Overview
Based on thorough assessment by a qualified exercise professional, individuals will be stratified into moderate or high-risk categories which leads to targeted and specialist prehabilitation intervention respectively1
Modified from MacMillan Prehabilitation interventions triangle1
Targeted exercise intervention
Who
Individuals who score a DASI ≤34 on initial screening and then upon further assessment of exercise capacity through CPET (AT 11-15 mL/kg/min or VO2 peak 15-20 mL/kg/min) and/or 6MWT (435-510m)2 are defined as moderate risk and receive targeted intervention.
How – exercise prescription principles
Exercise prescription principles3,4
Both strength and aerobic exercises can be delivered in sets or as interval training. High intensity interval training (HIIT) theoretically alternates periods above (or around) anaerobic threshold (AT) with lower intensity periods. HIIT may have advantages over moderate intensity continuous exercise including greater time efficient improvements in aerobic capacity, especially when faced with short time frames for prehabilitation.
The rate of perceived (RPE) scale can guide dosage and progression with target range typically 4-6 (moderate to hard) but should be tailored to the capacity and needs of the individual with cancer.
Rate of perceived exertion (RPE) scale
Exercise prescription principles for those undergoing neoadjuvant therapy
Individuals with cancer in general but particularly those going through neoadjuvant therapy, often find their physical capacity will fluctuate depending on the symptom burden of their disease and/or treatment side effects.
A ‘traffic light’ system can be helpful to guide prescription and how hard the individual works during the exercise session by asking them to self-rate how they are feeling that day before starting their program9.
Periodisation of exercise relative to patient neo- adjuvant therapy may be needed.
For example increase or decrease time and frequency based on timing of administration of cycles of chemo/immunotherapy (reduce in the week following therapy and increase between cycles)10.
Figure 1 Traffic light system (patient-self rating) used to assess patient wellbeing and inform daily adjustments to exercise prescription, as utilised by Abo et al.9
Frequency of review
Fortnightly to monthly face to face or telehealth review (if telehealth unavailable then phone review) to review and progress home based exercise program and review goals. Note: patients may transition between the stepped model of care and intervention should be adjusted accordingly.
Specialist exercise intervention
Who
Patients who are more deconditioned or frail (using CFS≥ 5) with a 6MWT (<435m)2 are defined as high risk and can be referred to receive specialist intervention.
How – exercise prescription principles
- Follows same principles detailed in Targeted intervention (above)
- In addition, supervision and frequency of review may vary
- Due to the frailty and/or deconditioning of this population group, supervision may be required for all exercise sessions.
Frequency of review
Weekly telehealth or face to face review (if telehealth unavailable then phone review) to review and progress exercise program. Some patients may be best managed face to face to enhance safety – for example if a falls risk.
Considerations for discharge from prehabilitation exercise service
Although there is no consensus on optimal timing and length of prehabilitation exercise programs, many studies utilise a program of 2-8 weeks to effect positive change towards reducing a patient’s surgical risk profile11. However, further considerations of concurrent or planned neoadjuvant treatment and the resulting impact should be factored in when determining if a patient should continue in prehabilitation beyond this period to support their progress prior to surgery.
The following considerations can be used to determine if a patient is suitable for discharge from the exercise service:
- Patient is independent with exercise program with consistent adherence
- Achieved minimal clinically important difference (MCID) in appropriate outcome measures.
A discharge package may be useful to support the patient, this may include:
- Updated individualised home exercise program (HEP)
- Contact details for prehabilitation clinician for the patient to contact with any concerns re: HEP
- Information about safe exercise e.g. when to stop and who to contact if concerns arise.
Also, ensure communication via the Identify, Situation, Background, Assessment, Recommendation (ISBAR) handover framework12 to the appropriate inpatient physiotherapy team is completed to ensure continuity of care.