Prehabilitation for Patients Undergoing Orthopedic Surgery

Punnoose, Anuj; Claydon, Leica S.; Weiss, Ori; Zhang, Jufen; Rushton, A.; Khanduja, Vikas

doi:10.1001/jamanetworkopen.2023.8050

Cited by 45 publications

(33 citation statements)

References 120 publications

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“…Although perioperative care is often the focus of clinically led efforts (eg, GIRFT)2 27 to improve the TJA pathway, participants also emphasised that obtaining a referral to a surgeon is often the greatest challenge, and the postoperative period following surgery is a priority. Despite some evidence to suggest that prehabilitation is associated with improving some of the outcomes for patients undergoing orthopaedic surgery both preoperatively and postoperatively, we have highlighted that non-surgical interventions (eg, physiotherapy) prior to surgical referral are perceived by patients and the public as a means of managing demand 38. While this remains the case, as well as potentially damaging patient trust, it is likely to impact patient engagement with evidence-based care.…”

Section: Discussionmentioning

confidence: 91%

‘Maze’ not pathway: focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway

et al. 2023

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ObjectiveTo explore patient and public perceptions of planned improvements to the National Health Service (NHS) total joint arthroplasty (TJA) pathway.DesignThree qualitative focus groups undertaken March–May 2018, as part of a mixed-methods evaluation of Getting It Right First Time. Transcripts were subject to framework analysis to identify thematic content between October 2018 and October 2021.SettingElective TJA surgery in the English NHS.ParticipantsTwo focus groups including patients who had undergone TJA in the previous 2 years (group 1: n=5; group 2: n=4) and the other individuals who had not but were aged 60+ (group 3: n=5). Participants were recruited via community groups and patient panels.ResultsFourteen individuals took part in the focus groups; all were aged over 60; seven (50%) were female and nine (64%) had undergone TJA surgery. Participants’ perspectives were categorised into themes and mapped onto stages of the TJA pathway. Although perioperative care is often the focus of improvement efforts, participants argued that the patient journey begins before individuals present to primary care. Participants had concerns about other aspects of the pathway, such as obtaining a surgical referral, with prereferral interventions aimed at potentially avoiding the need for surgery (ie, physiotherapy) being perceived as a mechanism to restrict access to secondary care. Patient experience was also conceptualised as a ‘maze’, rather than the logical, sequential process set out in clinical guidelines; exacerbated by a lack of information, knowledge and power imbalances.ConclusionThe linear conceptualisation of the TJA pathway is at odds with patient experience. Improvement programmes focused on perioperative care fail to consider patient concerns and priorities. Patients should be directly involved in improvement programmes, to ensure that patient experience is optimised, as well as informing related processes and important outcomes of care.

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Section: Discussionmentioning

confidence: 91%

‘Maze’ not pathway: focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway

et al. 2023

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“…Preoperative optimization programs, otherwise known as pre-habilitation programs, are appearing with increasing prevalence along with evidence supporting their implementation. However, the majority of pre-habilitation data to date pertain to the old, frail patients undergoing surgery [ 42 , 43 ]. This has become the minority of our patient population.…”

Section: Discussionmentioning

confidence: 99%

PReoperative very low-Energy diets for obese PAtients undergoing non-bariatric surgery Randomized Evaluation (PREPARE): a protocol for a pilot randomized controlled trial

McKechnie,

Ramji,

Saddik

et al. 2024

Pilot Feasibility Stud

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Background Patients with obesity presenting in need of surgical intervention are at 2-to-sixfold higher risk of prolonged hospitalization, infectious morbidity, venous thromboembolism, and more. To mitigate some of these concerns, prescribed preoperative weight loss via very low-energy diets (VLEDs) has become a standard of care for patients with obesity undergoing bariatric surgery. While VLEDs have become standard prior to bariatric surgery, their application in other surgical settings remains limited. A large, definitive trial is required to resolve the uncertainty surrounding their use in these patients. Prior to a definitive trial to compare the efficacy of VLEDs in patients with obesity undergoing major non-bariatric surgery, we require a pilot trial. We argue a pilot trial will provide the following critical feasibility insights: (1) assessment of recruitment ability, (2) evaluation of adherence to VLED regimens, and (3) assessment of our ability follow patients completely. Methods The proposed trial will be a multi-center, surgeon, outcome assessor, and data-analyst blinded, parallel pilot randomized controlled trial (RCT). Patients older than 18 years of age with a body mass index (BMI) of greater than 30 kg/m2 undergoing major elective non-bariatric surgery will be eligible for inclusion. Consecutive patients will be allocated 1:1 according to a computer-generated randomization schedule. Randomization will be stratified by center and will employ randomly permutated blocks. All patients in the intervention group will receive standard patient counseling on weight loss and an active VLED protocol. The preoperative VLED protocol will utilize commercially available weight loss products for three weeks preoperatively. The primary outcomes (randomization percentage, recruitment rate, intervention adherence, follow-up completion, network development) will assess feasibility. Descriptive statistics will be used to characterize the study sample. Discussion The PREPARE pilot RCT will aim to provide feasibility and safety data that will allow for the successful completion of the definitive PREPARE trial that has the potential to provide practice changing data pertaining to the regular use of VLEDs as a means of pre-habilitation for patients with obesity undergoing major non-bariatric surgery. Trial registration This study was registered on ClinicalTrials.gov (reference #NCT05918471) on June 23, 2023.

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“…Preoperative optimization programs, otherwise known as pre-habilitation programs, are appearing with increasing prevalence along with evidence supporting their implementation [ 23 – 26 ]. However, the majority of pre-habilitation data to-date pertain to the old, frail patients undergoing surgery [ 27 , 28 ]. Yet, in the 21 st century, the obesity epidemic has started to take center stage [ 1 , 29 ].…”

Section: Discussionmentioning

confidence: 99%

PREscribing preoperative weight loss prior to major non-bariatric abdominal surgery for patients with Elevated weight: Patient and Provider Survey Protocols (PREPARE surveys)

McKechnie,

Saddik,

Doumouras

et al. 2024

PLoS ONE

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Background Preoperative very low energy diet (VLED) interventions are used routinely in patients undergoing bariatric surgery, a surgical subspecialty that deals almost exclusively with patients with obesity. Yet, their use and study has been limited in non-bariatric abdominal surgery. To investigate the use of VLEDs in non-bariatric surgery, we plan on conducting a randomized controlled trial (RCT). Prior to proceeding, however, we have designed two surveys as important pre-emptive studies aimed at elucidating patient and provider perspectives regarding these interventions. Methods The patient survey is a cross-sectional, single-center survey aimed at assessing the safety, adherence, barriers to adherence, and willingness to participate in preoperative optimization protocols with VLEDs prior to undergoing elective non-bariatric intra-abdominal surgery (S1 File). The population of interest is all adult patients with obesity undergoing elective non-bariatric intra-abdominal surgery at St. Joseph’s Healthcare Hamilton who were prescribed a course of preoperative VLED. The primary outcomes will be safety and adherence. The target sample size is 35 survey responses. The provider survey is a cross-sectional national survey of practicing surgeons in Canada who perform major non-bariatric abdominal surgery aimed assessing the willingness and ability to prescribe preoperative weight loss interventions amongst practicing Canadian surgeons who perform major non-bariatric abdominal surgery (S2 File). The population of interest is independent practicing surgeons in Canada who perform major non-bariatric abdominal surgery. The primary outcome will be willingness to prescribe preoperative VLED to patients with obesity undergoing major non-bariatric abdominal surgery for both benign and malignant indications. The target sample size is 61 survey responses. Descriptive statistics will be used to characterize the sample populations. To determine variables associated with primary outcomes in the surveys, regression analyses will be performed. Discussion These survey data will ultimately inform the design of an RCT evaluating the efficacy of preoperative VLEDs for patients with obesity undergoing major abdominal surgery.

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Prehabilitation for Patients Undergoing Orthopedic Surgery

Cited by 45 publications

References 120 publications

‘Maze’ not pathway: focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway

‘Maze’ not pathway: focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway

PReoperative very low-Energy diets for obese PAtients undergoing non-bariatric surgery Randomized Evaluation (PREPARE): a protocol for a pilot randomized controlled trial

PREscribing preoperative weight loss prior to major non-bariatric abdominal surgery for patients with Elevated weight: Patient and Provider Survey Protocols (PREPARE surveys)

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