Margaret Gonzales gripped the aluminum railing as she slowly descended the stairs and submerged herself in the pool. Her face lit up like a young child at play. She waved her hands in the air in excitement, then began to move her legs as if running, allowing the current of the “lazy river” to carry her weight.

It was an exciting for Gonzales to be back in the pool: She had a new knee and no pain.

No better place

The pool first became Gonzales’ oasis in 2009. As a visual inspector for a medical device manufacturing company in Broomfield, Colorado, she was on her feet a lot. The pool provided a gravity-free activity after work that was easy on the joints.

So when she moved to Cheyenne, Wyoming, in 2017 after retirement, one of the first things she did was seek out a new water track to continue her routine. She began visiting the Cheyenne Aquatic Center daily, but despite her best efforts, her right knee continued to be a problem.

“I was limping and dragging it,” she said. “It was dead weight.”

Gonzales first tried two rounds of steroid injections for six months. But there was no improvement. So her doctor asked if she’d thought about surgery.

“How will I do that?” she thought, worried about finding the right resources in her new community.

Her debilitated knee, though, was troubling.

“I didn’t want to be in pain the rest of my life,” Gonzales said. “I couldn’t stand too long — even shopping was hard. You see all that is going on and you go, ‘Nope. I’ve got to do something about that.’”

Once she’d made up her mind, her primary care physician sent her to Fort Collins orthopedic surgeon Dr. Rocci Trumper to discuss surgery. He agreed with surgery but first recommended she set herself up for success through the Pre-procedural Impact Clinic, a prehabilitation program for patients choosing elective surgery.

Prehabilitation for elective surgery

The Impact Clinic (Interdisciplinary Management of the Pre-Procedure Assessment, Consultation, and Treatment) ensures patients are in the best physical condition for elective surgery. The clinic works to help patients grow stronger by working with them 30 to 90 days before their surgery date, according to Dr. Annette Vizena, an anesthesiologist at UCHealth in northern Colorado.

“By providing prehabilitation through an innovative patient-centered model of health care delivery prior to a patient’s surgery, the Impact clinic’s influence includes improved clinical outcomes, decreased health care costs, and improved patient satisfaction and engagement,” she said.

What is prehabilitation?

When a high-risk surgical patient, such as one with untreated diabetes, sleep apnea, anemia, or weight concerns, is contemplating or scheduled for elective surgery, the patient may be referred to the Impact Clinic.

As one of the nurse practitioners in the clinic, Laura Hildebrand evaluates a patient’s medical history, medications, past conditions and social habits, such as diet and physical activity, to create a specialized plan to address any surgical risks that patient may have.

“We have an assessment tool that looks at 11 different postoperative risks and where they may be at increased risk,” Hildebrand said.

Hildebrand first met with Gonzales on May 15, 2019, more than three months before her scheduled surgery.

Decreasing surgical risks with prehabilitation

Studies show that people with diabetes, for example, have a higher risk for surgical-site infections. People with untreated sleep apnea have an increased risk of pulmonary complications after any surgical procedure. There also are specific surgical risks for those who are anemic, or for those who are over- or underweight.

“The Impact Clinic takes a deep dive into their health and creates a plan to mitigate those risks,” Hildebrand said.

Gonzales’ diabetes was under control. However, she had an elevated BMI (body mass index) and untreated sleep apnea.

“Our primary concern was her sleep apnea,” Hildebrand said. “She’d had a sleep study done years before, but it wasn’t treated.”

The program provides a fast track for specialty referrals for such procedures as echocardiograms and sleep studies, which can normally take weeks to be scheduled.

“We can get a sleep medicine consultation within two business days,” Hildebrand said, adding that this allows those risks to be more quickly identified and rectified.

Creating a plan to address surgery risks

After the tests comes the plan.

“We really try to individualize the plan based on their resources and what they want to do,” she said.

Gonzales wasn’t using a CPAP machine because it had been stolen during one of her moves. Hildebrand worked with her primary care physician to get a new machine, which she brought with her for her hospital stay after surgery.

Weight loss and improved muscle tone lower risks for post-surgery problems and since Gonzales already was going to the pool several times a week, she didn’t need more encouragement, just a little direction.

“A realistic goal for her was to lose 1 to 2 pounds per week,” Hildebrand said. “We are very specific with our physical activity recommendations, from seated aerobics to medically supervised programs, or like in the case with Margaret (Gonzales), who was already doing some activity, she just needed guidance on how to best benefit from that activity.”

Gonzales implemented the plan right away, increasing her pool visits to five days a week and changing how she exercised.

“With Laura’s directions, I started pushing myself to pick up my knees,” Gonzales said. “I started losing weight and going faster.”

During the first 11 months of the clinic, 93 percent of Impact Clinic patients consulted for elevated BMI lost weight. Those seen four to six weeks prior to surgery lost an average of 5 pounds, while those seen more than six weeks before surgery lost an average of 15 pounds.

Patients who consulted for diabetes decreased their A1C level by 0.8% on average.

Post-surgery recovery

Gonzales stuck with her plan until her Sept. 5, 2019, surgery at UCHealth Poudre Valley Hospital in Fort Collins. After a few days in the hospital, she went to an inpatient rehabilitation center for two weeks. Then she had outpatient therapy at her home three days a week for a month.

She said her therapists were impressed with how quickly her flexibility in her knee returned, and Gonzales credits her work — and Hildebrand’s advice — with strengthening her joints before surgery.

And as soon as Gonzales got the note from her doctor, she was back at the Cheyenne Aquatic Center. She continues to exercise and use the information and education she received from the Impact Clinic to improve mobility.

“Yes, it really has improved my life,” she said.