Exercise prehabilitation in colorectal cancer surgery patients : the effects on physical functioning, health related quality of life and markers of cellular protection

Northgraves, Matthew James

Abstract

Since being introduced in the late 1990’s, enhancing recovery after surgery (ERAS) protocols have been promoted for inclusion in the care pathway for colorectal cancer patients scheduled for resection surgery (Gustaffson et al., 2012). This multimodal approach to stress management is thought to reduce the amount of surgical stress encountered; attenuating the debilitating effect surgery has on the patient and aiding subsequent recovery with a reduction in hospital length of stay reported (Lv et al., 2012). Although not currently included in ERAS, a period of pre-operative exercise training, known as PREHAB, has been proposed as a potential mechanism of improving the patient’s pre- operative fitness ahead of surgery (Carli & Zavorsky, 2005). As no research currently exists into how feasible it would be to incorporate a period of PREHAB into the current NHS colorectal cancer care pathway in the United Kingdom, this thesis aimed to address this gap in the literature as well as investigate whether participation in PREHAB would alter physical functioning and health related quality of life (HRQOL) prior to surgery and improve post-operative recovery. The impact of PREHAB on upregulating the body’s heat shock protein (Hsp) and glutathione defence systems was also explored.

The purpose of the first experimental chapter was to investigate through a questionnaire-based approach whether an interest in the potential use of PREHAB existed in the Hull and East Riding area and what were the perceived benefits and barriers to participation. Over 75% of respondents indicated they would be interested in PREHAB if awaiting surgery although a lack of time (62% of respondents), cost (46%) and work responsibilities (43%) were identified as the main barriers to participation. Having established an interest existed in PREHAB, the test-retest reliability and measurement error of the five tests of physical functioning (Timed up and go [TUG], five times sit to stand [FTSTS], 5 step stair climb [SCT], handgrip dynamometry [HGD] and 6 minute walk test [6MWT]) that would be used to assess the effectiveness of the PREHAB intervention was investigated. All five tests displayed excellent test-retest reliability (all ICCs: >0.90) with the standard error of measurement and minimum detectable changes at 95% as a percentage of the mean ranging from 2.3% to 5.2% and 6.3% to 16.1% respectively.

In the third experimental chapter, a randomised controlled pilot trial investigating a novel PREHAB intervention based on the joint-by-joint approach to training was conducted in colorectal cancer patients. The ineligibility of 43% (84 out of 198) of patients due to insufficient time to scheduled surgery (< 2 weeks) and subsequent poor consent rate of eligible patients (18.4%; 21 out of 114 patients) indicates implementing PREHAB into the current colorectal care pathway would be difficult. However, improvements in TUG, SCT and 6MWT performance were observed in all nine patients randomised to PREHAB (all p < 0.05), a result not replicated in the control group (improved performance at reassessment: TUG: 2 out of 9; SCT: 3 out of 9; 6MWT: 4 out of 9). This suggested that despite the limited time from recruitment to surgery (median PREHAB period: 23 [IQR: 14] days), the PREHAB programme was sufficient to improve physical functioning in these patients. There was however no significant difference in length of hospital between the two group (Control: 8 [5] days; PREHAB: 10 [7] days).

In the final two experimental chapters, the effects of the PREHAB intervention on basal Hsp72 and Hsp32 expression and the glutathione defence system was explored although the low recruitment rates previously described limited the results. No changes were evident in Hsp32 or Hsp72 expression; or in total glutathione or GSH/GSSH ratio for either group during the pre-operative period. There was a potential time of day effect for monocyte Hsp72 as expression decreased in 13 out of 16 at pre-operative reassessment (p < 0.05) thus potentially masking any adaptations to have taken place. Furthermore, attempts to establish whether PREHAB altered Hsp72 inducibility were not possible due to inadequate viable samples being available. Given the limited sample size, definite conclusions were difficult to make although it was plausible the absence of change in Hsp72, Hsp32 and glutathione following PREHAB was due to insufficient stimulus being present given the often low to moderate intensity of the intervention.

The findings of this thesis highlighted the issues regarding the limited time available in the pre-operative period that would need to be overcome in order to practically implement a PREHAB intervention into the current NHS colorectal cancer care pathway. Despite this, the improvements observed in physical functioning following PREHAB suggests if the intervention could be adapted to a cost-effective home-based programme it may be a viable addition to the ERAS programme.

Citation

Northgraves, M. J. (2016). Exercise prehabilitation in colorectal cancer surgery patients : the effects on physical functioning, health related quality of life and markers of cellular protection. (Thesis). University of Hull. Retrieved from https://hull-repository.worktribe.com/output/4219478

• Thesis Type: Thesis
• Deposit Date: Aug 11, 2017
• Publicly Available Date: Feb 23, 2023
• Keywords: Sports sciences
• Public URL: https://hull-repository.worktribe.com/output/4219478
• Additional Information: Department of Sport, Health and Exercise Science, The University of Hull
• Award Date: Sep 1, 2016