Preoperative Physical Conditioning

Physical fitness is increasingly recognized as a crucial and unfortunately diminishing component and contributor to overall biopsychosocial-spiritual well-being. Morbidity and mortality are closely linked to physical inactivity (PI), as are many chronic pain states; furthermore, there are complex and confounding relationships between PI and obesity, sleep disorders, depression, and anxiety, which all mediate chronic pain and other morbidity and mortality in their own right. Physical inactivity is also associated with worsened postoperative outcomes, and a growing body of evidence supports both rationale and effectiveness of improving physical fitness levels prior to surgery for optimal patient and overall system/economic outcomes. Recent evidence indicates that as little as four weeks of mild to moderate but regular physical activity can improve surgical outcomes. As with many if not all lifestyle issues, PI is at its root a biopsychosocial-spiritual issue, and adequate understanding and accommodation of underlying motivational deficits, obstacles and competing factors, and habit factors are essential to supporting patients in improving their fitness for surgery.

Putting It All Together

Joint behavioral health and medical care is required for optimal success in preoperative optimization of the chronic pain patient. This effort basically comprises lifestyle modification issues, and habit breaking and replacement do not come easily. Physical and psychological dependence on tobacco, alcohol, and opioids adds to the complexity and requires skilled and individualized intervention. Nonetheless, some basic principles, goals and a template/plan for multidimensional “baby steps” can be implemented in every case. Given that many of these variables (e.g., sleep, exercise, diet, kinesiophobia, etc.) are interdependent, such a multidimensional approach is preferred in terms of efficacy. Correspondingly, current forward-thinking charters such as the US National Pain Strategy recognize that the mainstream passivity-inducing and frequently opioid-reliant chronic pain management culture with its failure to encourage biopsychosocial-spiritual health and proactive solutions fosters dependence on reactive efforts. It is no wonder patients suffering with chronic pain in this country should pursue stronger drugs, more procedures and surgery, which in the absence of improved baseline mind-body health status all too often results in worsening of their pain syndrome and opioid dependence. The individual patient and the system at large require recalibration, focusing on what our forebears called “fitness for surgery.”

Sleep Optimization

Sleep deprivation is arguably the single most compromising event that prevents pain patients from changing behavior. To get the sleep-deprived patient to take action to improve their sleep and become more capable of healthy change, healthcare practitioners must approach the patient with the evidence of “what works,” but on his or her own terms, in a language that he or she can understand and cognitively retain, and in a psychological manner that will inspire hope and increase motivation. This chapter endeavors to accomplish the following: (1) review the scope of the problem; (2) clarify the frame of reference of the author; (3) explain how humans function as living rhythm machines; (4) define circadian rhythms, chronobiology, and clock genes; (5) describe the challenges of improving sleep hygiene in a patient population; and (6) identify the methods of change used clinically, including motivational interviewing.

The Pragmatism of Habit in Preoperative Optimization

As stated in the previous chapter’s introduction, effective preoperative optimization of patients suffering with chronic pain depends on behavioral modification. Chronic pain is largely influenced if not mediated by omission of healthy biopsychosocial-spiritual behaviors (e.g., healthy diet, sleep, exercise, and stress management patterns) and commission of unhealthy ones (e.g., pro-inflammatory diet, toxin consumption). This chapter explores the critical role of habit in directing behavior in general and, in particular, health behaviors. It examines what is currently known about the psychology and neurobiology of habit formation and maintenance. It then turns to a brief overview of the application of these concepts to the perioperative optimization of patients with chronic pain.

Preoperative Management of Chronic Opioid Therapy

The literature increasingly supports an association between

Preoperative Management of Tobacco

Despite significant reductions in prevalence in the United States over the past half-century, smoking (and the use of other tobacco products) continues to constitute the most common chemical dependency (aside from caffeine, perhaps) and the leading preventable cause of morbidity and mortality in the developed world. It is well documented that the use of tobacco products increases overall health risks and, in the context of this work, perioperative complications. Less well recognized but also supported by the literature is an independent association with chronic pain in general after adjusting for common comorbid health risks, and also with worsened postoperative pain control. Conversely, there is evidence that preoperative tobacco cessation results in substantial improvements in outcomes. This chapter briefly reviews basic and clinical science underpinning these phenomena, the descriptive epidemiology and available outcomes data pertinent to the issue, and what the current literature has to say about preoperative tobacco cessation and support, both biologic/pharmacologic and behavioral. Recognizing the complex issues surrounding tobacco use, the chapter highlights the importance of both motivational enhancement and habit alteration.

Pain Catastrophizing and Anxiety

The optimization of perioperative patients involves targeting the modifiable individual factors that influence pain, function, and surgical outcomes. However, many untapped opportunities exist, particularly in the psychological realm. Indeed, psychological factors—including pain anxiety and pain catastrophizing—are among the most influential perioperative factors yet rarely are targeted in the perioperative timeframe. To date, research has largely focused on the characterization of behavioral risk factors that associate with or predict poor surgical outcomes, whereas fewer perioperative studies and programs have focused on perioperative interventions. As such, interventions that effectively address the highest-yield targets may meaningfully improve perioperative care and favorably alter the long-term trajectory of health after surgery. This chapter aims to elucidate key research to date for pain anxiety and pain catastrophizing and underscore their importance as therapeutic targets in the perioperative timeline; it also reviews data on their malleability and responsivity to intervention, and highlights promising relevant clinical programs.

Preoperative Nutritional Management

Malnutrition in the developed world generally comprises both excess of calories with poor macronutrient (carbohydrate—protein—fat) proportioning, and deficit of multiple micronutrients (vitamins, minerals, and phytonutrients). These excesses, deficits, and imbalances all confer health risks, and many are associated with the development of systemic inflammation and chronic pain. In the perioperative context, malnutrition is also associated with suboptimal surgical outcomes; from a nutrient deficiency standpoint, compromised wound healing and increased incidence of infections are seen. From a caloric excess standpoint, obesity confers markedly increased perioperative morbidity and mortality. Most of the evidence-based literature supports the use of so-called immunonutrition preoperatively in populations at risk. As with all of the lifestyle modification issues discussed in this book, enhancement of patients’ intrinsic motivation and thoughtful identification and replacement of maladaptive habits with better alternatives are of the essence.

The Primacy of Motivation in Preoperative Optimization

Surgical patients with chronic pain frequently neglect basic health behaviors (e.g., maintenance of appropriate diet, sleep hygiene, exercise patterns) while engaging in harmful ones (e.g., tobacco use, alcohol excess, chronic opioid consumption) all of which have been shown to confer poor postoperative outcomes. Effective preoperative optimization of patients suffering with chronic pain requires at least a basic understanding of the complex and heterogeneous motivation behind deliberative (and subconscious) behaviors, and the application of interventions supporting self-determined elimination of toxic cognitive-behavioral patterns and their replacement with healthy ones. This chapter begins with an overview of motivational interviewing and select positive literature reviews addressing the utility of the method in modifying behaviors pertinent to this program. A survey of the development of our understanding of core common elements of human motivation is presented, followed by a biopsychosocial-spiritual framework for considering interpersonal variance; the chapter concludes with a brief consideration of dynamic intrapersonal variables affecting motivation within the individual.

Rationale and Process Overview for Preoperative Optimization of Chronic Pain

The previous chapter demonstrated that preoperative chronic pain and its many associated comorbidities pose significant risk of suboptimal and adverse outcomes after surgery. Morbidity and economic data clearly indicate room for improvement in the arena of preoperative preparation/optimization of these factors prior to elective surgery. Many have called for a better system of identifying patients at risk and intervening at various stages (preoperative, intraoperative, and postoperative) with multidisciplinary/multimodal approaches in an attempt to mitigate this growing problem. Principles of evidence-based standards of care and wise allocation of resources/fiscal responsibility require that in high-impact and high-prevalence conditions such as chronic pain, benefits clearly outweigh risks and justify the costs. The federal government is increasingly implementing drastic overhaul to the reimbursement system and one of those changes particularly relevant to the perioperative arena is the advent of bundled and capitated payments which further incentivizes quality care with minimization of both postoperative complications and costs involved in preventing and treating them.