Physiotherapy - Theses

Abdominal cancer surgery is the most common major surgical procedure performed in developed countries, however post-operative morbidity are high. Post-operative complications are common and associated with an increased morbidity and prolonged hospital stay whilst also contributing significant costs to the healthcare system. Prehabilitation aims to deliver interventions in the preoperative period to minimise the development of these complications and hasten recovery. The current evidence for prehabilitation for improving preoperative status is favourable, however its carry over into improvements in post-operative outcomes remain controversial and feasibility amongst high-risk patients in the real world setting unclear. An investigation into the feasibility of prehabilitation for the high-risk abdominal surgery population is needed. The studies within this thesis aimed to (1) identify, evaluate and synthesis the evidence examining the effect of prehabilitation with exercise on postoperative outcomes following abdominal cancer surgery (2) explore the acceptability of prehabilitation from the perspective of patients (3) investigate the feasibility of delivering a prehabilitation intervention to high-risk patients and (4) evaluate the current and likely future impact of a telehealth preoperative education package for patients preparing for major abdominal cancer surgery. Study 1 critically examined the literature, through a systematic review and meta-analysis, and found that multimodal prehabilitation programs were superior to unimodal programs at improving functional capacity prior to major abdominal cancer surgery as well as reducing hospital length of stay. However there was no difference in the number of postoperative complications, hospital re-admissions or postoperative mortality. Heterogeneity in the literature and a lack of consistency amongst outcome measures limited the ability to measure the effect of prehabilitation on post-operative complications. Study 2 explored the acceptability of prehabilitation from the patient perspective. Adult patients prior to major abdominal surgery were surveyed prior to the commencement of any prehabilitation program prior to major abdominal surgery. The results indicated that prehabilitation was a largely unknown concept for patients preparing for major cancer surgery. The survey found that although 82% of patients had not previously heard of prehabilitation, the majority of patients (71%) expressed interest in participating. Based on participants responses, several key recommendations for researchers, clinicians and policy makers designing prehabilitation programs in the future were developed. Results indicated that programs should be sensitive to the individual’s financial situation, recommended by treating health professionals (preferably doctors), delivered in convenient locations (preferably home) and telehealth interventions should be carefully chosen with the patient. Study 3 investigated the feasibility of a prehabilitation program, designed and conducted using the principles for high-risk patients awaiting major abdominal cancer surgery gained from Study 2. The findings showed trends to improvements in preoperative cardiorespiratory fitness. More research is needed to improve exercise fidelity reporting and adherence to exercise interventions within this complex group. Study 4 was conducted based on the findings of Study 3 to further explore the feasibility of providing a prehabilitation intervention to high-risk patients awaiting major abdominal surgery using a telehealth intervention developed to overcome distances required to travel to the hospital. Participants were delivered an online webinar consisting of six modules of prehabilitation information including the evidence behind prehabilitation, respiratory care bundle including breathing exercises and advice on oral hygiene, exercise prehabilitation, nutrition before surgery, psychological preparedness before surgery as well as pain management after surgery. Findings demonstrated that the webinar was well received, was memorable and had a positive effect on behaviour change within the two weeks after the session. Implementation within this study was examined using the RE-AIM framework and seven recommendations are provided for researchers, clinicians and/or policy makers to assist with implementation of similar programs in the future. These studies analysed the evidence for prehabilitation in the management of patients prior to major abdominal cancer surgery. Prehabilitation within this group was proposed to be feasible within the real-world setting. The evidence provided in this thesis consists of several recommendations regarding feasibility within this high-risk group that should be considered when designing and implementing prehabilitation interventions as well as for future research studies. They present an original contribution to knowledge in this area. These findings may not be generalisable to all settings and may require further research in different surgical populations, settings and healthcare systems. The literature base for prehabilitation needs to grow to fully determine its effectiveness and implementation strategies designed with patient input to maximise their impact.

Non-small cell lung cancer (NSCLC) is the fourth most commonly diagnosed cancer in males and the fourth most commonly diagnosed cancer in females in Australia. It is the leading cause of cancer-related mortality, being responsible for more deaths than breast, colorectal and prostate cancer combined. Pulmonary resection provides the best chance of a cure for patients with early stage lung cancer. However, pulmonary resection is associated with significant impairment in functional capacity along with a moderate risk of postoperative morbidity, particularly in frail or deconditioned patients. Prehabilitation is defined as “a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment that, in the perioperative setting, aims to enhance functional capacity of the individuals to enable them to withstand the stress associated with a procedure”. Prehabilitation can include a care bundle incorporating smoking cessation, diet optimization, psychosocial support and exercise, and aims to identify impairments and deliver targeted interventions that improve patient outcomes. It provides an opportunity to decrease treatment-related morbidity, increase available treatment options for patients who would not otherwise be surgical candidates and facilitate return of patients to the highest possible functional level. There is a growing body of evidence that supports prehabilitation as a means of preparing patients with newly diagnosed cancer for surgery by optimizing their health preoperatively. Enhancing a patient’s preoperative condition may help them withstand the stressors of surgery. Evidence supports the implementation of prehabilitation in the preoperative care pathway of other cancer cohorts, for example colorectal, breast and prostate cancers. Unfortunately, the evidence for the effects of prehabilitation in lung cancer has lagged behind and the use of prehabilitation (specifically the exercise component) for patients with lung cancer is now an emerging area. To date, exercise prior to lung cancer surgery has been shown to be safe and associated with improvements in functional capacity as well as postoperative morbidity (hospital length of stay) and rates of postoperative pulmonary complications), however the feasibility and acceptability of prehabilitation for patients with lung cancer is still unclear. The two studies within this thesis focus on the exercise component of prehabilitation in the context of surgical management of lung cancer in Australia.

Physiotherapy - Theses

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