Peri-Operative Rehab Program for Inguinal Hernia Repair Surgery
Condition: Inguinal Hernia
MeSH terms: Hernia; Hernia, Inguinal
Study type: Interventional

Summary: 
      Inguinal hernia repair is one of the most common surgeries, with more than 20 million
      performed globally each year. It is estimated that approximately 15% of patients undergoing
      inguinal hernia repair will experience persistent post-surgical pain that could last months
      to years. Evidence from related procedures indicates that better surgical preparation through
      pre-operative exercise and education (i.e. Prehabilitation) followed by ongoing post-surgical
      rehabilitation leads to more rapid recovery, return to activities and lower likelihood of
      persistent post-surgical pain. The investigators will determine the feasibility of a
      peri-operative rehabilitation program (pre- and post-surgery) and our study protocol for
      patients undergoing inguinal hernia repair surgery. The investigators hypothesize that: 1)
      our peri-operative intervention will be feasible and safe to undertake within a clinical
      setting; 2) adequate numbers will be enrolled to justify a larger trial; and that 3) our
      outcome measurement protocol will provide meaningful information with high response rate and
      low attrition after 3 months.
    

Detailed description: 
      Inguinal hernia repair is one of the most common surgeries performed globally, with more than
      20 million performed each year. Not only does this huge number of surgeries have a
      substantial direct economic burden on healthcare systems, there is also indirect impact from
      time off work and decreased productivity due ongoing post-surgical pain requiring extended
      time spent on modified duties. It is estimated that approximately 15% of patients undergoing
      inguinal hernia repair will experience persistent post-surgical pain that could last months
      to years. Furthermore, current clinical guidelines for return to work and activity after
      inguinal hernia repair are inconsistently informed by evidence, highly variable, and
      outdated. Forbes et al (2012) found that the average patient undergoing inguinal hernia
      repair experiences more than 40 days of short-term disability despite indications that
      earlier return to activity is safe (i.e. will not lead to repair failure) and likely
      beneficial for reducing chronic pain and disability.

      Evidence from related procedures indicates that better surgical preparation through
      pre-operative exercise and education (i.e. Prehabilitation) followed by ongoing post-surgical
      rehabilitation leads to more rapid recovery, return to activities and lower likelihood of
      persistent post-surgical pain. Prehabilitation was first described in the 1940's when the
      British Army developed a prehabilitation program as part of an experiment to increase the
      quality of recruits. The concept of prehabilitation gained traction within the medical
      community when Topp et. al. and Ditmyer et. al. promoted a theoretical model of
      prehabilitation, positing that patients who participate in presurgical exercise with the goal
      of improving functional capacity may experience more rapid postoperative recovery than
      patients who remain physically inactive through the preoperative period. Prehab has also been
      shown to increase self-efficacy, a moderator of pain catastrophizing and fear avoidance
      beliefs, that are important factors linked to the pain experience of those with persistent
      pain. The investigators propose that this theoretical model can be extrapolated to inguinal
      hernia repair and theorize that prehabilitation will increase patients' preoperative
      self-efficacy, allowing them to more rapidly regain abilities, subsequently shortening
      duration of modified duties and decreasing likelihood of persistent post-surgical pain.

      Little information is available regarding the use of prehabilitation in the context of
      inguinal hernia repair. There have been numerous studies looking at prehabilitation in
      orthopedics, cardiovascular surgery, and prior to major abdominal surgeries, but limited
      studies for inguinal hernia repair. A randomized control study by Liang et. al. examined the
      impact of prehabilitation on ventral hernia recurrence and post-operative complications. They
      concluded that patients undergoing prehabilitation have a higher likelihood of being
      hernia-free and complication-free 30 days postoperatively. Notably, this study is limited in
      that only obese patients were included, and outcomes only included recurrence and
      complications. No studies were located examining the impact of prehabilitation on recovery
      time, post-surgical pain, and return to activity after inguinal hernia repair. However
      psychosocial factors such as pain catastrophizing appear to be important predictors. Typical
      practice guidelines often recommend limiting activity for at least 3 months to avoid
      re-rupture. However, these guidelines are based on expert opinion due to a lack of quality
      research and can pose a risk in building unhelpful beliefs about pain, fear of movement and
      poor coping strategies. Research is needed to inform practice guidelines and
      return-to-activity recommendations.
    

Intervention name(s): Rehabilitation
Intervention type(s): Other
Intervention description(s): Pre- and post-operative exercise and education.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Pilot Parallel-Group Randomized Controlled Trial
Masking: Single (Outcomes Assessor)
Primary purpose: Health Services Research
Keywords: rehabilitation; prehabilitation