No! This piece is not about social distancing, hand washing, wearing masks, etc. Not because these aren’t important. But because by now these have been drilled
Mar 27, 2020,
By Sanjay Nagral
No! This piece is not about social distancing, hand washing, wearing masks, etc. Not because these aren’t important. But because by now these have been drilled into you. The epidemic is closing in. What we saw on TV few weeks back, I now see being enacted in hospitals in Mumbai. Can we do anything to prepare ourselves while we sit at home? Today, I will discuss an idea that may help in the fight against the coronavirus infection. This is not a cure but an allied strategy which has a scientific base and, more importantly, can be implemented at home without any equipment or medicines. It’s called ‘prehabilitation
’ – a concept which involves simple interventions aimed at rapidly improving a person’s health prior to an anticipated upcoming massive stress on the body so that they withstand it better.
Like many other advances in modern health care, the origin of ‘prehabilitation’ was duringWWII
. Many of the men presenting for enlistment in theBritish Army
were rejected on account of their poor physical and mental conditioning. As the small country could not afford to reject too many soldiers, a programme of educational, physical, andnutritional interventions
was launched. Of the 12,000 men who passed through prehabilitation centres, more than 85 per cent improved both physically and mentally. The other area where a similar idea has stood the test of time is mountaineering, where climbers planning a major expedition undergo rigorous training or conditioning to get themselves in shape for a few weeks prior. Conditioned mountaineers survive the high altitude better.
It was only recently that this was absorbed into health care. It has now entered the world of modern surgery. The number of surgical procedures has risen exponentially across the globe. Though techniques and technology have advanced, there still are a lot of complications. Also, we are operating on older patients with coexisting diseases like diabetes, obesity, heart and lung conditions; the kind of population now common in India. After all, surgery is like a sudden major stress on the body, avery violent one at that. That’s where ‘prehabilitation’ to prepare a patient for afew weeks came in and has become standard in some countries. The elements of this now include, physical conditioning and exercise to build muscle mass and improve heart and lung function, nutritional inputs, cessation of smoking, tight diabetes control, breathing exercises and psychological strengthening. There is crucial evidence that even a short burst of three to four weeks of all these reduces surgical complications and has even been applied to those needing early surgery like for cancer.
There is a large body of research that shows that muscle wasting and cardiopulmonary deconditioning occurs quickly during reduction in physical activity. Both these impact one’s ability to maintain oxygenation in case of lung infection or when on a ventilator. What sort of exercise is recommended? Avoiding prolonged periods of sitting is agood start. Given the lockdown, the exercises will have to be done at home and could include just walking around the house, on the spot jogging to aerobic exercises. Short bursts of high intensity exercise are an alternative. Dancing is a good option. Deep breathing and holding one’s breath to expand the lungs like in the traditional ‘pranayam’ is good lung exercise and can be done as often as possible.
Indians are prone to restricting certain foods during illness.Indian studies
have shown very low protein levels in patients presenting for surgery. And short-term intensive feeding is known to improve surgical results. A highprotein diet
is crucial. Non-vegetarians are lucky as eggs, chicken and fish provide high proteins. For vegetarians, paneer, sprouts, soya, dals and milk are good sources. I tell my fencesitting veg /non-veg patients to quickly shift to eggs and chicken before surgery. Artificial protein supplements are an option.
Other interventions are also a crucial part of ‘prehabilitation’. The first is to quit smoking. There is no doubt that smokers have much higher lung complications after surgery. It has also been reported as a risk factor for death in the corona epidemic. Diabetics must control sugar levels – a key factor in fighting any major health condition. Asthmatics need to optimise their therapy.
‘Prehabilitation’ has not been evaluated in an infectious pandemic disease. However, it is logical, intuitive and can do no harm. A Harvard professor has recently called for considering this, though it may be a bit late for the US. There is currently a window of opportunity for India. Social distancing, quarantine and prehab can be done together. It may hold the greatest benefit for those who are most vulnerable – the elderly with coexisting diseases. The lockdown, key to slowing the spread of the disease, has an unintentional effect of decreased physical activity leading to cardiopulmonary deconditioning.
I am acutely aware that that some of this advice is not easy to implement, especially for the poor. And that when it comes to nutrition, mainly dietary protein, the state will have to help people procure it. As I have repeatedly stated in my previous articles, decisive government action like rapidly infusing health care with funds is the key to treatment. But many a health challenge has been fought not by spectacular steps but low key changes in behaviour and lifestyle by the entire community. India is already in a chronic epidemic of non-communicable diseases. Prehabilitation is a strategy which may not only help us in the present but perhaps even in the future.
(Sanjay Nagral is a surgeon, who when not wielding the scalpel wields the pen
courtesy Mumbai Mirror