In Reply

We thank Bordes et al. for the opportunity to clarify this point. Our results1 indicate that the compliance to the trimodal program in the first 4 weeks postsurgery was significantly higher in the prehabilitation group than in the rehabilitation group (53 vs. 31% respectively, P < 0.001). Bordes et al. thus hypothesized that the observed improvement in functional walking capacity in the prehabilitation group could be the result of a greater compliance to the postoperative program rather than the usefulness of a prehabilitation program.We would argue that the usefulness of the prehabilitation program is directly linked to the ability to maintain compliance postoperatively. Our argument is based on two main points: (1) Prehabilitation maintains functional integrity so that patients are physically capable of complying with the trimodal program postoperatively; and (2) Prehabilitation is rooted in the belief that the preoperative period is an opportune time to encourage compliance by educating and preparing patients for the tasks that need to be completed in the postoperative period.The prehabilitated patients gained, on average, +25.2 m (50.2 m) in functional walking distance before surgery; a mean difference of distance walked of approximately 40 m between groups. This preoperative difference was considered clinically and statistically significant (P < 0.001) and substantiates the impact of prehabilitation. The finding attests to successful attainment of a “buffer” (i.e., reserve) against the expected decline in physical function and overall wellbeing that is typically observed postoperatively. Moreover, a number of investigations have identified preoperative physical fitness as a predictor of surgical complications and early convalescence.2–6Compliance was tabulated subjectively, based on adherence to the entire trimodal program. The value reported is an equally weighted average among all three interventions, as prehabilitation is believed to be a work of synergy. It should be noted that the self-reported physical activity, as measured using the validated CHAMPS questionnaire, 4 weeks after surgery was not significantly different between the two groups. This implies that prehabilitated patients were more compliant with the nutrition and psychological component, rather than the exercise component, of the trimodal intervention after surgery. Although anxiety reduction strategies likely contributed to overall well-being, there is no direct link between these techniques and improvement in functional capacity. Similarly, maintenance of adequate dietary protein is essential to preserve lean body mass and therefore skeletal muscle function; however, it is generally accepted that exercise is the main anabolic stimulus and that adequate nutrition augments the effect.7–9 Adherence to the nutrition intervention after surgery may have been useful in sustaining the functional gain achieved in the preoperative period, yet unlikely to stimulate anabolic gains independent of increased exercise.Finally, the use of preoperative counseling to provide information on the expectations of surgical procedures is believed to reduce fear and anxiety and enhance postoperative recovery.10,11 It is a fundamental component of Enhanced Recovery Programs.11 Preoperative instruction that focuses on the tasks expected of the patient during the perioperative period is also believed to improve adherence to the guidelines and thus improve recovery.11–13 Prehabilitation can be perceived similarly. It is likely that patients who begin and establish a routine preoperatively find it easier to continue the routine postoperatively. Indeed, it has been found that intention increases rates of goal achievement, only in the absence of strong antagonistic habits.14 The preoperative period thus allows time to identify barriers15 and counterproductive habits early, which enables later adherence.In conclusion, we would argue that the ability of the prehabilitation group to comply with the trimodal program earlier than the rehabilitation group after surgery simply suggests that prehabilitation was implemented successfully.The authors declare no competing interests.

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