Prehabilitation for Heart and Lung Transplant Patients at UPMC: Optimizing the Recovery Path and Long-Term Clinical Outcomes
April 1, 2025
Heart and lung transplant candidates face multiple physiological and psychological challenges that can impact their ability to recover postoperatively. Advanced organ failure often leads to significant deconditioning with substantial muscle loss, malnutrition, and overall reduced functional capacity. Many patients experience chronic fatigue, breathlessness, and mobility limitations, making it difficult to maintain their strength.
Compounding these issues, transplant candidates frequently experience psychological distress, including anxiety and depression, which can further affect their ability to adhere to preoperative conditioning and postoperative rehabilitation. Addressing these challenges before surgery through a structured prehabilitation program can significantly improve post-transplant outcomes.
Karen Barr, MD, DipABLM, associate professor in the University of Pittsburgh Department of Physical Medicine and Rehabilitation and physiatrist at the UPMC Rehabilitation Institute, leads a comprehensive and multidisciplinary prehabilitation program designed to optimize the health and functional capacity of heart and lung transplant candidates prior to and after transplant. Originally launched in 2020 for lung transplant candidates, the prehabilitation program expanded to patients in need of a heart transplant in 2023.
The program focuses on reversing or mitigating frailty, improving strength and functional capacity, optimizing nutrition, and addressing mental health concerns and other factors that can impact post-transplant recovery and long-term outcomes.
While the concept of prehabilitation in general is not a new one to medical and surgical disciplines, it is relatively new to the field of transplant medicine. UPMC’s program is one of the first in the country to tackle the prehabilitative needs of heart and lung transplant candidates through a formalized and coordinated approach.
“The approach is all about setting up patients for success prior to surgery and after the transplant,” says Dr. Barr. “If we can make patients as strong as possible, the evidence shows they will do better long-term.”
Identifying Frailty and Building a Prehabilitation Plan
Frailty is a significant predictor of post-transplant complications, including longer hospital stays, increased rates of infection, and higher mortality. Every heart and lung transplant candidate is now assessed for functional impairments, muscle weakness, and overall fitness for surgery.
“Every lung transplant and heart transplant candidate see me as part of their initial evaluation, and I work with them throughout the process,” says Dr. Barr. “For heart transplant patients, many are evaluated while hospitalized, so we adjust their plan based on their immediate condition and available resources,” says Dr. Barr.
Prehabilitation for transplant patients focuses on three core areas – a patient’s physical condition, their nutritional status, and their psychological resilience. Many transplant candidates have not been able to exercise due to the limitations imposed by their underlying heart or lung failure.
“We design exercise programs that help patients build strength and endurance in a way that is safe and achievable given their limitations,” says Dr. Barr.
For patients who are extremely weak, therapy may begin with small movements, breathing exercises, and gradual activity progression. Malnutrition is common among transplant candidates, either due to poor appetite, medication effects, or weight restrictions for transplant eligibility.
“We work closely with dietitians to ensure patients get the nutrients they need to rebuild strength. For those who need to lose weight, we focus on maintaining muscle mass while achieving necessary weight loss,” says Dr. Barr.
The emotional burden of waiting for a transplant, combined with the stress of chronic illness, can contribute to depression and anxiety.
“Patients who are depressed at the time of transplant have a higher risk of complications and even death. Addressing mental health is not optional — it’s an essential part of the plan prior to and after a transplant occurs,” says Dr. Barr.
Individualizing Care Based on Patient Needs
Prehabilitation for transplant patients is not a one-size-fits-all approach. Each patient’s plan is customized based on their own health factors and the potential timeline for transplant. Some patients may have months or longer to prepare their transplant, while others may only have weeks.
“We adjust the plan based on the time available. If someone has two years, we can work toward long-term improvements, but if they only have a month, we focus on the highest-yield interventions,” says Dr. Barr.
The goal is to make meaningful improvements regardless of the timeframe.
“There also isn’t a ceiling effect for prehabilitative care – at least that we know of right now,” says Dr. Barr. “The stronger and more resilient we can make our patients, their chance for optimal outcomes goes up.”
Unlike some transplant centers that may require patients to relocate for a time for prehabilitation, the program at UPMC provides a more flexible model, one that enables patients to receive care within their own communities.
“Some centers require patients to move and complete prehab on-site, but for many of our patients who travel from other states or countries, that’s just not feasible. Instead, we develop a plan that works within their home environment,” says Dr. Barr.
This approach allows patients to remain with their support systems while still receiving the care and rehabilitation therapies they need.
Applying Principles of Lifestyle Medicine to Transplant Prehabilitation
A key aspect of Dr. Barr’s lung and heart transplant prehabilitation program is its holistic approach to patient care, and one that incorporates principles from lifestyle medicine.
In December 2024, Dr. Barr became a diplomate of the American Board of Lifestyle Medicine, a certification that recognizes expertise in using lifestyle interventions — including nutrition, physical activity, sleep, stress management, and behavior change — to improve patient outcomes.
“Applying this expertise to transplant medicine is novel,” says Dr. Barr. “Our program is likely the first in the country to begin to integrate lifestyle medicine principles into our patient care plans.”
The integration of lifestyle medicine concepts into transplant prehabilitation represents a unique approach aimed at further optimizing patient health prior to transplant, but also for long-term patient success post-transplant.
Advancing Research and International Collaboration
Beyond direct patient care, Dr. Barr’s prehabilitation program also is contributing to transplant research and education. One of the major areas of investigation is the role of muscle mass as an objective marker of frailty.
“Right now, we track progress based on functional strength improvements, but we’re working with radiology researchers to explore imaging-based measures of muscle mass to add more precision to our assessments,” says Dr. Barr.
Dr. Barr and her transplant colleagues also are working to expand the heart and lung transplant prehabilitation model internationally. Through a partnership with ISMETT, the UPMC transplant center located in Palermo, Italy, Dr. Barr’s team is working to implement the concept of prehabilitation and its strategies within the very different health care system that exists in European countries.
“They have a very different model, but we’re looking at ways to adapt our principles and protocols and apply them to their lung transplant population,” says Dr. Barr.
Additionally, Dr. Barr has contributed to the “Prehabilitation Handbook for All”, recently published by Springer Press. The book serves as a resource for practitioners across medical specialties, including transplant medicine, oncology, and orthopaedic surgery.
Dr. Barr also is presenting on the subject of prehabilitation for transplant patients at the 2025 Association of Academic Physiatrists (AAP) annual meeting
“Our goal is to introduce this approach to other academic PM&R departments, share how we developed our program, and help institutions address challenges in implementing similar models. I truly believe this is an important next step for our field, and we want to ensure that more rehabilitation specialists become involved in transplant care,” says Dr. Barr.
Upcoming Publication
In March 2025, Dr. Barr and colleagues had a new paper accepted for publication later in 2025 in PM&R: The Journal of Injury, Function and Rehabilitation. The paper, titled “An Innovative Prehabilitation Approach for Lung Transplant Candidates,” describes in detail the program she and colleagues have created to address the prehabilitation needs of patients who are attempting to qualify for a lung transplant.”
“We’re excited to have our paper accepted for publication and look forward to sharing the details of our work with our colleagues and other programs around the country,” says Dr. Barr.
Supporting Patients After Transplantation
Prehabilitation is only one component of a long-term transplant care strategy. Many patients assume that receiving a new organ will immediately resolve their health challenges, but post-transplant recovery comes with its own set of potential challenges.
“Patients have to adjust to new medications, prevent weight gain, and maintain their physical progress. Depression and weight gain are common after transplant, and once they set in, they’re much harder to reverse,” says Dr. Barr. “We try to prevent these issues from the outset so patients can maintain their health long term.”
By embedding rehabilitation within every stage of the transplant process — from initial evaluation through postsurgical recovery — UPMC’s prehabilitation program for heart and lung transplants is helping patients achieve better outcomes and sustain long-term health.
“Our goal is to give every patient the best possible chance at a successful transplant and a high quality of life afterward,” says Dr. Barr.
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