As suggested in the prior post, we will be releasing a few blog posts directly inspired by Healing in Advance to refresh everyone's minds on the core concepts while I refine the draft of Winning in Advance. This review is particularly timely, as we just learned today of two additional awards it won:

• Indies Today Award (Inspirational): "The Indies Today Awards recognize and honor the top independent and self-published books of the year. Our judges will rate each book based on a variety of literary qualities. These vary by genre, but typically include overall plot, character development, narrative coherence, grammar, and reader engagement."
• Literary Titan Award (Medical): "The Literary Titan Book Awards are given to books and authors that have astounded and amazed us with unique writing styles, vivid worlds, complex characters, and original ideas. Awards are given out monthly to the best books reviewed through our book review service. These books deserve extraordinary praise and we are proud to acknowledge the hard work, dedication, and writing skill of talented authors."

We also were thrilled to hear we've earned a solid 4.8 stars on IndieReader.

I only mention these to say to our readers: it seems like we're on to something here!

The Prehabilitation Revolution

I observed a troubling pattern during my early training that pushed me into the world of prehabilitation: previously strong, independent patients often emerged from "routine" surgeries unexpectedly weakened and dependent on others. This observation led me to a critical insight – much like a complex exercise where you're limited by your weakest muscle, all it takes is one physiological system weakened by surgery, illness, or hospital bed rest to dramatically impact your overall function.

What makes prehabilitation powerful is its defined timeframe. While open-ended wellness goals can be challenging to maintain ("exercise 3-4 times weekly... forever"), the known deadline of an upcoming procedure creates urgency, motivation, and even a little self-competition. Whether you have three weeks or three months before surgery, targeted prehabilitation interventions can significantly improve your outcomes during and after treatment.

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*As always, this is for educational purposes only, does not constitute medical advice, and should not lead to delay in seeking treatment for any symptoms or medical conditions. Always consult your personal medical team prior to trying out anything listed here or anywhere else in our Admire ecosystem!

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The Three Essential Pillars

Effective prehabilitation rests on three fundamental pillars: Exercise, Lifestyle, and Neuropsychiatric interventions. Other professional may mix and match these differently, but I like to bucket the core concepts this way. Here's how each component contributes to better surgical outcomes:

Pillar 1: Exercise - Building Physical Resilience and Reversing Pre-Existing Illnesses

The exercise pillar focuses on improving two critical aspects of physical function:

1. Cardiopulmonary (aerobic) capacity: Many surgical procedures negatively impact heart and lung function or other organs from utilizing the oxygen delivered to them. Improving your aerobic capacity provides crucial reserves. Remember, most aerobic benefits come not from improved heart/lung function directly, but from oxygen demanding tissues (muscles) becoming more efficient – a fact that should provide significant reassurance for those with chronic, irreversible cardiopulmonary conditions.
2. Muscle strength and preservation: Surgery, chemotherapy, and bed rest rapidly deplete muscle mass, especially when in a state of inflammation (so, like, everyone who needs prehab... and most of the rest of us who don't). Resistance training before these interventions creates a protective buffer against this inevitable loss and offers other metabolic benefits such as improved blood sugar, anti-inflammatory chemicals ("myokines") released from muscles, improved bone density, and overall resilience.

What type of exercise works best? The research points to combination approaches. While any exercise you'll consistently perform is valuable, programs that integrate both resistance training and aerobic conditioning provide maximal benefits in limited timeframes.
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Advanced Techniques Worth Exploring:

• Blood Flow Restriction (BFR) Training: This specialized technique allows you to gain significant muscle stimulus while lifting much lighter weights – particularly valuable for patients with joint issues or those with medical restrictions on heavy lifting. By applying controlled pressure to limit venous return from the active muscle (but not arterial inflow), muscles are "tricked" into responding as if they've performed much heavier work, because they are exposed to the metabolic byproducts of exercise for longer.
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• High-Intensity Interval Training (HIIT): Time-efficient training that alternates short bursts of intense activity with recovery periods. Particularly valuable in prehab where time before treatment may be limited. This has a greater impact on overall aerobic condition (and VO2 max, in particular) than any "steady state" cardio done at a moderate pace for the same amount of time. For example, 18 minutes of high intensity rowing intervals (~3 minutes of the fastest pace you can sustain for that duration, followed by 3 minutes of a low intensity recovery pace, repeated for 3 cycles) has a greater impact on aerobic fitness than 18 minutes at a steady pace. Note: there are no free lunches here; you definitely earn that benefit with the effort required.
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• Aquatherapy: An underutilized modality that combines resistance and aerobic benefits while reducing joint stress – making it ideal for patients with obesity, arthritis, pain conditions, or others. The biggest drawback is that the buoyancy reduces the bone-fortifying effects of strength training.

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Pillar 2: Lifestyle - Optimizing Your Biochemistry

The lifestyle pillar encompasses interventions outside structured exercise programs that optimize your body's biochemical environment before surgery.

Key Nutritional Strategies:

1. Protein Optimization: While the general recommendation is 0.8g protein per kg body weight daily, research suggests most individuals benefit from significantly higher intake – between 1.2-2.0g per kg (approximately 0.75-1g per pound). This supports muscle maintenance, wound healing, and recovery, especially important for older adults who experience "anabolic resistance"- reduced ability to build muscle despite adequate nutritional and exercise stimuli. In most cases, protein restriction is only really necessary for individuals with advanced liver disease, and even then, there are ways of gradually titrating up the protein amount and mitigating risk.
   
   Kidney disease is another area of debate here, but from my deep dive into the research, it appears that the only potential negative effect on kidney health with high protein diets appears to be in diets with high consumption of meat protein (i.e. beef or pork; NOT dairy, eggs, plant based, etc.). Likely it's a combination of the increased workload and the clearance of uric acid that acts like a one-two punch to the kidneys.
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2. Strategic Supplementation: Creatine monohydrate stands out as one of the most extensively studied and beneficial supplements for prehabilitation. Beyond its well-known muscle-building effects, creatine shows promising benefits for metabolic health, injury prevention, and even potential mood improvement.
3. Fructose Awareness: Limiting fructose (particularly from added sugars and sweetened beverages) can significantly impact metabolic health by reducing liver fat accumulation and improving insulin sensitivity – crucial factors for surgical outcomes. In most fruits, it's not a big deal since the fiber in the fruit tempers intestinal absorption. Fructose also has some interesting negative effects on physiology of the liver and intestine that may make you more likely to gain weight later from foods that don't even contain fructose.
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4. ‍Thoughtful Fasting Approaches: Time-restricted feeding or intermittent fasting strategies may offer accelerated metabolic improvements compared with simple calorie reduction. By extending periods without food intake and then maintaining a low carbohydrate diet during fed periods, these approaches can improve insulin sensitivity, especially when paired with certain insulin-sensitizing exercise strategies. The research on this specific strategy is mixed, as many of the studies rightly stick to one variable at a time like time restricted feeding/intermittent fasting vs low carb dieting vs continuous caloric restriction instead of a combined TRF/IF and low carb/ketogenic diet. Also, these approaches require careful medical supervision, especially for patients on medications that increase insulin release or insulin medications themselves.

Pillar 3: Neuropsychiatric - Optimizing Mind-Body Connection

The often-overlooked neuropsychiatric pillar addresses the powerful influence of psychological factors on physical recovery.

Key Components:

1. Sleep Optimization: Quality sleep isn't merely comfort of slovenly behavior– it's physiologically essential for recovery, muscle repair, immune function, and metabolic control. Poor sleep increases stress hormones and hunger signals while decreasing satiety hormones – directly impacting weight management and healing. Good sleep improves mood and motivation to do all of the other "prehab stuff!"
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2. Pain Management: Addressing pain before surgery creates a dual benefit: it improves engagement with other prehabilitation elements while establishing effective pain control strategies before the additional stress of surgical recovery.
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3. Stress and Mood Support: Surgery and serious medical conditions inevitably create psychological strain. Integrating stress management techniques, addressing stigma, and providing appropriate psychological support improves both physiological outcomes and quality of life throughout treatment.

Beyond the Basics: The Power of Personalization

What separates truly effective prehabilitation from generic pre-surgical advice is personalization. When your physiatrist or prehabilitation specialist carefully tailors interventions to your specific condition, timeframe, and personal circumstances, the impact multiplies.

For example, a patient with severe joint arthritis awaiting replacement might focus heavily on non-weight-bearing aerobic activities like swimming, BFR training on land, and anti-inflammatory nutrition with pain optimizing medications. Meanwhile, someone preparing for cancer treatment might prioritize building muscle mass reserves and preemptively preparing a limb before lymph node dissection, immune-supportive and anti-inflammatory nutrition, and stress management techniques specific to their diagnosis.
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The Case for Deliberate Preparation

One misconception I've encountered is the well-intentioned concern that delaying treatment (even treatment for cancer) to allow for prehabilitation is dangerous. Research typically demonstrates the opposite – in most cases, a short, deliberate delay of a few weeks for intensive prehabilitation may significantly improve outcomes without increasing risks. Even for newly identified cancers, studies show the benefit of prehabilitation may outweigh any theoretical risk from brief treatment delay, though, this concept is extremely case dependent. Understandably, early stage cancer vs late stage cancer, or a critically ischemic limb with gangrene clearly all have different time sensitivity considerations.

Putting It All Together

The most powerful prehabilitation programs integrate all three pillars, creating synergistic effects greater than any single approach. For instance:

• Improved sleep enhances exercise recovery, metabolic control/food choice discipline, and increased ease of controlling pain
• Optimized nutrition accelerates exercise adaptation, reduces pain, improves sleep quality, and reverses insulin resistance (and the myriad downstream effects)
• Better pain management increases exercise participation and sleep quality

As surgical guidelines increasingly recognize the value of prehabilitation, the question isn't whether to prepare – it's how comprehensively to approach this preparation. The data clearly demonstrates that patients who engage in multimodal, structured prehabilitation often experience:

• Shorter hospital stays
• Fewer complications
• Reduced pain medication requirements
• Faster return to functional independence
• Better long-term outcomes

Studies without such benefits are often not intensive enough, not comprehensive enough, or are too short in duration to have a significant impact. Even without a profound, objective impact on procedural outcomes, they often give patients greater satisfaction and feeling of control. Prehab puts patients in the driver's seat.

Final Thoughts

While this overview introduces the foundational concepts of effective prehabilitation, Chapter 1 of the book Healing in Advance delves much deeper into specific protocols for different surgical types, detailed nutritional guidance, exercise progression planning, and personalized approaches for various medical conditions.

Remember, prehabilitation isn't just about enduring surgery – it's about emerging from medical interventions with your function and quality of life not just preserved, but potentially enhanced. As I often tell patients: a few weeks of focused preparation can reshape months or years of your recovery journey.

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