Skip to main content

Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study



Patients undergoing colorectal cancer resections are at risk for delayed recovery. Prehabilitation aims to enhance functional capacity preoperatively for better toleration of surgery and to facilitate recovery. The authors previously demonstrated the limited impact of a prehabilitation program using exercise alone. They propose an expanded trimodal prehabilitation program that adds nutritional counseling, protein supplementation, and anxiety reduction to a moderate exercise program. This study aimed to estimate the impact of this trimodal program on the recovery of functional capacity compared with standard surgical care.


Consecutive patients were enrolled in this pre- and postintervention study over a 23-month period. The postoperative recovery for 42 consecutive patients enrolled in the prehabilitation program was compared with that of 45 patients assessed before the intervention began. The primary outcome was functional walking capacity (6-min walk test [6MWT]). The secondary outcomes included self-reported physical activity (CHAMPS questionnaire) and health-related quality of life (SF-36). Data are expressed as mean ± standard deviation or median (interquartile range [IQR]) and were analyzed using Chi-square and Student’s t test. All p values lower than 0.05 were considered significant.


The prehabilitation and control groups were comparable in terms of age, gender, body mass index (BMI) and American Society of Anesthesiology (ASA) class. There was no difference in walking capacity at the first assessment (6MWT distance, 422 ± 87 vs 402 ± 57 m; p = 0.21). During the prehabilitation period lasting a median of 33 days (range, 21–46 days), functional walking capacity improved by 40 ± 40 m (p < 0.01). The postoperative complication rates and the hospital length of stay were similar. The patients in the prehabilitation program had better postoperative walking capacity at both 4 weeks (mean difference, 51.5 ± 93 m; p = 0.01) and 8 weeks (mean difference, 84.5 ± 83 m; p < 0.01). At 8 weeks, 81 % of the prehabilitated patients were recovered compared with 40 % of the control group (p < 0.01). The prehabilitation group also reported higher levels of physical activity before and after surgery.


In this pilot study, a 1-month trimodal prehabilitation program improved postoperative functional recovery. A randomized trial is ongoing (NCT01356264).

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D (2011) Global cancer statistics. CA Cancer J Clin 61:69–90

    PubMed  Article  Google Scholar 

  2. Schilling PL, Dimick JB, Birkmeyer JD (2008) Prioritizing quality improvement in general surgery. J Am Coll Surg 207:698–704

    PubMed  Article  Google Scholar 

  3. Zingmond D, Maggard M, O’Connell J, Liu J, Etzioni D, Ko C (2003) What predicts serious complications in colorectal cancer resection? Am Surg 69:969–974

    PubMed  Google Scholar 

  4. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast-track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev (online):CD007635

  5. Christensen T, Kehlet H (1993) Postoperative fatigue. World J Surg 17:220–225

    PubMed  Article  CAS  Google Scholar 

  6. Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P (2002) Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 97:540–549

    PubMed  Article  Google Scholar 

  7. Wilson RJT, Davies S, Yates D, Redman J, Stone M (2010) Impaired functional capacity is associated with all-cause mortality after major elective intraabdominal surgery. Br J Anaesth 105:297–303

    PubMed  Article  CAS  Google Scholar 

  8. Reilly DF, McNeely MJ, Doerner D, Greenberg DL, Staiger TO, Geist MJ, Vedovatti PA, Coffey JE, Mora MW, Johnson TR, Guray ED, Van Norman GA, Fihn SD (1999) Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med 159:2185–2192

    PubMed  Article  CAS  Google Scholar 

  9. Lawrence V, Hazuda H, Cornell J, Pederson T, Bradshaw P, Mulrow C, Page C (2004) Functional independence after major abdominal surgery in the elderly. J Am Coll Surg 199:762–772

    PubMed  Article  Google Scholar 

  10. Timmerman H, de Groot JF, Hulzebos HJ, de Knikker R, Kerkkamp HEM, van Meeteren NLU (2011) Feasibility and preliminary effectiveness of preoperative therapeutic exercise in patients with cancer: a pragmatic study. Physiother Theory Pract 27:117–124

    PubMed  Article  CAS  Google Scholar 

  11. Carli F, Zavorsky GS (2005) Optimizing functional exercise capacity in the elderly surgical population. Curr Opin Clin Nutr Metabol Care 8:23–32

    Article  Google Scholar 

  12. Carli F, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim DJ, Scott S, Mayo NE (2010) Randomized clinical trial of prehabilitation in colorectal surgery. Br J Surg 97:1187–1197

    PubMed  Article  CAS  Google Scholar 

  13. Mayo NE, Feldman L, Scott S, Zavorsky G, Kim DJ, Charlebois P, Stein B, Carli F (2011) Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery 150:505–514

    PubMed  Article  Google Scholar 

  14. Burden ST, Hill J, Shaffer JL, Todd C (2010) Nutritional status of preoperative colorectal cancer patients. J Hum Nutr Dietetics 23:402–407

    Article  CAS  Google Scholar 

  15. Burd NA, Yang Y, Moore DR, Tang JE, Tarnopolsky MA, Phillips SM (2012) Greater stimulation of myofibrillar protein synthesis with ingestion of whey protein isolate v. micellar casein at rest and after resistance exercise in elderly men. Br J Nutr1–5

  16. Aoi W, Takanami Y, Kawai Y, Morifuji M, Koga J, Kanegae M, Mihara K, Yanohara T, Mukai J, Naito Y, Yoshikawa T (2011) Dietary whey hydrolysate with exercise alters the plasma protein profile: a comprehensive protein analysis. Nutrition 27:687–692

    PubMed  Article  CAS  Google Scholar 

  17. Burke DG, Chilibeck PD, Davison K, Candow D, Farthing J, Smith-Palmer T (2001) The effect of whey protein supplementation with and without creatine monohydrate combined with resistance training on lean tissue mass and muscle strength. Int J Sport Nutr Exercise Metabol 11:349–364

    CAS  Google Scholar 

  18. Walzem RL, Dillard CJ, German JB (2002) Whey components: millennia of evolution create functionalities for mammalian nutrition: what we know and what we may be overlooking. Crit Rev Food Sci Nutr 42:353–375

    PubMed  Article  CAS  Google Scholar 

  19. Marshall K (2004) Therapeutic applications of whey protein: alternative medicine review. J Clin Therapeutic 9:136–156

    Google Scholar 

  20. Carli F, Charlebois P, Baldini G, Cachero O, Stein B (2009) An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can J Anaesth (Journal canadien d’anesthésie) 56:837–842

    Article  Google Scholar 

  21. Bauer J, Capra S, Ferguson M (2002) Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr 56:779–785

    PubMed  Article  CAS  Google Scholar 

  22. American Thoracic Society (2002) ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 166:111–117

    Google Scholar 

  23. Gibbons WJ, Fruchter N, Sloan S, Levy RD (2001) Reference values for a multiple repetition 6-minute walk test in healthy adults older than 20 years. J Cardiopulm Rehab 21:87–93

    Article  CAS  Google Scholar 

  24. Moriello C, Mayo NE, Feldman L, Carli F (2008) Validating the six-minute walk test as a measure of recovery after elective colon resection surgery. Arch Phys Med Rehab 89:1083–1089

    Article  Google Scholar 

  25. Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications. Ann Surg 240:205–213

    PubMed  Article  Google Scholar 

  26. Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr, Tudor-Locke C, Greer JL, Vezina J, Whitt-Glover MC, Leon AS (2011) 2011 Compendium of physical activities: a second update of codes and MET values. Med Sci Sports Exer 43:1575–1581

    Article  Google Scholar 

  27. Feldman LS, Kaneva P, Demyttenaere S, Carli F, Fried GM, Mayo NE (2009) Validation of a physical activity questionnaire (CHAMPS) as an indicator of postoperative recovery after laparoscopic cholecystectomy. Surgery 146:31–39

    PubMed  Article  Google Scholar 

  28. Hopman WM, Towheed T, Anastassiades T, Tenenhouse A, Poliquin S, Berger C, Joseph L, Brown JP, Murray TM, Adachi JD (2000) Canadian normative data for the SF-36 health survey. Can Med Assoc J 163:265–271

    CAS  Google Scholar 

  29. Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370

    PubMed  Article  CAS  Google Scholar 

  30. Graham JW, Olchowski AE, Gilreath TD (2007) How many imputations are really needed? Some practical clarifications of multiple imputation theory. Prevent Sci 8:206–213

    Article  Google Scholar 

  31. Kervio G, Carre F, Ville NS (2003) Reliability and intensity of the six-minute walk test in healthy elderly subjects. Med Sci Sports Exerc 35:169

    PubMed  Article  Google Scholar 

  32. Honaker J, King G, Blackwell M (2011) Amelia II: a program for missing data. J Stat Softw 45(7):1–47

    Google Scholar 

  33. Imai K, King G, Lau O (2006) Zelig: everyone’s statistical software. R package version 2.7–4

  34. Rasekaba T, Lee AL, Naughton MT, Williams TJ, Holland AE (2009) The six-minute walk test: a useful metric for the cardiopulmonary patient. Intern Med J 39:495–501

    PubMed  Article  CAS  Google Scholar 

  35. Perera S, Mody SH, Woodman RC, Studenski SA (2006) Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc 54:743–749

    PubMed  Article  Google Scholar 

  36. Canadian Society for Surgical Oncology (2009) CSSO position statement. Retrieved 31 March 2012 at

  37. Simunovic M, Theriault ME, Paszat L, Coates A, Whelan T, Holowaty E, Levine M (2005) Using administrative databases to measure waiting times for patients undergoing major cancer surgery in Ontario, 1993–2000. Can J of Surg (Journal Canadien de Chirurgie) 48:137–142

    Google Scholar 

  38. Bilimoria KY, Ko CY, Tomlinson JS, Stewart AK, Talamonti MS, Hynes DL, Winchester DP, Bentrem DJ (2011) Wait times for cancer surgery in the United States: trends and predictors of delays. Ann Surg 253:779–785

    PubMed  Article  Google Scholar 

  39. Moene M, Bergbom I, Skott C (2006) Patients’ existential situation prior to colorectal surgery. J Adv Nurs 54:199–207

    PubMed  Article  Google Scholar 

  40. McHugh JE, Lawlor BA (2011) Exercise and social support are associated with psychological distress outcomes in a population of community-dwelling older adults. J Health Psychol

  41. Scott JG, Mavros MN, Athanasiou S, Gkegkes ID, Polyzos KA, Peppas G, Falagas ME (2011) Do Psychological variables affect early surgical recovery? PLoS ONE 6:e20306

    Article  Google Scholar 

  42. Linn BS, Linn MW, Klimas NG (1988) Effects of psychophysical stress on surgical outcome. Psychosom Med 50:230–244

    PubMed  CAS  Google Scholar 

  43. Rimer J, Dwan K, Lawlor DA, Greig CA, McMurdo M, Morley W, Mead GE (2012) Exercise for depression. Cochrane Database of Systematic Reviews (Online) 7:CD004366

    Google Scholar 

Download references


This research was supported by grants from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Ethicon Endosurgery Canada, and the Department of Anesthesia, McGill University Health Centre. The Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation is supported by an unrestricted educational grant from Covidien Canada.


C. Li reports research support from the Surgeon Scientist Program, Department of Surgery, McGill University. L. S. Feldman reports research and fellowship support from Covidien and research support from Ethicon. L. Lee reports research support from the Canadian Association of General Surgeons and salary support from the Fonds de la recherche en santé du Québec (FRSQ) and the McGill Surgeon Scientist program. F. Carli, P. Charlebois, B. Stein, A. S. Liberman, P. Kaneva, B. Augustin, M. Wongyingsinn, A. Gamsa, D. J. Kim, and M. C. Vassiliou have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Liane S. Feldman.

Additional information

Presented at the SAGES 2012 Annual Meeting, March 7–March 10, 2012, San Diego, CA.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Li, C., Carli, F., Lee, L. et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc 27, 1072–1082 (2013).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Functional recovery
  • Perioperative care
  • Prehabilitation
  • Preoperative exercise