The Origin of Prehabilitation
What if there was a way to reduce the risk of injuries or improve patient outcomes following surgery simply by providing treatment prior to the surgery?
Prehabilitation, or “prehab,” is an emerging concept in both the physical therapy and sports medicine fields. This treatment method was first recognized in 1946 when the British Army created a program for their recruits who were found to be in poor physical health during the war. To improve their physical well-being, the army had the recruits participate in a prehab program that consisted of physical therapy, strength training, and drills for warfare. Over 12,000 recruits participated in the program, and upon completion, 85% of them had significantly improved, both physically and mentally.
Prehabilitation in Relation to Physical Therapy
In physical therapy, prehabilitation is used as a rehab program that occurs before surgery or injury instead of after the event. This is based on the concept that patients with a higher functional capacity before surgery will be better equipped to tolerate the surgery itself. Studies have shown that patients with a higher level of physical well-being prior to surgery have decreased complications following surgery and improved outcomes. Some of these improved outcomes include a decreased length of stay in the hospital, improved tolerance to exercise, higher quality of life, faster return to work, and decreased levels of disability, illness, and death following surgery.
Several studies have shown improved outcomes following orthopedic surgeries, specifically following TKA (total knee arthroplasty, or “knee replacement”) or ACL (anterior cruciate ligament) surgeries when the patient participates in prehabilitation. A study performed by Swank et al. (2011) focused on 71 patients following knee replacement surgery. Nearly half of these patients (35 total) participated in a prehab program 3x/week for 4-8 weeks, consisting of flexibility exercises, resistance band strengthening exercises, and stepping exercises. After following the program, it was found that many measures improved, including leg strength, how long it took patients to climb a flight of stairs, and how many times they could stand up from a chair in 30 seconds.
The Benefits of Prehabilitation Before ACL Surgery
Another more widely studied treatment method is prehabilitation before Anterior Cruciate Ligament, or ACL, surgery. Studies have demonstrated that prehabilitation can assist in improving knee strength, re-establishing neuromuscular control of the knee, decreasing pain levels, and preparing patients mentally for their return to their sport. Prehabilitation for ACL surgery focuses on some of the major impairments seen initially following surgery, such as decreased range of motion, decreased knee stability, and impaired quadriceps strength. Many programs also lead to increased patient confidence and improved balance, which can assist in the prevention of future injuries or injuries to the opposite knee.
In a study conducted by Shaarani et al., they focused on prehabilitation before ACL surgery was performed where patients underwent a 6-week prehab program consisting of balance and strengthening activities. It was found that patients who participated in the program reported higher scores on their self-assessments and showed significantly higher scores on a single-leg hop test. These patients were also shown to return to their sport approximately eight weeks sooner compared to those patients who did not complete the 6-week prehab program.
Why Physical Therapists are Essential to Prehabilitation
Prehabilitation is producing a more proactive approach to treatment and allowing patients to be more active in their care. Physical therapists are an important part of the process because they are able to help tailor each program to an individual's circumstance. These treatment routes are determined by the patient’s needs, weaknesses, compensations, and the type of procedure they are undergoing. Physical therapists are imperative to the compliance aspect of the program because they can ensure the patient is performing their exercises properly, help motivate patients, give them feedback, answer questions, and make any changes to the program itself.
What to Expect from a Prehabilitation Program
A typical prehabilitation program usually ranges from 2-3 sessions a week, lasting approximately 30-60 minutes each session. It has been shown that a blend of strengthening exercises and cardiovascular activities is important because these are the impairments typically seen following surgery. Prehabilitation is not only beneficial to a patient seeking surgery but can also be important to prevent injuries in athletes participating in sports or even the general population who participate in regular exercise.
Prehabilitation for Athletes
In the athletic and strength and conditioning world, prehabilitation is used more as a means of injury prevention. Physical therapists or trained professionals can perform assessments on individuals to see if they have specific movement dysfunctions, joint pattern issues, or other compensations. They will assess how people run, walk, jump, and hop to determine if an individual has a muscle imbalance. Additionally, they can determine if there are asymmetries between their arms or legs, or if there is a specific weakness or stiffness present in the body.
From this data, a physical therapist can predict certain injuries that may occur and help to create a specific program to address the issues at hand, helping to reduce the risk of injury. Typically, in preseason training, athletes are focused on power and flexibility. During the season, it is important for athletes to maintain the strength, power, and flexibility they gained prior to the season. Lastly, postseason prehab programs tend to focus on muscle growth and gaining further strength to set athletes up for success in the next season.
Prehabilitation in Various Ways
In “Prehabilitation for the Tactical Athlete” the author describes how prehabilitation can be utilized in a specific workout program. Prehabilitation exercises can be added in various ways to the warm-up before the workout, as well as supplemental exercises during the workout, or even to the workout cooldown. When these exercises are placed into the warm-up, they should be exercises that follow movement patterns similar to those that are going to take place in the workout itself to prepare the individual’s body for what’s coming. When performing activities before the workout, the movements are usually a progression of the warm-up, such as adding resistance. As a supplemental exercise, they can be performed during the workout itself to fill the time spent resting. Finally, following a workout, prehab exercises can be done, such as foam rolling, to help return the body back to its normal resting state. All of these can assist in injury prevention for both athletes and the general population.
Prehabilitation for Specific Joints
Another way prehabilitation is used in injury prevention is by looking at specific joints, such as the shoulder or knee. Sarah Mros, CSCS, USAW, and Jay Dawes, Ph.D., CSCS, *D, NSCA-CPT, *D, TSAC-F, FNSCA, conducted a study that focused on a prehabilitation program for the prevention of shoulder injuries in firefighters. The study showed that shoulder injuries are commonly sustained during training activities involving bending/lifting/squatting or pushing/pulling activities. Many of these injuries are caused by muscle imbalances, repetitive overhead activities, instability in the shoulder, or trauma. Additionally, it was found that using a prehabilitation program of suspension-based resistance training prior to a firefighter’s usual training or as a warm-up can help improve the muscular endurance of specific shoulder structures. This not only works to improve movement patterns but also reduces the risk of injury.
How to Get Started with Prehabilitation
Prehabilitation studies continue to be performed to demonstrate the effectiveness of prehabilitation programs in relation to athletes, outcomes following surgery, and the general population looking to remain active. This emerging field continues to grow with more interest and research; you may even know someone who has participated in prehab before surgery or to prevent injury. Prehabilitation continues to demonstrate its value in injury prevention, as well as improving health and wellness, and functional capacity. If you are interested in improving your chances of success for surgery or reducing your risk of injury, contact your local FYZICAL today!
The Author’s Experience with Prehabilitation
The author and one of our physical therapists, Dr. Amanda Martin shared with us how prehabilitation played a key role in her recovery from a high school sports injury. She is a physical therapist, Certified Strength and Conditioning Specialist, and Track and Field Coach. She has witnessed many injuries firsthand and treats individuals daily following an injury or surgery. As a junior in high school, she tore her ACL while playing soccer. She sustained the injury on the field and after an MRI, she learned that she was going to need surgery. Amanda was frustrated with the whole incident but what made it worse for her was that they were not going to do the surgery for another month. What she did not realize at the time, was that this preparation time was a blessing in disguise.
For the 4 weeks prior to surgery, she participated in a prehabilitation program with her physical therapist, 2-3 days per week for about 45 minutes to an hour. Amanda’s physical therapist tailored a program specifically to fit her needs, focusing on improving her strength and balance, as well as training her muscles correctly to improve her outcome following surgery. Because of the prehabilitation prior to surgery and the rehabilitation following, she was able to return to her sport within 7-8 months. This was much quicker than the full year her doctor had previously told her to expect. Amanda’s experience with her prehabilitation and physical therapy in high school was what inspired her to become a physical therapist and help others who had similar experiences.
By:
Dr. Amanda Martin, PT, DPT, CSCS
References:
- Lundberg M, Archer KR, Larsson C, Rydwik E. Prehabilitation: The Emperor’s New Clothes of a New Arena for Physical Therapists? Physical Therapy. 2018;99(2):127-130. doi:http://doi.org/10.1093/ptj/pzy133.
- Myers JN, Fonda H. The Impact of Fitness on Surgical Outcomes. Current Sports Medicine Reports. 2016;15(4):282-289. doi:https://doi.org/10.1249/jsr.0000000000000274.
- Cunha J, Solomon DJ. ACL Prehabilitation Improves Postoperative Strength and Motion and Return to Sport in Athletes. Arthroscopy, Sports Medicine, and Rehabilitation. 2022;4(1):e65-e69.doi:https://doi.org/10.1016/j.asmr.2021.11.001.
- Banugo P, Amoako D. Prehabilitation. BJA Education. 2017;17(12):401-405.doi:http://doi.org/10.1093/bjaed/mkx032.
- Stone B. Prehabilitation for the Tactical Athlete. NSCA’S TSAC Report. (36):20-23.
- Noble RM, Linder M, Janssen E, et al. Prehabilitation Exercises for the Lower Extremities. STRENGTH AND CONDITIONING JOURNAL. 1997;19(1):25. doi:http://doi.org/10.1519/1073-6840(1997)019%3C0025:peftle%3E2.3.co;2.
- Mros S, Dawes J. Using Suspension-Based Resistance Training as a Method of Shoulder Prehabilitation for Firefighters. NSCA TSAC Report. (53):14-18.