Paul, Melanie Alya
(2025)
Postoperative exercise rehabilitation after elective colorectal cancer surgery.
PhD thesis, University of Nottingham.
Abstract
Introduction
Colorectal cancer (CRC) is common, accounting for approximately 11% of all new cancer cases, and is primarily a cancer associated with increasing age (Cancer Research UK, 2021). Surgery is usually the most appropriate option (if feasible and depending on staging) to try to achieve cancer free status. However, it carries significant morbidity, especially given the generally older patient population in which colorectal cancer presents (Argillander et al., 2021; Kolarsick et al., 2020). Appropriately stratifying preoperative risk to improve immediate outcomes is an appropriate strategy, but after a significant physiological insult through surgery, patients are not given clear guidance on how to regain their preoperative physical state (Karlsson et al., 2020). A structured exercise programme, such as proposed within this thesis, aims to assess the use of both aerobic and resistance exercises to safely improve postoperative patients’ physical and mental fitness and wellbeing, looking at objective measures through cardiorespiratory exercise testing (CPET) but also milestones important to the patient such as the ability to carry out their activities of daily living in order to improve not only their speed of recovery but maintain their mental well-being during a difficult period.
Methods
A systematic review was performed to assess the impact of postoperative aerobic exercise training in patients undergoing surgery for intra-abdominal cancers which included studies that began the exercise regimen within 3 months of surgery and reported on outcomes that included cardiorespiratory fitness. A cohort study (PHYSPAL) was performed to evaluate the quantity and type of immediate in-hospital postoperative activity that patients did was performed. Finally, a randomised controlled trial (RCT) (POSTEX) was undertaken to explore whether a combined aerobic and resistance programme improved physical fitness as well as quality of life parameters in postoperative colorectal cancer patients.
Results
The systematic review showed that there is benefit in exercise training in the immediate postoperative period and is safe. However, due to the heterogenous study designs and exercise regimens, there is no one clear programme that confers the most benefit. The PHYSPAL study showed some increase in activity over time in the immediate postoperative period, but overall step count is low and sedentary time is high. The POSTEX study conferred a potential benefit in preserving muscle strength and fatiguability, likely in response to the resistance component of the exercise regimen. Patients in the exercise group gave excellent feedback with regards to the programme delivery and ability to complete the exercises at home.
Conclusions
The work presented in this thesis shows the importance of and potential benefits in providing patient-focussed, achievable postoperative goal-directed exercise targets to maintain and/or improve activity levels after surgery. Multimodal exercise programmes can be safely performed with indirect supervision, which is an important consideration in a resource-limited healthcare setting. Both functional and patient-related factors, especially with regards to quality of life, are positively impacted but greater focus needs to be on integrating this into direct guidance with enhanced recovery after colorectal surgery protocols.
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