Rehabilitation pre- and post thoracic surgery: Progress and future opportunities

The rehabilitation needs of patients undergoing thoracic surgery are evolving over the last two decades. ¹ Surgical management is being undertaken for older patients and those with increased co-morbidities, which are established risk factors for functional limitations peri-operatively.^1,2 Thus, there is a growing need to understand the implications of pre-operative function, peri-operative course and pre- and post-operative rehabilitation strategies. This special collection of articles highlights keys areas in pre- and post-thoracic surgical rehabilitation focusing on principles of frailty, skeletal muscle function, gait, balance, physical activity levels, and surgical outcomes.

A narrative review by Daniel Langer summarizes the landscape of rehabilitation in thoracic surgery focusing on interventions that aim to optimize physical function pre-operatively and recovery in the post-operative period. ³ This review highlights that the majority of the evidence is in the areas of thoracic oncology and lung transplantation. It also reinforces that rehabilitation programs can be beneficial in improving skeletal muscle function, exercise capacity, quality of life, and functional recovery, but there remains a lack of guidelines with respect to training regimens, duration and referral pathways. The review identifies gaps that could be addressed in the future including opportunities for tele-rehabilitation, web-based activity counselling, and rehabilitation strategies beyond the immediate post-operative period.

An article by Hanada et al. extends our knowledge on the importance of pre-operative physical function. ⁴ Hanada and colleagues demonstrate in a prospective multi-centered study of 364 older adults (> 65 years) undergoing elective surgical resection for lung cancer in Japan, that a reduced Short Physical Performance Battery (SPPB < 10 out of 12) was associated with post-operative pulmonary complications. ⁴ The SPPB captures three functional domains (balance, gait speed and chair stands), which have been shown to be important elements of physical and lower extremity function predictive of surgical outcomes in gastrointestinal ⁵ and lung transplant populations. ⁶ The premise is pre-operative physical fitness correlates with cardiorespiratory, musculoskeletal, and physiological reserve that can help mitigate surgical stressors. ⁶ Pre-operative physical function can help with earlier post-operative mobilization, improved airway clearance and ventilatory mechanics that can help reduce postoperative pulmonary complications.^3,7

Similarly, a study by Roy et al. highlights the importance of underlying chronic lung disease on post-surgical outcomes, given the high prevalence of chronic obstructive pulmonary disease (COPD) in patients undergoing surgical lung cancer resection. ⁸ Of the 1126 patients included in their study cohort, 672 (60%) had COPD. ⁸ The authors highlight that following surgical lung cancer resection, patients with COPD are at higher risk of all cause morbidity, including risk of post-operative pneumonia and prolonged air leak, given risk factors such as active smoking, diminished ventilatory reserve, and increased comorbidities. ⁹ However, the surgical resection for mild-moderate COPD patients did not effect long term survival, once other prognostic surgical factors such as age, smoking history, heart disease, and lung cancer staging were factored into the multivariable model. ⁹

Post-operatively, Tough et al. evaluated older adults (≥ 50 years old) who underwent surgical resection for lung cancer in the previous 3-months. ¹⁰ When compared to age-matched healthy controls, dynamic balance and gait were affected, including a lower proportion achieving moderate-vigorous physical activity, which may be a consequence of multiple post-operative symptoms such as pain, fatigue, dyspnea, and possibly fear of falling. Interestingly, the majority of participants reported no particular balance impairments or limitations in daily activities during interviews, but were open to attending outpatient rehabilitation. This study highlights some of the functional limitations experienced in the early post-operative period (< 3 months), but the trajectory of recovery in balance and gait characteristics beyond the early post-operative period remains to be evaluated.

Hume and colleagues extend our knowledge of post-operative rehabilitation applying a novel 3-month tele-coaching intervention aimed at improving post-operative physical activity levels after hospital discharge. ¹¹ Twelve lung transplant recipients were randomized to tele-coaching versus usual care. The usual care group underwent individual exercises in the home environment post-discharge and encouraged to stay physically active. In the tele-coaching arm, physical activity data were transmitted using a smartphone to an electronic platform, which provided further feedback on physical activity levels, education, and activity goals over a 12-week period. The tele-coaching group demonstrated significant improvement in daily steps (about 3500 mean step increase) and physical intensity, where as no significant increase was observed in the usual care arm over 12 weeks. Both groups of lung transplant recipients demonstrated clinically important improvements in physical SF-36 scores as expected with post-transplant recovery. Even though this was a small sample of lung transplant recipients, the tele-coaching intervention was feasible and well accepted by patients. This study highlights an important opportunity to integrate web-based coaching in the post-transplant period to promote physical activity and lifestyle, which is an important element to offset some of the metabolic risk factors and weight gain observed beyond the early post-transplant period. ¹²

In summary, this special collection highlights the evolving landscape of thoracic surgery, the utility of functional assessments and rehabilitation strategies pre- and post-operatively. The articles reinforce the importance of pre-operative physical function and COPD management in reducing the risk of peri-operative pulmonary complications.^3,4,8 Furthermore, functional limitations in balance, gait, and physical activity are highlighted in the early post-operative period. ¹⁰ A web-based coaching strategy of physical activity promotion is discussed as one novel strategy in improving physical activity and lifestyle, ¹¹ which is a promising strategy to be explored in the pre- and post-surgical settings.

Future directions in thoracic surgery rehabilitation will need to evaluate strategies in other surgical populations beyond lung cancer and transplantation. Other thoracic surgical populations may include those undergoing lung volume reduction surgery, chronic thromboembolic pulmonary hypertension, and elective thoracic non-oncological surgeries. Furthermore, tele-rehabilitation strategies pre- and post-operatively have emerged to be important in thoracic surgery given the evolving COVID-19 environment. ¹³ The integration of hybrid models for in-person and remote activities in thoracic surgery through web-based applications, tele-monitoring, and synchronous group training appear promising. Tele-rehabilitation may help break down certain geographical barriers, travel costs, and promote greater access to rehabilitation.^3,13,14 Additionally, rehabilitation strategies will need to be studied beyond the early post-operative period (> 3 months) in order to evaluate the degree of functional recovery experienced. Unlike the international pulmonary rehabilitation guidelines ¹⁵ and recent consensus, ¹⁶ there seems to be a need to develop a guiding framework for rehabilitation principles in thoracic surgery addressing optimal timing, exercise training strategies, and accepted functional outcomes that will aid with pre- and post-operative management. There has been great progress made in the field of thoracic surgical rehabilitation and the future in this area looks very promising.