Prehabilitation: A proactive approach to enhancing outcomes in joint replacement surgery

Abstract

Prehabilitation is an emerging proactive and preventive approach to healthcare that focuses on preparing individuals for upcoming medical interventions or procedures. It aims to optimize physical and mental health before the planned medical and surgical interventions. By integrating exercise, psychological support, and lifestyle modifications, prehabilitation empowers individuals to face medical interventions with increased resilience and a higher likelihood of successful outcomes. Prehabilitation helps patients build strength and endurance, which can enhance their ability to withstand the physical stress of surgery and contribute to faster recovery. It plays a crucial role in optimizing outcomes for patients undergoing joint replacement surgery, by enhancing postoperative recovery, reducing complications, and improving the overall quality of life for patients. As the field of orthopaedics continues to evolve, the integration of prehabilitation into standard care protocols has the potential to redefine the landscape of joint replacement surgeries, ultimately improving patient outcomes, and hence more research is required from diverse population groups from developed and developing countries to collate required data and formulate evidence-based clinical guidelines.

1. Introduction

Prehabilitation or “Prehab,” is an emerging proactive and preventive approach to healthcare that focuses on preparing individuals for upcoming medical interventions or procedures. It aims to optimize physical and mental health before the planned medical and surgical interventions. The main aims of prehabilitation are to improve patients' overall fitness, resilience, and functional capacity, thus minimising the risk of potential complications related to medical interventions or surgery.¹

Prehabilitation is a proactive strategy that recognizes the interconnectedness of physical and mental well-being and emphasizes the importance of holistic health. Based on individual assessments, prehabilitation may include physical exercises, nutrition management, pain relief, psychosocial support, counselling, and mindfulness techniques.² This strategy is also beneficial to individuals with chronic conditions, such as cardiovascular diseases, diabetes or cancer, by improving their overall health and managing symptoms effectively. In these cases, Prehabilitation becomes an ongoing process that integrates seamlessly into the patient's lifestyle, contributing to a better quality of life.³

The benefits of prehabilitation extend beyond the individual level to healthcare systems and society as a whole. By reducing the complications and recovery time associated with medical interventions, prehabilitation can lead to cost savings in healthcare expenditures.⁴ Moreover, it aligns with the shift toward preventive healthcare, emphasizing the importance of maintaining health rather than simply treating illness.

2. Prehabilitation before surgery

Postoperative complications may affect 15–40% of patients, with 2–4 fold increase in length of stay (LOS) in the hospital and increased likelihood of readmissions,¹ especially in under prepared patients for major elective surgeries. Even in the absence of postoperative complications, after major surgery. There is 20–40% reduction in physical function and a significant deterioration in quality of life.⁵ Prehabilitation can play a cruicial role to build strength and endurance, which can enhance their ability to withstand the physical stress of surgery and contribute to faster recovery (Fig. 1). Physical exercises, tailored to individual needs and medical conditions, form a crucial component of prehabilitation programs. These exercises may target specific muscle groups, cardiovascular fitness, or flexibility, depending on the anticipated challenges of the upcoming medical intervention. One primary aspect of prehab is physical conditioning. Engaging patients in targeted exercises to strengthen muscles around the affected joint helps improve range of motion and joint stability. By addressing muscle imbalances and weaknesses before surgery, individuals are better equipped to handle the demands of rehabilitation postoperatively. This not only aids in a smoother recovery process but may also contribute to long-term joint function. Moreover, prehabilitation involves educating patients about the surgical procedure and setting realistic expectations. Understanding the process, potential challenges, and expected outcomes empowers patients to actively participate in their recovery. This knowledge can reduce anxiety and fear associated with surgery, promoting a positive mindset that is conducive to rehabilitation efforts.⁵

Fig. 1.

Scope of prehabilitation.

Nutritional optimization is another crucial component of prehabilitation. Adequate nutrition plays a pivotal role in tissue healing and recovery. Preoperative nutritional interventions can help address any deficiencies, ensuring that patients have the necessary building blocks for tissue repair. This holistic approach recognizes the interconnectedness of physical and nutritional well-being in achieving optimal surgical outcomes.⁶ In addition, prehabilitation allows for the identification and management of comorbidities that may impact the surgical process. Addressing underlying health issues beforehand can minimize complications during and after the surgery, contributing to a safer and more effective overall experience for the patient (Fig. 2).

Fig. 2.

Role of prehabilitation before surgery.

3. Prehabilitation and joint replacement surgery

There is a subset of dissatisfied patients (10–20%) following Total Knee Arthoplasty (TKA). The main identified reasons are inadequate counselling, preoperative patient optimization, poor patient coping skills like pain management and anxiety/depression,³ and we believe that prehabilitation should plays a crucial role in optimizing outcomes for such patients undergoing joint replacement surgery. Prehabilitation enhances postoperative recovery, reduce complications, and improve the overall quality of life for patients.⁷ Its role in joint replacement surgery is multifaceted and impactful. By incorporating physical conditioning, education, nutritional optimization, and addressing comorbidities, Prehabilitation sets the stage for a successful surgical experience and a smoother recovery.⁸ As the field of orthopaedics continues to evolve, the integration of prehabilitation into standard care protocols has the potential to redefine the landscape of joint replacement surgeries, ultimately improving patient outcomes and quality of life.

Prehabilitation has the potential to reduce the economic burden associated with joint replacement surgeries. By optimizing patients' physical and mental health preoperatively, there may be a decrease in postoperative complications, hospital readmissions, and rehabilitation duration. This can result in cost savings and more efficient resource utilization within the healthcare system.^9,10

Emerging data has shown that prehabilitation can positively impact both short-term and long-term outcomes in various medical contexts. These benefits are:

• A)
  Short-term benefits:

  • •
    Reduced postoperative complications
  • •
    Faster recovery
  • •
    Shorter hospital stays
• B)
  Long-term benefits:

  • •
    Improved overall health
  • •
    Increased functional capacity
  • •
    Enhanced quality of life for patients undergoing surgery or medical interventions.

Since prehabilitation is a new concept, there is a paucity of research, but recently publications on it are slowly emerging. Some recent systematic reviews have shown a positive impact of prehabilitation on the functional outcomes in joint replacements in terms of improvements in pain relief, function, muscle strength, functional recovery, and length of hospital stay.

More research is required from diverse population groups of developed and developing countries, to collate valuable evidence and formulate the clinical guidelines related to various Orthopaedic surgeries. We believe that prehabilitation offers a great strategy not only to improve individual outcomes in various clinical contexts but also to improve population health in general and reduce overall economic burden. However, several questions need to be answered in near future regarding ideal time and duration of prehabilitation, which specific exercises or therapy setting is beneficial, standardization of rehabilitation procedures, the influence of associated medical comorbidities on the recovery, and if the effects of prehabilitation reduce over time.

4. Conclusion and way forward

Prehabilitation represents a forward-thinking paradigm in healthcare, emphasizing the significance of proactive measures to optimize physical and mental well-being. By integrating exercise, psychological support, and lifestyle modifications, prehabilitation empowers individuals to face medical interventions with increased resilience and a higher likelihood of successful outcomes.

The authors call for researchers, clinicians, healthcare providers and policymakers to come together and see how we can incorporate prehabilitation into our fabric of evidence-based clinical practice for the benefit of our patient population.

Funding

No funding was received in any form for this paper.

CRediT statement of the authors’ contributions

RV: Conceptualization, Literature review, Manuscript writing, editing and final approval. RPM: Conceptualization, Literature review, Manuscript writing, editing and final approval. AS: Conceptualization, Manuscript writing, editing and final approval.

Declaration of competing interest

• •All the three authors (Raju Vaishya, Ravi Prakash Mahajan, and Anupam Sibal) confirm that they do not have any competing interests, related to his article.
• •The manuscript is original and has not been submitted to any other journal for consideration for publication.
• •All the authors have contributed significantly to this manuscript.
• •NO funding in any form has been received for this research.