From prehab to rehab

How Stanford physicians and researchers prepare patients to thrive after surgery

Toni Notar wasn’t used to anything slowing her down. She worked over 40 hours a week as a literacy specialist in Hollister, California, teaching adults to read and write. In her off hours, she volunteered for an animal rescue organization and went to the gym three times a week with her husband.

That all changed in 2005, when the pain started. It felt like a punch to the gut, but a punch that somehow kept burrowing into her. Sometimes it was so bad she’d double over, unable to walk or even stand.

“It was literally destroying my life because it was all I could focus on. It was affecting my performance at work, my relationship with my husband and my children,” Notar said. “When you don’t feel good, it’s very hard to interact with other people.”

Illustration by Stuart Bradford

Her doctors diagnosed her with diverticulitis, a condition in which part of the intestine becomes infected or inflamed. She was prescribed antibiotics that she estimates she took for two to three weeks every month. But the pain kept coming back, which meant multiple diagnostic colonoscopies but no new treatment strategies.

By 2018, the pain worsened, making Notar desperate for other options. She turned to Stanford, where a surgeon offered to remove the inflamed section of her colon to relieve the pain.

“I was ecstatic that she could do something to help me,” Notar said, but she also felt a bit worried about undergoing such a procedure at age 62.

On average, nearly 23,000 surgeries are performed at Stanford Health Care each year, and Notar is far from the only patient to feel a mix of relief and concern about a pending procedure.

To alleviate some of those patients’ concerns, Stanford physicians and researchers have developed programs designed to better prepare patients for surgery and encourage them to play more active roles in their recovery.

The efforts include adding training to improve how doctors communicate with patients about surgery. Also, a surgical intensive care unit at the new Stanford Hospital will enhance the care doctors can give patients immediately after an operation.

Here, we highlight some of the programs that help surgeries and recovery go more smoothly so patients can live healthier, happier lives in the long run.

Training for the big race

Many doctors, including Cindy Kin, MD, assistant professor of surgery, compare the stress surgery places on the body to running a marathon. Running for hours and lying on an operating table might seem like polar opposites, but general anesthesia stresses the heart, and even having minor surgery can be exhausting.

That got Kin thinking — if you wouldn’t run a marathon without training, why would you have surgery without preparing?

Kin’s patients often asked her what they should do before surgery, but the standard answers she’d been trained to provide were vague — eat healthy, stay active, keep doing what you’re doing.

“Patients are looking for something to do before surgery because they’re nervous, fearful and vulnerable,” Kin said.

So, to come up with better answers, she launched a study on prehabilitation, or “prehab.”

In a 2014 pilot study, Kin enrolled 40 patients who were slated to have abdominal surgery — including removal of sections of their intestine because of cancer or inflammatory bowel disease.

Twenty of the patients were told to walk 5,000 steps a day and to perform strengthening exercises in the weeks before surgery. The same patients also downloaded a mindfulness meditation app and were counseled to eat a diet rich in whole foods and low-fat proteins. Patients in the control group were given no specific instructions.

“Patients are looking for something to do before surgery because they’re nervous, fearful and vulnerable.”

Four weeks after surgery, an analysis of pain outcomes showed that prehab patients’ self-reported pain was one point lower on a 10-point scale than that of control group patients — an encouraging sign.

In a follow-up study from 2018 to 2019, Kin enrolled 250 colorectal surgery patients — including Notar — and instructed them to use an app that sent them information about the Mediterranean diet; it also reminded them to walk at least 5,000 steps a day and perform core-strengthening exercises three times a week.

Notar incorporated the exercises into an already busy schedule by waking up at 3:30 a.m. instead of 5 a.m. so she could squeeze in some of the exercises. And when she got home around 6 p.m., she’d prep dinner and finish the remaining exercises while her food cooked.

It was a grueling routine, but she lost 8 pounds during six weeks of prehab and felt stronger and more energetic. She was also much more relaxed about her upcoming surgery.

It turned out that Notar would need every ounce of her newfound strength to recover from the January 2019 surgery. Her surgeon had to remove more of her colon than was expected and, during the operation, Notar’s spleen started bleeding and had to be removed.

By the time Notar was well enough to return home, she had lost about 30 pounds. Still, she credits prehab for her ability to return home at all.

“I don’t think I’d be here if I hadn’t done the prehab. The recovery was really tough, and if I had not built up that extra strength I don’t think I would have made it.”

Overall, prehab seemed to pay off for other patients in the trial, too. After surgery, they used half the amount of opioids per day spent in the hospital than a group of 250 surgical patients who did not have prehab, though various medical and demographic factors also could have played a role, Kin said.

“I don’t think I’d be here if I hadn’t done the prehab,” said Notar. “The recovery was really tough, and if I had not built up that extra strength I don’t think I would have made it.”

A member of Kin’s research team presented these findings at a meeting of the American College of Surgeons in October. Kin and another Stanford surgeon, Brendan Visser, are planning a new app-based prehab study in which patients use wearable fitness trackers to monitor their heart rates, sleep patterns and activity levels. Patients will perform exercises that prepare for the first step of their recovery — getting out of bed. The researchers will track whether prehab reduces postoperative pain, narcotic use and infection rates.

Such prehab programs are in place at some health care centers, including at McGill University in Quebec, Canada, but are not widespread. Kin hopes her research will expand the scope of prehab and empower more patients to make concrete, evidence-based lifestyle adjustments that improve recovery.

“If your doctor suggests that you do prehab, do it,” Notar said. “If your doctor doesn’t suggest it, ask them about it.”

Talking it out

Patients facing surgery are often full of questions: “Is what I’m feeling normal?” “What are the risks?” “How am I going to feel afterward?”

Underlying the questions are sometimes regrets, both spoken and unspoken: “I should have taken better care of myself.” “I should have gotten the mammogram sooner.”

Communicating surgical expectations and risks — and listening to what patients say in response — is a delicate art. It’s also a requirement for physicians. The Accreditation Council for Graduate Medical Education, which sets the training standards for medical residency and fellowship programs, includes among its standards that physicians show compassion, respect and responsiveness to patient needs.

Kimberly Kopecky, MD, general surgery resident, was well trained in this arena during a one-year hospice and palliative medicine fellowship. She said she learned how to talk to patients with serious illnesses about their goals, fears and priorities in end-of-life situations.

But Kopecky knew that the amount of communication training other residents received varied greatly by specialty — and surgery was among the specialties that were lagging.

“Historically, surgical residency has not focused much at all on how we communicate with patients,” Kopecky said. “It mostly has focused on our operative skill and clinical decision making.”

So in 2018, Kopecky launched a series of courses to help residents strengthen their patient communication skills in preparation for the responsibilities they will eventually face as attending physicians. Her courses, which she teaches each quarter, cover empathy, discussing best- and worst-case scenarios, and how to break bad news.

“Historically, surgical residency has not focused much at all on how we communicate with patients. It mostly has focused on our operative skill and clinical decision making.”

In each session, 25 to 30 surgical residents gather to learn through a blend of presentations, group discussion and brainstorming.

“It’s about practice,” Kopecky said. “In the operating room, we practice suturing, stapling and cutting all the time. So why would we think we can learn these skills without practicing them?”

Kopecky is leading more sessions during the 2019-2020 academic year. During the fall course, residents are using a game Kopecky helped create called the Empathy Project. To play, residents draw from a stack of cards containing hypothetical patient statements — for example, that a tube running from a patient’s nose to the stomach is uncomfortable and the patient wants it removed.

Participants take turns playing the roles of doctor and patient. The key is to acknowledge a patient’s feelings rather than launching into a technical and procedural explanation of their ailment and the treatment they’re undergoing.

“Most patients don’t want the medical textbook answer,” Kopecky said. “They want to be validated and they want to be heard and they want to be supported.”

A new space: the next frontier

Perhaps the greatest boon to Stanford’s care for surgical patients is the new hospital’s surgical intensive care unit. Located on the fourth floor of the hospital, which opened in November, the surgical ICU holds 20 beds.

The new space allows providers to closely monitor patients after an organ transplant, trauma surgery or other major operation. Patients in the unit often need specialized equipment to help them breathe and circulate blood. Each ICU patient is cared for by a team of upward of 10 residents, fellows, specialized nurses, respiratory therapists, pharmacists, nutritionists, medical students and an attending physician.

“We not only receive a high volume of local patients, but also accept many transfer patients. These are often some of the sickest patients in the state, or sometimes the country, sent to receive specialized care at Stanford,” said Lisa Knowlton, MD, assistant professor of surgery.

The surgical ICU won’t just increase the number of patients who can receive care, it will also enhance the quality of the care they receive, said Mary Hawn, MD, chair of the department of surgery.

“ICU patients are quite different, depending on what the reason is for them needing critical care,” said Hawn. “Having a dedicated ICU focused on surgical patients fits into our precision medicine ethos.”

Each surgical ICU recovery room is 222 square feet, large enough to allow doctors to perform certain procedures, such as inserting a tube to help with breathing or feeding, at a patient’s bedside rather than in an operating room.

“ICU patients are quite different, depending on what the reason is for them needing critical care. Having a dedicated ICU focused on surgical patients fits into our precision medicine ethos.”

There is a growing consensus in the medical community that if a procedure can be safely done at the bedside, it should be. That’s because simply moving a sick, frail patient to an operating room risks infection or dislodging sensitive medical equipment.

Health care providers won’t be alone at the bedside. Each recovery room has a fold-out couch that doubles as a bed so family members can spend the night with a recovering loved one.

“Treating patients in the ICU goes part and parcel with caring for their family members,” said Knowlton.

Postoperative pain

Pain is the body’s natural response to being cut open. Yet while our pain responses wisely remind us to take it easy after surgery, they can also prevent us from starting rehabilitation. Ironically, the fear of pain during rehab can slow recovery and thereby prolong pain.

“Our mind and body perceive pain as something that we want to escape,” said Beth Darnall, PhD, associate professor of anesthesiology, perioperative and pain medicine. “But it doesn’t help us after surgery because there’s nothing to escape. Those hard-wired responses actually work against us because they keep us in a heightened state of ongoing stress and tension.”

Darnall doesn’t speak only as a trained pain psychologist — she speaks from personal experience. Throughout her childhood and into her early 20s, she struggled with chronic gut pain so severe it once landed her in the emergency room.

Her doctors, unable to pinpoint the cause, sent her home from that visit with a bottle of Vicodin. But what Darnall needed most was someone to tell her how to reduce her suffering.

Darnall is now doing that for others. Her research shows that the mind shapes how we experience pain and that focusing on pain only amplifies it. We end up unwittingly getting more of what we fear. This may be part of the reason about 10% of patients develop chronic pain after surgery.

“Our mind and body perceive pain as something that we want to escape. But it doesn’t help us after surgery because there’s nothing to escape. Those hard-wired responses actually work against us because they keep us in a heightened state of ongoing stress and tension.”

To test evidence-based pain management strategies, Darnall and her colleagues recruited women with breast cancer who were scheduled to have a tumor or a portion of breast tissue removed.

Women in the control group of this randomized trial received general information about nutrition and movement rather than a specific pain relief strategy. Women in the test group viewed a 90-minute online video explaining what pain is and how our emotions and thought patterns shape it.

The video provided practical tips on staying calm by using muscle relaxation techniques and diaphragmatic breathing — or belly breathing. Participants also received an audio recording designed to induce relaxation by transmitting sound to each ear, and thus each hemisphere of the brain. Finally, the treatment included a personalized plan for surgical success. They were encouraged to complete it and apply the key skills daily after surgery.

Pain medication is not discussed in the video. Yet women in the test group stopped using opioids after surgery an average of five days sooner than women in the control group, according to results published in May 2019.

Darnall’s team is now testing this program, called My Surgical Success, on orthopaedic trauma patients, and collaborators at Cleveland Clinic are testing it on spinal surgery patients. The video has been condensed from 90 to 45 minutes to boost the percentage of patients who complete it from the 56% reported in the latest study.

My Surgical Success is a digital version of a two-hour pain management course Darnall developed in 2013 called Empowered Relief. Stanford patients are offered the class for free, and it’s been adopted by health care systems throughout Australia, Canada, Denmark, the United Kingdom and the United States.

“It’s the class that my younger self needed back when I had pain,” Darnall said.

Darnall’s aim isn’t to supplant the use of medication, but to give patients a range of options for managing pain in a more holistic manner.

“When we treat pain comprehensively and focus on empowering patients to best control their own experience, we will naturally observe that patients will need less medical intervention,” Darnall said.

“When we treat pain comprehensively and focus on empowering patients to best control their own experience, we will naturally observe that patients will need less medical intervention.”

Managing pain, eating healthy and exercising regularly can benefit all of us, not just those preparing for and recovering from surgery. But surgical patients get to see the direct impact of lifestyle changes on their recovery — which can cement new habits.

“If patients see that what they did helped their recovery, that might spur them on afterwards,” said Kin.

That brings us back to Notar, who still lives by the diet and exercise guidelines she learned during prehab and said that she always will. But she’s not the only one in her household living by those rules. Four weeks into prehab, Notar was tired of preparing different meals for her husband and herself. So she delivered an ultimatum: “Look, you either eat what I eat or you make your own food.”

He decided to join her, and Notar said they are both in better shape than they have been in many years. She’s also working, volunteering and going to the gym again.

“Just the difference in how I feel is a blessing,” said Notar, on her way to pick up a pregnant dog that she plans to care for until the puppies are born and go to new homes. “I have so much more energy and, I don’t know how to explain it, but I’m a very happy person now.”

Jonathan Wosen is a science-writing intern in the Office of Communications.

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