Exercise Prehabilitation—Supporting Recovery From Major Head and Neck Cancer Surgery

Abstract

Head and neck cancer (HNC) is the seventh most common type of cancer worldwide. 1 Surgery involving resection and free flap reconstruction is a mainstay of HNC treatment. Multimodal care pathways using Enhanced Recovery After Surgery (ERAS) guidelines have transformed perioperative care in HNC, 2 and the overall goal of ERAS is to achieve early functional recovery for patients undergoing major surgery. ERAS is a set of evidence-based recommendations that span preoperative, intraoperative, and postoperative care. A key component of preoperative care is prehabilitation, or optimizing a patient's condition before surgery. In HNC, prehabilitation has focused on optimizing nutritional status and includes a comprehensive assessment and nutritional interventions for individuals who are malnourished. 2 A frequently overlooked but equally important component of preparing a patient for surgery is exercise. Considering the overwhelming evidence for the benefits of exercise as adjunct care in cancer, 3 the purpose of this Viewpoint is to highlight the potential role of exercise prehabilitation in patients scheduled to undergo major surgery for HNC.Cancer prehabilitation is a process that occurs between the time of cancer diagnosis and the beginning of acute treatment. The process includes baseline assessments, identification of impairments, and targeted interventions. 4 The goals of prehabilitation are to prevent or reduce the severity of treatment-related impairments that may cause significant disability, to decrease hospital length of hospital stay or readmissions, and/or to facilitate the return of patients to the highest level of function possible. 4 As part of patient-centered care, exercise prehabilitation is an opportunity to (1) foster personal empowerment, a sense of control and purpose, facilitating preparation for treatment and improving quality of life; (2) improve physical function and psychological well-being, thereby increasing resilience to the effects of cancer treatment; and (3) promote behavior change and positively affect long-term health.Exercise prehabilitation may involve assessment of functional capacity (a cardiopulmonary exercise test or the 6-minute walk test are common examples) and interventions designed to improve physical impairments, cardiovascular fitness, and/or musculoskeletal fitness. Exercise may be the single prehabilitation modality or used in combination with nutritional or psychological interventions. Evidence supports exercise prehabilitation in other surgical settings, such as major abdominal surgery, where preoperative exercise was shown to reduce postoperative pulmonary complications and overall morbidity. 5 In adults with cancer, numerous studies show that exercise prehabilitation is safe and feasible. Randomized clinical trials demonstrate improve-VIEWPOINT

Enhanced recovery after surgery, current, and future considerations in head and neck cancer

“…Following the recommendation of the Society of Sarcopenia, Cachexia, and Wasting Disorders, sarcopenic patients should be instructed to undergo progressive resistance training two to three times a week to increase muscle mass and function. This can be self‐directed or under the instruction of a physical therapist 129–131 …”

Impact of Early Mobilization on Recovery after Major Head and Neck Surgery with Free Flap Reconstruction

“…Where feasible, this requires further consideration in future advancements of HNC-specific ERAS pathways. However, we believe that future research should also explore the benefits of physical activity in the waiting period before HNC surgery [26] and build on promising early evidence that postoperative exercise (in addition to standard physical therapy) reduces LOS [27].…”

Wearable activity trackers and mobilization after major head and neck cancer surgery: You can't improve what you don't measure

“…It has previously been suggested that exercise physiologists could take on the role of early and progressive mobility specialists who reduces the burden on physical therapists and nurses 48 . An intervention supported by clinical exercise physiologists may be important in implementing tailored recommendations for physical activity, which is especially relevant for prehabilitation 49 . Objective measurement of physical activity via WATs before HNC surgery will enable remote monitoring of prehabilitation interventions (which extends to the use of a WAT across the pre and postoperative phases).…”