Millions of people face challenging medical journeys, often feeling hopeless about their future health and well-being. Even with promising treatments on the horizon, the path forward can seem daunting. Health and fulfillment mean something different to every person reading this, but the core message rings true: at times, we could all use a figurative GPS to guide the way.
As I wrote in a forthcoming (*shameless plug alert) book on prehabilitation, I like to use a metaphor to illustrate the uncertainty individuals face after a fateful doctor’s appointment, where they just learned of:
Picture the pre-surgical/pregnancy/chemotherapy period as a series of winding roads leading up to a tunnel in the mountains. When you get started, you can see the tunnel up ahead, embedded in the side of a mountain, but from your seat, all you see is a forest of trees and dense fog or snow obstructing your view of the winding roads to get there. A multimodal prehab program is your GPS, snow tires, warm cup of coffee, and a great audiobook playing in the speakers- may I suggest a soon-to-be released prehab book even? Suddenly the journey goes from treacherous to adventurous and when all is said and done, you pass through the tunnel to see an open road and a beautiful view. That is the second life you’ve got ahead of you, ripe with opportunities to try something new with your fresh hip, relieved back pain, cancer remission, or highly functioning prosthetic.
Why I consider “prehabilitation” its own subspecialty
Residency training programs and industrious health care professionals are combining the “best” features of obesity medicine, lifestyle medicine, and physical medicine & rehabilitation (PM&R) to produce a distinct subspecialty that offers patients an efficient and empowering preparatory program- prehabilitation. Full disclosure, I’m obviously biased, but physicians and other providers who are skilled in these related areas offer a “premium” to traditional physicians and other providers with training limited to one of the aforementioned specialties.
Listen, I am not the singular authority on prehab and am in no way disparaging other specialists with deeper training than I have in obesity-related fields like endocrinology, pulmonology, and oncology. However, PM&R provides a skillset including advanced knowledge of multimodal pain management, nutrition, adaptive equipment (prosthetics/orthotics, canes, walkers, etc.), and musculoskeletal medicine that overcomes the pain and functional impairments that often limit individuals with obesity from increasing physical activity. While nutrition is the stronger influence on bodyweight, exercise/physical activity can have a bigger impact on overall metabolic health. Naturally, exercise supports weight loss and maintenance of weight loss, and exercise’s impact on reversing diabetes is turbocharged by a finely tuned nutritional regimen.
Prehabilitation as a field is still materializing
If you were to ask 10 providers what prehab is, you’ll probably get many different interpretations. Broadly, it’s just the idea that patients can improve outcomes for certain procedures and major interventions with preparation. Usually, this preparation rests on certain “pillars,” which I prefer to group together into “exercise/physical activity,” “lifestyle,” and “neuro/psychiatric.”
Exercise includes all exercise modalities, tailored to patients’ preferences, health problems like diabetes, and the nature of the upcoming procedure/intervention. Someone with diabetes and an upcoming leg amputation requires a different program than another person with congenital heart abnormalities and an upcoming transplant. Skilled practitioners are able to improve metabolic parameters through exercise despite limitations on resistance training or design programs for the fastest effect if the prehab timeline needs to be accelerated.
I use “lifestyle” as a catchall for dietary optimization, anti-obesity medications, and nutritional supplements. Individuals struggling with obesity need different approaches depending on their upcoming procedure; weight maintenance is typically the goal during cancer therapy, whereas maximizing weight loss is the priority before bariatric surgery. In most situations, muscle mass preservation is one of the highest priorities, but in the setting of cancer cachexiaI, this is more of an uphill battle than in orthopedic prehabilitation scenarios, for example. Some medications and supplements can reduce the muscle inflammation associated with cachexia or frailty, but in other situations, these same treatments may slow down exercise progress.
The neuro/psychiatric pillar incorporates any disorders of the brain and nerves, including but not limited to pain, depression/anxiety, insomnia, spasticity, sleep apnea, stress, and stigma. Pain itself comes in many flavors ranging from joint arthritis, chronic low back pain, sciatica, diabetic neuropathy, cancer-related pain, and others. Acute pain tricks us into thinking the safest thing to do is rest- usually not the case. Chronic pain saps motivation, provokes depression, and ravages our sleep quality.
You’ll see that targeting each of these “pillars” really requires concurrent optimization of the others. How can you possibly exercise when it already hurts just to stand or when you’re so fatigued you can barely get out of bed? How long will it take to recover from exercise when you’re so nauseated from cancer, you’re only able to stomach 1,000 calories per day, but need 3,000 due to increased metabolic demand? If you have only a few weeks to prepare, having to visit a half dozen specialists just to get started is not feasible.
Dedicated prehabilitation providers are few and far between
As it stands presently, most “prehab” clinics are incorporated in large academic medical centers and tethered towards single conditions. Where I trained, the most established clinic teamed up with the organ transplantation teams to prepare and evaluate patients before heart, kidney, lung, and other transplants. In other cases, physiatrists (PM&R physicians) subspecializing in cancer rehabilitation will guide cancer prehabilitation, often applied in breast and lung cancers. These specialists anticipate the negative effects of cancer surgery and chemotherapies and work with patients to mitigate these effects. Knowledge of chemotherapy mechanisms and side effects, or circulatory diseases like post-op lymphedema are critical. Outpatient musculoskeletal physiatrists may work with orthopedic surgeons and neurosurgeons to improve patients’ quality of life before joint replacement or spine surgery. Some of this collaboration exists in community hospitals, but this integration is even less assured.
As you move away from large cancer and transplant centers, such providers may be hundreds of miles apart. As it stands, PM&R as a medical specialty is less known and even less understood due to our relatively few graduates each year and disparate practice environments. Even if your oncologist recommends “cancer rehab,” we wouldn’t hold it against you for thinking he or she was recommending you find a physical therapist.
With that, I present to you this blog. I will be compiling insights from my training and clinical practice to help fix the “I don’t know what I don’t know” problem of pre-procedural optimization. Nothing in this or future posts should be taken as “medical advice,” but you can consult your personal treatment teams about some of these educational points to see if they may apply to your situation. Sometimes, some of my posts may feature unconventional off-label uses for medications or hot takes on areas of rabid debate within the medical community. So, again, anything I write here is not medical advice, and if it appears to be counter to the medical advice given by your personal provider, go with what they say- they know you better.
That said, I’ve picked up a few nuggets of wisdom that may escape the standard training programs of non-PM&R and/or non-obesity-medicine trained professionals. If your curiosity is piqued by this, click here to be notified when that book I’d mentioned earlier is available. We’re also putting together a monthly newsletter that will compile this kind of information and other interesting insights published by colleagues, mentors, and inspirations of mine. Click here and enter your email address to join that free newsletter and to learn about how you may have tools at your disposal that have been hiding in plain sight.
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