Implementation and effectiveness of a novel model of multimodal prehabilitation for patients living with Cancer in regional and rural NSW: Supported PRehabilitation – Improving fiTness, Ensuring well-being before Surgery (C-SPRITES)

The intervention will occur over a period of 4 weeks, with a minimum of 2 weeks, occurring immediately prior to surgery. This will comprise of 2-weeks commencing with physical activity counselling, utilisation of a wearable device (Fitbit) to monitor and support the increase in physical activity (PA) and attending a surgical school with a dietitian, psychologist and physiotherapist. This will be followed by 2-weeks of supervised exercise provided in a participant’s own community. Referral to the supervised exercise program will be made at the completion of the initial assessment. Attendance at each of the intervention components will be recorded. Week 1-2 The first 2 weeks of the intervention are coordinated and delivered via audio-visual telehealth. With 1-2 individual session and one group session. Prior to the initial appointment participants will be provided with a Fit bit in the mail and a “participant passport”. The individual session will be with a physiotherapist with at least 3 years of clinical experience. Participants will be provided with counselling regarding increasing their physical activity with specific targets for enhancing daily step count, duration of activity and frequency each week. The goal will be to increase PA over the 2 weeks with a goal of achieving the current PA recommendations i.e. 30 minutes of walking, most days of the week, at a moderate intensity. Motivational interviewing will be employed using The Five A’s: Ask, Advise, Assess, Assist and Arrange. The 5 As have been linked to higher motivation for health behaviour change. Participants will be able to see their step count on their Fitbit. An additional individual session will be offered with a dietitian for people who have a Malnutrition Screening Tool (MST) score >2 or who have specific dietary needs. The group session will involve: 1. A 15 minute session presented by a dietitian on the link between nutrition and surgery, protein and goal setting. 2. A 15-minute session regarding preoperative physiotherapy-led education focusing on teaching breathing exercises for the patient to do themselves on waking from surgery. This intervention has been shown to prevent postoperative pulmonary complications (PPC) after abdominal surgery. Physiotherapists will be trained in the intervention with formative feedback. 3. A 15 minute session presented by a psychologist called “preparing mind and body for surgery” following a cognitive behaviour framework. These will be supported by the information provided in the “participant passport”. Week 3-4 The second 2 weeks of the intervention will be delivered in-person by community partners in the participants local community. Each of the partners ie. exercise physiologist or physiotherapist, will have undergraduate training in exercise oncology as per requirements for accredited undergraduate courses. Additional training and support will be provided for the community partners regarding the supervised exercise program. The intervention comprises of high intensity interval training (HIIT) , functional strength training and will be performed with the community partners on 2-3 days per week – totaling 5 sessions per participant. The prescription encompasses Frequency, Intensity, Time, Type (FITT) principles. Patients attend 2-3 supervised training sessions of approximately 60 minutes/session each week (totaling 5 sessions in 2 weeks) in conjunction with an unsupervised home-based walking program. The HIIT program is delivered on an electromagnetically braked cycle ergometer. Cycling uses large muscle groups and is feasible and safe in most people. The intensity on the cycle ergometers is monitored and prescribed according to the patients subjective rating of exertion and as identified using the Rating of Perceived Exertion (RPE). The HIIT program consists of: i. 5 min warm-up and 5 min cool-down. ii. alternating high intensity (RPE of 14-17) (4×2 min intervals at high intensity) to moderate intensity (RPE 6-11) (4×3 min intervals at moderate intensity) for the first two sessions. iii. increase to 40 min (6×2 min intervals at high intensity and 6×3 min intervals at moderate intensity) for the subsequent sessions. Progression: Training intensity is titrated with the goal of evoking symptoms that are perceived to be between 14 to 17 on the RPE scale. Progression of the intervals is achieved by increasing the work rate by increments of 5W as symptoms permit; that is, RPE < 14. Where a patient is unable to maintain either of the intensities, focus is on adhering to and progressing the high intensity interval workload. If the patient requires a complete rest, this will occur during the moderate intensity interval. Response and adherence to prescription will be monitored and recorded. Participants will also engage in a program of general circuit strength training, eg. bicep curls, shoulder flexion with light weights, at the end of these sessions.