Your activity: 140 p.v.
your limit has been reached. plz Donate us to allow your ip full access, Email:

Overview of prehabilitation for surgical patients

Overview of prehabilitation for surgical patients
Maurice F Joyce, MD, EdM, FASA
Ruben J Azocar, MD, MHCM, FASA, FCCM
Section Editors:
Natalie F Holt, MD, MPH
Amalia Cochran, MD, FACS, FCCM
Deputy Editors:
Nancy A Nussmeier, MD, FAHA
Wenliang Chen, MD, PhD
Literature review current through: Nov 2022. | This topic last updated: Nov 17, 2022.

INTRODUCTION — Preoperative prehabilitation programs emphasize nutritional supplementation, smoking cessation, physical and cognitive exercise, and stress reduction to improve postoperative functional status and outcomes. In some cases, elective surgery may be delayed to optimize the patient’s preoperative condition. This topic discusses prehabilitation protocols including specific preoperative interventions, patient selection, timing, and outcomes after patient participation in such protocols.

Other anesthetic and surgical interventions that may be employed throughout the perioperative period to enhance recovery after certain types of surgery are addressed in separate topics:

(See "Enhanced recovery after colorectal surgery".)

(See "Enhanced recovery after gynecologic surgery: Components and implementation".)

(See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)

(See "Anesthetic management for enhanced recovery after cardiac surgery (ERACS)".)

(See "Anesthetic management for enhanced recovery after thoracic surgery".)


Definition and scope of prehabilitation programs — Prehabilitation involves preoperative processes to enhance a patient’s functional capacity and optimize recovery from the stress of surgery and anesthesia. "NEW" prehabilitation programs address Nutrition, Exercise (both physical and cognitive), and Worry (stress reduction) [1]. For current smokers, another critically important aspect of a prehabilitation program is smoking cessation [2]. These interventions involve patient effort and behavior modification during the preoperative period. The need for surgery is considered to be a "teachable moment" that might serve as a driver for permanent behavioral changes to improve health [3].

While some prehabilitation protocols have focused on a single issue, "multimodal" approaches employing two or more preoperative interventions are likely optimal for most patients [4-7]. Selection criteria for participation in a prehabilitation program and decisions to delay elective surgery during attempts to improve functional capacity are patient- and procedure-specific, although specific criteria vary among institutions (see 'Patient-related factors' below and 'Selected surgical procedures' below). Institution-specific protocols also dictate management of the prehabilitation process and may be the purview of surgical, anesthesiology, oncology, and/or primary care services. Perceived challenges to broad adoption of prehabilitation programs for a wide range of surgical procedures include the resources (financial and personnel) and multidisciplinary cooperation that are necessary to implement such programs. Some centers have implemented a multidisciplinary team approach to prehabilitation and enhanced recovery programs [8-11]. (See "Enhanced recovery after colorectal surgery" and "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)

Prehabilitation requires patient effort, unlike clinical interventions, to optimally manage medical conditions such as initiation or adjustment of medications to decrease blood pressure or control glucose levels [12]. It is particularly important to identify and appropriately treat iron deficiency anemia (as soon as the decision is made to pursue surgery or at least four weeks before the scheduled date of the procedure (algorithm 1)), whether or not prehabilitation protocols are initiated during the preoperative time period. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia'.)

Although four or more weeks is generally considered to be sufficient time for prehabilitation efforts, a longer period may be optimal for patients who are older and/or frail [13,14]. Also, this duration is individualized according to the patient’s diagnosis and the urgency of the planned surgical procedure [15-17].

Outcome data and limitations

Outcome data Patient-specific, procedure-specific, and intervention-specific studies of prehabilitation efforts are presented in the sections below. Large studies of multimodal prehabilitation efforts have noted the following results:

In a 2022 umbrella review of 55 systematic reviews, improvements in functional recovery were noted in patients undergoing cancer surgery (moderate certainty evidence) [18]. Some of these systematic reviews reported that various types of prehabilitation programs improved incidence of postoperative complications and/or hospital length of stay (LOS) after cardiothoracic, cancer, or other major noncardiac surgical procedures, but evidence of certainty was low to very low [18].

A 2019 statewide review of 523 Medicare claims in Michigan for various types of major noncardiac surgery noted that participation in a multimodal prehabilitation program that included a home-based walking protocol, education regarding nutrition, smoking cessation, and psychological preparation shortened median hospital LOS (6 [range 4-7] versus 7 [range 4-10] days) and increased likelihood of discharge to home rather than to another facility (65.6 versus 57 percent) compared with no participation [19].

Limitations Data supporting development of prehabilitation programs are limited by heterogeneity among studies due to small size and lack of randomized controlled trial design in most, as well as variability in outcome endpoints, differences in types of surgical procedures and clinical settings (eg, unsupervised home-based interventions, supervised clinic visits), criteria for patient selection, which specific prehabilitation intervention(s) were employed, and the duration, frequency, and intensity of these intervention(s) [13,18,20,21]. Assessment of the impact of prehabilitation programs on clinically important outcomes such as perioperative complications, hospital LOS, unanticipated readmission, short- and long-term impairments, and ability to participate in planned postsurgical treatments has been challenging due to these factors [6].

TARGET PATIENT POPULATIONS — Although some centers offer prehabilitation programs for all surgical patients, most focus on use of resources for patients at high risk for postoperative morbidity and due to patient- and procedure-related factors.

Patient-related factors — Older age (typically ≥65 years) and documented frailty are the most common factors for patient selection for prehabilitation efforts before major surgical procedures.

Older age — Elective surgery may be postponed in older patients undergoing selected surgical procedures (see 'Selected surgical procedures' below) in order to improve preoperative functional capacity [13,14]. However, evidence regarding the impact of unimodal or multimodal prehabilitation programs on clinical outcomes is scant [14,20,22,23]. (See "Anesthesia for the older adult", section on 'Preanesthesia consultation'.)

Frailty — Similarly, elective surgery may be postponed during prehabilitation efforts in frail patients undergoing selected surgical procedures (see 'Selected surgical procedures' below) [20,22,24-30]. Notably, a longer preoperative duration may be required for prehabilitation interventions in frail patients [13]. However, evidence is scant regarding the impact of unimodal or multimodal programs on clinical outcomes in frail surgical patients [24,31,32]. (See "Frailty".)

Frailty is associated with increased mortality, postoperative complications, hospital length of stay (LOS), discharge to institutional care, functional decline, and lower quality of life (QOL) after various types of surgical procedures [33,34]. For example, frailty is present in a high percentage of patients undergoing cardiac surgery (33 to 47 percent) and is considered to be a more relevant predictor of postoperative mortality, morbidity, and inferior health-related QOL than chronological age alone [25-29,35]. Ideal implementation of prehabilitation programs would include individualized strategies for an otherwise healthy 60-year-old adult compared with a frail 80 year old patient [4,8,10,20,22,36].

Although a simple preoperative screening test such as measurement of gait speed may help identify patients at increased risk, various assessment tools are available. However, few frailty assessment instruments have been validated for surgical patients, which has contributed to heterogeneity among studies of the impact of prehabilitation [26]. (See "Frailty", section on 'Instruments developed to identify frailty' and "Frailty", section on 'Rapid screening tools'.)

Selected surgical procedures — Multimodal prehabilitation has primarily focused on major gastrointestinal, thoracic, urologic, and gynecologic surgical procedures for treatment of cancer, as well as on cardiac surgery.

Major gastrointestinal or esophageal surgery In our institution, we employ a multimodal prehabilitation program for patients undergoing major gastrointestinal tract procedures for cancer or other indications.

In a 2019 meta-analysis that included 202 patients (two randomized controlled trials and one cohort study) undergoing colorectal cancer surgery, those participating in multimodal prehabilitation that included exercise and nutritional interventions noted improved disease-free survival five years after colorectal cancer surgery (hazard ratio [HR] 0.45, 95% CI 0.21-0.93; 202 total patients) compared with those who did not participate [37]. However, postoperative complications were similar in the two groups. A subsequent 2020 prospective study in 418 older frail colorectal cancer surgery patients (see 'Patient-related factors' above) also noted that prehabilitation had little effect on postoperative outcomes [38]. Similar results were noted in several retrospective studies of prehabilitation efforts [39,40].

However, results are inconsistent for major abdominal surgery. Some smaller studies have noted fewer postoperative complications and cost savings over $20,000 [41], fewer 30-day hospital readmissions [42], decreased incidence of delirium [40], increased likelihood of recovery of baseline functional capacity at four postoperative weeks [43], or longer postoperative six-minute walking test (6MWT) distances at four and eight postoperative weeks [44] in patients participating in multimodal prehabilitation protocols compared with controls.

For patients undergoing esophageal surgery for cancer resection, a 2018 randomized trial in 68 patients noted that prehabilitation (nutrition and physical exercise) improved postoperative functional capacity measured with the 6MWT (mean change +15.4 ± 65.6 versus -81.8 ± 87.0 meters) [45].

Urologic surgery We also employ our prehabilitation program for patients undergoing major urological surgical procedures. In a 2021 randomized trial of 70 males undergoing radical cystectomy, a prehabilitation program that included aerobic and resistance exercise, nutrition, and relaxation techniques resulted in improved functional capacity measured with the 6MWT (mean change +40.8 ± 114.0 versus +9.7 ± 108.4 meters) meters) four weeks after surgery [46].  

Gynecologic surgery – We also employ our prehabilitation program for major gynecologic surgery. Outcome studies noting improvements in physical and psychologic parameters, complication rates, as well as shorter length of stay are discussed in a separate topic. (See "Enhanced recovery after gynecologic surgery: Components and implementation", section on 'Health status optimization'.)

Thoracic surgery Many institutions employ prehabilitation for patients undergoing lung cancer resection.

A 2020 randomized trial in 73 patients undergoing thoracoscopic lobectomy for lung cancer noted improved perioperative functional capacity after a two-week home-based multimodal prehabilitation program that included nutrition counseling, aerobic and resistance exercises, respiratory training, and psychological guidance, compared with standard preoperative care [47]. Specifically, forced vital capacity was 0.35 L higher (95% CI 0.05-0.66) and the 6MWT was 60.9 m longer (95% CI 32.4-89.5) in patients receiving prehabilitation.

Other studies of unimodal prehabilitation before thoracic surgery have focused on physical exercise and respiratory muscle training, as discussed below. (See 'Physical exercise programs' below.)

Cardiac surgery Many institutions follow guidelines established for cardiac surgical patients who may benefit from prehabilitation programs, including those who are frail, have cognitive dysfunction, or need for smoking cessation identified during the preoperative consultation [4,35,48]. The importance of nutrition support is particularly emphasized (see 'Nutritional supplementation' below) [49-51]. Notably, preoperative vitamin D deficiency is associated with postoperative delirium in cardiac surgical patients [52].  

One 2019 network meta-analyses of four meta-analyses concluded that multimodal prehabilitation efforts reduce postoperative pulmonary complications and hospital LOS in cardiac surgical patients [53]. Evidence of benefit was strongest for inspiratory muscle training.

SPECIFIC INTERVENTIONS — Multimodal approaches to prehabilitation that employ two or more preoperative interventions are optimal for most patients [4-7]. Descriptions and outcomes for specific components of prehabilitation programs are discussed below.

Nutritional supplementation — Malnutrition is common in patients undergoing major surgical procedures. Preoperative assessment of nutritional status (figure 1) and interventions to treat malnutrition are addressed in separate topics:

(See "Clinical assessment and monitoring of nutrition support in adult surgical patients".)

(See "Overview of perioperative nutrition support".)

Regardless of assessment results, these authors recommend oral protein supplementation and immunomodulation nutrition five to seven days before surgery for all patients, and more aggressive interventions for a longer duration for malnourished patients.

Smoking cessation — Strong encouragement to cease smoking is often part of a prehabilitation program. Cessation for four to eight weeks before surgery is ideal to minimize risk of postoperative pulmonary complications. Details regarding perioperative risks of smoking, benefits of cessation, and specific behavioral interventions and pharmacotherapy to aid with cessation are discussed separately:

(See "Smoking or vaping: Perioperative management".)

(See "Overview of smoking cessation management in adults".)

(See "Behavioral approaches to smoking cessation".)

(See "Pharmacotherapy for smoking cessation in adults", section on 'Preoperative management'.)

Physical exercise programs

Identification of poor functional capacity – Low anaerobic threshold is associated with perioperative mortality [54-56]. We screen high-risk patients undergoing major abdominal or cardiothoracic surgery for poor functional capacity based on the following risk factors:

Age >70

Frailty (see 'Frailty' above)

Poorly controlled chronic illnesses (eg, diabetes or hypertension)

Preoperative chemotherapy or radiation therapy

Inactivity by WHO standard (<150 minutes of moderate intensity or <75 minutes of vigorous intensity exercise per week)

Patients who meet one or more of these criteria would benefit from physical exercise programs as a part of their prehabilitation [57].

Additionally, we use assessments of functional capacity that include:

Gait speed. In one prospective cohort study of more than 15,000 cardiac surgical patients ≥60 years of age, gait speed was an independent predictor of adverse outcomes; an 11 percent relative increase in mortality was noted for each 0.1 m/sec decrease in speed [58].

Time to complete five chair sit-to-stand repetitions [59].

Dominant handgrip strength (average of three measurements) [60].  

Quadriceps femoris thickness measured by ultrasound [61].

Other assessments include:

Stair-climbing test [62].

Shuttle walk test [63].

Six-minute walking test (6MWT) distance to assess aerobic capacity and endurance by measuring the distance traveled by the patient while walking for six minutes [64,65]. This test has been used in studies to compare baseline versus post-intervention changes. Unfit patients with poor baseline walking capacity are most likely to improve with prehabilitation that includes physical exercise [66].

Cardiopulmonary exercise testing (CPET), which indicates the transition from aerobic metabolism to anaerobic metabolism (ie, the anaerobic threshold) [67,68]. However, CPET can be time- and resource-consuming.

Interventions to improve physical function – Some prehabilitation programs include preoperative physical exercise for sedentary patients with poor functional capacity [7,66,69]. Training programs may include aerobic, resistance, flexibility, balance, and strength exercises, as well as inspiratory muscle training (IMT) [13,57,69]. Inclusion of IMT in the exercise program may be particularly important for patients with obesity [70], chronic obstructive pulmonary disease [71,72], or those undergoing major upper abdominal, cardiothoracic, or cancer surgical procedures [36,47,53,72-80]. Typically, these interventions are implemented in a supervised setting; however, some centers use home-based interventions [13].

Systematic reviews of the efficacy of preoperative physical exercise and/or respiratory training after major abdominal, thoracic, and cardiovascular surgical procedures have reported inconsistent results as well as substantial heterogeneity among studies:

Major abdominal surgery – A 2020 systematic review of preoperative exercise programs (aerobic together with resistance training, IMT, coughing, or stretching) before major liver, colorectal, gastroesophageal, or general abdominal surgery that included eight randomized trials with 442 patients noted a significant reduction in overall morbidity (OR 0.52, 95% CI 0.30 to 0.88) and postoperative pulmonary complications (PPCs) (odds ratio [OR] 0.37, 95% CI 0.20 to 0.67) compared with standard care [81]. Other systematic reviews in patients undergoing major abdominal surgery have also noted reduction in PPCs [21,80-84].

Thoracic surgery – A 2022 systematic review reported postoperative outcomes after preoperative exercise training that included supervised or unsupervised aerobic, resistance, IMT or any combination of these types of training before open or video-assisted resection of non-small cell lung cancer (636 participants; 10 randomized trials) [85]. The investigators noted reduced risk of developing PPCs (risk ratio [RR] 0.45 95%CI 0.33-0.61) and reduced postoperative length of stay (LOS) in the hospital (–2.24 days, 95% CI -3.64 to –0.85 days). Exercise training also improved preoperative exercise capacity (measured by peak oxygen consumption), but had little or no effect on lung function (measured by forced expiratory volume in one second). Similar results were noted in older systematic reviews [75,76,86]. However, implementation of exercise training programs before esophageal cancer surgery has not resulted in similar beneficial effects [73,74,86].

Cardiovascular surgery – A 2019 systematic review of nonrandomized studies before cardiac surgery (seven studies) or vascular surgery (two studies) noted that preoperative exercise programs improved objective physical functioning and subjective measurements of quality of life (QOL) compared with controls [87]. A 2019 network meta-analyses noted that evidence of benefit was strongest for use of IMT in prehabilitation efforts [53].

Cognitive prehabilitation — Preexisting cognitive impairment is common in patients who are older or have certain other risk factors. Some prehabilitation programs have included cognitive exercises. Details regarding preoperative assessment and interventions to potentially improve postoperative cognitive function are discussed in a separate topic. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Preoperative risk assessment and management'.)

Stress reduction

Identification of anxiety or depression – Some prehabilitation programs have included psychological screening and interventions to reduce preoperative stress and anxiety before major surgical procedures [3,88,89]. In rare cases, counselling or specialist psychological or psychiatric care may be necessary for a patient with severe anxiety or depression [13,90]. Notably, preoperative education alleviates anxiety by setting expectations regarding the patient's own role in the recovery process [91-97]. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preoperative considerations'.)  

In noncardiac surgical patients, preoperative anxiety or depression has been associated with impairment of functional recovery as well as with postoperative pain [91,92,98-101]. One study in cardiac surgical patients noted increased mortality risk in patients with preoperative anxiety [102].

Interventions to reduce preoperative stress – Some prehabilitation programs employ targeted behavioral interventions to reduce preoperative stress and anxiety including progressive muscle relaxation techniques, cognitive behavioral therapy (CBT), virtual reality experiences, guided imagery, deep breathing, and mindful meditation [3,7,13,93,103-110]. Improvements in traditional surgical outcomes such as incidence of complications or hospital LOS have not been found [77,93,101,103,111-113]. However, beneficial patient-reported effects have included QOL indicators, improved mood and sense of physical well-being, less fatigue and somatic symptoms, and more rapid recovery.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Enhanced recovery after surgery".)


Definition of prehabilitation Prehabilitation refers to interventions that aim to enhance functional capacity and optimize recovery after surgery. These may include nutritional assessment and supplementation, physical exercise programs, efforts to improve cognitive function, smoking cessation, and stress reduction. Multimodal approaches are likely optimal for most patients. (See 'Definition and outcomes' above.)

Outcomes and limitations There is limited evidence that various unimodal or multimodal prehabilitation programs reduce complications and hospital length of stay (LOS) and only for selected patient groups. Substantial heterogeneity among studies has contributed to inconsistent results. (See 'Outcome data and limitations' above.)

Target patient populations

Patient-related factors Many centers use older age and/or frailty as criteria for offering participation in a prehabilitation program. (See 'Older age' above and 'Frailty' above.).

Selected procedures Research on multimodal prehabilitation has focused on patients undergoing major gastrointestinal tract or cardiothoracic surgical procedures. (See 'Selected surgical procedures' above.)

Specific interventions

Nutritional supplementation Malnutrition is common in patients undergoing major surgical procedures. Preoperative assessment of nutritional status (figure 1) and interventions to treat malnutrition are addressed in separate topics:

-(See "Clinical assessment and monitoring of nutrition support in adult surgical patients".)

-(See "Overview of perioperative nutrition support".)

Smoking cessation Smokers should be strongly encouraged to cease smoking for four to eight weeks before surgery to minimize risk of postoperative pulmonary complications, as discussed separately:

-(See "Smoking or vaping: Perioperative management".)

-(See "Overview of smoking cessation management in adults".)

-(See "Behavioral approaches to smoking cessation".)

-(See "Pharmacotherapy for smoking cessation in adults", section on 'Preoperative management'.)

Physical exercise programs We screen patients undergoing major surgery for poor functional capacity based on whether they exhibit frailty, or have decreased mobility, inactivity, or other risk factors such as recent chemo- or radiotherapy. Assessment tests include gait speed, time to complete five chair sit-to-stand repetitions, dominant handgrip strength, and quadriceps femoris thickness. Training programs have included aerobic, resistance, flexibility, balance, and strength exercises, as well as inspiratory muscle training. Results are inconsistent, although decreases in pulmonary morbidity and hospital LOS have been noted in some studies. (See 'Physical exercise programs' above.)

Interventions to improve cognitive function Some prehabilitation programs include preoperative cognitive exercises in their prehabilitation programs, as discussed separately. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Preoperative risk assessment and management'.)

Stress reduction Some prehabilitation programs employ targeted behavioral interventions to reduce preoperative stress and anxiety (eg, progressive muscle relaxation techniques, cognitive behavioral therapy [CBT], virtual reality experiences, guided imagery, deep breathing, mindful meditation). Improvements in some patient-reported quality of life indicators have been noted. (See 'Stress reduction' above.)

  1. Arora RC, Brown CH 4th, Sanjanwala RM, McKelvie R. "NEW" Prehabilitation: A 3-Way Approach to Improve Postoperative Survival and Health-Related Quality of Life in Cardiac Surgery Patients. Can J Cardiol 2018; 34:839.
  2. Wynter-Blyth V, Moorthy K. Prehabilitation: preparing patients for surgery. BMJ 2017; 358:j3702.
  3. Aglio LS, Mezzalira E, Mendez-Pino L, et al. Surgical Prehabilitation: Strategies and Psychological Intervention to Reduce Postoperative Pain and Opioid Use. Anesth Analg 2022; 134:1106.
  4. McCann M, Stamp N, Ngui A, Litton E. Cardiac Prehabilitation. J Cardiothorac Vasc Anesth 2019; 33:2255.
  5. Scheede-Bergdahl C, Minnella EM, Carli F. Multi-modal prehabilitation: addressing the why, when, what, how, who and where next? Anaesthesia 2019; 74 Suppl 1:20.
  6. Carli F, Silver JK, Feldman LS, et al. Surgical Prehabilitation in Patients with Cancer: State-of-the-Science and Recommendations for Future Research from a Panel of Subject Matter Experts. Phys Med Rehabil Clin N Am 2017; 28:49.
  7. Minnella EM, Coca-Martinez M, Carli F. Prehabilitation: the anesthesiologist's role and what is the evidence? Curr Opin Anaesthesiol 2020; 33:411.
  8. Grocott MPW, Edwards M, Mythen MG, Aronson S. Peri-operative care pathways: re-engineering care to achieve the 'triple aim'. Anaesthesia 2019; 74 Suppl 1:90.
  9. Levett DZ, Edwards M, Grocott M, Mythen M. Preparing the patient for surgery to improve outcomes. Best Pract Res Clin Anaesthesiol 2016; 30:145.
  10. Glance LG, Osler TM, Neuman MD. Redesigning surgical decision making for high-risk patients. N Engl J Med 2014; 370:1379.
  11. Moore JA, Conway DH, Thomas N, et al. Impact of a peri-operative quality improvement programme on postoperative pulmonary complications. Anaesthesia 2017; 72:317.
  12. du Toit L, Bougard H, Biccard BM. The developing world of pre-operative optimisation: a systematic review of Cochrane reviews. Anaesthesia 2019; 74:89.
  13. Carli F. Prehabilitation for the Anesthesiologist. Anesthesiology 2020; 133:645.
  14. Wong SP, Zietlow KM, McDonald SR, et al. Delaying Elective Surgery in Geriatric Patients: An Opportunity for Preoperative Optimization. Anesth Analg 2020; 130:e14.
  15. Strous MTA, Janssen-Heijnen MLG, Vogelaar FJ. Impact of therapeutic delay in colorectal cancer on overall survival and cancer recurrence - is there a safe timeframe for prehabilitation? Eur J Surg Oncol 2019; 45:2295.
  16. Trepanier M, Paradis T, Kouyoumdjian A, et al. The Impact of Delays to Definitive Surgical Care on Survival in Colorectal Cancer Patients. J Gastrointest Surg 2020; 24:115.
  17. Curtis NJ, West MA, Salib E, et al. Time from colorectal cancer diagnosis to laparoscopic curative surgery-is there a safe window for prehabilitation? Int J Colorectal Dis 2018; 33:979.
  18. McIsaac DI, Gill M, Boland L, et al. Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews. Br J Anaesth 2022; 128:244.
  19. Mouch CA, Kenney BC, Lorch S, et al. Statewide Prehabilitation Program and Episode Payment in Medicare Beneficiaries. J Am Coll Surg 2020; 230:306.
  20. Gurlit S, Gogol M. Prehabilitation is better than cure. Curr Opin Anaesthesiol 2019; 32:108.
  21. Lyons NB, Bernardi K, Olavarria OA, et al. Prehabilitation among Patients Undergoing Non-Bariatric Abdominal Surgery: A Systematic Review. J Am Coll Surg 2020; 231:480.
  22. Chan SP, Ip KY, Irwin MG. Peri-operative optimisation of elderly and frail patients: a narrative review. Anaesthesia 2019; 74 Suppl 1:80.
  23. Borrell-Vega J, Esparza Gutierrez AG, Humeidan ML. Multimodal Prehabilitation Programs for Older Surgical Patients. Anesthesiol Clin 2019; 37:437.
  24. Norris CM, Close JCT. Prehabilitation for the Frailty Syndrome: Improving Outcomes for Our Most Vulnerable Patients. Anesth Analg 2020; 130:1524.
  25. Nakano M, Nomura Y, Suffredini G, et al. Functional Outcomes of Frail Patients After Cardiac Surgery: An Observational Study. Anesth Analg 2020; 130:1534.
  26. Kim DH, Kim CA, Placide S, et al. Preoperative Frailty Assessment and Outcomes at 6 Months or Later in Older Adults Undergoing Cardiac Surgical Procedures: A Systematic Review. Ann Intern Med 2016; 165:650.
  27. Amabili P, Wozolek A, Noirot I, et al. The Edmonton Frail Scale Improves the Prediction of 30-Day Mortality in Elderly Patients Undergoing Cardiac Surgery: A Prospective Observational Study. J Cardiothorac Vasc Anesth 2019; 33:945.
  28. Nomura Y, Nakano M, Bush B, et al. Observational Study Examining the Association of Baseline Frailty and Postcardiac Surgery Delirium and Cognitive Change. Anesth Analg 2019; 129:507.
  29. Delaney PK, Brohan J, Bhakta P, et al. Preoperative frailty assessment predicts inferior quality of life outcomes up to one year after cardiac surgery: A prospective observational cohort study. J Clin Anesth 2020; 67:109939.
  30. Carli F, Gillis C, Scheede-Bergdahl C. Promoting a culture of prehabilitation for the surgical cancer patient. Acta Oncol 2017; 56:128.
  31. Milder DA, Pillinger NL, Kam PCA. The role of prehabilitation in frail surgical patients: A systematic review. Acta Anaesthesiol Scand 2018; 62:1356.
  32. McIsaac DI, Jen T, Mookerji N, et al. Interventions to improve the outcomes of frail people having surgery: A systematic review. PLoS One 2017; 12:e0190071.
  33. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016; 16:157.
  34. McIsaac DI, Aucoin SD, Bryson GL, et al. Complications as a Mediator of the Perioperative Frailty-Mortality Association. Anesthesiology 2021; 134:577.
  35. Koh LY, Hwang NC. Frailty in Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:521.
  36. Barberan-Garcia A, Ubré M, Roca J, et al. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. Ann Surg 2018; 267:50.
  37. Trépanier M, Minnella EM, Paradis T, et al. Improved Disease-free Survival After Prehabilitation for Colorectal Cancer Surgery. Ann Surg 2019; 270:493.
  38. Carli F, Bousquet-Dion G, Awasthi R, et al. Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer: A Randomized Clinical Trial. JAMA Surg 2020; 155:233.
  39. Nakajima H, Yokoyama Y, Inoue T, et al. Clinical Benefit of Preoperative Exercise and Nutritional Therapy for Patients Undergoing Hepato-Pancreato-Biliary Surgeries for Malignancy. Ann Surg Oncol 2019; 26:264.
  40. Janssen TL, Steyerberg EW, Langenberg JCM, et al. Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study. PLoS One 2019; 14:e0218152.
  41. Howard R, Yin YS, McCandless L, et al. Taking Control of Your Surgery: Impact of a Prehabilitation Program on Major Abdominal Surgery. J Am Coll Surg 2019; 228:72.
  42. Barberan-Garcia A, Ubre M, Pascual-Argente N, et al. Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial. Br J Anaesth 2019; 123:450.
  43. van Rooijen SJ, Molenaar CJL, Schep G, et al. Making Patients Fit for Surgery: Introducing a Four Pillar Multimodal Prehabilitation Program in Colorectal Cancer. Am J Phys Med Rehabil 2019; 98:888.
  44. Minnella EM, Bousquet-Dion G, Awasthi R, et al. Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience. Acta Oncol 2017; 56:295.
  45. Minnella EM, Awasthi R, Loiselle SE, et al. Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial. JAMA Surg 2018; 153:1081.
  46. Minnella EM, Awasthi R, Bousquet-Dion G, et al. Multimodal Prehabilitation to Enhance Functional Capacity Following Radical Cystectomy: A Randomized Controlled Trial. Eur Urol Focus 2021; 7:132.
  47. Liu Z, Qiu T, Pei L, et al. Two-Week Multimodal Prehabilitation Program Improves Perioperative Functional Capability in Patients Undergoing Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial. Anesth Analg 2020; 131:840.
  48. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg 2019; 154:755.
  49. Stoppe C, Goetzenich A, Whitman G, et al. Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery. Crit Care 2017; 21:131.
  50. Lopez-Delgado JC, Muñoz-Del Rio G, Flordelís-Lasierra JL, Putzu A. Nutrition in Adult Cardiac Surgery: Preoperative Evaluation, Management in the Postoperative Period, and Clinical Implications for Outcomes. J Cardiothorac Vasc Anesth 2019; 33:3143.
  51. Engelman DT, Adams DH, Byrne JG, et al. Impact of body mass index and albumin on morbidity and mortality after cardiac surgery. J Thorac Cardiovasc Surg 1999; 118:866.
  52. Velayati A, Vahdat Shariatpanahi M, Dehghan S, et al. Vitamin D and Postoperative Delirium After Coronary Artery Bypass Grafting: A Prospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 34:1774.
  53. Sandhu MS, Akowuah EF. Does prehabilitation improve outcomes in cardiac surgical patients? Interact Cardiovasc Thorac Surg 2019; 29:608.
  54. Junejo MA, Mason JM, Sheen AJ, et al. Cardiopulmonary exercise testing for preoperative risk assessment before hepatic resection. Br J Surg 2012; 99:1097.
  55. Older P, Smith R, Courtney P, Hone R. Preoperative evaluation of cardiac failure and ischemia in elderly patients by cardiopulmonary exercise testing. Chest 1993; 104:701.
  56. Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest 1999; 116:355.
  57. Tew GA, Ayyash R, Durrand J, Danjoux GR. Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery. Anaesthesia 2018; 73:750.
  58. Afilalo J, Kim S, O'Brien S, et al. Gait Speed and Operative Mortality in Older Adults Following Cardiac Surgery. JAMA Cardiol 2016; 1:314.
  59. 30-Second Chair Stand. Centers for Disease Control and Prevention: National Center for Injury Prevention and Control. (Accessed on November 02, 2022).
  60. Kilgour RD, Vigano A, Trutschnigg B, et al. Handgrip strength predicts survival and is associated with markers of clinical and functional outcomes in advanced cancer patients. Support Care Cancer 2013; 21:3261.
  61. Canales C, Mazor E, Coy H, et al. Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study. Anesthesiology 2022; 136:268.
  62. Brunelli A, Xiumé F, Refai M, et al. Peak oxygen consumption measured during the stair-climbing test in lung resection candidates. Respiration 2010; 80:207.
  63. Fennelly J, Potter L, Pompili C, Brunelli A. Performance in the shuttle walk test is associated with cardiopulmonary complications after lung resections. J Thorac Dis 2017; 9:789.
  64. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166:111.
  65. Pecorelli N, Fiore JF Jr, Gillis C, et al. The six-minute walk test as a measure of postoperative recovery after colorectal resection: further examination of its measurement properties. Surg Endosc 2016; 30:2199.
  66. Minnella EM, Awasthi R, Gillis C, et al. Patients with poor baseline walking capacity are most likely to improve their functional status with multimodal prehabilitation. Surgery 2016; 160:1070.
  67. Wijeysundera DN, Pearse RM, Shulman MA, et al. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 2018; 391:2631.
  68. American Thoracic Society, American College of Chest Physicians. ATS/ACCP Statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med 2003; 167:211.
  69. Richardson K, Levett DZH, Jack S, Grocott MPW. Fit for surgery? Perspectives on preoperative exercise testing and training. Br J Anaesth 2017; 119:i34.
  70. Barbalho-Moulim MC, Miguel GP, Forti EM, et al. Effects of preoperative inspiratory muscle training in obese women undergoing open bariatric surgery: respiratory muscle strength, lung volumes, and diaphragmatic excursion. Clinics (Sao Paulo) 2011; 66:1721.
  71. Lee AHY, Snowden CP, Hopkinson NS, Pattinson KTS. Pre-operative optimisation for chronic obstructive pulmonary disease: a narrative review. Anaesthesia 2021; 76:681.
  72. Weiner P, Man A, Weiner M, et al. The effect of incentive spirometry and inspiratory muscle training on pulmonary function after lung resection. J Thorac Cardiovasc Surg 1997; 113:552.
  73. Valkenet K, Trappenburg JCA, Ruurda JP, et al. Multicentre randomized clinical trial of inspiratory muscle training versus usual care before surgery for oesophageal cancer. Br J Surg 2018; 105:502.
  74. Guinan EM, Forde C, O'Neill L, et al. Effect of preoperative inspiratory muscle training on physical functioning following esophagectomy. Dis Esophagus 2019; 32.
  75. Rosero ID, Ramírez-Vélez R, Lucia A, et al. Systematic Review and Meta-Analysis of Randomized, Controlled Trials on Preoperative Physical Exercise Interventions in Patients with Non-Small-Cell Lung Cancer. Cancers (Basel) 2019; 11.
  76. Sebio Garcia R, Yáñez Brage MI, Giménez Moolhuyzen E, et al. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2016; 23:486.
  77. Treanor C, Kyaw T, Donnelly M. An international review and meta-analysis of prehabilitation compared to usual care for cancer patients. J Cancer Surviv 2018; 12:64.
  78. Soares SM, Nucci LB, da Silva MM, Campacci TC. Pulmonary function and physical performance outcomes with preoperative physical therapy in upper abdominal surgery: a randomized controlled trial. Clin Rehabil 2013; 27:616.
  79. Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018; 360:j5916.
  80. Katsura M, Kuriyama A, Takeshima T, et al. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Rev 2015; :CD010356.
  81. Heger P, Probst P, Wiskemann J, et al. A Systematic Review and Meta-analysis of Physical Exercise Prehabilitation in Major Abdominal Surgery (PROSPERO 2017 CRD42017080366). J Gastrointest Surg 2020; 24:1375.
  82. Hughes MJ, Hackney RJ, Lamb PJ, et al. Prehabilitation Before Major Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2019; 43:1661.
  83. Piraux E, Caty G, Reychler G. Effects of preoperative combined aerobic and resistance exercise training in cancer patients undergoing tumour resection surgery: A systematic review of randomised trials. Surg Oncol 2018; 27:584.
  84. Hijazi Y, Gondal U, Aziz O. A systematic review of prehabilitation programs in abdominal cancer surgery. Int J Surg 2017; 39:156.
  85. Granger C, Cavalheri V. Preoperative exercise training for people with non-small cell lung cancer. Cochrane Database Syst Rev 2022; 9:CD012020.
  86. Steffens D, Beckenkamp PR, Hancock M, et al. Preoperative exercise halves the postoperative complication rate in patients with lung cancer: a systematic review of the effect of exercise on complications, length of stay and quality of life in patients with cancer. Br J Sports Med 2018; 52:344.
  87. Drudi LM, Tat J, Ades M, et al. Preoperative Exercise Rehabilitation in Cardiac and Vascular Interventions. J Surg Res 2019; 237:3.
  88. Epker J, Block AR. Psychological screening before spine surgery: avoiding failed surgery syndrome. Psychol Inj Law 2014; 7:317.
  89. Strøm J, Bjerrum MB, Nielsen CV, et al. Anxiety and depression in spine surgery-a systematic integrative review. Spine J 2018; 18:1272.
  90. Bates A, West MA, Jack S. Framework for prehabilitation services. Br J Surg 2020; 107:e11.
  91. Wilson CJ, Mitchelson AJ, Tzeng TH, et al. Caring for the surgically anxious patient: a review of the interventions and a guide to optimizing surgical outcomes. Am J Surg 2016; 212:151.
  92. Levett DZH, Grimmett C. Psychological factors, prehabilitation and surgical outcomes: evidence and future directions. Anaesthesia 2019; 74 Suppl 1:36.
  93. Powell R, Scott NW, Manyande A, et al. Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database Syst Rev 2016; :CD008646.
  94. Shuldham C. A review of the impact of pre-operative education on recovery from surgery. Int J Nurs Stud 1999; 36:171.
  95. Edwards PK, Mears SC, Lowry Barnes C. Preoperative Education for Hip and Knee Replacement: Never Stop Learning. Curr Rev Musculoskelet Med 2017; 10:356.
  96. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2011; :CD007635.
  97. Forsmo HM, Pfeffer F, Rasdal A, et al. Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal surgery. Int J Surg 2016; 36:121.
  98. Nixon DC, Schafer KA, Cusworth B, et al. Preoperative Anxiety Effect on Patient-Reported Outcomes Following Foot and Ankle Surgery. Foot Ankle Int 2019; 40:1007.
  99. Rosenberger PH, Jokl P, Ickovics J. Psychosocial factors and surgical outcomes: an evidence-based literature review. J Am Acad Orthop Surg 2006; 14:397.
  100. Ip HY, Abrishami A, Peng PW, et al. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology 2009; 111:657.
  101. Mavros MN, Athanasiou S, Gkegkes ID, et al. Do psychological variables affect early surgical recovery? PLoS One 2011; 6:e20306.
  102. Williams JB, Alexander KP, Morin JF, et al. Preoperative anxiety as a predictor of mortality and major morbidity in patients aged >70 years undergoing cardiac surgery. Am J Cardiol 2013; 111:137.
  103. Parrish JM, Jenkins NW, Parrish MS, et al. The influence of cognitive behavioral therapy on lumbar spine surgery outcomes: a systematic review and meta-analysis. Eur Spine J 2021; 30:1365.
  104. Paul L, van der Heiden C, van Hoeken D, et al. Cognitive Behavioral Therapy Versus Usual Care Before Bariatric Surgery: One-Year Follow-Up Results of a Randomized Controlled Trial. Obes Surg 2021; 31:970.
  105. Hanley AW, Gililland J, Erickson J, et al. Brief preoperative mind-body therapies for total joint arthroplasty patients: a randomized controlled trial. Pain 2021; 162:1749.
  106. Preparing for Surgery — Mind, Body and Spirit. University of California Irvine.
  107. Baytar Ç, Bollucuoğlu K. Effect of virtual reality on preoperative anxiety in patients undergoing septorhinoplasty. Braz J Anesthesiol 2021.
  108. Yang JH, Ryu JJ, Nam E, et al. Effects of Preoperative Virtual Reality Magnetic Resonance Imaging on Preoperative Anxiety in Patients Undergoing Arthroscopic Knee Surgery: A Randomized Controlled Study. Arthroscopy 2019; 35:2394.
  109. Miró J, Raich RM. Effects of a brief and economical intervention in preparing patients for surgery: does coping style matter? Pain 1999; 83:471.
  110. Preparing for Surgery — Mind, Body and Spirit. UCI Health. (Accessed on November 17, 2022).
  111. Freeman SC, Scott NW, Powell R, et al. Component network meta-analysis identifies the most effective components of psychological preparation for adults undergoing surgery under general anesthesia. J Clin Epidemiol 2018; 98:105.
  112. Tsimopoulou I, Pasquali S, Howard R, et al. Psychological Prehabilitation Before Cancer Surgery: A Systematic Review. Ann Surg Oncol 2015; 22:4117.
  113. Powell R, Scott NW, Manyande A, et al. Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database Syst Rev 2016; 1:CD008646.
Topic 120301 Version 11.0