A multimodal prehabilitation class for Enhanced Recovery After Surgery: a pragmatic randomised type 1 hybrid effectiveness-implementation trial

Abstract

Background: Prehabilitation promotes postoperative recovery through preoperative optimisation; however, few studies have been conducted under real-world conditions. Our objective was to determine the extent to which a multimodal prehabilitation programme influenced intermediate and late recovery post-colorectal surgery in a type 1 effectiveness-implementation and randomised pragmatic trial. We hypothesised that a prehabilitation class, as part of an Enhanced Recovery After Surgery (ERAS) pathway, would reduce length of hospital stay (LOS).

Methods: Adult male and female patients with colorectal disease requiring an elective primary resection at a single centre were randomised to the intervention or standard care group at least 2 weeks before surgery. All participants attended an ERAS class, which was extended to include prehabilitation components of nutrition education, supplements, walking with a smartwatch, functional exercises, and deep breathing in the intervention group. Effectiveness outcomes included LOS (primary) and 6-min walking distance (6MWD; secondary outcome) at 6 weeks post-surgery. Implementation outcomes included adherence to prescribed step count and nutrient intakes. Multivariable regression analyses were adjusted for age, sex, type of surgery, and COVID-19.

Results: The study ended prematurely. In total, 110 patients were included. Two-thirds had cancer and mean prehabilitation duration was 17.2 (sd 5.5) days. LOS was not different between groups. Preoperative median step count did not differ between groups, but protein inadequacy (prevalence ratio: 0.59 [95% CI: 0.36-0.82]) decreased substantially with prehabilitation. After surgery, the mean difference in 6MWD was +38 m (95% CI: 9-67 m) for prehabilitation vs control, indicating earlier functional recovery.

Conclusions: A pragmatic prehabilitation programme did not influence length of hospital stay (underpowered because of early trial termination), but did reduce preoperative protein inadequacy (implementation outcome) and improve early functional recovery (secondary outcome).

Clinical trial registration: ClinicalTrials.gov (NCT04247776).

Keywords: ERAS; before surgery; perioperative; pre-rehab; surgery school; universal prehabilitation.