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430 CHAPTER 21 pacity. 21 They found that a significant improvement in the functional capacity, quality of life and prevention of worsening of fatigue in the exercise group. Multimodal andmultidisciplinary pre-habilitationwith engagement of patients and health care teams may lead to more effective and sustainable clinical practice. However, the challenge in head and neck cancer is that there is often just a 4-week window of opportunity to undergo this pre-habilitation because treatment must begin within 4-6 weeks after diagnosis or in the adjuvant setting after surgery. Although it is not known if pre-habilitation in head and neck cancer patients is feasible in this short window of opportunity, it has already been shown that this time frame is sufficient in patients with colorectal cancer. 22 In addition, Bhatia et al. conducted an randomized controlled trial in lung cancer patients in which they have also shown that pre-habilitation in a short time frame (median 25 days) was effective and safe. 23 Pre-operative high-intensity interval training (HIT) significantly increased cardio-respiratory fitness and walk capacity compared to patients who received usual care. The adherence to HIT in the pre-habilitation group was high 87% (SD 18%). Recently, Boright et al. proposed a protocol for physical therapist-administered head and neck cancer pre-habilitation program and also did a feasibility study for three patients. 24 The authors conclude that their developed pre-habilitation protocol consisting of a home exercise program (strength, endurance and range of motion) and nutritional support is feasible in patients with head and neck cancer. Due to the short window of opportunity to train muscle mass in head and neck cancer, it is proposed that HIT is the preferred formof exercise training in pre-habilitation. Although there is no universal definition, HIT generally refers to repeated sessions of relatively short intermittent exercise. Exercise in HIT is performed at a high inten - sity close to VO 2 max during few seconds with previous warming up period, peak-exercise of minutes and followed up by a cooling down, this is repeated 4-6 times per training session. Dunham et al. performed a randomized controlled trial in which they showed that HIT offers a time-efficient alternative to endurance training in aerobic capacity and performance. 25 Considering the similar beneficial effects of HIT than endurance training in a shorter period of time, this physical exercise training system seems to the best option in a pre-habilitation program in order to not delay the surgery. The work rate in the HIT training needs however to be adjusted by the physiotherapist on each patient and session to target near VO 2 max without being too intensive for the patient’s physical capacity. NUTRITIONAL SUPPORT Amandatory prerequisite in preventing muscle loss and stimulating muscle mass growth is an adequate intake of nutrients. Patients with head and neck cancer are prone for malnutrition due to tumor site and treatment-related side effects such as xerostomia, nausea, mucositis and fibrosis. It has already been shown that weight loss and systemic inflammation leads to hypermetabolism in which the resting energy expenditure is increased. 26,27 This high resting energy expenditure leads to a loss of skeletal muscle mass. 27 The higher catabolic and inflam- matory state in patients with cancer leads to further deterioration of skeletal muscle mass