You may be referred to prehabilitation by your clinical team because you have been told you have, or may have, cancer and you are likely to be preparing for surgery. Your NHS team are working hard to plan your cancer treatment as safely and quickly as possible and will be helping you to get prepared for your treatment. The earlier you get involved in prehabilitation then the better for your overall long-term health.
What is prehabilitation?
Prehabilitation (prehab) is an element of rehabilitation where your journey to recovery starts before surgery has even begun through physical, nutritional and psychological support. It introduces some steps you can take to help you prepare for your upcoming surgery and improve your health and fitness. The actions you take now can help you recover more quickly and reduce the time you spend in hospital. Many people are glad to know they can do something immediately to help their health.
Your prehab care plan will be designed with you so that it meets your needs and will support you to achieve the greatest health benefits in the pre-operative period. Prehab includes:
- Increasing your physical activity levels with a personalised exercise programme from a physiotherapist based on your current health and fitness.
- Healthy eating advice and access to a dietitian to provide tailored support if required.
- Mental wellbeing and emotional support if needed.
- Assessment of your medical status from the pre-operative assessment team.
- Information, support and education about your diagnosis and planned treatment from your clinical nurse specialist.
- Access to other services such as help with stopping smoking if required and support from the Macmillan cancer information and support service.
Why is prehab so important?
Improving your health and fitness before surgery has been shown to have huge benefits, particularly for people who may be about to have surgery for cancer.
- It'll help you to recover from your surgery quicker. Evidence has shown that people need to stay less time in hospital and return to full function faster if they have participated in a prehab programme.
- It helps to optimise your health before surgery. We will help you to ensure you are ready for your operation.
- You're less likely to suffer from complications after the surgery. People are less likely to be admitted to intensive care or be readmitted to hospital if they are fitter before surgery.
- It's been shown to improve patient wellbeing. During a very worrying time, it can help you to feel empowered to manage this aspect of your health.
- It reduces the risk of cancer recurrence. People who are physically active are less likely to suffer a recurrence in the future.
- It reduces side effects of other cancer treatments. If you need to have treatment such as chemotherapy, it has been proven that being physically active will help you to withstand the effects.
- It provides more personalised care. We can target our interventions to make sure they are right for you.
What can I do?
Increase your physical activity levels
We need you to be as physically fit as possible before your upcoming operation to minimise the health risks after your surgery and to help you recover more quickly. Being physically active has a range of health benefits which include keeping your heart and lungs healthy, improving your immune function, and improving your mental health.
When you are referred to prehab, your physiotherapist will assess your current health and fitness, and will devise a physical activity plan which will be set at the right level for you. Your plan will also consider any existing medical conditions that you have and will gradually increase in effort (exercise intensity) during the prehab period. Your exercise programme will consist of aerobic exercise (this is exercise which increases your heart rate) and strength training.
- You'll be able to attend our gym sessions at Kings Hall Gym (Hackney Baths) on Mondays, Wednesdays and Fridays. These exercise sessions will be fully supervised by a specialist fitness professional from Kings Hall and your physiotherapist from Homerton. You don’t need to have been to a gym before – we will show you exactly what to do (sessions are free for patients on the prehab programme).
- If you can't attend the gym, we'll help devise a programme of exercise that you can do at home. If you're already very active, we'll help you to monitor your activity levels.
- On your gym-free days a brisk walk will help you to reach your exercise target.
- Remember, you don't have to do all your daily exercise in one go. You can complete smaller more manageable chunks of exercise throughout the day, with rest periods in between.
- Aerobic exercise is intensity-based. Getting the intensity right is very important – it produces the necessary fitness improvements that we're aiming for. Your physiotherapist or exercise specialist will tell you what intensity you should be exercising at.
- We'll start your exercise programme at the level that best suits your current fitness level, but we'll aim to progress to 150 minutes (5 days of 30 mins) of moderate intensity per week, and 2 strength training sessions.
|Low||With low intensity aerobic exercise, you should notice only mild increases in heart rate and body temperature. You should be able to breathe easily and maintain a normal conversation during exercise.|
|Moderate intensity aerobic exercise is where you’re able to hold a conversation but can’t sing the words to a song. Your breathing is quicker and deeper, and your heart is beating faster but not racing. Your body is warming up, and you may break into a sweat.|
|High||High intensity aerobic exercise is where your heart rate has increased significantly. You will be breathing hard and fast, and you won’t be able to say more than a few words without pausing for breath. With high intensity exercise, you can reduce the total time that you exercise per week (75 mins).|
Trying to lose weight is generally not encouraged before surgery and the most important message is to continue to eat a balanced diet. Choosing a wide variety of foods and well-balanced meals can help you feel better and increase your energy levels. If you have lost weight recently, are having problems with your appetite, or have symptoms such as constipation or diarrhoea, please inform the prehab team so they can signpost you to further support.
- Ensure starchy carbohydrates are included in each meal or snack. Examples include cereals, bread, potatoes, rice, chapattis, and pasta. They provide your body with energy.
- Aim to eat 2-3 portions of dairy or dairy alternatives a day. Include yoghurt, milk/soy milk and cheese. They are an important source of protein, calcium and vitamins.
- Incorporate at least 2 portions of meat, eggs, beans or meat alternatives a day. These include chicken, eggs, beans, lentils, nuts and vegetarian alternatives such as Quorn and tofu and are an important source of protein.
- Aim to eat two portions of fish each week, one of which should be oily. These are an important source of protein, vitamins and minerals such as iron.
- Have at least 5 portions of a variety of fruit and vegetables per day. This includes fresh, frozen, canned and dried fruit and vegetables. They provide your body with important vitamins and minerals and are a good source of fibre.
- Foods and drinks high in fat and/or sugar should be eaten in small amounts only. These include butter, chocolate, oil, cream, cakes, biscuits, sweets and fizzy drinks.
- Drink plenty of fluids. As a minimum aim to drink 6-8 cups of fluid every day. When you are exercising, take a bottle of water with you and drink regularly. Avoid alcohol before your surgery.
- Eat a snack after exercising to replenish energy stores and help to build muscle. A protein-based snack is perfect, this might include eggs on toast, jacket potato and beans, nuts or pitta bread with meat.
If you are underweight, are losing weight, or have a poor appetite:
For people who are underweight, losing weight and at risk, there is strong evidence that nutritional support is effective at improving nutritional status and improving clinical outcomes, particularly before surgery.
By eating as well as you can prior to your surgery, you will give your body the energy and nutrients it needs to help increase your energy levels, fight infection, cope with the side effects of treatment and minimise weight loss.
Enriching your diet can help you to maintain your muscles, minimise weight loss and or can sometimes help you regain any weight that you may have already lost. It may involve changing the balance of what you eat by encouraging foods that are higher in energy and protein.
- You should try to eat 3 meals a day with snacks and nourishing drinks in between. Try including mixed nuts, yoghurts, cheese and crackers, toast, crumpets or full fat milk, hot chocolate, milkshakes or smoothies.
- If you find that you are overwhelmed by large meals, try to eat smaller amounts but more frequently, grazing through the day on nutritious drinks and snacks.
- Aim to include some protein foods in each meal, such as meat, fish, milk, cheese, eggs, beans and nuts.
- Try having drinks separately from meals, as the liquid can fill you up.
- Try having a pudding once or twice a day such as full cream yogurt, ice cream, cake, custard, rice pudding.
- Choose full fat dairy produce, such as full cream milk and full fat yogurt in place of low fat varieties. Avoid bio/probiotic yogurts if you are undergoing chemotherapy or have a low white blood cell count.
- Replace cups of tea and glasses of water with milky drinks such as hot chocolate, malted milk and milky coffee – also lattes, cappuccinos and flat whites. Try drinking these between meals and at suppertime.
- Make fortified milk by mixing 4 tablespoons of milk powder with 1 pint of whole, full fat milk and use whenever you would use ordinary milk, to increase the protein content.
- Keep a box of grated cheese ready in the fridge (or full cream, yogurt, mascarpone cheese or crème fraîche)sprinkle onto soup or pasta, add extra to pizza, sauces or casseroles, use to fill sandwiches, have with crackers and butter or mix into mashed potatoes.
- Put plenty of butter, margarine or mayonnaise/cream cheese on bread, toast, scones, crumpets, malt loaf, teacakes, crackers, jacket potatoes, mashed potatoes and vegetables.
- Sugary food can provide extra energy – add jam, chocolate spread or honey. Snack on chocolate or biscuits. Remember this advice is for the pre-surgery period, you should return to a more balanced diet after your operation or when your weight is more stable.
If you are feeling sick:
Nausea or sickness can be due to your disease, treatment or medication. If you are experiencing this, talk to your doctor or specialist nurse. They may be able to prescribe antisickness medication to help.
- Try salty snacks such as crisps, crackers or savoury biscuits; dry foods such as toast, plain cake, plain biscuits, or bland foods such as chicken and eggs.
- Avoid foods with a strong smell if they make you feel worse. Cold folds often smell less than hot foods.
- Eat and drink slowly and avoid lying down after meals.
- Sometimes ginger can be helpful – taken as ginger ale, gingernut biscuits, crystallised ginger or lemon and ginger fruit tea.
- Avoid going long periods without food. You may find that nibbling frequently on snacks or light meals helps keep the sickness under control.
- If you have diarrhoea it is important to drink plenty of fluids to replace any lost fluids and to avoid becoming dehydrated. Check for signs of dehydration (passing less urine, or small amounts of dark urine). If this persists, please speak to your doctor or clinical nurse specialist. As a guide, aim for a minimum of 10-12 drinks (2 litres) per day. There is little evidence for reducing the fibre content in your diet if you have diarrhoea. Try to continue eating your normal diet, but eat little and often and chew your food slowly.
- If you are constipated, for some people it is advisable to increase the fibre content of their diet, for others they may need to decrease it, if it is not diet related. Please speak with your doctor, nurse or dietitian for advice on what is appropriate for you and if you require laxatives. Make sure you drink plenty of fluids – aiming for at least 10-12 glasses or mugs daily. Try taking some gentle exercise such as walking.
Looking after your mental health
Being diagnosed with cancer can have a huge impact on your life, as well as the lives of the people around you. It's normal to go through a range of emotions which may include anxiety, fear, sadness and anger.
- Goals, expectations and pacing yourself: Particularly during and after treatment, you may find that you need to be more flexible and kinder with the goals and expectations you set for yourself. It can help to break down your goals into achievable steps based on what you feel able to do at the time.
- Talk. Talking about your diagnosis can be comforting and can help you feel less anxious and more in control. If you feel like you need to speak with a counsellor or psychologist, we can help. Your Clinical Nurse Specialist can also provide a huge amount of information. The Homerton Macmillan cancer information and support service can provide a range of support with things that might be worrying you. Additional help is provided centrally by Macmillan, which includes one-to-one counselling sessions provided by Bupa (this service is free).
- Involve your family or those closest to you. Bring them to appointments, education sessions or gym sessions for support if you want to. Let them know how you feel so they can help.
- Get enough sleep. Tiredness can affect your concentration, your energy levels and affect your physical health.
- Look after your physical health. Exercise has been proven to improve mental health. It can reduce anxiety and improve our mood. It's not always easy to start exercising when you feel down, or are feeling unwell, but if you start gently, you should notice an immediate benefit to your mental health. Try an outdoors walk to boost your mood.
- Relaxation techniques. Some techniques can be useful when fear or anxiety levels are high. Maggie's Centre at Barts Hospital has free online/in-person relaxation and mindfulness sessions (contact Maggie's on firstname.lastname@example.org or 020 3904 4338).
- Nourishing/depleting activities. Make a list of those things in your life that you enjoy doing, things which nourish and enrich you, and a list of things that deplete you. Try to add an extra nourishing activity into your day and reduce the depleting things you do.
Stop smoking: Stopping smoking is hard, but strongly advised, and well worth it. Quitting or cutting down will improve your general health and will help you recover faster from your surgery.
Smokefree City and Hackney can provide free one-to-one support and medication to help you quit smoking. Ask your clinical team for more information or contact Smokefree directly on 0800 046 9946 or email@example.com.
Reduce alcohol intake: Make sure you are drinking within the recommended limits, or lower, to improve your body’s ability to cope with surgery and any future cancer treatment. It is also helpful from an emotional wellbeing perspective as alcohol can affect how we cope with our feelings and can even intensify feelings of low mood and anxiety in the longer term. If you need help to reduce your alcohol intake, please speak to your clinical team.
What happens next?
Once you have been referred to prehab, you will be contacted by a member of the prehab team for an assessment. This will be to get an understanding of your current health and fitness so that we can tailor your prehab programme for you.
The prehab team will take some information, and will develop a physical activity plan set at the correct level for you. They will provide all of the information you need to support you to increase your physical activity levels and get access to our specialist exercise classes at Kings Hall Leisure Centre.
The prehab team will also assess your nutritional and psychological status to see if you will require individualised help from a dietitian or psychologist, or access to additional services such as counselling, financial help, Macmillan support, or help with stopping smoking.
During the prehab period, your medical status will be assessed by the specialist Pre-Assessment Team. They will decide if you are medically fit for surgery.
You will also always have access to your clinical nurse specialist throughout your cancer journey, both before surgery and afterwards. Your clinical nurse specialist can provide help and guidance with your care, and advice and education on what to expect. They will also complete a holistic needs assessment.