Get fit for surgery

Research aims to prevent post-op complications and disabilities in older people living with frailty

Imagine you are 75 or 80 and facing a major surgery. Are you confident in your ability to stay strong and recover quickly from the procedure? Or, are you worried the operation will leave you weak and unable to get around in your day-to-day life? If you had a chance to take part in a coached and customized exercise program to get you strong before your surgery, would you take it?

Research led by Dr. Daniel McIsaac set out to help older adults living with frailty get stronger before surgery by offering them exactly that: a well-rounded pre-op exercise program to complete at home for three to six weeks before their surgery, supported with a weekly phone call from a member of the research team. The ultimate goal of the research is to develop evidence-based programs to prevent post-op complications and disabilities in older adults with frailty.

As Dr. McIsaac discovered in the pilot study funded by Canadian Frailty Network (CFN), one in five older people with frailty end up with a new disability—or significant worsening of an existing disability—after surgery.

“This is almost twice the rate of disability we see in older people who don’t have frailty before surgery,” says Dr. McIsaac, an anesthesiologist and scientist at the University of Ottawa and The Ottawa Hospital. “When we took an in-depth look at the nature of these disabilities, we found that most patients were having difficulty with standing and walking after surgery. This led to the next question: if we can get them stronger before surgery, will they be stronger after? Can we prevent the disabilities?”

Dr. McIsaac calls the concept “prehab” rather than rehab, and describes it as helping people become more resilient in advance of a major surgery—through a structured pre-surgery exercise program—so they can better withstand the rigours of the procedure. The program also includes nutritional advice to help people make sure that they are getting enough nutrition to support an increase in activity levels.

“Surgery is a bit like running a half-marathon,” says Dr. McIsaac. “It places a big demand on the body. You want to train for that, so you can recover quickly and well. For older patients with frailty, it’s about getting stronger to avoid disability and reduce the chances of post-operative complications like blood clots, pneumonia, heart attacks and infections, so they can return to their lives in a better state of health than before the surgery.”

Working with kinesiologists in Montreal and Ottawa, Dr. McIsaac and his colleagues adapted a well-rounded exercise program to meet the fitness needs of older people who might have limited exercise experience. They also made sure the program could be done at home, so patients wouldn’t be burdened with extra trips to the hospital.

The researchers are now testing this program with 200 patients at The Ottawa Hospital, with funding from the International Anesthesia Research Society, the University of Ottawa and the Canadian Frailty Network. Patients in the study are randomized to take part in a three-to-six-week pre-surgery exercise program (intervention arm), or to receive a pamphlet describing the World Health Organization’s recommendations for physical activity in older age (control group). Patients in the intervention arm receive at least one phone call a week to offer encouragement and address any concerns.

“The CFN funding is really helping us take a patient-centred approach to the research,” says Dr. McIsaac. “It’s allowing us to talk to patients in depth about their experience with the program—was it doable for them? Did they feel empowered to do the exercises? How do they think it affected their recovery and confidence when going home from hospital?”

While final results about the impact of the exercise program on complication and disability rates will not be available until the study is complete, preliminary results show that 95 per cent of participants are following the program to at least some extent, while 70 per cent are following it to the letter. Study exit interviews show the program is of benefit to patients:

“I completed the prehab program over a five-to-six week period and was pleasantly surprised to see a noticeable improvement in my strength, flexibility and overall fitness,” reported one patient. “As a result, I feel I was very well prepared for my surgery. I felt confident and much less anxious than I had anticipated on the day of my surgery. When I was discharged from the hospital after an 11-day stay, I was surprised at how well I felt given my extended stay. Although I had lost some strength, I was able to walk and use stairs with little difficulty and experienced no shortness of breath, dizziness or other side effects. I was able to quickly resume my normal routine.”

The CFN funding is also helping Dr. McIsaac and his team identify what factors make people more likely to comply with a pre-surgery exercise program and what barriers prevent people from following through. This evidence will be incorporated in the program, for future study.

“We want to be able scale up this program so centres all across Canada can use it,” notes Dr. McIsaac. “Part of that will involve letting health care providers know how they can identify and support those patients who are likely to have the hardest time following the program.”

With CFN as a key partner, the Canadian Institutes of Health Research has recently awarded Dr. McIsaac and his team more than $1.1 million to launch an expanded study of the exercise program, with 750 more patients at more than 10 hospitals across Canada.

“The multi-centre study will really help us drill down to the practical issues of what’s required to make this prehab approach work in community hospitals as well as larger institutions,” Dr. McIsaac says. “It’s about identifying frailty far enough ahead of the surgery to intervene in time, setting people up with the program and supporting them to do it.”

In an earlier CFN-funded study, Dr. McIsaac and his team found that clinicians can use the Clinical Frailty Scale—developed at Dalhousie University by another CFN-funded researcher, Dr. Kenneth Rockwood—to identify frailty more easily and efficiently than the modified Fried Index, a commonly used frailty-assessment tool. As a result, The Ottawa Hospital and other Canadian hospitals have started using the Clinical Frailty Scale in their pre-op clinics, and Dr. McIsaac speaks about it to colleagues across North America.

“The Canadian Frailty Network is committed to addressing frailty across the continuum of care, from primary to acute to long-term care,” notes Dr. John Muscedere, CFN’s Scientific Director and CEO. “That means supporting efforts to identify frailty and risk of frailty as early as possible in a patient’s care path. We’re funding projects to reduce frailty through exercise and nutrition leading up to, during, and after surgery or another hospital stay.”

To help older patients maintain muscle mass during extended hospital stays, for example, CFN has funded physiotherapist Dr. Michelle Kho to pioneer the use of “in bed” bicycling in the intensive care unit. CFN is also funding Dr. Heather Keller to help hospitals do early screening and intervention for malnutrition in older patients. Malnourished patients are at risk of longer stays, worse outcomes and even greater frailty if they are not well fed in hospital.

And CFN is putting the information from its funded projects to use, by producing practice guidelines for clinicians and health care providers. Guidelines on nutrition and physical activity across different care settings for seniors will provide evidence-based knowledge to help them make more well-informed decisions and provide personalized care.

“We’re taking a comprehensive approach to frailty,” Dr. Muscedere says. “The work of our CFN-funded researchers fits together like the pieces of a puzzle, to create a healthier picture for the growing numbers of older adults living with or at risk of frailty in Canada.”