Is “Move, Breathe, Eat and Relax” Training for Major Surgery Effective?

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To the Editor:
We congratulate Englesbe et al1 for describing their experience with starting a surgical home. The patient-centered medical home was introduced by the American Academy of Pediatrics in 1967, and the model of a surgical home is an extension of it.2 The surgical home is a physician led paradigm for care that is patient-centered and has the goals of improving clinical outcomes, care coordination, and compliance with best practices, which then results in reduced costs. In short, this involves a multidisciplinary team that focuses on risk assessment, decision making, and pre-, peri- and postoperative optimization. The days or weeks leading up to surgery is called prehabilitation, and is a long established initial part of the rehabilitation care continuum.3–5 By definition prehabilitation includes physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments.6
The surgical home described by Englesbe et al starts with an initial assessment followed by “patient training.” Four components are proposed in preparation for surgery—namely, move, breathe, eat, and relax. Although all these prehabilitation interventions make sense intuitively, there is a compelling need to verify whether they are in fact effective in improving outcomes. Moreover, it is unlikely that a “one size fits all” model will work, as the preoperative population is so diverse in terms of baseline fitness, comorbidities, diagnosis, and whether they are undergoing neoadjuvant cancer treatment interventions. Prescribing and monitoring compliance with the interventions is resource intensive, and it is crucial to better understand which patients will benefit and for which types of surgery.
For example, walking is one type of physical activity, but for walking to be a “therapeutic exercise” that improves fitness, it needs to be prescribed, dosed, and titrated appropriately. This means that if walking is the mode of exercise prescribed, then it should be quantified in the context of a structured program including a goal for intensity and frequency. Although a recent systematic review confirms that preoperative exercise training in abdominal or thoracic surgery can improve fitness, there was limited or no impact on postoperative outcomes.7 Of note, the exercise interventions were aerobic training, not simply “movement.”Therapeutic exercise should take into account not only aerobic fitness but also flexibility and strength training. Similarly, the primary goal of preoperative nutritional assessment is to evaluate physiological reserve, and intervene to promote anabolism and meet energy requirements. By integrating exercise and nutrition supplements, muscle protein synthesis can be maximized and this translates into greater strength and functional capacity. The relationship between diet and exercise and the need for both interventions to work synergistically with each other is a well-established and intensely studied paradigm in the sports medicine literature.
Implementation of these interventions must be evaluated in the context of each surgical procedure to verify whether they meet the intended goal to improve fitness in a short period, are embraced by patients and are safe. At present, there is simply no strong evidence that prescribing walking and improving general nutrition to a broad population of surgical patients impacts postoperative morbidity, indicating that more robust research needs to be carried out in addressing questions related to exercise training and nutrition strategies.
Although promoting preoperative optimization is to be commended, there is very little mention by the authors on whether their multidisciplinary approach to improve outcomes extends throughout the perioperative period. Procedure-specific, evidence-based enhanced recovery programs (ERPs) are associated with shorter hospital stays, decreased complications, lower costs, and decreased variability in processes of care across a variety of operations.
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