Should Anesthesia Providers Recommend Preoperative Exercise Therapy (PET)?

Surgery presents the body with many stressors, including tissue trauma, physical inactivity, temporary starvation and psychological distress.¹ Despite major advances in surgical technology, perioperative care and anesthesiology, many patients still have difficult or prolonged recovery periods.¹ After surgery, patients may experience physical fatigue, sleep problems and decreased capacity to concentrate for up to nine weeks.¹ Recent studies have investigated the effectiveness of preoperative exercise therapy (PET) in reducing postoperative complications and recovery time.² Given the role of anesthesia providers in perioperative care,³ they should understand the functions of PET, the possible effects of PET on surgical recovery time and the anesthesiologist’s role in preoperative exercise.

The main goal of preoperative exercise is to combat physical inactivity, which is a major public health issue and—in the context of surgery—is associated with increased risk of perioperative complications.⁴ Though previous approaches traditionally focused on postoperative rehabilitation, research shows that the preoperative period is most effective for intervention.¹ Patients may use PET in a variety of surgical fields, ranging from gastrointestinal surgery⁵ to cardiac surgery.⁶ PET interventions range from focused, procedure-specific exercises to whole-body therapy, and may change in duration depending on the amount of lead time before a procedure.⁵ For example, PET might include inspiratory muscle training for patients with pulmonary dysfunction⁷ or pelvic floor muscle training for patients who will undergo gastrointestinal surgery.⁵ Aerobics and muscular strength training in particular have been shown to increase endurance, improve general physical fitness, reduce weight gain and improve muscle strength in major surgical patients.^2,4 These activities can also increase physiological reserve in cancer patients, which helps their bodies prepare for inflammation, cancer pain, cancer treatments and reduced functional capacity after surgery.⁴ Recent research has emphasized high-intensity interval training (HIIT), which is time-efficient, effective and can target various areas of the body.⁴ Though constraints on the procedure itself can limit the preoperative exercise period, PET can range from three weeks to 16 weeks in duration.⁴ Evidently, PET can be tailored to the patient’s needs and the surgical team’s time constraints.

The anesthesiology professional is responsible for the patient throughout the perioperative period, and thus may need to incorporate PET into perioperative care. This includes considering the best types of PET for the patient’s condition and the effects of PET on postoperative recovery. A systematic review by Valkenet et al. showed that PET consisting of inspiratory muscle training and exercise training before cardiac or abdominal surgery was associated with shorter hospital stay and reduced risk of postoperative complications.² However, PET involving strength and/or mobility training did not significantly reduce complications or hospital stay times for patients undergoing joint replacement surgery.² According to a more recent review by Vermillion et al., patients with gastrointestinal cancer who underwent PET were more likely to recover to their baseline functional capacity after surgery.⁵ Results were varied on the effect of PET on length of postoperative hospital stay and complications.⁵ Several other studies reported that even though PET has overall beneficial effects on physical condition and postoperative outcome measures,⁶ a lack of data precludes any conclusions about PET in specific patient populations.^4,7-9 According to Whitney and Parkman, though, PET can help patients regain functional capacity in ways that anesthesia or analgesia may not.¹⁰ Thus, anesthesia providers might consider PET to improve a patient’s general health and overall recovery, despite gaps in the literature.

Surgery and anesthesia inflict stress on a patient’s body. An anesthesia provider who aims to reduce recovery time and improve patient outcomes may consider preoperative exercise as a preventive measure. PET encompasses a variety of exercise types and durations. Though its exact effects remain unclear due to limited data, it is beneficial to patients’ health and recovery. Future research should aim to standardize PET procedures and explore the mechanisms of PET.⁴ Also, larger sample sizes and refined methodologies will be necessary to properly evaluate the efficacy of PET interventions.⁹

1.         Carli F, Scheede-Bergdahl C. Prehabilitation to Enhance Perioperative Care. Anesthesiology Clinics. 2015;33(1):17–33.

2.         Valkenet K, van de Port IGL, Dronkers JJ, de Vries WR, Lindeman E, Backx FJG. The effects of preoperative exercise therapy on postoperative outcome: A systematic review. Clinical Rehabilitation. 2010;25(2):99–111.

3.         White PF, Kehlet H, Neal JM, et al. The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care. Anesthesia & Analgesia. 2007;104(6):1380–1396.

4.         West MA, Wischmeyer PE, Grocott MPW. Prehabilitation and Nutritional Support to Improve Perioperative Outcomes. Current Anesthesiology Reports. 2017;7(4):340–349.

5.         Vermillion SA, James A, Dorrell RD, et al. Preoperative exercise therapy for gastrointestinal cancer patients: A systematic review. Systematic Reviews. 2018;7(1):103.

6.         Topal B, Smelt HJM, Van Helden EV, et al. Utility of preoperative exercise therapy in reducing postoperative morbidity after surgery; a clinical overview of current evidence. Expert Review of Cardiovascular Therapy. 2019;17(6):395–412.

7.         Jack S, West M, Grocott MPW. Perioperative exercise training in elderly subjects. Best Practice & Research Clinical Anaesthesiology. 2011;25(3):461–472.

8.         Pouwels S, Hageman D, Gommans LN, et al. Preoperative exercise therapy in surgical care: A scoping review. Journal of Clinical Anesthesia. 2016;33:476–490.

9.         Mainini C, Rebelo PFS, Bardelli R, et al. Perioperative physical exercise interventions for patients undergoing lung cancer surgery: What is the evidence? SAGE Open Medicine. 2016;4:1–19.

10.       Whitney JAD, Parkman S. Preoperative physical activity, anesthesia, and analgesia: Effects on early postoperative walking after total hip replacement. Applied Nursing Research. 2002;15(1):19–27.