Multidisciplinary Prehabilitation Management Pathway and Network Platform Construction
Phase: NA
Conditions: Lung Cancer, Prehabilitation
Sponsor: Peking Union Medical College Hospital

 
Multidisciplinary prehabilitation management 
pathway and network platform construction 
 
 
 
Research program 
 
 
 
 
Primary research organization:  
Peking Union Medical College Hospital, Peking Union Medical College, Chinese 
Academy of Medical Sciences,Beijing, China 
 
PI: Zijia Liu, Department of Anesthesiology, Peking Union Medical College Hospital, 
Beijing, China   
 
 
 
Version number：3.0 
Version date：2024-04-12 
Registration Number: MR-11-23-027446 

 
1. Background of the study 
Prehabilitation, with its focus on preoperative optimization, is an important 
component and initiator of ERAS management, a process that enhances the 
patient's functional reserve prior to surgery so that they are better able to withstand 
the surgical stresses that follow. For preoperative patients, prehabilitation provides 
“continuous optimization between the basic diagnosis and the initiation of surgical 
treatment”. Currently advocated multimodal prehabilitation programs generally 
include moderate to high intensity aerobic and strength exercise, whey protein 
supplementation-based nutritional support, and psychological support to eliminate 
anxiety, whose benefits in improving perioperative functional status, shortening 
hospital stay, and reducing postoperative complications have been demonstrated 
in cardiac, abdominal, and other surgical fields [1-5]. Multimodal prehabilitation can 
improve patients' perioperative functional status, and many domestic and 
international ERAS guidelines, including lung cancer surgery guidelines, have added 
prehabilitation-related content or raised the level of evidence, recommending or 
strongly recommending prehabilitation as an important part of ERAS management 
[6-9]. 
However, in clinical practice, the implementation rate of prehabilitation is still 
very low, multidisciplinary collaboration is difficult to put into practice, the scale of 
previous related studies is relatively small, the degree of intervention 
standardization is low, these are mainly limited by the relatively fragmented 

prehabilitation program, the lack of multidisciplinary co-management platforms 
and clinical specifications for the management of prehabilitation, and regardless of 
whether home-based or in-hospital programs are used, a large investment in 
human resources and time costs are required. 
In order to improve the implementation of prehabilitation, we have, on the one 
hand, streamlined the content of prehabilitation, improved the implementation 
process, and published a prehabilitation guideline in our previous prehabilitation 
research; on the other hand, we hope to explore a more feasible management 
model. Multidisciplinary collaboration is the foundation of prehabilitation. 
“ Internet+medical service ”  has become a new mode of modern medical 
management, which can intuitively and vividly deliver information to patients and 
obtain effective feedback, enhance the efficiency of doctor-patient communication, 
and improve the enthusiasm of patients to participate in the perioperative 
management, which is especially suitable for the popularization and application of 
patient-oriented prehabilitation, and reduces the waste of medical human resources 
and economic burden. and economic burden. Under the normalization of epidemic 
prevention and control, the Internet and online diagnosis and treatment will provide 
a more effective way for preoperative prehabilitation. 
“Internet +” perioperative management is in line with the trend of China's 
medical service innovation and development. The application of the Internet in the 
field of healthcare is becoming more and more widespread, and has also been 
strongly supported and advocated by the state. 2016, the CPC Central Committee 

and State Council issued the “Healthy China 2030” planning program, in 2017, 
the General Office of the State Council issued the “China's medium- and long-term 
plan for the prevention and treatment of chronic diseases (2017-2025),” and The 
Opinions on Promoting the Development of “Internet+Medical Health” issued by 
the General Office of the State Council in 20l8, all emphasize the construction of a 
health information service system, innovation, exploration and improvement of the 
“Internet+” medical and health service system, the development of telemedicine, 
health consultation and health management services, and the enhancement of 
clinical and health care services. consulting, health management services, and 
strengthen the integration, sharing and application of clinical and scientific research 
data [10-11].  
Prehabilitation is still a hot topic and emerging content in the field of ERAS 
research at home and abroad, and the application of Internet and wearable 
technology to prehabilitation is still a gap. We hope to try to establish a 
multidisciplinary full-process prehabilitation model, explore the main technical 
medium of “ Internet + wearable devices ” , and build an “ Internet + ” 
prehabilitation management model. 
Reference： 
[1] Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilitation:a randomized 
control trial in patients undergoing colorectal resection forcancer. 
Anesthesiology. 2014;121(5):937-947.  
[2] Dezube AR, Cooper L, Jaklitsch MT. Prehabilitation of the Thoracic Surgery 

Patient. Thorac Surg Clin. 2020; 30(3):249-258.  
[3] Licker M, Karenovics W, Diaper J, et al. Short-term preoperative high-intensity 
interval training in patients awaiting lung cancer surgery: a randomized 
controlled trial. J Thorac Oncol. 2017;12(2):323-333.   
[4] Daniels SL, Lee MJ, George J, Kerr K, Moug S, Wilson TR, Brown SR, Wyld L. 
Prehabilitation in elective abdominal cancer surgery in older patients: 
systematic review and meta-analysis. BJS Open. 2020;4(6):1022–41. 
[5] Liu Z, Qiu T, Pei L, et al. Two-week multimodal prehabilitation program 
improves perioperative functional capability in patients undergoing 
thoracoscopic lobectomy for lung cancer: a randomized control trial. Anesth 
Analg. 2020;131(3):840-849. 
[6] Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for 
enhanced recovery after lung surgery: recommendations of the Enhanced 
Recovery After Surgery (ERAS®) Society and the European Society of Thoracic 
Surgeons (ESTS)[J]. Eur J Cardiothorac Surg.2019;55(1):91-115. 
[7] Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for Perioperative Care in 
Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society 
Recommendations: 2018[J]. World J Surg. 2019;43(3):659-695. 
[8] Nelson G, Bakkum-Gamez J, Kalogera E, et al. Guidelines for perioperative care 
in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society 
recommendations-2019 update. Int J Gynecol Cancer. 2019;29:651-668.   
[9] 中华医学会外科学分会, 中华医学会麻醉学分会.中国加速康复外科临床实践指南

（2021）(一). 协和医学杂志.2021;12(5):624-632 . 
[10] Baimas-George M, Watson M, Elhage S, et al. Prehabilitation in Frail Surgical 
Patients: A Systematic Review. World J Surg. 2020;44(11):3668-3678. 
[11] Kehlet H. Prehabilitation in surgery-Need for new strategies? Eur J Surg Oncol. 
2021;47(5):929-930. 
 
2. Purpose of the study 
1) Exploration and development of a smartphone-based online prehabilitation 
management application for VATS surgery for lung cancer； 
2) Conduct perioperative stereoscopic assessment of functional status and quality 
of life in VATS surgery for lung cancer； 
3) Construction of an Internet-based short-term home-based multicomponent 
prehabilitation model for VATS surgery for lung cancer in combination with 
wearable exercise devices； 
4) Evaluation of the clinical feasibility and clinical significance of Internet + 
wearable device prehabilitation applied to VATS surgery for lung cancer. 
 
3. Content of the study 
3.1 
Construction of a user-screen friendly version of the Multi-Link Pre-
Rehabilitation online application experience： 
1) 
Introduction to Prehabilitation: A short video is used as the main format, 
supplemented by pictures and brief text, to introduce the basic contents 

and significance of Prehabilitation; 
2) 
Details of the prehabilitation program: details of the purpose of the 
prehabilitation, the timing of the essential elements and the details of the 
contents in concise and easy-to-understand language text and pictures; 
3) 
Scheduling: Provide examples of prehabilitation weekly scheduling. In the 
pre-operative assessment clinic, the doctor conducts a pre-operative 
assessment of the patient, combining the patient's personal habits and 
arrangements, and the doctor and patient work together to develop an 
individualized prehabilitation plan; 
4) 
Demonstration of follow-up exercises: including breathing training follow-
up videos, anaerobic exercise follow-up videos, aerobic exercise warm-up 
follow-up videos, etc., which are suitable for elderly patients with debility, 
patients with mildly reduced activity tolerance and patients with 
significantly reduced activity tolerance. It also includes synchronized 
instruction, so that patients can complete efficient follow-up exercises 
without leaving home;  
5) 
Three-dimensional assessment of perioperative functional status and 
quality of life: the application realizes online functional status assessment, 
including NRS2002 Nutritional Risk Screening, Hospitalization Anxiety and 
Depression Scale (HADS), Quality of Recovery Rating Scale (QoR-15), and 
WHO Disability Assessment Scale version 2.0 (WHODAS 2.0), etc., with the 
patients completing the questionnaires online; and also includes the self-

measurement of the 6-min walking distance (6MWD). At the same time, it 
includes the self-measurement of 6min walking distance (6MWD), and 
patients can complete the self-measurement of 6MWD according to the 
prompts of the application; 
6) 
Implementation and feedback function: It can realize the guidance and 
adjustment of prehabilitation strategy after reassessment; and set up 
functions such as daily reminder and prehabilitation activity record. 
3.2  To conduct a study on the impact of short-term internet + wearable device-
based home-based multilink prehabilitation management on preoperative 
functional status and prognosis of patients undergoing VATS surgery compared to 
the traditional model. 
A prospective randomized controlled single-blind clinical trial. 64 patients with 
diagnosed lung occupations intended for VATS surgery were to be included. They 
were randomized into the “Internet+” group and the traditional prehabilitation 
control group. 
1) Sixty-four adults aged ≤75 years; suspected lung cancer intended for VATS 
lobectomy/sublobar resection were selected for the study. 
2) Prehabilitation intervention: Both groups underwent individualized home-
based multimodal prehabilitation strategies, and the timing of the 
prehabilitation intervention was about 2 weeks from the time the doctor and 
the patient jointly decided to have the surgery to 1 day before the surgery. The 
content of prehabilitation included smoking cessation, aerobic training, 

anaerobic exercise, nutritional optimization and psychological support. The 
“Internet+” group used the management mode of online application + 
wearable devices; the traditional prehabilitation group used the traditional 
management mode of preoperative preaching + paper records + regular 
weekly reminders from medical staff. 
3) Study endpoints: The follow-up period was from the time when the surgeon 
and the patient decided to operate to 30 days after the operation. The 6MWD 
was used as the primary assessment of perioperative functional status and the 
primary endpoint of the study, and patients were evaluated at enrollment, 
before surgery, and 30 days after surgery. Secondary endpoints included: 
length of hospitalization, postoperative complications, and pulmonary function, 
as well as multiple perioperative functional status scores. The feasibility of 
“Internet Plus” management and patient implementation were assessed. 
4. Sample size and statistical methods 
The design of this study was a prospective randomized controlled study, and 
the sample size of this study was based on the difference in the primary outcome 
6-minute walk test distance (6MWD) between the two groups at 30 days 
postoperatively. It is currently recognized that a difference of 30m in a patient's 
6MWD is clinically significant. According to the pre-test of the research team, the 
standard deviation of the 6MWD was 40 m. The probability of class I error was 
calculated as 0.05 bilaterally and β=0.2 to obtain 29 patients in each of the two 
groups, and 32 patients in each of the two groups were taken to account for the 

10% shedding of medical records. 
The statistical software for this study was in R language (R Foundation for 
Statistical Computing, Vienna, Austria; version 3.5.2). Measurements were expressed 
as mean ± standard deviation or quartiles, depending on the distribution, and 
counts were expressed as frequencies. In this study, for the primary outcome 6MWD, 
as well as for the WHODAS 2.0, and the HADS psychological scores, repeated 
measurements were taken at different time points in the same patient. Considering 
the correlation between multiple measurements, a linear mixed-effects model was 
developed in this study to analyze the effect of the intervention. Intervention factors, 
time points as categorical variables, and interactions between intervention factors 
and time as fixed effects were included in the model. When there was no evidence 
in the model suggesting an interaction between the intervention and time, it was 
removed from the model to estimate the effect of the intervention on the primary 
outcome at all time points and the effect of time on the primary outcome. Also, 
given the potential bias of patients missing visits, we will perform sensitivity 
analyses of the worst measurements for all patients with missing 6MWD data and 
determine whether missing data have an impact on the analysis of the primary 
outcome. For other single-measure secondary outcomes, group comparisons were 
performed using the paired t test for measures that satisfied normality and the 
nonparametric Mann-Whitney U test for measures that did not satisfy normality. 
Count data were expressed as frequencies, and intergroup comparisons were 
performed using the χ2 test. The test level was α=0.05. A statistically significant 
difference was defined as a two-sided P<0.05. 
5. Patient inclusion and exclusion criteria 
5.1 
Inclusion 

1) Age: 18-75 years; 
2) 64 
adults 
with 
suspected 
lung 
cancer 
proposed 
for 
VATS 
lobectomy/sublobar resection. 
5.2 
exclusion： 
1) Patient refusal; 
2) ASA classification III or higher; 
3) Pre-neoadjuvant chemotherapy; 
4) Inability to cooperate (psychiatric abnormalities, impaired consciousness, 
mental retardation); 
5) Comorbidities cannot tolerate home rehabilitation or functional motor 
examination; 
6) Inability to use a smartphone or read Chinese; 
7) 
Average 
weekly 
moderate-intensity/high-intensity 
exercise 
of >90min/>60min. 
6. Research process 
1)  Patients were assessed for enrollment criteria at the time of their initial 
outpatient visit and decision to proceed with surgery. After obtaining informed 
consent from the patients, basic information (basic, past medical history, metabolic 
equivalents, etc.), smoking status, ASA classification, metabolic equivalents, 6MWD, 
lung function, grip strength, NRS 2002 nutritional risk screening, HADS and 
WHODAS 2.0 scores were collected 
2)  Both groups were given routine preoperative anesthesia clinic visits and 

guidance, and a short-term home multimodal prehabilitation intervention strategy 
of about 2 weeks, including smoking cessation, aerobic exercise, impedance training, 
respiratory exercise, nutritional guidance, whey protein powder supplementation 
and psychological support. Elastic bands, whey protein powder and respiratory 
trainers were distributed to patients in both groups.  
The “Internet+” team trained patients on the online application of the 
“Preoperative Family Prehabilitation Program”. The patients used the 
online application for prehabilitation, followed the exercises, and used the 
sports bracelet as a wearable device to adjust the exercise intensity and 
record the exercise time. 
Patients in the traditional group were issued a portable finger oxygenator 
to assist in the completion of exercises, as well as a Pre-Rehabilitation 
Manual and Completion Record Form, which patients were instructed to fill 
out daily, and patients were followed up twice a week. 
 
Comprehensive reference to previous studies and prior research by the group, 
combined with patient execution, to propose a concise and easy-to-follow exercise 
program: 
i) 
Tobacco and alcohol cessation 
ii) 
Aerobic exercise 
Aerobic exercise is the core of exercise training in a way that consists 
of two steps, the first step being a 5-minute warm-up process. The second 

step is a 25-minute aerobic exercise in the form of simple popular methods 
such as brisk walking, jogging, stair climbing, swimming, aerobics or cycling, 
depending on the patient. The frequency of exercise is at least 3 times a 
week. 
Exercise intensity was evaluated by both rating of perceived exertion 
(RPE), i.e., Borg score (see table below), and target heart rate. The target 
heart rate was calculated based on the patient's age, i.e., target heart rate 
= (220 - age - base heart rate) × 70% + base heart rate, which could be 
recorded by finger oxygenator or exercise bracelet. The exercise intensity 
setting of aerobic exercise should be controlled between 13-16 points of 
modified Borg score, i.e., subjective exertion is felt as a little bit hard or 
forceful, and the exercise intensity is appropriately increased if it is felt that 
the exercise can be easily accomplished, and the intensity of the exercise 
can be lowered when the self-perception of fatigue is heavy or slightly 
severe dyspnea is felt, and overly strenuous exercise is not recommended. 
 Improved Borg Scoring Indicator 
Brog score 
Self-perceived level of 
exertion 
6-8 
Very, very light. 
9-10 
very light 
11-12 
light 
13-14 
A little hard 

15-16 
hard 
17-18 
Very hard 
19-20 
Very, very hard 
 
iii) Anaerobic exercise 
Muscle strength training includes all muscle groups needed in daily life 
(biceps, triceps, deltoids, pectoralis major, latissimus dorsi, obliques, lumbar, 
abdominal, gluteal, quadriceps, etc.), and the exercises are performed with self-
weighted training or resistance bands. Movements can be selected according 
to the patient's own situation. Resistance bands with appropriate weights are 
individualized according to the patient's condition. Strength training was done 
in 3 sets of 10-12 repetitions for each movement. Again the intensity of exercise 
was evaluated on Borg scale. The duration of anaerobic exercise i.e. strength 
training was about 10-15 minutes to prevent muscle soreness and affect 
compliance. The frequency of training was 2 times a week, alternating with 
aerobic exercise. 
iv) Breathing exercise 
The prehabilitation program for patients undergoing lung surgery 
requires emphasis on breathing exercises in addition to exercise workouts. 
The latter helps to improve lung function, facilitates sputum expulsion, 
increases lung capacity, and prevents the occurrence of perioperative 
pulmonary atelectasis. Respiratory function training is recommended to be 

performed twice a day for 10 minutes each time, and respiratory exercises 
include balloon blowing, three-ball instrument, respiratory trainer, and 
active cycle breathing techniques. Individualized protocols are developed 
based on the patient's underlying respiratory function and tolerance. 
v) 
Dietary and psychological adjustments 
The European Society of Clinical Nutrition and Metabolism 
recommends a daily protein intake of 1.2g/kg-1.5g/kg (ideal weight for 
obese patients) for surgical patients. Patients are advised to change 
unhealthy dietary habits, especially high-calorie and high-fat diets, and 
increase the intake of vegetables, fruits and high-quality proteins (fish, 
chicken breast and other lean meats, milk, eggs, soybeans) as appropriate. 
In addition, patients are advised to supplement high-quality protein, such 
as whey protein powder, one hour before exercise every day to better 
promote muscle synthesis according to their individual conditions. 
Encourage patients to perform self-psychological adjustment and listen to 
relaxing music to sleep before bedtime every day. 
 
The 6MWD at 30 days postoperatively was used as the primary assessment of 
functional status and the primary endpoint of the study (enrollment, preoperative 
and 30 d postoperative); secondary endpoints included pulmonary function, length 
of hospital stay, ICU stay, postoperative complications, and hospitalization costs, 
and the HADS assessed perioperative psychosocial, the QoR-15 scale assessed 

near-term prognosis, and the WHODAS-2.0 scale assessed mid-term prognosis. 
 
7. Research quality control 
1) All 6-minute walk tests were measured by a unified person, conducted in 
accordance with international standard procedures and equipped with first-aid 

medicines, so that patients could be dealt with in a timely manner if they felt unwell 
or needed to take a rest; 
2) The whey protein powder provided free of charge to the patients was selected 
from “Nerishi” isolate whey protein powder through the Nutrition Department 
of the hospital, taking into consideration the purity, purification method, safety, 
taste and other issues; 
3) For patients in the traditional prehabilitation group who have no wearable 
devices, patients are provided with free finger oxygen meters to facilitate patients 
to record their heart rate during aerobic exercise, adjust the intensity of exercise, 
and ensure the safety and effectiveness of exercise; 
4) provide patients with free three-ball instrument respiratory trainer, resistance 
respiratory trainer and elastic band exercise equipment without safety problems. 
The three-ball instrument respiratory trainer and our hospital unified sale for the 
same manufacturer and supplier products; 
5) Full-process supervision of patients' prehabilitation implementation, including 
daily short message reminders and study log-in records for patients in the Internet 
+ wearable device group, and 2 weekly SMS/WeChat or telephone follow-up visits 
for patients in the traditional group to ensure their implementation; 
6) Data are entered by two persons, and data consistency test is conducted to clean 
and screen the data to avoid entry errors.