Exercise in preparation for surgery

Almost the best thing that anyone can do before surgery is regular exercise. (“Almost” because stopping smoking is the best.) The evidence is overwhelming. The waiting list should be a ‘preparation list’. This blog explains how individuals and organisations can make the change, focusing on the “why” (an explanation) and the “how” (practicalities). Preparing for an operation is a ‘teachable moment’.

Why:

Complications are at least four times more likely if a patient is physically inactive or frail. People who do an exercise programme reduce their risk of complications of surgery by around 40%. The UK Chief Medical Officers and the World Health Organization recommend a minimum of 150 minutes of moderate intensity exercise per week. I led the report “Exercise the miracle cure” from the Academy of Medical Royal Colleges in 2015, showing the general benefits to health, reducing the risks of getting dementia, depression, type 2 diabetes and some cancers each by 30% and reducing complications of these and other conditions at this “dose”. The best health improvements come from people changing from doing no activity to just doing something. Every bit of physical activity helps. A very high proportion of citizens in the UK now are worryingly completely inactive (See Table 1).

Before surgery, people who get fitter have fewer complications, less time in intensive care, shorter bed stays and better outcomes. They are also more suitable for day case surgery, which saves NHS beds and complications of admission and is far more efficient.

Table 1: Current levels of inactivity in England (from Sport England Active Lives 2022)

 

Why is exercise so good at improving outcomes?

There are many different benefits, some of which require slightly different forms of exercise. The most important is to do some aerobic exercise – this improves the outcome from an anaesthetic and has powerful metabolic and anti-inflammatory effects. Strength and breathing exercises are also important (see Table 2).

Table 2: Types of exercise and their benefits

 

Also, muscle is a store of protein. Your body recycles the building blocks of protein: “amino acids”. Immediately after the operation, your body can use this protein to create healing tissue (e.g. collagen to repair skin, bone and other tissue) and antibodies (against infection).

Words:

Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure, including gardening and walking. Exercise is a subset of physical activity that is planned, structured, and repetitive. The word “exercise” can be off-putting. The advantage of “exercise” is that it can make it into a habit and tends to have increased intensity. Any movement helps. Higher intensity has better results. Moderate intensity is anything that gets you a bit short of breath “so you can talk but can’t sing” – jogging, cycling, swimming, stair-climbing, brisk walking, etc.

How:

The best results are with aerobic exercise at high intensity. However, anything helps. The biggest gains are when somebody moves from no exercise to just a bit. Most people need to be encouraged, with the “why” and the “how”.

Table 3: Top tips for patients:

“How” for organisations:

All staff must understand the general importance of the waiting list being a preparation list. This includes non-clinical staff and support staff. The ‘Making Every Contact Count’ training has modules for ALL staff. This includes listening for the patient’s “change talk” and reinforcing it; and acknowledging the “sustain talk” (reasons they think they can’t) but not letting the negativity take over. Patients need to see the practicalities of how it will work for them.

Clinical staff, especially surgeons, other doctors, nurses and allied health professionals need to mention exercise to each patient. We are all short of time. But a few words can set the scene. And the patient will realise that we are individualising the instruction to them, with all their personal medical, psychological and social uniqueness, because it is important. Ideally there would be a care coordinator who could explain things further.

Places where there is a prehabilitation programme can have excellent results. Patients are taught some principles and techniques and get a coach who checks in. ‘Surgery schools’ with group discussions work well, but often happen late in the process. Apps and videos can be good, but each patient needs to be informed that this is important and applies to them.

We must not abandon those for whom a prehabilitation programme is not available. A consensus statement coordinated by the Faculty of Sports and Exercise Medicine states that the risks of inactivity are so great that it is almost always safer to be active than to do nothing. There are very few warnings to stop (from the consensus statement, stop if: new heart pain, irregular heartbeat, dizziness, a sudden change in vision or a systemic infection). The best results occur with just starting exercise. All clinicians should advice people to do aerobic exercise and strength, eg sit-to-stand from a chair. You may want to suggest going for a walk and building up, or stair climbing. Some people have problems with knees, hips, legs or back. For them, electric-cycling, static cycling or swimming may be best. See Table 3 for ideas. I worked with Swim England to write 25 leaflets about how to swim with a number of different disabilities or health conditions.  I used an electric-cycle myself every day before my own hip replacement – but the knowledge about the benefits should be shared widely.

Table 4: Resources for health professionals

 

Please just start! The most relevant resources are at www.movingmedicine.ac.uk. Please encourage other staff and students to learn knowledge and skills, or just tips, from it too.

Thank you!

Prof Scarlett McNally