Feature Better Sooner and Later: Prehabilitation There's growing evidence that adding a "p" to rehabilitation improves patient outcomes pre- and postsurgery and following cancer treatments—and saves money, too. By Eric Ries | February 2016 "There's no way I would've been able to handle chemotherapy if I hadn't done this first." That was the assessment of a patient who'd had surgery for abdominal cancer, lost 40 pounds, and initially was "so weak she couldn't even complete half of our fitness testing," recalls Cheryl Guarna, PT, MPT, CLT, STAR/C, owner of Oncology Rehab and Wellness Resources in Ashburn, Virginia. Over the course of 4 weeks of prehabilitation leading up to chemotherapy, Guarna worked with the patient to build up her strength and conditioning. As a result, she tolerated chemotherapy well. Another patient came to Guarna after a mastectomy but before scheduled chemotherapy and radiation. "We addressed postsurgical weakness and some other issues, put her on a strength and endurance training program that included gradually progressed resistance, then added core strengthening and cardiovascular exercise," Guarna recounts. "Her overall strength actually increased, and her cardiorespiratory status improved, while she was undergoing chemotherapy. Her final treatment was last week. She's feeling good and working full-time. She's been discharged from physical therapy but is maintaining an exercise program that we set up for her." Amy Snyder, PT, DPT, cites a recent patient who'd had a hip replaced 2 years ago without having had prehabilitation, but who worked with Snyder before her second hip surgery earlier this year. "She came in the other day just to thank me, because everything went so much better the second time around," says Snyder, a co-owner of PT Plus in Milwaukee. "She was up and walking so much faster after the second THR [total hip replacement]. She couldn't believe the difference. She knew, she said, that the prehab had made her healthier and stronger heading into surgery." That's an acknowledgement that Heather Moore, PT, DPT, CKTP, hears "all the time." Her patients at Total Performance Physical Therapy in eastern Pennsylvania get prehab prior to surgeries for rotator cuff and anterior cruciate ligament repair, total knee and total hip replacement, cancer/tumor removal, and cardiac procedures. "Patients initially are skeptical about it, but then they're amazed by the speed of their recovery compared with that of people they know who didn't get prehab before the same surgery. That's when they recognize what a huge difference it made." Jeannette "Jet" Lee, PT, PhD, CLT, CSCS, knows well the benefits of prehabilitation for patients with cancer, having given a platform presentation at APTA's Combined Sections Meeting last February titled "The Effects of Prehabilitation on Endurance, Length of Stay, and Quality of Life for Patients With Cancer: An Evidence-Based Review and Meta-Analysis."1 The presentation, a statistical review of published studies, concluded that prehab "can result in significant improvements in quality of life in patients with lung and colon cancer." It primarily was the work of Jenna Powers, a student in the joint DPT program of the University of California, San Francisco and San Francisco State University, where Lee is an assistant professor. Lee was 13 when cancer claimed her mother, who was in her 40s. "I remember her losing a lot of weight from chemotherapy and getting weak—needing help walking, being carried to the bathroom by my dad," Lee recalls. "It made her world so much smaller. Would prehab have helped her? I'd like to think so. She certainly would have benefitted from education about her surgery and what to expect from chemotherapy. I believe she would have tried to be more active if a health provider had told her that was important. I think prehabilitation would have kept her stronger longer, with a better quality of life." However, Lee notes, "That was a different time. Back then, people with cancer were encouraged to just 'take it easy and rest.'" Profiles in Coverage Times are changing, however, for the practice and acceptance of prehab—even in cancer treatment, where, Guarna notes, "the concept of rehab, let alone prehab, is still very new." The profile of prehabilitation has been raised in recent years by some eye-catching studies and related media coverage. In October 2014, the Journal of Bone & Joint Surgery published "Associations Between Preoperative Physical Therapy and Post-Acute Care Utilization Patterns and Cost in Total Joint Replacement,"2 which looked at hip- and knee-replacement cases within a 39-county Medicare hospital referral cluster. It concluded, "The use of preoperative physical therapy was associated with a 29% decrease in the use of any post-acute care services." This translated, after adjusting for demographic variabilities and comorbidities, into cost reductions of $1,215—"driven largely," the authors wrote, "by reduced payments for skilled nursing facility and home health agency care." The following month, the journal Anesthesiology published "Prehabilitation Versus Rehabilitation: A Randomized Control Trial in Patients Undergoing Colorectal Resection for Cancer."3 The study of 77 patients randomized to receive either prehabilitation 4 weeks before or rehabilitation in the 8 weeks after colorectal resection surgery concluded that "meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program." The authors further posited that "the preoperative period may, in fact, be a more salient time to intervene, as patients are generally in a better physical condition." The health care news service Kaiser Health News cited that trial in a subsequent news release about prehabilitation for patients with cancer who are about to undergo surgery, chemotherapy, or radiation.4 That piece quoted Francesco Carli, MD, a coauthor of the study, as saying, "Prehab could be a relatively cheap way to get people ready for cancer treatment and surgery, both of them stressors." But the Kaiser Health News piece, which was reported by the Washington Post and other media outlets, summarized both the promise and the challenges of broadening a practice that makes objective sense. "It seems intuitive that people's health during and after invasive surgery or a toxic course of chemo or radiation can be improved by being as physically and psychologically fit as possible going into it," the news release noted. "But," it cautioned, "research to examine the impact of prehab is in the beginning stages." The piece quoted an American Cancer Society official as saying, "There are some physiatrists who don't believe in prehab. They feel like the science isn't there." The news release added that, while "insurance plans typically cover rehabilitation services such as physical therapy and occupational therapy, patients can face problems with coverage, such as preauthorization requirements and limits on visits. There may be even more coverage obstacles with prehab." Guarna confirms that insurance coverage "definitely can be an issue, especially with some of the managed care insurances that require coming back to them for authorization every couple of treatments. It presents a challenge." The Kaiser Health News piece focused specifically on prehab for patients with cancer, noting that prehabilitation more commonly is associated with orthopedic operations such as knee and hip replacements or cardiac procedures. But physical therapists (PTs) who treat patients with orthopedic issues report that they, too, face physician resistance to prehab, as well as reimbursement issues that in some cases can require creative solutions. John Mishock, PT, DPT, DC, owner of Mishock Physical Therapy & Associates in eastern Pennsylvania, says physicians in his area "seem to undervalue the benefits of prehabilitation." Snyder echoes that assessment, saying, "I've found many [physicians] to be indifferent [to prehab]. They don't seem to think it will make a difference." Payment for prehabilitation at Moore's orthopedic practice, meanwhile, "depends on the insurance plan," she says. "A lot of times it is reimbursable, but we often deal with visit limits for physical therapy. As a result, some of our patients may see the physical therapist just once presurgery, with the PT setting them up on a prehab program." The PTs with whom PT in Motion spoke are optimistic, however, that, as evidence of the efficacy and cost-effectiveness of prehabilitation continues to build, both evidentially and anecdotally, its reach will expand. P as in Preparation "I use the analogy that people wouldn't run a marathon without training for it," says Tony Brosky, PT, DHS, SCS, a professor of physical therapy and assistant dean of the Lansing School of Nursing and Health Sciences at Bellarmine University in Louisville, Kentucky. "Total joint replacement is by no means a benign procedure. We know that a percentage of patients experience serious side effects and complications from these surgeries. So, I think we need to do everything we can as PTs to help people build a reserve capacity—physically and psychologically—to anticipate and prevent potential problems." Brosky coauthored "Prehabilitation and Quality of Life Three Months After Total Knee Arthroplasty: A Pilot Study."5 It looked at a group of 18 patients with knee osteoarthritis who randomly were assigned to a control or prehabilitation group, and found that "the prehabilitation group scored significantly higher than the population norms" in 8 health-related quality of life measures that ranged from physical functioning and bodily pain to emotional and mental health. Quality of life is very much on the minds of her prehab patients, says Moore. "Most of my patients self-refer," she notes. "They've researched their surgery and the projected recovery time, and they want to know, 'How am I going to get better faster?' People are making a conscious effort to do everything they can to limit the amount of time they'll need to spend in rehab after surgery. They want to return to work quickly and get on with their active lifestyles." Rob Worth, PT, DPT, MS, ATC/L, OCS, owns Advanced Physical Therapy & Sports Medicine, which operates 8 clinics in eastern Wisconsin. He characterizes prehabilitation, even for patients receiving joint replacements, as being in "the infancy stages," and says it may take time for it to become anything close to standard practice within the US health care system. "Prehab" wasn't a word that anyone used when he became a PT more than 20 years ago, Worth notes. At that time, physical therapy might be employed in a last-ditch effort to avoid surgery, but it wasn't seen as viable presurgery tool. "What we've learned in the past 20 years," Worth says, "is that when surgery is imminent, there are things PTs can do to ensure the best possible patient outcomes. We can work to optimize range of motion, strength, and function, so the patient is in front of the starting line when he or she undergoes surgery and has a head start afterward." Patient education is a big part of prehabilitation, Mishock says. Patients are instructed in what to expect and do before and immediately after surgery to maximize healing, range of motion, strength, and overall recovery. Beforehand, he says, "Patients are educated on their specific impairments and functional deficits, so they can begin to work on those deficits prior to surgery. Afterward, "Because patients know from their education that the new joint is stable, they quickly begin the early-activation process of movement that helps reduce swelling, initiates muscle contraction, increases range of motion, and reduces pain." Another benefit of prehabilitation, Worth observes, is that "knowing the patient's range of motion, strength, and function preoperatively, through clinical examination and direct observation, allows the patient and PT to more accurately set realistic postoperative goals." For example," he says, "if the patient has 20° knee flexion contracture prior to replacement surgery, full knee extension may not necessarily be an attainable postoperative goal." For patients with cancer, Guarna adds, prehab affords "a sense of control at a time in their life when they otherwise may feel helpless and overwhelmed. They're taking an active role in their treatment," she notes, "which makes them feel more positive about their experience. Various studies have shown that positive thinking can play a role in improving patient outcomes." Physician Education and Collaboration The good news for prehab practitioners is that Moore's experience is not isolated. Patients and clients increasingly are self-referring, say the PTs interviewed for this article. The bad news, however, is that, per Mishock's and Snyder's comments, many physicians remain skeptical of prehab's benefits. "Patients often find us online by doing a search for 'cancer and exercise' or 'cancer and physical therapy,'" Guarna says. "We evaluate and consult with them under direct access." Which is a good thing, because, she adds "not enough oncologists are referring for cancer rehab—whether it's pre- or postsurgery or procedure." A review of the scientific literature published in 2013 in CA: A Cancer Journal for Clinicians6 concluded that a large majority of individuals with cancer who might benefit from rehabilitation are not being referred by oncologists to PTs or occupational therapists (OTs). The cited difference in percentage ranges is stark, Guarna notes: According to the study, 55%-90% of patients might benefit from rehabilitation (depending on the type of cancer and personal circumstances), but only 5%-20% of those are referred to PTs or OTs. While Mishock can't cite corresponding figures for prehab referrals for joint replacement surgeries, he estimates that "approximately 30% of the orthopedic surgeons in our area refer patients to us specifically for prehab"—meaning that 70% do not. This despite the fact that, the frustrated PT says, "there are some good studies out there showing that patients do better during and after surgery when they've had prehabilitation." The reasons for physician skepticism or indifference are varied, PTs say. For one thing, more of those "good studies" are needed. Another problem, they say, is that many physicians retain fixed and inaccurate views of physical therapy as a reactive postsurgery treatment and not a proactive presurgery option. Also, Brosky suggests, PTs "could do a better job marketing these services." But that's not to say that PTs are content simply to serve a rising number of self-referring patients while waiting for the evidence base to build and for physicians to take notice. Engaging with physicians is very much a strategy of PTs who offer prehabilitation services. Worth, in fact, is collaborating with orthopedic surgeons in the Appleton, Wisconsin, area to create clinical guidelines for prehab referrals. "We're fashioning a model to optimize the impact of prehabilitation for patients while, at the same time, being good stewards of health care resources and dollars," Worth says. "The question at the heart of this is, what's the 'sweet spot' for the number of prehab visits?" In Worth's case, it helped that a local orthopedic surgeon was familiar with that study from the Journal of Bone and Joint Surgery that touted prehab's role in improved patient outcomes and cost savings. "We, then, were able to say [to local physicians], 'Together, we can take this information on prehab and be leaders in developing a program that will benefit our patients while conserving money and resources.'" Critical to this fledgling collaboration, Worth says, is that his practice already has worked with local physicians on other projects, including development of bundled payment models for more than 30 patient diagnoses. "I didn't have to convince anyone involved of the value of physical therapy in a variety of situations," Worth notes. "That buy-in from the start was important." The resulting prehab guideline is for physicians to refer patients who are scheduled for total knee- or total hip-replacement surgery to undergo prehab once a week for 4 weeks, within a timeline of 4 to 8 weeks presurgery. Alternatively, should the patient face physical therapy visit limits under his or her health plan, the referral can be for a single prehab visit focused on education and home-exercise instructions. The model was applied on a case-by-case basis last year and will be "implemented on a more wide-scale basis in 2016," Worth says. In northern Virginia, meanwhile, "in recognition of the knowledge gap about cancer rehab, we are developing a screening tool to help physicians—general practitioners and oncologists—better identify patients who can benefit from physical therapy, both pre- and posttreatment," Guarna says. "It likely will combine an evidence-based functional test with subjective screening questions." Guarna anticipates doing "a lot of legwork" this year, as she hits the road to present and distribute the tool. She's excited by its potential to help "identify problems such as weakness, range-of-motion deficits, and poor physical conditioning that can be improved by physical therapy prior to cancer treatment." She adds, however, that she anticipates "very slow going" in getting physicians onboard. "It can feel like an uphill battle," Moore agrees. "But more and more people are learning about prehab on the Internet and talking about it with their doctors. And I inform physicians about the results we've achieved with our patients. I emphasize that better results mean greater patient satisfaction—and that makes every member of the health care team look better in patients' eyes." Potential for Growth Brosky says trends in patient demographics and health care delivery auger well for prehabilitation's growth. He references the "silver tsunami" of aging baby boomers seeking to prolong their active lifestyle, and predicts that interest in perioperative care—care both before and after surgery—for joint replacements will get a major push from the federal government's Comprehensive Care for Joint Replacement model.7 That initiative, to be launched this spring in 67 geographic areas across the United States, mandates bundling payment and quality measures for each episode of care associated with hip or knee replacement. The idea is to encourage hospitals, physicians, and other health care providers to work together to improve quality and coordination of care. APTA soon will be launching an online resource center to navigate PTs through this program, given the fact that efficiently compiling data about quality and cost will be vital to demonstrating physical therapy's value and ensuring that it is appropriately recognized in bundled payment allocations. "As the bundled payment concept grows and the relevance and importance of prehabilitation to patient outcomes and cost savings increasingly is recognized, perioperative care is going to assume increasing importance," Brosky predicts. "Prehab absolutely is going to grow," Moore concurs. "In this changing health care environment, given the increasing number of these surgeries being performed and the number of people who want to remain as active as possible for as long as possible, I see prehab becoming a very big market for physical therapy." "We have a huge opportunity here to improve patient outcomes and drive cost savings in the health care system," echoes Snyder. Guarna is less optimistic about the pace of recognition of prehab's value in cancer treatment. On the day she spoke with PT in Motion, an insurance provider had declined prehab authorization for a patient who'd been treated for breast cancer and was awaiting chemotherapy. The patient's physician had advocated supervised exercise and Guarna had argued, to no avail, that "for this patient to exercise on her own posed a significant safety risk." The response from the insurance provider nevertheless was that if the patient desired prehab, she'd have to pay for it out of pocket. "I've seen what cancer can do to people," Guarna says with a sigh. "My mom has had cancer twice. What's interesting is that people who are diagnosed with cancer often feel much, much worse after they're treated, which is so much the opposite of the situation with other diseases." Her commitment to turning that situation around is what keeps Guarna going. "I tell people, 'I left a really good job in home health to do this,'" she says. "But whenever I'm tempted to change career paths, I walk into the clinic, talk to my patients, and see for myself how much physical therapy is helping them. It keeps me committed to finishing what I've started." Eric Ries is associate editor. He can be reached at firstname.lastname@example.org.Addressing the Fear FactorCheryl Guarna, PT, CLT, STAR/C, concedes that the words "exercise" and "chemotherapy" don't pair naturally—particularly for individuals who may already feel overwhelmed by a cancer diagnosis and fearful of chemo-induced sickness and weakness to come."To add to all of that, 'Hey, you really need to start exercising' is very difficult for some patients to deal with," says Guarna, whose Virginia practice specializes in serving patients with cancer. "Historically, these individuals have been instructed to rest and not exert themselves. So, they may think any type of exertion is ill-advised in the first place. And they may interpret 'exercise' to mean that you plan to work them out at very high intensity."That's where education comes in. "We emphasize from the start that this is low-level activity," Guarna says. "We stress that prehab is not rigorous, but that it is designed to address, arrest, and reverse physical decline, muscular atrophy, and decreased quality of life during and after the surgery or procedure. We explain that we're going to determine their baseline via strength assessment and fitness testing, monitor them closely while they're exercising, very gradually build up their activity level, then teach them how to further prepare themselves for treatment after they've been discharged from physical therapy."Heather Moore, PT, DPT, CKTP, puts it this way in a blog entry on prehabilitation that prospective patients can read on her clinic's website before they ever step through her clinic's door for physical therapy ahead of rotator cuff or anterior cruciate ligament repair, total knee or hip replacement, or cancer or cardiac procedures: "Don't worry: Your prehab program won't look like you are training to win a bodybuilding competition, but it will focus on getting you strong and fit enough for surgery."Asked if she nevertheless must reassure skeptical patients that prehabilitation is nothing to fear, Moore responds, "All the time. Especially older patients who may be getting their knee replaced because the pain won't let them to sleep through the night, but who are afraid we're nevertheless going to put them on the treadmill, jack the thing up, then leave them there on their own." While all of her clinic's prehab programs are individualized to the type of surgery and the patient's specific needs, they share the same basic, measured, safe structure, Moore reassures patients. "There's warm-up, strengthening, flexibility, then cool-down. It's not intensive. We immediately dispel any fears that physical therapy is going to be overbearing in any way."Fear is a very real issue for patients facing joint-replacement or other surgeries, or procedures such as chemotherapy or radiation, notes Amy Snyder, PT, DPT. "These individuals typically have many worries and questions," she notes. "'How bad will it be?' 'How much pain will I be in?' 'How long will it be until I can walk again? When will I be able to enjoy my life again?'"While prehab exercises strengthen the patient for the procedure and reduce recovery time, "simply having a professional to talk to also is extremely valuable to the patient," Snyder says. "We tell them what they can expect throughout the process. They have less fear as a result. And the less fear-avoidance behavior there is, the better patient outcomes tend to be."John Mishock, PT, DPT, DC, regularly sees this cause-and-effect in patients who've had prehab for knee-replacement surgery. "We've taught them in prehab not to be afraid to move—to work on their range of motion and strength early in the healing process," he says. "As a result, by the time they return to us for formalized physical therapy 1 to 3 weeks after the procedure, they are weeks ahead in their rehab of where they might otherwise have been."