Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews
Open accessAbstract
BACKGROUND The certainty that prehabilitation improves postoperative outcomes is not clear. The objective of this umbrella review (i.e. systematic review of systematic reviews) was to synthesise and evaluate evidence for prehabilitation in improving health, experience, or cost outcomes. METHODS We performed an umbrella review of prehabilitation systematic reviews. MEDLINE, Embase, Cochrane, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Joanna Briggs Institute's database, and Web of Science were searched (inception to October 20, 2020). We included all systematic reviews of elective, adult patients undergoing surgery and exposed to a prehabilitation intervention, where health, experience, or cost outcomes were reported. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation. Primary syntheses of any prehabilitation were stratified by surgery type. RESULTS From 1412 titles, 55 systematic reviews were included. For patients with cancer undergoing surgery who participate in any prehabilitation, moderate certainty evidence supports improvements in functional recovery. Low to very low certainty evidence supports reductions in complications (mixed, cardiovascular, and cancer surgery), non-home discharge (orthopaedic surgery), and length of stay (mixed, cardiovascular, and cancer surgery). There was low to very low certainty evidence that exercise prehabilitation reduces the risk of complications, non-home discharge, and length of stay. There was low to very low certainty evidence that nutritional prehabilitation reduces risk of complications, mortality, and length of stay. CONCLUSIONS Low certainty evidence suggests that prehabilitation may improve postoperative outcomes. Future low risk of bias, randomised trials, synthesised using recommended standards, are required to inform practice. Optimal patient selection, intervention design, and intervention duration must also be determined.
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Most available systematic reviews of prehabilitation are rated as low quality and have not included patient and public perspectives.
“most available systematic reviews are rated as low quality1 16 and have not included patient and public perspectives.1”
Reviews typically estimate one effect for either a single prehabilitation component or pool heterogeneous interventions together.
“Reviews typically estimate one effect for either a single prehabilitation component (eg, exercise only) or pool heterogeneous interventions together.1 14 17 18”
The overall certainty of benefit of prehabilitation is low.
“However, the overall certainty of benefit is low for several reasons.1”
Many reviews, including an umbrella review of 55 unique systematic reviews, suggest that prehabilitation may have protective effects in reducing complications, length of stay, and improving functional recovery.
“Many reviews,11 12 13 14 including an umbrella review that synthesised 55 unique systematic reviews,1 suggest that prehabilitation may have protective effects in reducing complications, length of stay, and improving functional recovery.”
Leading contributors to the uncertainty about prehabilitation components are a lack of rigour in conduct of existing reviews, use of quantitative methods that do not align with the multicomponent nature of prehabilitation interventions, and risk of bias at the trial level.
“While this uncertainty is multifactorial, leading contributors are a lack of rigour in conduct of existing reviews, use of quantitative methods that do not align with the multicomponent nature of prehabilitation interventions, and risk of bias at the trial level.1”
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Self-citationPrehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis
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ESPEN guideline on clinical nutrition in surgery – Update 2025
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Prehabilitation: high-quality evidence is still required
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Perioperative care for older people
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Enhanced Recovery After Surgery (ERAS) in Surgical Oncology
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Outcomes reported in randomised trials of surgical prehabilitation: a scoping review
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Home-Based Prehabilitation for Older Surgical Patients With Frailty
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Self-citationPrehabilitation: Who can benefit?
Coca-Martínez, M., & Carli, F. (2023) · European Journal of Surgical Oncology · doi:10.1016/j.ejso.2023.07.005 · Cited by 31 · see citing works
Self-citationReporting quality of randomized controlled trials in prehabilitation: a scoping review
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Self-citationThe inequalities and challenges of prehabilitation before cancer surgery: a narrative review
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Nutritional Prehabilitation in Patients Undergoing Abdominal Surgery—A Narrative Review
Wobith, M., Hill, A., Fischer, M., & Weimann, A. (2024) · Nutrients · doi:10.3390/nu16142235 · Cited by 26 · see citing works
Impact of preoperative uni- or multimodal prehabilitation on postoperative morbidity: meta-analysis
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Transitional Pain Service: An Update
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ESPEN Guidelines on Clinical nutrition in surgery - Special issues to be revisited
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Self-citationPerioperative Optimization of the Cardiac Surgical Patient
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Prehabilitation programs – a systematic review of the economic evidence
Ke, Y., Ng, R. R. G., Elangovan, S., Leong, Y. H., Goh, Z. H., Graves, N., Shannon, N. B., & Abdullah, H. R. (2023) · Frontiers in Medicine · doi:10.3389/fmed.2023.1281843 · Cited by 19 · see citing works
Demystifying Malnutrition to Improve Nutrition Screening and Assessment in Oncology
Corriveau, J., Alavifard, D., & Gillis, C. (2022) · Seminars in Oncology Nursing · doi:10.1016/j.soncn.2022.151336 · Cited by 19 · see citing works
Self-citationImmune Modulation by Personalized vs Standard Prehabilitation Before Major Surgery
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Preoperative Optimization for Abdominal Wall Reconstruction
Ramaswamy, A. (2023) · Surgical Clinics of North America · doi:10.1016/j.suc.2023.04.022 · Cited by 17 · see citing works
Preoperative exercise and prehabilitation
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The effect of multimodal prehabilitation on postoperative outcomes in lung cancer surgery
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Self-citationTailoring prehabilitation to address the multifactorial nature of functional capacity for surgery
Gillis, C., Coca-Martínez, M., & Mina, D. S. (2022) · Journal of Human Nutrition and Dietetics · doi:10.1111/jhn.13050 · Cited by 17 · see citing works
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Shen, C., Gu, L., Li, N., Wang, R., Yang, X., & Chu, Z. (2023) · British Journal of Health Psychology · doi:10.1111/bjhp.12705 · Cited by 15 · see citing works
Gouez, M., Raynard, B., Marijnen, P., Hen, N. H. H., & Fervers, B. (2022) · Bulletin du Cancer · doi:10.1016/j.bulcan.2022.02.008 · Cited by 14 · see citing works
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Self-citationPostoperative Nutrition Management: Who Needs What?
Wobith, M., & Weimann, A. (2022) · Visceral Medicine · doi:10.1159/000526665 · Cited by 14 · see citing works
Development and expansion of a pediatric transitional pain service to prevent complex chronic pain
Isaac, L., Rosenbloom, B. N., Tyrrell, J., Ruskin, D. A., & Birnie, K. A. (2023) · Frontiers in Pain Research · doi:10.3389/fpain.2023.1173675 · Cited by 13 · see citing works
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Effectiveness of prehabilitation for patients undergoing complex abdominal wall surgery
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Self-citationThe Role of Exercise Before Cancer Treatment
Denehy, L., & Edbrooke, L. (2022) · Seminars in Oncology Nursing · doi:10.1016/j.soncn.2022.151330 · Cited by 13 · see citing works
Prehabilitation for general surgery: a systematic review of randomized controlled trials
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Prehabilitation: Impact on Postoperative Outcomes
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Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant
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Self-citationPrehabilitation exercise programs for patients undergoing cancer surgery, does one size fit all?
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Prehabilitation provision and practice in the UK: a freedom of information survey
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Prehabilitation Practices for Patients Undergoing Cancer Surgery—An International Survey
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The Cost-Effectiveness of Early High-Acuity Postoperative Care for Medium-Risk Surgical Patients
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Optimisation of the patient having oncological surgical through prehabilitation: a narrative review
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Future Perspectives on Prehabilitation Interventions in Cancer Surgery
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Transitional Pain Service: Optimizing Complex Surgical Patients
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Preoperative optimization and rapid discharge after coronary artery bypass grafting
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Prehabilitation before elective coronary artery bypass grafting surgery: a scoping review
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Evaluation of postoperative results after a presurgical optimisation programme
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Supervised prehabilitation in patients scheduled for spinal surgery – a scoping review
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Perioperative care of the geriatric patient
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Editorial: Personalised multimodal prehabilitation in cancer
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Prehabilitation and Inflammation
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- Authors
- McIsaac, D. I., Gill, M., Boland, L., Hutton, B., Branje, K., Shaw, J., Grudzinski, A. L., Barone, N., Gillis, C., Akhtar, S., Atkins, M., Aucoin, S., Auer, R., Basualdo-Hammond, C., Beaule, P., Brindle, M., Bittner, H., Bryson, G., Carli, F., Eskander, A., Fata, P., Fergusson, D., Fiore, J., Forster, A., Gillam, M., Gramlich, L., Holroyd-Leduc, J., Jackson, T., Jacobsohn, E., Khadaroo, R., Lalu, M., Love, C., Martel, G., McCartney, C., McKeen, D., Meliambro, A., Moloo, H., Moore, R., Muscedere, J., Nantel, J., Poitras, S., Scheede-Bergdahl, C., Taljaard, M., Wallace, T., & Wijeysundera, D.
- Affiliations
- University of Ottawa (CA)
- University of Calgary (CA)
- Ottawa Hospital Research Institute (CA)
- McGill University (CA)
- Yale University (US)
- Alberta Health Services (CA)
- Ottawa Hospital (CA)
- Sunnybrook Hospital (CA)
- University of Alberta (CA)
- University Health Network (CA)
- University of Manitoba (CA)
- Memorial University of Newfoundland (CA)
- Carleton University (CA)
- Kingston General Hospital (CA)
- University of British Columbia (CA)
- St. Michael's Hospital (CA)
- Corresponding author
- McIsaac, Daniel I.
- Akhtar, Shamsuddin
- Atkins, Marlis
- Aucoin, Sylvie
- Auer, Rebecca
- Brindle, Mary
- Bittner, Honorata
- Bryson, Gregory
- Carli, Franco
- Eskander, Antoine
- Fata, Paola
- Fergusson, Dean
- Fiore, Julio
- Forster, Alan
- Gillam, Melani
- Gramlich, Leah
- Holroyd-Leduc, Jayna
- Jackson, Timothy
- Jacobsohn, Eric
- Khadaroo, Rachel
- Lalu, Manoj
- Love, Cameron
- Martel, Guillaume
- McCartney, Colin
- McKeen, Dolores
- Meliambro, Amanda
- Moloo, Husein
- Moore, Ronald
- Muscedere, John
- Nantel, Julie
- Taljaard, Monica
- Wallace, Tom
- Wijeysundera, Duminda
- ORCID
- McIsaac, Daniel I.
- Boland, Laura
- Hutton, Brian
- Branje, Karina
- Shaw, Julia
- Grudzinski, Alexa L.
- Barone, Natasha
- Gillis, Chelsia
- Akhtar, Shamsuddin
- Aucoin, Sylvie
- Auer, Rebecca
- Brindle, Mary
- Bryson, Gregory
- Carli, Franco
- Eskander, Antoine
- Fata, Paola
- Fergusson, Dean
- Fiore, Julio
- Forster, Alan
- Gillam, Melani
- Gramlich, Leah
- Holroyd-Leduc, Jayna
- Jackson, Timothy
- Jacobsohn, Eric
- Khadaroo, Rachel
- Lalu, Manoj
- Martel, Guillaume
- McCartney, Colin
- McKeen, Dolores
- Moloo, Husein
- Moore, Ronald
- Muscedere, John
- Nantel, Julie
- Taljaard, Monica
- Wallace, Tom
- Wijeysundera, Duminda
- Venue
- British Journal of Anaesthesia
- Publisher
- Elsevier BV
- Published
- 2022-02
- Volume
- 128
- Issue
- 2
- Pages
- 244-257
- ISSN
- 0007-0912 (ISSN-L)
- OpenAlex
- W4200413066
- Semantic Scholar
- ea56e19fb012b851f938df9f748371f43e1fef37
- Cited by
- 312
- References
- 98
- Citations by year
- 2026: 69 · 2025: 82 · 2024: 78 · 2023: 44 · 2022: 39
- FWCI
- 9.70
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- British Journal of Anaesthesia (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Ottawa Hospital Anesthesia Alternate Funds Association
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Medicine › Surgery › Enhanced Recovery After Surgery
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
- Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
- Keywords
- prehabilitation, elective surgery, postoperative outcomes, cancer surgery, exercise prehabilitation, nutritional prehabilitation, postoperative complications, length of hospital stay, functional recovery, non-home discharge, cardiovascular surgery, orthopedic surgery, patient selection
- MeSH terms
- Systematic Reviews as Topic, Preoperative Exercise, Adult, Humans, Length of Stay, Postoperative Complications, Randomized Controlled Trials as Topic, Elective Surgical Procedures, Patient Selection, Nutrition Therapy
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