Contributions to the literature
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Prehabilitation is a new care pathway aiming to make patients fit for an upcoming surgery. Frail patients might particularly benefit from prehabilitation.
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To support future implementation of prehabilitation for frail patients, this realist review looked at what works, for whom, in what circumstances and why based on the existing literature in the field.
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A total of 34 documents were found and used to create refined programme theories on the facilitators and barriers to implementation.
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Based on the review’s findings, we present evidence-based recommendations for stakeholders seeking to implement prehabilitation for frail surgical patients, adding to the existing literature at a meta-level.
Background
Rationale for review
Methods
Realist review design
Development of preliminary programme theories
Searching processes
Selection and appraisal of documents
Inclusion criteria | |
P – population | Frail patients who had to undergo surgery; prehabilitation patients had to include frail individuals; term frail/frailty had to be used in the article, or a structured/standardised frailty assessment had to be conducted, e.g., concept of frailty by Fried et al. [27] |
I – intervention | Prehabilitation programme |
C – comparator | Experimental studies could include a comparison group, but this was not a condition of inclusion. Observational studies and other article types did not have to include a comparison group. |
O – outcomes | Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care. These can be considered from different perspectives such as the patients, the surgeons, the institutions, or the therapists carrying out the prehabilitation programme. |
S – study design | No restriction on study design, includes non-empirical sources, or publication type, i.e., grey literature like dissertations, opinion papers etc. |
H – healthcare context | Any healthcare setting that provides prehabilitation to frail patients, including ambulatory, inpatient, or partially inpatient, or community settings. Home-based interventions, including tele-medical interventions, were also included. |
Exclusion criteria | |
- Publication language other than English or German - Study registration records and other documentation (e.g., conference abstracts) of ongoing studies on the (cost-)effectiveness and/or safety of prehabilitation - Programmes that were comprised of medication or supplement intake only as well as mere educational programmes - Prehabilitation programmes prior to chemotherapy or other non-surgical interventions - Articles were excluded if they did not contain information that hints at challenges, problems, supportive or helpful factors for the implementation of prehabilitation programmes for frail patients |
Data extraction
Analysis and synthesis
Relevance and rigour of the included literature
Results
Preliminary programme theories
Search results
Document characteristics
References | Document type (study design) | Location | Study Period | Sample Size | Sample Characteristics | Disease Focus | Surgery Type | Frailty Assessment | Description of prehabilitation |
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Afilalo [31] | Review article | n.a. | n.a. | n.a. | n.a. | Cardiac disease | Different types | Not defined | Not defined |
Study article (qualitative study) | Netherlands | April 1, 2017 – May 1, 2018 | 37 | 15 patients, 13 informal caregivers, 9 healthcare professionals | Colorectal cancer | Colorectal cancer surgery | comorbidity (Chronic Obstructive Pulmonary Disease, Diabetes Mellitus), chemotherapy in the last half year, severe osteoarthrosis, heart failure, or other recent surgery limiting functional capacity | Not defined | |
Arora et al. [34] | Review article | n.a. | n.a. | n.a. | n.a. | Bladder disease | Radical cystectomy | Not defined | Not defined |
Balagué & Arroyo [35] | Editorial | n.a. | n.a. | n.a. | n.a. | Not defined | Not defined | Not defined | Not defined |
Bongers et al. [36] | Letter to the editor | n.a. | n.a. | n.a. | n.a. | Colorectal cancer | Colorectal cancer resection | Fried Frailty Index | personalised, supervised, and home-based multimodal programme prescribed by a kinesiologist, a nutritionist, and a psychology-trained nurse; programme started after the baseline visit and continued for 4weeks before surgery |
Boreskie et al. [37] | Review article | n.a. | n.a. | n.a. | n.a. | Cardiac disease | Different types | Not defined | Not defined |
Bruns et al. [38] | Study article (Non-randomised pilot observational study) | Netherlands | February 2017 – February 2018 | 14 | ≥ 70 years who underwent a resection for colorectal cancer | Colorectal cancer | Colorectal cancer surgery | Fried criteria, Clinical Frailty Scale, Short Physical Performance Battery (SPPB), KATZ – Independence of Activities of Daily Living (KATZ-ADL-6 questionnaire) | daily elderly-adapted computer-supported strength training workout (home-based) and two protein-rich meals |
Carli et al. [39] | Review article | n.a. | n.a. | n.a. | n.a. | Colorectal cancer | Colorectal cancer surgery | Not defined | Not defined |
Durand et al. [40] | Review article | n.a. | n.a. | n.a. | n.a. | Cardiac disease | Different types | Not defined | Not defined |
Feng et al. [41] | Study article (nested qualitative study within an RCT) | Ottawa, Canada | Unknown | 7 (recruitment ongoing) | patients ≥60 years having elective cancer surgery | Cancer | intraabdominal/intrathoracic surgery | Clinical Frailty Scale | home-based exercise prehabilitation (≥3 weeks of prehabilitation (strength, aerobic, and stretching)) |
Furyk et al. [42] | Study article (randomised controlled study) | Queensland, Australia | March 2016 – November 2017 | 5(106 participants eligible for screening) | patient undergoing colorectal surgery for cancer; frail or prefrail; able to attend exercise training in the regional city; and age ≥ 50 | Colorectal cancer | Colorectal surgery | Edmonton Frail Scale | 4-week supervised exercise program with dietary advice; three 1 h exercise sessions per week on non-consecutive days to increase muscular strength and cardiorespiratory/aerobic function |
Gill et al. [43] | Study article (randomised controlled study) | Connecticut, USA | Unknown | 94 | physically frail, community-living persons, aged 75 years or older | Not defined | Not defined | rapid gait (i.e., walking back and forth over a 3-m course as quickly as possible) and a single chair stand (i.e., standing up from a hard-back chair with arms folded) | home-based physical therapy including progressive balance and conditioning exercises, using Thera-Bands |
Gurlit & Gogol [26] | Review article | n.a. | n.a. | n.a. | n.a. | Not defined | Not defined | Not defined | Not defined |
Heil et al. [44] | Study article (qualitative study) | Unknown | September 2019 – October 2020 | 13 | 5 surgeons, 3 specialised nurses, 3 physical therapists, 2 dieticians | Colorectal cancer | Colorectal cancer surgery | n.a. | prehabilitation = at least aim of improving physical fitness and nutritional status |
Hoogeboom et al. [45] | Study article (Single-blind, randomised clinical pilot trial) | Netherlands | July 2007 – November 2008 | 21 | Frail elderly with hip osteoarthritis awaiting total hip replacement | Hip osteoarthritis | Total hip arthroplasty | Clinical Frailty Scale | supervised exercise twice a week (60 minutes each) at an outpatient department of physiotherapy; additionally encouraged to exercise at home; strength and aerobic training, functional physical activities for daily living |
Jensen et al. [46] | Review article | n.a. | n.a. | n.a. | n.a. | Bladder disease | Radical cystectomy | Not defined | Not defined |
Johanning & Hall [47] | Editorial | n.a. | n.a. | n.a. | n.a. | Not defined | Not defined | Not defined | Not defined |
Lin et al. [48] | Study article (Cohort study) | Pennsylvania, USA | July 2018 – July 2019 | 517 | All-comers were included in the analysis because all potential liver transplant candidates received an exercise prescription at their initial PT evaluation | Liver disease | Liver transplantation | Liver Frailty Index | individualised exercise prescription, mainly as home-based exercise workouts; on rare occasions, home health physical therapy or outpatient physical therapy (at a facility close to home) was recommended |
McAdams-DeMarco et al. [49] | Study article (Single-arm intervention pilot study) | Maryland, USA | May 2016 – September 2017 | 24 | kidney transplant candidates assessed for frailty | Kidney disease | Kidney transplantation | Fried physical frailty phenotype, Short Physical Performance Battery frailty score | centre-based prehabilitation consisting of weekly physical therapy sessions at an outpatient centre with at-home exercises |
Mohamed et al. [50] | Review article | n.a. | n.a. | n.a. | n.a. | Degenerative spine disease | Complex spine surgery | Compares multiple assessments | Not defined |
Ng et al. [51] | Review article | n.a. | n.a. | n.a. | n.a. | Not defined | Not defined | Not defined | Not defined |
Oosting et al. [52] | Study article (Single-blind pilot randomised controlled trial) | Netherlands | Unknown | 30 | elective total hip arthroplasty (minimum waiting period of 3 weeks), osteoarthritis as underlying diagnosis for total hip arthroplasty, age older than 65 years; frail patients | End-stage hip osteoarthritis | Total hip arthroplasty | Identification of Seniors at Risk | home-based programme supervised by an experienced physical therapist to train functional activities and walking capacity |
Perlmutter et al. [53] | Study article (Observational study) | Ohio, USA | April 2019 – February 2021 | 32 | adult patients to undergo pancreatic resection, surgeries planned for at least 2 weeks after clinic visit | Pancreas disease | Pancreatectomy | Modified Johns Hopkins Frailty Score | daily prehabilitation regimen at home consisting of 100 chair-stands, 30 hand squeezes of a stressball and walking 7,500 steps |
Punt et al. [54] | Review/perspective article | n.a. | n.a. | n.a. | n.a. | Not defined | Not defined | Not defined | Not defined |
Rumer et al. [55] | Review article | n.a. | n.a. | n.a. | n.a. | Not defined | Not defined | Not defined | Not defined |
Shovel & Morkane [56] | Review article | n.a. | n.a. | n.a. | n.a. | Vascular disease | Open and endovascular aortic surgery | Not defined | Not defined |
Study article (Non-randomised, observational pilot study) | California, USA | December 2015 – November 2017; Start of recruitment in March 2016 | 15 | patients aged ≥50 who were listed or soon to be listed for lung transplantation | Lung disease | Lung transplantation | Short Physical Performance Battery frailty score | home-based combined exercise and nutrition intervention using a commercially available telehealth platform (AidCube) | |
Wang et al. [59] | Study article (pilot observational study) | Unknown | 8 | Not defined | Not defined | Not defined | Not defined | 4-week prehabilitation programme that includes a blood flow restriction exercise combined with daily consumption of a sports nutrition cocktail; use of a mobile app as a home-based strategyd | |
Waterland et al. [60] | Letter to the editor | n.a. | n.a. | n.a. | n.a. | Colorectal cancer | Colorectal cancer resection | Fried Frailty Index | personalised, supervised, and home-based multimodal programme prescribed by a kinesiologist, a nutritionist, and a psychology-trained nurse; programme started after the baseline visit and continued for 4 weeks before surgery |
Williams et al. [61] | Review article | n.a. | n.a. | n.a. | n.a. | Chronic liver disease | Liver transplantation | Not defined | Not defined |
Study article (stratified RCT and systematic review) | Hong Kong | July 3, 2019 – December 31, 2020 | RCT: 63 (recruitment ongoing), later 153 | frail patients (pre-frail to moderately frail) undergoing elective cardiac surgery; non-participants were defined as: inability to regularly attend, or indecisive/refusal to participate | Cardiac disease | Cardiac surgery | Clinical Frailty Scale | preoperative exercise training twice a week to optimise physical and psychosocial fitness at a dedicated room with gymnasium equipment at the Day Surgery Centre |
Main findings
CMOC | Context | + Mechanism | = Outcome | References |
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1 Well-timed and appropriate information provision | If information about the prehabilitation intervention is provided • in an understandable, “intuitive and user-friendly”([58], p. 7) way, • in a way that emphasises the “value of physical activity and the need to exercise”([33], p. 5) and stresses how prehabilitation helps “perform ADLs [activities of daily living]”([31], p. 449) • at an early time point, “since it helps demystify the reason for the intervention”([39], p. 324) | then this enacts • an understanding of the benefits • facilitation of exercise • increased willingness and interest in active participation | resulting in • patient empowerment • increased adherence and motivation • awareness and understanding of one’s own active role in improvement • maintenance of a healthy lifestyle | |
2 Patient-centred individualisation | If prehabilitation programmes can be • developed with “patient-centered approaches”([37], p. 580) • “easily accessible and take personal preferences, needs and abilities into account”([33], p. 1) • home-based or centre-based, supervised or unsupervised, depending on the patients’ needs, and • “goal-directed, with individualized targets”([51], p. 21) | then this enacts • a feeling of attainability/manageability • patients feeling comfortable with the intervention • stress-free participation • confidence among the patients | resulting in • increased participation • increased adherence and motivation • facilitating implementation in various patient groups | |
3 Guidance and (social) support | If the prehabilitation intervention • includes adequate guidance and monitoring by healthcare professionals (digitally and in person), • incorporates goal setting, gamification aspects, and/or rewards, and • integrates the patients’ social environment (family, friends, peers) | then this enacts • enjoyment of the intervention • a feeling of accountability and security with the intervention • emotional and psychological well-being | resulting in • increased adherence • increased participation • self-affirmation by the patients | |
4 Integration into and adaption of the setting | If prehabilitation programmes can be • “integrated in the perioperative trajectory and performed in the patient’s preexistent living context”([36], p. 896), • “administered within the scope of multidisciplinary collaboration and as an integrated concept”([26], p. 112), and • diffused by an ambassador | then this enacts access to and acceptance of the programme by patients and providers alike | resulting in • more opportunities and motivation to implement prehabilitation interventions into a given setting • increased participation • increased adherence | |
5 Multidisciplinary team approach | If, in a multidisciplinary team, • prehabilitation is “understood as an appeal to cooperation between all professions involved”([26], p. 112), • leadership and responsibilities are clear, and • a “shift in the current health care paradigm”([46], p. 6) can be achieved | then this enacts • a new understanding of a common purpose, • an understanding of roles, • mutual respect and support | resulting in • more integrated care, • more cooperation and teamwork • maximised benefit for the patient | |
6 Clear patient pathway | If there are • specific and early entry points, • clear referral guidelines, and • possibilities “to lengthen the time interval between operation indication and surgery”([44], p. 11) | then this enacts • smooth referral of patients between disciplines, • shared accountability, • sufficient time for the intervention | resulting in • maximisation of the benefits of prehabilitation, • care integration, • optimal use of resources |
CMOC | Context | + Mechanism | = Outcome | References |
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1 Overwhelming and/or inadequate information provision | If information is provided • at an inappropriate time when patients are “minimally able to process further information”([42], p. 3) • in a non-engaging, imprecise manner, and • does not address patients’ incorrect conceptions of health behaviour | then this enacts • overwhelming of the patients, • no engagement and understanding for the benefit of the programme by the patient, and • continuance of detrimental behaviour | Resulting in • no motivation/will to participate, • no awareness of own role in improving pre-surgery, and • difficulties in adherence | |
2 Lack of multi-modality and/or adaptability | If the prehabilitation programme • is a “one-size-fits-all intervention”([38], p. 13), • is not adaptable to the individual capabilities, needs and mobility of the patient, e.g., if there is “inflexibility of ‘prescribed’ prehabilitation”([44], p. 11), and • is not adapted to the local setting | then this enacts • excessive demand on the patients (feeling overwhelmed), • extra stresses, • dissatisfaction with the intervention | resulting in • low compliance or drop out, • inability to participate in or even access the intervention (e.g., due to long distances), • exclusion of patient groups | |
3 Fragmentation and misalignment of providers | If providers • do not endorse the prehabilitation intervention equally, • “are unaware of (the importance) of prehabilitation programs”([44], p. 4), and • if parts of the patient pathway take precedence over others | then this • enacts “miscommunication and misaligned goals among the healthcare team and lack of commitment among the patients”([51], p. 21), • enacts a lack of common purpose, and • disturbs the referral of patients | resulting in • difficulties in implementation, • difficulties in maximising the benefits of the intervention, and • lack of care integration • tension between different professions along the care pathway | |
4 Resource constraints | If the “clinical demand could outstrip existing resources, both human and financial”([47], p. 1) and there is a lack of reimbursement | then this enacts • lack of acceptance for the implementation, and • variability in content of prehabilitation provided | resulting in • exhaustion, • lack of sustainability, and • suboptimal and limited prehabilitation provision | |
5 Lack of (social) support | If there is a “lack of physician support, attributed to a lack of conviction regarding the benefit of prehabilitation”([51], p. 21) and if patients feel like a burden to their family and friends, especially due to transportation needs | then this enacts • lack of focus on the intervention, • emotional/psychological stress, and • uncertainty about the importance of the intervention | resulting in • difficulties in compliance/adherence, • limited success, and • non-participation/drop-out of patients |