Frailty and Prehabilitation in Spinal Deformity

Podcast Transcript

Alex Rae-Grant, MD: Neuro Pathways, a Cleveland Clinic Podcast for medical professionals, exploring the latest research discoveries and clinical advances in the fields of neurology, psychiatry, neurosurgery and neuro rehab.

As the percentage of middle aged and elderly population grows in the United States, so does the incidence of back pain and spinal deformity. In today's episode of Neural Pathways, we're discussing frailty and prehabilitation in patients with chronic back pain and spinal deformity. I'm your host, Alex Rae-Grant, Neurologist at Cleveland Clinic's Neurological Institute. In an effort to explore the latest advances in neurological and neurosurgical practice, I'm very pleased to have Doctor Augusto Hsia Junior, join us for today's conversation. Doctor Hsia is a medical spine specialist in the Center for Spine Health in Cleveland Clinic's Neurological Institute. Gus, welcome to Neural Pathways.

Augusto Hsia, Jr., MD:  Thank you, Alex, for inviting me into this podcast.

Alex Rae-Grant, MD: So Gus, before we get started with the topic, tell us a little bit about yourself so our listeners can get to know you better. Where are you from and where did you train and when did you begin your career at the Cleveland Clinic?

Augusto Hsia, Jr., MD:  Yes. I grew up in the Philippines and I actually finished medical school there. After that, in 95, I started an internal medicine residency program at the New York University Hospital in New York. And after I finished that, I went to a postgraduate fellowship in rheumatology, here at the Cleveland Clinic in 1999 and then went on to do another medical spine fellowship after. So I was in private practice for a few years before coming back here as full-time staff in 2006.

Alex Rae-Grant, MD: And we're glad to have you with us. Gus, let's start, kind of broadly, we know that age can play a large role in frailty, but is there also other risk factors and can you define a frailty for us and why it matters?

Augusto Hsia, Jr., MD:  A frailty is an aging related syndrome, which leads to a physiologic decrease in overall functioning of the body. And this also increases vulnerabilities relating to medical illness, stress relating to any medical or surgical procedure. So it's very important to differentiate physiologic age and chronological age. So an example for this is an 85 year old gentleman who is relatively healthy or well controlled hypertension, doesn't smoke, exercise, may be less frail than a 65 year old who has multiple medical issues, who still smokes and does not do any exercise.

Why does it matter in spine health? As you correctly alluded in the introduction, the present age of elderly population is increasing, here in the U.S. That comes with increased spinal disorders, increase in spinal pain and disability. As the aging process assaults the physiologic functioning in our body, so does spinal diseases and spinal surgery. Also, substantially increases the stress and vulnerabilities.

So an example for this is a 65 year old male with COPD, smoker, carotid disease, who is more sedentary. His functional reserve is lower than a 65 year old, who is in good health and who exercises daily and does not smoke. And if a spinal condition occurs, like a lumbar disc herniation, the healthier 65 year old can adapt more easily, despite lower functioning and increased level of pain. And if both of this patients will need surgery eventually, the patient who has more medical comorbidities and poorer physical functioning, tend to do, in general, worse with postoperative complication as well as poorer outcome. So it's very important to screen for frailty in our elderly population.

Alex Rae-Grant, MD: So when we're thinking about the spinal surgery situation, I think we all know that rehabilitation is crucial. Tell us a bit about a prehabilitation program and what kind of difference it could make with post-surgery pain level and recovery time and give us a bit more information about just what prehabilitation is.

Augusto Hsia, Jr., MD:  Yes. Prehabiliation is defined as a process of preoperatively improving and maximizing functional capabilities in our elderly patients prior to any spine surgery. So with the ultimate goal of decreasing perioperative and postoperative complications, as well as improving outcomes after spine surgery.

Alex Rae-Grant, MD: We know that successful management of a patient's spine surgery depends on a number of factors, but also includes a number of healthcare providers. Can you talk about the multidisciplinary approach that you're team takes in treating patients with frailty concerns and the kind of goals set out for each member?

Augusto Hsia, Jr., MD:  As you know, Alex, the Center for Spine Health is pretty multidisciplinary. So before even the patient sees a spine surgeon, they have already seen a medical specialist, like myself. And in that department we have physical medicine specialists, rheumatologists, osteopaths, spine interventionist, and allied health professionals, that sees the patient initially and institute programs. A common program is physical therapy to improve overall functioning and lower their pain. We also use multimodal management approach with spine injections, non-opiate type medications, cognitive behavioral therapy, Back on TREK programs.

So if the patient fails nonoperative management or conservative management and are deemed surgical candidates. We then refer to our surgical colleagues. And we have a protocol in spine surgery called the ERAS Protocol, or Enhanced Recovery After Surgery and frailty screening is one of those components, but it includes also smoking cessation, better control of diabetes, screening of bone health and osteoporosis and spinal fusion candidates and also referring people who are obese, greater than 40 BMI, for weight loss specialists.

Any frailty suspected, and this is usually a patient who is over 70 with multiple medical comorbidities, decreased overall physical and cognitive function, then we refer them to a geriatric clinic for a comprehensive assessment of frailty. In this evaluation, there is assessment of overall physical functioning. This also includes depression and dementia screening and risk for delirium is assessed and the medical comorbidities is assessed. There's also nutritional assessment and medication review, looking at polypharmacy specifically. A prehabilitation program based on the variables I mentioned, is instituted and usually management goals are individualized. So it's definitely a multidisciplinary program that we have here.

Alex Rae-Grant, MD: So it sounds like a pretty complex preoperative process. Can you tell us a bit more about how these interventions might improve postoperative outcomes after spine surgery?

Augusto Hsia, Jr., MD:  If the patient already has problems with gait, speed and strength, the physical therapy can improve strength, like in patients who have sarcopenia. Otherwise, we know that people who have multiple medication or polypharmacy and already has high risk for delirium initially and then address the issue, then we are more successful postoperatively. And that's together with diabetes control and heart disease and COPD in a medical assessment and management, prior to surgery. It's probably better to do it preventatively than postoperatively.

Alex Rae-Grant, MD: I guess the whole conversation about frailty has broader impact in medical care. Is there anything that you think we could be changing in our practice, to reduce frailty in our patient population? Are there things we should be working on, even before they get to you guys to help the situation?

Augusto Hsia, Jr., MD:  Yes, definitely. Half of the component of frailty is in the physical deconditioning, so we encourage patients to exercise daily, strength training and neural reconditioning. We also try to avoid opiate-type medication that may cause more problems, postoperatively. And certainly, other medical risk factors should also be sought out and treated.

Alex Rae-Grant, MD: Well, Gus, thank you so much for joining us today. It sounds like you guys are doing some great work, so thank you for your time and your insights and have a safe rest of your day.

Augusto Hsia, Jr., MD:  Okay. You too now. Thanks for inviting me.

Alex Rae-Grant, MD: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast or subscribe to the podcasts on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD. All one word that's at C-L-E, Clinic M-D on Twitter. Thank you for listening. Please join us again soon.