • Abdominal weakness • Chest weakness/atelectasis • Fatigue

Lung prehabilitation improving pumonary function and changing treatment options

High prevalence of COPD (left) Total oxygen intake of muscles during low level exercise

Morano MT et al. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. • Prehab pilot vs incentive spirometry without IMT • Warm up and cool down • 1. Upper limb- 15 reps per minute of diagonal movements • 2. Lower limb- treadmill walking- 10 min 1 st week, 20 min 2 nd week, 30 min 3 rd week, 30 min 4 th week • 3. Inspiratory muscle training- inhaling through the mouth against pressure

Rodriguez-Larrad, Ana, et al. "Perioperative physiotherapy in patients undergoing lung cancer resection. " • 8 studies of 599 patients: two preoperative, four postoperative, and two that started preoperatively and continued • Prognosis is related to preoperative performance on exercise testing • Presurgical time period is most crucial in changing exercise performance

Timeline and heterogeneity • 5 sessions per week for 4 weeks of aerobic exercise • 14 sessions per week for one week of aerobic exercise • 14 -21 sessions per week of physical therapy for one week before surgery and until discharge • 35 sessions per week of independent noninvasive pressure support ventilation for one week before surgery to three days after

Lung impairments • Cardiopulmonary dysfunction • Respiratory muscle weakness/ atelectasis • Fatigue

Prostate prehabilitation Preventing pelvic floor dysfunction and overcoming changing hormones Presentation Title 17

Bernardo-Filho, Mario, et al. "The Relevance of the Procedures Related to the Physiotherapy in the Interventions in Patients with Prostate Cancer: Short Review with Practice Approach. " • Physiotherapy is effective before and after treatment • Urinary incontinence – Internal sphincter deficiency – Bladder dysfunction • Erectile dysfunction 05 December 2020 Presentation Title 18

• Unique functions of pelvic floor muscles • Biofeedback, electrotherapy, external vacuum devices • 29%-97. 5% rate of ED after radical prostatectomy • Psychotherapy; sex therapy; oral, intraurethral, or intracavernosal pharmacologic agents; and surgery 05 December 2020 Presentation Title 19

• Decrease of postoperative complications in patients who have undergone prehab • Improvement not observed until exercises are done after surgery • Taught and practiced for at least 3 weeks for UI and 3 months for ED 05 December 2020 Presentation Title 20

Bruun, D. M. , et al. "“All boys and men can play football”: A qualitative investigation of recreational football in prostate cancer patients. " • 50% undergo androgen deprivation • Unlike male colorectal and lung cancer patients, do not change behavior at diagnosis • 12 weeks of supervised football increases exercise compliance • Access to professionals and accountability 05 December 2020 Presentation Title 21

Genitourinary impairments • Urinary dysfunction • Sexual dysfunction • Fatigue

Breast prehabilitation Preventing shoulder problems and lymphedema

Sagen, Aase, et al. "Upper Limb Physical Function and Adverse Effects After Breast Cancer Surgery: A Prospective 2. 5 -Year Follow-Up Study and Preoperative Measures. " Type of surgery ALND SLNB arm lymphedema 17% (only affected side) shoulder abduction- increase 6% provoked pain 3% Grip strength reduction 2% 12% decrease 50%

Martins Da Silva RC, Rezende LF. Asessment of impact of late postoperative physical functional disabilities on quality of life in breast cancer survivors. Tumori 2014 Jan-Feb: 100(1): 87 -90 • 4 -5 years after ALND • Limited ipsilateral shoulder flexion, external rotation, and abduction range of motion • Negative impact on functional capacity and global quality of life • 28% had lymphedema

NIH Clinical Center Program Springer BA et al. Preoperative assessment enables early diagnosis and recovery of shoulder function in patients with breast cancer. Breast Cancer Research and Treatment 26

Breast prehab study • Prehabilitation intervention: 3 exercises – Codman’s exercise – Scapular squeezes – Reach for the pillow - 3 sets of 10 daily in the one to four weeks prior to surgery • Eval pain and range of motion before surgery, 1 month postoperative, and 3 months postoperative

Courneya, K. S. , et al. "Subgroup effects in a randomised trial of different types and doses of exercise during breast cancer chemotherapy. " British journal of cancer (2014). • Metabolic vs “cancer” variables • Dose response: Elevated BMI moderates the effect of exercise during chemotherapy in breast cancer, but self-reported exercise baseline does not – 25 -30 minutes of aerobic – 50 -60 minutes of aerobic and resistance

Cerulli, Claudia, et al. "Therapeutic Horseback Riding in Breast Cancer Survivors: A Pilot Study. " The Journal of Alternative and Complementary Medicine 20. 8 (2014): 623 -629. -10 of 20 women > 6 months after breast cancer treatment -VO 2 max, strength including shoulder press, and FACIT-F after 16 weeks of equine-assisted therapy

Breast Cancer Impairments • Range of motion of shoulder • Bone/ joint pain from aromatase inhib. • Chemo-induced neuropathy • Lymphedema • Sexuality 30

Head and neck cancer Preventing swallowing and speech dysfunction

Cavalot AL et al. The importance of preoperative swallowing therapy in subtotal laryngectomies. Otolaryngology–Head and Neck Surgery (2009) 140, 822 -825 • 47 subtotal laryngectomy patients • The average time to swallowing resumption was 27. 76 days for the 25 patients who received ST only after surgery, and 16. 38 for the 22 patients who underwent ST both before and after surgery.

Impairments in HNC Impairment Prevalence (%) Ingestion 75 Articulation 67 Taste 66 Voice 61 Pain 59 Structure of head and neck 82%

Prehabilitation clinical trials and clinical care Compliance – Accountability – Access to health care professionals – Able to do it