Effects of exercise-based prehabilitation in children undergoing elective surgeries: a systematic review

Abbreviations used

ACBT: Active Cycle of Breathing Technique

CG: Control Group

FEV1: Forced Expiratory Volume 1

FEV1/FVC Ratio: Tiffeneau-Pinelli index

FVC: Forced Vital Capacity

IG: Interventional group

PEFR: Peak expiratory flow rate

POP: Postoperative Physiotherapy

POPE: Preoperative Physiotherapy Education

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCT: Randomized control trial

ROM: Range of Motion

TUGT: Time up and Go test

6MWT: Six-minute walk test

9SCT: 9 Step climbing test

10MWT: 10-minute walk test

Introduction

Major surgeries in children along with the deleterious effects of the condition that predisposes a child for the surgery lead to complications that need to be therapeutically managed in children.

Prehabilitation is a multimodal type of approach that helps a patient planned for any major surgery and also allows them to prepare to, manage the stressors in the pre-surgical period and also undertake the necessary rehabilitation successfully so that they can return to their pre-operative state with better and improved outcomes.^1,2 Prehabilitation encompasses pre-operative physical exercises, nutritional support, and stress and anxiety reduction.^3,4 The concept of prehabilitation dates as far back as World War II and was initially started not as a part of the pre-surgical procedure.¹ Prehabilitation has its first mentions in articles in 1942 where it raised the fact that military recruits would be medically screened and treated with respect to their health and comorbidities, resulting in a higher number of acceptances.^1,5 and came to light post-2011 after the systematic review published by Valkenet et al. about prehabilitation before joint, cardiac and abdominal surgeries^3,6

Prehabilitation/preoperative exercise is a set of interventions done before surgery that helps the patient to be prepared for post-surgical stressors and also help improve their functional capacity (FC) through the exercises.^1,7 Patients’ ability to function to their fullest capacity can deteriorate because of inactivity during the surgical period and even if the surgery has been successful there can be chances of deconditioning.^1,8,9 Current studies and reviews done in prehabilitation concerning the adult population do show that there is improvement in the post-operative complications and length of stay and also in their post-operative pain.^3,10 Therefore the concept of prehabilitation is said to not only help the patient prepare themselves before a major surgery for post-surgical complications, but it also helps the patient to understand the importance of it to reduce the complications, helping them promote physical fitness and also optimize their psychological wellbeing. This also helps the patients return to their normal levels of functionality that were present before surgery.^11–13

This review aims at examining the current body of evidence in the area of exercise-based prehabilitation in children undergoing various elective surgeries.

Methods

Results

Characteristics of studies

All the data retrieved from the databases, summing up to 2219 articles, were fed in the Mendeley Desktop v1.19.8 after which duplicates were removed. The articles were then screened through the titles and 181 articles were found eligible, following this the abstract screening removed 150 articles, after which full-text screening was done, and 29 papers were excluded, eventually yielding three papers that meet the inclusion criteria of this review. The PRISMA flow chart as in Figure 1. Outlines details regarding the identification, screening, eligibility, and inclusion of the studies in this review.

Figure 1. PRISMA flow chart.

Qualitative analysis

The risk of bias scoring was done using the NIH Quality assessment scales as shown in Figure 2.¹⁴ The quality assessment scales were used depending on the type of study. Two separate scales were used for the pre-post study design and the RCT. The scales covered everything regarding the type, duration of the study, the sample sizes, characteristics of the population and about its randomization, the interventions used, and whether participants and therapists were blinded. A score of 9/12 was rated for the pre-post type of study done by Sharma N et al.¹⁵

Figure 2. NIH study quality assessment tool.¹⁴

A score of 7/14 was given for the RCT done by Sharma N et al.¹⁶ and Felcar et al.¹⁷respectively.

Discussion

This systematic review aimed at identifying studies that gave an exercise-based prehabilitation intervention to children undergoing various surgeries. While searching articles for this review various studies were found that included post-operative exercise after surgery in children, but very few studies included prehabilitation in the routine clinical care of these patients.

Sharma N et al. published two studies in 2020¹⁵ and 2021¹⁶ about the effects of prehabilitation on pulmonary function and FC in the patients undergoing elective abdominal surgeries and Felcar et al. studied its effects in the reduction of post-op pulmonary complications in children undergoing cardiac surgery.¹⁷

In the two studies conducted by Sharma N et al.^15,16 the effects of prehabilitation on FC and pulmonary functions were studied using a spirometer as a measurement tool. There was a trend seen in both the studies that no major changes in the values of the spirometer (that includes Forced Vital Capacity (FVC), Forced Expiratory Volume 1 (FEV1), Tiffeneau-Pinelli index (FEV1/FVC ratio), Peak Expiratory Flow Rate (PEFR)) were seen in the pre-surgical period and on POD 5, but there was a decline seen from the pre-operative period to POD 1 and from POD1 to POD5. The only difference seen in the RCT¹⁶ compared to the pre-post study¹⁵ conducted by Sharma N et al. was that FVC improved post prehabilitation and surgery. Values of chest expansion seemed to be better in the IG than CG in the RCT.¹⁶ Lastly, one of the common findings in both the studies was that the values of 10MWT, TUGT, 9SCT were seen better in the CG of both studies rather than in the IG.^15,16 This study implies that exercise-based prehabilitation, when given in a proper format and incorporated well in routine care can have beneficial effects in children during the post-operative period.

In the study done by Felcar et al.,¹⁷ its was seen that children in the CG were seen to have a higher frequency of developing pulmonary complications such as pneumonia or atelectasis or both as compared to the IG that received both the treatment options, i.e., prehabilitation and post-operative exercises.¹⁷ This implies that children who received exercise-based prehabilitation have a lesser frequency of developing any other complications as compared to the children that didn’t receive prehabilitation.

Quality assessment of each of the studies was done by using the NIH Quality assessment scale. Two different scales were used for each type of study i.e. the pre-post type of study and the other for an RCT¹⁴ The Pre-post study was done by Neha et al.¹⁵ had a scoring of 9/12 which acc to their scale was categorized as fair. This study included clearly stated objectives, had pre-set inclusion and exclusion criteria. The sample size was around 12 participants but enough to conclude about the effects of the N-PARP (prehabilitation protocol) in that set population and to conclude that the study could be done in a larger population. there is also no information regarding the blinding of the populations in this study.

The NIH Quality assessment is done for The articles of Felcar et al.,¹⁷ and Neha et al.¹⁶ scored them (7/14) and (7/14) respectively which according to their scale belonged to the fair category. Both these RCTs did not have any details regarding the blinding and concealment of the participants.

Conclusion

Although few in number, the available literature leads us to the conclusion that exercise-based prehabilitation plays an important role in improving health-related outcome measures in children undergoing various surgeries.

Data availability