What is prehab? Is it for me? Moving and fueling for surgery (2024)

Manju George 0:00 
Good morning, everyone! I’m Manju George, I’m the Scienetific Director at Paltown Development Foundation, the non-profit that supports Colontown. So, welcome to DocTalks!Today, we have a different kind of DocTalk. We have experts from the Smilow Cancer Hospital at Yale and I will have them introduce themselves. The title of the talk is What is prehab? Is it for me? Moving and Fueling for Surgery. Scott, over to you.Welcome everyone!

Scott 0:00 
Thank you so much for having us today. Thank you all for logging in. We are excited to have this conversation with you all today. With that let’s get into it. I’m Scott Capooza, I’m a physical therapist at Smilov Cancer Hospital at Yale Cancer Center in Connecticut. I have been working in oncology since 2006. And over the course of my career, I have seen patients throughout their courses of treatment, and this area of prehab has become an area of interest of mine. I am board certified in oncology physical therapy, I hope that we are able to give you a little bit of information today about what is prehab and if it’s for you.

Lora  0:00 
Hi everyone! My name is Lora Silver and I’m a registered dietician, also at Smilow Cancer Hospital here at Yale. And when I got started working in oncology with patients, I was working with folks on the medical oncology infusion side, so I was seeing patients with all kinds of diagnoses, but many of them with GI cancers. I have worked with folks through the continuum of chemotherapy and radiation and surgery or some combination of the above. And then now I’m specializing a little bit more working with folks before and after major GI surgeries.

Alyssa  0:00 
Allright, I’m Alyssa Velez. I’m Scott’s student still. I will be a new grad next week. I’m also interested in oncologic physical therapy. So that is my goal going forward and I’m really excited to be giving this talk today.

Manju George  0:00 
Ok, great! Great panel! Let’s get started.

Alyssa  0:08 
What’s prehab or prehabilitation? We know that surgery really presents a major stress to our body and so the goal of prehab or prehabilitation is to prepare our body for that stress. And good outcomes following a surgery depend on so many different factors. Some of the top ones can include how quickly we are returning to our previous level of physical function we had before surgery. Good outcomes can also be determined by how our wounds are healing, by our bowel function after surgery, how quickly it takes for our bowel function to come online so as to speak. During prehab, during this process, we really want to get you all the building blocks you need for good recovery. And we know that high quality nutrition and targeted specialized movement and activity, all of that combined can really give you that support, give you the right building blocks for recovery and also really support good blood flow for healing. You will see as we are talking, everything is interconnected here. I know the three of us are working together on this. We are often really discussing, we are seeing those connections with each other. And also looking at what are the areas in this process that we can control, that you can exert some control over. I think we all know here that whenever a diagnosis of cancer is involved, whenever we are told we are stepping into a major surgery, there is a lack and a loss of control that we experience. One of our messages here today is to share that focusing on physical activity and nutrition, these are 2 areas you can really have some control over. And any comprehensive prehab program will also often include a psychological prehab component, we’ll touch on that a little bit here and there in the talk today. But we just wanted to mention that because there’s really a 3rd piece of psychological prehab, where you are really looking at ways to mentally prepare for how to cope for the stress of surgery, to ways to practise relaxation or reduce anxiety that can also be part of a successful prehab program. We can talk more about that when we have time for questions later.

Scott  0:36 
You might be asking is prehab for me? And I think that all the 3 of us would make the argument that yes, that prehab is a vital component of your continuum of care regardless of what your cancer diagnosis is. And what we see clinically is that you might be coming to us and or you maybe going to your provider with a new cancer diagnosis. But if you have any other what we call co-morbidities, any other medical condition such as lung disease, heart disease, or diabetes, then it means that you are further at risk for any potential adverse effects and potential delayed healing after your surgery, so that’s probably one of the things we are trying to get you ahead of time. And you can see all the different areas of where we think that prehab can really be beneficial for you. I think again, it is important to know that, I want to get to this in the next slide is that not only is prehab supported by major organizations including the American College of Surgeons and American Institute for Cancer Research to promote prehab early on, but that we have all these years of clinical experience too that shows that it works. we have research that it works. Ideally, we would say that if we could get to you at least 2 weeks prior to that surgery, it’s important to us and Alyssa is going to talk about this in a minute, for us to be able to identify where you are starting from. I think one of the biggest things in addition to getting some control back is for us to meet you where you are at. So we can come up with an individualized plan to help you. Scott:So you might say, what’s the research on this? Is there any research. As physical therapists, prehab is not new for us. For anybody having an orthopedic procedure, like a hip replacement or knee replacement, you start prehab. You see the orthopedic doctor and and you do prehab to strengthen your hip, strengthen your knee so that you can get to walking faster after surgery. So the concept of prehab is not new. We are taking prehab and applying it to this population. I will say that there’s this interesting thing to know that the research that I have quoted here, that so much of this research is being done in the prehab space in Australia, a lot of this is being done in Europe, so I will say that i feel like here is America, we do have a little bit more of work to be done, when it comes to prehab specifically in relation to colorectal cancer and to other different cancer diagnoses. But I will say that our colleagues from around the world are leading the charge on this. I think that we have seen time and time again, especially with recent randomized control trials, especially this prehab randomized clinical trial from Molenaar et al., they had almost 250 people enrolled in their study. That’s a pretty powerful study and it showed some very impressive benefits including that it decreased the amount of adverse effects, severe adverse effects of surgery by about 45% that pretty significant.

Alyssa  4:41 
So now I’m going to transition to more of the physical therapists role and how PT can help with prehab so our goal in PT is to help optimize your medical treatments and quality of life by helping you prepare for what’s to come in terms of surgery, other treatments, whatever that may be, and the first step in doing that is meeting you where you’re at. So it’s not kind of mentioned our goal isn’t to stress you out with more appointments and more things to do but more so to find ways to provide you with the education and resources that you need to improve your outcomes and really cater to what works best for you. So in our first time meeting with you in the clinic, we like to see what is going to work best for you. And from there give you the tools for success. So the last part of our job is to be an advocate for you and to initiate this continuum of care which I’ll dive into in a little bit. And so when planning to undergo surgery, we’d like to inform you of what’s to come in terms of recovery, expectations for after surgery, and then providing you with the tools and knowledge that you’re going to need for down the line. And it’s common that with this, you’ll see people like us in outpatient physical therapy prior to your surgery. Then as you’re in the hospital recovering from surgery, it’s likely that an inpatient PT is going to come see you and help with that early mobility and then even once you first transition home, you might even see a homecare physical therapist. So there’s this continuum that follows and we are that start of that continuum.

Alyssa  6:13 
So a little bit about what we do in our clinic and what we do when we first meet you. So in almost all of our new patients you’re seeing for both an initial evaluation of PT and with nutrition, and that’s because we like to obtain some baseline data. So that way we know that post surgery, post treatment whatever may be us in whatever PTs might see you down the line have an idea of what level of function we’re supposed to get back to doing. So this data is going to include subjective information, which is more of what we hear from our patients. And then also objective data which we get from our examination and other tests and measures. So the subjective data typically includes asking you about physical impairments that are affecting your quality of life. So these can be anything from pain fatigue, any side effects from chemotherapy, including neuropathy, or just overall deconditioning. And then we also like to know similar to what Scott said, if you have any medical comorbidities any other relevant past medical history, in addition to knowing about what you already are doing and your prior level of function and current exercise routine, so that’s important for us as PTS because we’re going to use that and take the text types of activities that you enjoy to create a comprehensive program for you based on where the deficits lie. And so from that, we then transition to our objective information, which we get to get a nice picture of your overall strength, endurance and things like that. So we’ll use this device in this top right corner there. And that’s to measure upper extremity strength and so using grip strength is actually a really good measure of how well your upper extremity your your arm is functioning. And so it’s backed by research, which is another reason why we use it but it’s also pretty easy and quick. So what we’ll have you do is squeeze that device as hard as you can, and it tells us a lot about your overall strength in a specific number so gives you the exact amount of pounds, which again is easily reproducible across settings. So if your PT down the line wants to check where you’re at, they just need one of these devices. And similarly with lower extremity strength or leg strength, we do something called a 30 second sit to stand test. So we ask you to stand up and sit down from a chair and it’s timed so for 30 seconds, we count how many times you can do this. And that tells us a little bit about endurance but mainly about that lower extremity strength. So to get a good measure of endurance we use something called a two minute walk test where like it sounds we ask you to walk for two minutes. And we will see the amount of distance that you can cover and how easy medium or hard that is. And that tells us about the endurance aspect. And these are not set in stone because we know that these are not going to be great for everybody. So these are just the common ones that we know are backed by research but they’re easily able to be substituted for other measures.

Alyssa  9:05
So an example being instead of a 30 second stitch stand test, we can do a five times sit to just stand test and see how long it takes you to sit up and down five times. And so again, we’re going to choose something that’s good for you but also going to give us good results. So this is just what our typical examination looks like. But again, it’s not set in stone. So from there, what we like to do is transition into what our interventions are going to be. So now that we have our data and see where we can improve, we’re going to give you some education, work on maybe scheduling some appointments with you if necessary, and I’m giving you the exercise that you need to enhance that post surgical recovery. So initially, we’d like to start with informing you about the benefits of prehab and why we’re suggesting this for you, and then also to create goals with you about why we want to improve these things. And then from there we like to discuss the options for prehab. So typically you think of physical therapy as going into a facility meeting with a physical therapist and that is one of the options so we will often set up in person appointments. For our patients either one or two times per week. But we also understand that some people might not need that much structure and so for others will give something called a home exercise program. And this is a comprehensive set of exercises again that you can create at home and independently work through this with maybe infrequent check ins throughout this process with a physical therapist. And then specifically in our clinic too, we have a decent amount of patients coming from farther away. So we can do check ins with telehealth but either way, we’re there for you as a resource and are able to give you those tools that you need to, in whatever way works best for you, complete this prehab. So the types of exercises that we’re going to give you are going to be dependent on what we see in our evaluation. So that can range from anything from strengthening exercises, endurance exercises, stretches and even working on balance. So another thing we determine is frequency. So how often you should be doing it in terms of how often you should be coming in for appointments but also how often you should be completing these exercises at home. And we also take into account your access to equipment. So if you have a home gym or access to a gym, we’re going to give probably slightly different but still very similar exercises to somebody who doesn’t have access to that. And instead, we incorporate resistance bands and stuff that is easily reproduced with household items like just sitting up and down from a chair. So it’s very easy to cater to what was going to work best for you. And then the last thing that we typically do is start to prepare you for post-op and one of the most common things that we experience is getting questions about how you’re supposed to move after surgery given you just had likely an abdominal surgery and these muscles are very inflamed, irritated and can be quite painful. So in almost all cases, we inform our patients about how to log roll. So in this picture in the bottom right, it’s a great way to try and get out of bed with minimizing the use of the abdominal muscles to therefore reduce pain. So starting laying on your back, you roll onto your side and use your arms to push yourself up or for sitting lower yourself down and then roll onto your back to avoid that use of those muscles until they’ve healed a little bit and you’re in a little bit less pain.

Alyssa 12:29 
So this chart is pretty much the basis of the majority of things that we give people because this is again research based. So this comes from the American College of Sports Medicine and this chart gives us guidelines to how to incorporate exercise with certain factors in terms of fatigue, you know, physical function and even emotional well being, so anxiety and depression so we often not only use this for our prehab patients, but majority of our patients we like to give these recommendations to because of their proven benefits with these factors here on the left. So we’ll take this into account. And then on the right side I put just some common exercises that we give for prehab. Again, you can see a lot of resistance bands use so that you can do it anywhere you can do it at home. You can do it at work whenever you can find time throughout the day. And then you see that there’s a mix of upper extremity and lower extremity exercises in addition to even some core exercises to really build that strength beforehand. And lastly, we like to encourage some form of aerobic activity. So whether that be walking, biking, swimming, anything that you enjoy, that’s why we like to ask these questions to see what’s going to work best for you and to make it enjoyable for you.

Alyssa  13:42 
And lastly, as I mentioned before we initiate this continuum of care, so in this dark blue spot, the preventative, the prehab section, that’s where we are right now and getting you set up for success but you can really see PT at any point throughout this continuum. So again, creating that baseline in that foundational data to say okay, here’s what we need to get back to because you can see PT during treatment, after treatment, even years down the line because now you’re not only dealing with a cancer diagnosis, but even some of these side effects from treatments and surgeries. So we as PTs are available to help you throughout this continuum and it’s our job in prehab to kind of get this continuum started and inform the patient of these options. So we do this again by making appropriate referrals, documenting that baseline data and then from there giving you those tools to enhance post surgical recovery.

Lora  14:35 Awesome. So similarly, what is it like to work with a dietitian during this process? There was a lot of overlap, I think in the processes between how physical therapists and dietitians are working with you. So in a similar way, we’re trying to get a baseline set of information. And you know, dietitians are often teased for being really detail oriented but I think this is part of why we really love getting into the details and will usually take longer to meet with you the first time we meet with you to hopefully understand, you know, everything about of course, your medical history and what brought you to this moment but then also trying to understand, what do you eat and when and how often and how did it get to be that way? And what side effects or symptoms might you be navigating at the same time and there’s so much personally and culturally that informs what we decide to eat on a daily basis, right? So we’re often really digging into those details with you too. And really trying to respect those preferences and food cultures and traditions as much as possible, in addition to everything else that you might be navigating. And then we’re also looking at ways you know, we have a few ways where we’re able to try to standardize information across patients, right, so in a similar way, in some settings, dieticians will actually use that same that same hand grip strength to assess functional status. We’re also looking at signs of malnutrition that may show up as places in the body where it’s clear that you’ve lost fat or have experienced muscle wasting or accumulating fluid in your abdomen or other parts of your body. There are some lab tests that we can look at that can add to the picture of what someone’s nutrition status is and then there are some physical signs that might confirm or support that you know the quality of any changes or the quality of your nails or your skin or your oral cavity, what things are looking like inside your mouth or your hair. We’re looking at all those things to understand that sometimes some of those physical signs and symptoms can support what we’re seeing in the lab tests. But I often get asked, you know, isn’t there a lab test that we can use to really understand and measure nutrition status and I wish that was the case. And we still do not have a single lab test that really does a good job of reflecting what you’re taking in as far as your diet. We don’t have a good test that really reflects your nutrition status, unfortunately. And we can certainly talk about that more in the q&a if folks have questions, but really in order to understand your nutrition status, the best information for us is to understand what changes you’ve experienced in your weight? What you’re eating and looking at the overall adequacy of your diet and balance, looking at these physical signs and symptoms, things like that. And another common question that we’ll get is okay, so I’m getting ready for surgery, what kind of diet is best for me? What should I be following? And of course, we’re going to try to take it as individualized approach as possible, similar to the physical therapy team. But these are some of the themes I guess, that I’m often working with.

Lora  17:58 
So first mindset. This is really important. I know I’m talking to a varied audience here and people might be in different situations. But generally speaking, if you’re gearing up and heading into a surgery, I’m often going to be recommending as nutritionally balanced as possible, but still overall high calorie high protein menu. And that’s really the mindset that I’ll be encouraging you to take and I use that word mindset. very intentionally. For a lot of us at once we are getting to adulthood as I’m working with adults here, it’s really common for us to have to have had at some point some experiences with dieting with intentional or desiring weight loss in the past, and it can be a real shift and change in mindset to be actually trying to eat more and to be eating high calorie high protein foods. For a lot of folks, there’s a real mental shift that needs to happen. It’s not everyone’s story, but a lot of folks that I work with will experience this. So I’m often talking about that with people extensively and you’re fueling for something right you’re really fueling if you have any background in sports or athletic events. I encourage you to think about it in a similar way you’re really fueling for this for that surgery. And of course, everyone’s coming from a different place, in some cases, you know, increasing the overall volume or increasing how much you’re eating, there’s going to be a natural limit to that. It’s not realistic for me to tell you oh yeah, just go ahead and double your portion sizes are you’re eating three meals a day, great. Just go ahead and eat six or seven meals a day. That’s not realistic for most folks, especially if they’re already navigating recent treatments and various side effects already. So a lot of times we’re also encouraging folks to consider a schedule for their eating and drinking and to at least practice that habit. Again, a lot of us might be used to in the past we might be used to eating when we feel hungry or eating when we see something that looks good or when someone invites you to eat. Those are more natural cues and nudges to eat. But unfortunately, if we’re experiencing a loss of appetite, navigating a variety of symptoms and side effects, that can be really challenging. And so using different strategies to eat and drink on something of a schedule can be really useful and it’s really helpful to practice this before surgery because it’s very likely that you’ll need to adapt some kind of schedule for eating and drinking after surgery. So again, it’s kind of like training.

Lora  20:35 
I’m also looking at overall diet quality with folks. So again, if you don’t have much of an appetite or what you’re able to eat is limited to begin with, then, I want to help make sure that every bite you are taking in counts, right? We want to help you make the most of everything you’re drinking everything you’re eating. And one way to do that is to really evaluate. You know, in a lot of cases folks are putting together pretty balanced meals for themselves. But what they’re drinking throughout the day and what they’re snacking on throughout the day. A lot of people will tell me you know, that’s my downfall. My snacks are my downfall or what I ended up drinking at work that’s my downfall. So those are often really opportunities for us to work together and really improve the quality of your diet. And one way we can do that is by making substitutions where we’re reducing things that are giving you added sugar not because added sugar is evil or there’s no room for that because there can be room for some added sugars in moderation in your diet. The but the the trick is really I want to help you avoid empty calories or empty foods where you’re just not getting much nutrition back for your effort. And I really want you to get the most for that effort. And then fruits and vegetables. We can definitely be talking about that more in the q&a too, because I know some folks have questions about that. Fruits and vegetables can be tricky for folks when they’ve got these diagnoses or preparing or recovering from a major GI surgery because they the fibers that are in these fruits and vegetables can be triggering as far as symptoms go. But there can be ways that we work around that. And I’ll actually talk about that in a minute. So I’ll say that. Something I haven’t said yet, but you’ll see repeated on here several times is protein because for the average person preparing for surgery, they do need to be more intentional about adding protein foods on a regular daily basis. And that’s usually a key area that I’m working on with people.

Lora  22:31 
Even though we like to give a more personalized goal when it comes to protein, I know it can help to just have some estimate of what that might look like. So I wanted to give that to you here on this slide. So I’m suggesting if you are gearing up for a surgery, this is likely a good starting place for you to take your weight in pounds and divide it in half. And that’s the grams of protein that I would encourage you to get on a typical day. Some days you come in lower some days you might come in higher. And again, that’s a higher protein goal than I would give to the average person who’s maybe not recovering from or who’s not gearing up for surgery, or maybe someone who’s not just coming off with treatments. So here’s a few more ideas that I wanted to share when we think about the kinds of things that we’re working on. And folks, I’m often working with folks to incorporate, like I said more protein and it’s not even necessarily that you need a crazy high amount of protein but you do need to be more intentional every time you’re getting a snack, every time you’re getting a meal. I’m really working with people that I want to make sure that you can point to something that you know is a good source of protein there. So here’s some ideas that have been useful for other patients that I work with, and are usually well tolerated. Again, everyone’s different and everyone’s coming in with different experiences but some of these ways can be a little better tolerated so for example, hot cereal sometimes when folks don’t have much of an appetite, and are limited as far as what’s agreeing with them hot cereal even something as simple as cream of rice, Farina, oatmeal, those are often better tolerated. And so sometimes we’ll use that as a base and see well let’s try that and then let’s see if there’s something we can sneak in to make it a little more nutritious and a little more substantial for you. So here’s some examples.

Lora  24:28 
Believe it or not, you can actually do this with the egg whites where you add egg whites to the last little bit of cooking such as the last minute or so that it’s cooking. You really don’t it does not change the flavor so much but it does change the texture and it makes it a little fluffy and light. So it’s worth trying because it’s something again that you’re not increasing the portion size of food that’s staring back at you, but you are squeezing in and sneaking in a little more nutrition to that same portion size. If you tolerate smooth creamy peanut butters or almond butters or sunflower seed butter or something like that, that can be another good idea. I really should have added pictures of the labels the packages, you know to look for at the store. But in any case, shelled hemp hearts or hemp seeds are something that I’ll often suggest. Even if you feel like the average nut or seed is something that does not agree with you and or that you’ve been told to stay away from by your healthcare team, you can usually tolerate these they’re very small, they look like sesame seeds, but they’re soft, and they can be incorporated pretty easily into a variety of foods and certainly into something like a smoothie or a soup as well. And then a couple other examples below. Again we’re looking at ways to not significantly increase your portion size but we are trying to sneak in more nutrition into that same portion size. Cottage cheese has been a hot trend lately, so I had to put something in here that included cottage cheese. If you haven’t tried that into your scrambled eggs. I do encourage you to try it. A lot of folks are into it and then you hear a lot about protein powders. We can talk about that more too. Sometimes protein powders are really useful, even if it’s just as a short term tool to get you geared up for surgery and then maybe on the other side of surgery as you’re adjusting gradually back into eating solid food that can be really useful tools. But sometimes protein powders don’t taste so good or they’re hard to find or they’re expensive. So there’s always other options that a dietitian can explore with you. I think powdered milk is one of those options where you can find it at any grocery store. It’s usually significantly less expensive than the average protein powder. And it incorporates into foods really well so it can incorporate really well into your favorite milk or into a hot cereal or mashed potatoes or soups. And that’s actually adding a decent source of protein and calories again into a smaller portion.

Lora  27:02 
So I have to talk about supplements because folks are always asking about this and it’s a very hot topic in this area. So here’s a couple ideas that may work for you but you have to know I’m giving you a big disclaimer on this slide. It’s so important whenever you are adding anything, any over the counter supplement, it’s really important that you discuss this with your healthcare team. Because there can always be some possible interaction or conflict with something that you add and your healthcare team would want to know about it, it might influence the way that your lab work looks, but if they don’t know that you’re taking it, they won’t be able to discuss that and identify that with you. So a big disclaimer on this. But again, for a lot of folks that I work with there’s some emerging growing research on this where if you’re currently undergoing cancer treatment, and you’re having difficulty maintaining your weight, it may be useful to try an over the counter supplement of about two grams a day of EPA. And EPA is one component or one part of fish oil supplements. And it’s the average fish oil supplement will have a pretty low dose of this EPA. So I do encourage you to you know ask someone from your healthcare team or ask a dietitian to help you find one that’s best for you but you are taking a higher dose of the average fish oil supplement in order to get to that dose which would be again about two grams a day of that EPA. Now there can be some negative side effects and especially interacting with bleeding and platelet function once you get to four grams a day so that’s why I’m suggesting you want to stay under three grams a day. And again, there’s the most research for this number, about two grams a day. So that way you’re avoiding getting up to that limit of three to four grams a day. But again, discuss with your healthcare team and remember that this would be something that definitely counts as that you know, they’ll tell you before surgery at least seven days before surgery, you need to stop taking all of your vitamins or any herbal medications. This would be included in that. So again, definitely communicate with your team if you’re considering this.

Lora  29:19 
And then also thinking about things like constipation and diarrhea that may be showing up as baseline symptoms for you or maybe showing up as side effects from recent treatments or they can appear or be an issue as you recover from a surgery. Sometimes there’s things we can do with that that can help in addition to the medications they’ll give you to help manage that. Many of you might be familiar with brown flax seed or chia seed. So these are things that can be incorporated on a daily basis. You can kind of sneak them into a lot of different foods and shakes and soups and things like that. And even though they even if you’re on a low fiber diet, which is something that will often recommend if you’ve had a history of blockages for example, ground flaxseed or chia seed is still often well tolerated and is okay to incorporate into your diet. Whenever you’re adding something like this to help promote regularity and to help manage and reduce constipation you do want to be hydrating adequately whenever you add sources of fiber or you want to add fluids so you want to be drinking well and hydrating adequately with that when it comes to the other end of the spectrum with loose bowel movements. or diarrhea. Something that can help improve the consistency of your bowel movements is to use a psyllium based fiber supplement Metamucil is just one example of that. But sometimes that can be useful as well. And then these labels at the bottom here. So when you’re selecting supplements over the counter without a prescription, you do want to look for what’s called a third party testing label of some sort. So it means that someone is having some oversight into the process of how that supplement supplement was made. And there’s a higher chance that it has what it says it has and is not contaminated with something it doesn’t say that it has. There’s not enough regulation in our country for these over the counter supplements. So that’s why we we tried to be extra cautious with our recommendations

Lora  31:25 
So similar to what my physical therapy colleagues are talking about here, prehab presents a real opportunity to practice your post op habits right now. So as many of you know, certainly if you’ve had prior surgeries and you’re gearing up for another one, you know just because surgery is scheduled doesn’t mean the rest of your life stops. You have a variety of responsibilities in your life. And there’s a lot of habits that we have as adults that can be really hard to break and change. And so again prehab gives you a real intentional opportunity to practice those habits. And again similar to what I was saying before about your mindset. I’m often coaching people and reminding them to expect certain things on the other side of surgery. When we lose our appetite, it can be very distressing and upsetting for especially if we’re someone who really loves to eat and enjoys food, to lose your appetite it’s can feel really stressful and upsetting. And so expecting that and talking about that with your team beforehand can be really useful and is really preparing you for the mental aspects after surgery. And then prehab is also a time to be exploring and experimenting with maybe it’s a new protein drink or a different protein powder or some of these recipes or ideas that I’ve mentioned, so that it’s not the very first time that you’re doing it when you wake up after surgery and are trying to do some of these things. And then we don’t really have time today to talk about this in detail. But I did want to mention that when when your healthcare team is preparing you for surgery, it’s often also really important to seek resources for smoking cessation, because ongoing smoking can you know can really increase your risk for various complications through a surgery, so I just wanted to put a reminder there about that. And then also if you’re someone who has found that you’ve been relying quite a bit on alcohol, that’s also something we really want to support you with during the prehab process to reduce your reliance and reduce symptoms of withdrawal. And again, we just want to give you the best foundation that we can going into surgery.

Lora  33:40 
Yeah, and so then here we wanted to share, you know whether you have extensive prehab resources, you know, with your local healthcare team or not, here’s some of our favorites that we like to share. So from a nutrition perspective I did want to share on the bottom left, you know a lot of folks are sensitive to cold foods as a result of certain treatments, and you may also just have a preference or not be very into cold or chilled shakes and smoothies and things like that. So sometimes people are asking for a warm and savory substitute. So this is just one way of doing it where you can make a soup that’s going to be pretty well tolerated by most people, but you’re bulking it up and making it as substantial as you can. And so here’s a reminder again that if protein powder is not your thing, you can use something like a powdered milk to boost the nutrition of your soup. And then there’s also like unflavored or plain protein drink options that are out there and that can give you a protein boost as well. Some insurances will cover protein drinks, from your pharmacy at no cost to you. And so it’s just a case of asking your dietician or asking your healthcare team if it can be covered and if they can write you a prescription for it. So it’s worth asking your team about that. And then cancer dietitian.com I think is a great resource. They have so many self guided online programs for you to walk through, you know, diet changes and lifestyle and it’s all about folks going through any stage of treatment. So I think it’s a great resource.

Scott  35:25 
And likewise, again, depending on where you live you may be getting your surgery at a major academic institution like where we were, but you may be you may live an hour, two hours, even three hours away from that. So again, you know, we’re trying to list some resources here for you so that you can find those resources on your own. We wanted to list here a couple of our physical therapy colleagues, who again, and that’s a whole nother discussion for a whole nother day about social media and what you see on social media, I’m sure Lora, I’m sure you see it all the time with supplements and that sort of thing. And, you know, and Alyssa, you and I see as as far as you know, do this exercise and do that. So if you are looking for credible people who follow evidence based practices, I’ve listed a couple of contacts here before you especially Alex Hill, who is a public health PT, again that’s a conversation for another day but you know if you are experiencing any any bowel and bladder, irregularities because of your surgery she is both a certified specialist in oncologic physical therapy as well as pelvic health therapy. So she will be a credible follow for you. And so we want to, you know, we want to wrap up here to make sure that we have time for questions. But again, I think one of the things we want to leave you all with is that prehab and the components of prehab including exercise, rehab, mobility, how to move your body and nutrition how you fuel your body are two very important components of your care that you have control of, but we want you to reach out to us as registered dieticians and as physical therapists to help you identify you know, I hope you set those goals. You know to make sure that those goals are attainable, measurable, and then we are able to follow you through that continuum of care. And again everything that we do is all evidence based. Again, it’s based on on evidence and research from the American College of Surgeons. And the American College of Sports Medicine, the American Institute of Cancer Research. So there are a lot of national organizations that support prehab and again, specifically prehab for patients with colorectal cancer. And so we just want you all to know that this is a resource that you should be a part of to help optimize your health after surgery.

Scott  38:18 
These are some of our references. And thank you all for having us. Today.

Lora  38:29 
We left some time for questions, thankfully. Yeah.

Manju George  38:33 
Okay, thank you so much. So what I did is that I posted the questions in chat, and then we can see if there are any new questions and thank you so much. This was very very helpful.

Scott  38:56 
I’m gonna go through chat real quick unless you can go through them.

Manju George  39:00 
Yeah, I can start from the beginning. How much exercise is okay as preparation for major surgery? So this question is I have not been very active but have recently started working out. So I don’t know what I’m doing. Can I overdo it? What’s the right amount of exercise?

Scott  39:17 
Yeah, that’s a great question. I’ll start and I’ll show you I want you to jump in here. I think again, that’s why meeting with a with a physical therapist is so important to help you dose that amount of exercise. What I would say is if you have not been very active previously, we don’t want you to immediately join and I don’t want you to start flipping tires and swinging sledge hammers, because that’s not something that your body is used to. You want to enter an exercise program, slowly and progressively. A lot of times with what we would describe and Alyssa you had the pictures of a lot of the what we call bodyweight exercises using your own bodyweight. You don’t necessarily need a whole bunch of weights. You don’t need to go to Dick’s Sporting Goods and buy a whole bunch of equipment. Being able to do 10 standing up and sitting down from a chair or doing a push up off of your countertop or your push ups off of a kitchen island. Those are all exercises and those are all a great place to start.

Alyssa  40:24 
Yeah, I would agree. And I think the one thing I would add is in terms of can you overdo it? I think that’s a very subjective question. And the way to figure that out is you know, how sore are you after doing these exercises? How do you feel afterwards? So again, we have this conversation this morning. You know, doing your round of exercises that is suggested to you and then seeing how your body reacts to that. So seeing how sore you are, see how long it takes you to recover. And we want you to be if anything a little sore because that shows a little improvement, but also not sore for days on end where you can’t do your normal activities. So in terms of overdoing it, it’s very much how you feel after doing these and then that’s where that conversation with your physical therapist comes in of, Oh, I was really sore after this or Oh, I didn’t feel any soreness at all and that directs us as to what is the right amount of exercise for you.

Manju George  41:17 
Okay, So then I go to the next exercise question. So it says I was told exercises to strengthen the abs are very important to avoid hernias. Is this true?

Scott  41:27 
I do think that that that is true to some degree. And again, to work with a physical therapist to give you the proper core exercises and I know the question talks about your abs and I think we think about more than just the Abs more than you know, the kind of what we see again on social media that six pack abs or whatever. When we think about the core, we’re really thinking about from the shoulders to the hips. We need good stability in the middle of our body to be able to do anything including carrying a basket of laundry up the set of stairs. So we again, we can help prescribe different exercises. I’m a proponent again, more of what I would consider bodyweight exercises kind of like a plank or even doing things like you know, like, like yoga poses I think are very important. You know, you can do certain yoga poses like a downward facing dog, or like a bird dog or that sort of thing and you’re going  to be engaging those those core muscles to help get you stronger and potentially help prevent the development of a hernia.

Manju George  42:41 
Okay, Thank you. Yeah, go ahead, Alyssa.

Alyssa  42:45 
I was just saying I would agree with all of that. It’s really bigger picture than just what we think of abs. Okay.

Manju George  42:51 
Okay. So I think this question is for Lora. There’s a lot of information about various diets, what would be a good diet to be on as one gets ready for surgery?

Lora  43:01 
Yes, I would say for most people, a high calorie high protein menu or diet is going to be appropriate and I would encourage people to avoid picking a new diet or a diet that’s kind of on the extremes or fad diet that might be going around at the time only because what feels most realistic and what you’re going to be following most consistently is what’s actually going to be useful, to be ready or fit for surgery. We want to know that you’re able to maintain your weight and that you’re maintaining your muscle mass. If you’re losing weight quickly, you’re more likely to be losing that weight as muscle.

Lora  43:40 
extra fat is usually the hardest and the slowest to for us to lose unfortunately, we lose we tend to lose muscle the fastest and so we want you to be getting enough to eat overall and so again, I’ve emphasized you know, really a high protein menu is appropriate for most folks heading into surgery. And then when it comes to fruits and vegetables and those plant based sources of antioxidants. I do want you thinking about colorful fruits and vegetables, if those are foods that you tolerate, and some of the ways you know so again, foods that are high in fiber, the peels and the skins and the seeds of fruits and vegetables, that’s where a lot of fiber lives that’s harder for us to digest. It’s a little harder on our system. So for many folks that need to be on the low fiber menus but even leading up to surgery, I will encourage you to certainly be removing the peels and the skins and the seeds of fruits and vegetables but even to take a step further of eating mostly cooked fruits and vegetables so incorporating cooked fruits like as part of a compote into a hot cereal, for example, or cooked vegetables, even well cooked peels and pureed vegetables as part of a soup. I often think of you can get can I know canned vegetables are usually not very popular but canned pumpkin puree or canned, pureed butternut squash where that’s the only ingredient it’s just pureed squash or it’s just pureed pumpkin. Those are examples those brightly colored vegetables are actually really good for us. They have some good antioxidants and other nutrients that can be protective as we head into a surgery and those are usually really well tolerated forms of vegetable that you can sneak into a soup or a casserole or a sauce. And so that would be a way even if you’re following a low fiber diet and being more cautious with your fruits and vegetables. That would be an important thing to include.

Manju George  45:33 
Okay. Thank you. So this question is for both of you. Can anything be done to avoid complications like adhesions, fistula formation, etc after surgery?

Alyssa 45:46
I think one component that we talked about actually in reading these questions was that at least in the exercise, world, mobility is motility. So staying active, even if it’s just walking or doing some of these leg exercises does continue to help motility in terms of bowel movements and stuff like that. So Lora can talk more about the nutrition side but just staying mobile and not sitting and not moving for too long at a time, there’s definitely ways that you can keep that bowel regularity.

Scott  46:20 
And you talked about this earlier about even the proper way to get out of bed rather than coming straight up. Right after a major surgery if you do that log roll like you were describing as a safe way to get up. And again, even little movement-breaks like exercise, what are they called? exercise snacks? Now that’s like the one of the terms has become popular. You’re just getting up and moving around your house or if you have returned to work to be able to get up and go fill your water bottle or be able to go to the bathroom but go to the bathroom further away from where your office is all of that is movements to help with motility.

Lora  47:07 
And then I would add any strategies that help to manage constipation will also be useful here right, so hydrating adequately. We usually tell folks when you’re recovering from a surgery, you’ll usually benefit and feel better from drinking even more than this but if you can get to at least 50, five zero ounces of fluids a day. That’s a really good start and usually a bare minimum to help promote regular bowel movements. And then keeping up with, it’s all connected, keeping up with any of the medications and really staying ahead of symptoms like constipation and pain and nausea when you can, when you’re able to do so staying ahead of those symptoms really makes such a difference here with any of these complications.

Manju George  47:54 
Okay, so, next, the question I’m going to ask is about low anterior resection surgery and butt cramps. So even people who get radiation, they have a lot of cramping. And are there any exercises they can do to relax the pelvic floor? Would that help?

Alyssa  48:11 
Yeah, so that’s actually a great time to get connected with a pelvic floor physical therapist because they definitely have the expertise to prescribe exercises that will help with those types of things. Again, I think movement is one of the best things but, specifically, pelvic floor physical therapist can address those concerns on a deeper level and really dealing with those internal muscles as well to try and avoid some of that cramping sensation. So getting connected with a pelvic floor physical therapist, really my recommendation Scott got anything to add?

Scott 48:45 
I think. Yeah, I would agree. I think probably the, the one exercise that any buddy post surgical can do is diaphragmatic breathing. That is bad. I think most public health therapists would start there, because you’re trying to wake up, you know, those abdominals and to try to reengage that diaphragm. And so to be able to work on breathing exercises is a great place to start. Again, you don’t need any equipment, but to be able to either talk with a physical therapist or even talk with the nursing staff. And you know, that’s on the post surgical floor to say, can we talk about breathing and have that as a foundation so then we move on to more specific pelvic floor exercises.

Manju George  49:35 
Okay. What would be a good time to see a pelvic floor physical therapist, this is another question that comes up in our communities. So do you suggest seeing somebody before surgery or how long after surgery, like what would be a good time?

Speaker 1  49:49 
Again, I mean, if you’re able to connect with a pelvic health physical therapist as part of your prehab program,  you were talking about this before about setting expectations. And so I think that that would be actually a great opportunity to have that conversation and how to set those expectations what to expect following a major abdominal surgery. And then I would say as soon as that patient is cleared by the surgical team, a lot of this depends for us as physical therapists, a lot of it does depend on clearance from from the surgeon from the APRN, the PA whoever it might be. So once they are clear to resume any kind of activity in physical therapy, then I would say as soon as we get that green light, then we want to start working with you. Okay,

Manju George  50:39 
Okay. Terri has a question will appear to be able to recommend specific exercises to help prepare and recover from VATS surgery of the lungs, or is it better directed to a powered neurologist?

Scott 50:58 
I’m sorry. Can you repeat that question? Again?

Manju George  51:01 
It’s about having lung surgery. So as preparation for lung surgery, are there specific exercises that can help? Or you know, is that something to ask the physical therapist or is it better to be directed to a pulmonologist?

Speaker 1   51:16 
Okay. Yes, again, to make sure that the pulmonologist has cleared you for rehab. But again, we can work with you to regain some of your overall strength. Again, working on breathing exercises, being able to again strengthen that core. I’ve worked with patients who have had lung surgery, whether it’s lung cancer specifically or because of metastatic disease to the lung, and a lot of times we’re starting with pain management. So to be able to teach simple stretches,  just the how to move the body again. So yes, there’s absolutely a role for physical therapy in that setting.

Manju George  51:58 
Okay, then the next thing, we have two minutes left, so I will have a permanent ostomy what exercises can I do safely without affecting my stoma? Are there things that we should be careful about?

Scott 52:11 
Yeah, with with the stoma, you want to make sure that first and foremost you’re not going to do anything that’s going to have any kind of an impact that could affect the integrity of that ostomy so I would say you know obviously no like lacrosse or anything like that. But then beyond that, to be able to again, work on strengthening the shoulders, the hips, the glutes, and then working towards strengthening those core muscles I would avoid any kind of Valsalva movement, though when you’re doing your exercises to not hold your breath. So again to being able to time your exercise to be able to do the actual repetition with your breathing is so important. And I think yeah, in this instance having an ostomy bag, I think it was also very important to make sure that you’re not bearing down as you’re doing those exercises.,

Manju George  53:16 
Okay. Any other questions? I’m not seeing anything. I’m sorry that we have not been able to get through all the questions. I think some of the other questions have been covered by your talk already. So thank you so much. This was very informative. Thank you for your time, and putting this presentation together. So and thanks to everyone who had time to attend. So we will edit the video and have this posted on Colontown University in about two or three weeks, though. Thanks, everyone.

Scott  53:48 
Oh, great. Thank you so much. Bye