Prehabilitation – what the evidence shows, and how to deliver it
For primary care physicians, specialist nurses, and allied health professionals supporting patients before major surgery. Companion to our patient-facing guide at prehabforsurgery.com/what-is-prehab.
This article summarises the evidence base for prehabilitation before major surgery and offers a practical framework for delivering it from primary care, with or without an established hospital prehab pathway. It is intended as a working resource for clinicians who care for patients in the weeks between the decision to operate and the operation itself.
Definition and scope
Prehabilitation – prehab – is the structured, multimodal optimisation of a patient’s physical, nutritional, psychological, medical, lifestyle, and social state in the period between the decision to operate and the operation. The aim is to enhance physiological reserve and functional capacity such that the patient tolerates the surgical insult better, develops fewer complications, recovers function more rapidly, and returns to baseline (or above baseline) activity sooner.
Modern prehab is distinct from historical pre-operative “fitness optimisation” advice in three ways: it is multimodal (not exercise-alone), it is structured with explicit goals and follow-up, and it is increasingly supported by an evidence base – including randomised trials, meta-analyses, and guideline endorsement from the ERAS Society, the Royal College of Anaesthetists (UK), Macmillan Cancer Support, and analogous bodies internationally [1-4].
The evidence base – what we know, and what we don’t
The prehab evidence base has matured substantially since 2010. The summary position, recognising that it remains an active field of research:
Strong evidence
• Multimodal prehab reduces post-operative complications, particularly pulmonary complications, in patients undergoing major abdominal surgery [5-7].
• Inspiratory muscle training and structured exercise reduce post-operative pulmonary complications in cardiac and major thoracic surgery [8, 9].
• Preoperative smoking cessation, even for as little as 4 weeks before surgery, reduces wound complications and post-operative pulmonary complications [10, 11].
• Preoperative correction of iron-deficiency anaemia reduces transfusion requirements and improves length of stay in some surgical populations [12], though large RCT evidence (PREVENTT) on intravenous iron in elective abdominal surgery has yielded mixed primary-endpoint results [13] – interpretation requires care.
• Structured prehab is associated with shortened hospital length of stay across most major surgical populations studied [5, 14].
Moderate evidence
• Psychological prehab (relaxation, anxiety management, mindfulness-based interventions) reduces preoperative anxiety and improves patient-reported quality of recovery [15, 16]. Effect on hard outcomes is less robustly demonstrated.
• Nutritional prehab, particularly protein supplementation and correction of micronutrient deficiencies in malnourished patients, reduces complications [17, 18]. Effect in nutritionally replete patients is smaller.
• Mortality benefit is biologically plausible and demonstrated in some studies of high-risk surgery (major HPB, cardiac, oesophageal), but underpowered in most trials [5, 7].
Uncertain or evolving evidence
• Optimal duration of prehab (the marginal value of 2 vs 4 vs 8 weeks of intervention) remains uncertain and varies by domain.
• Cost-effectiveness in different healthcare systems is incompletely characterised but broadly favourable in modelling studies [19].
• Effect in very elderly (>85), palliative-intent, and neoadjuvant-treated patients is incompletely characterised and likely heterogeneous.
• The relative contribution of each of the six pillars when delivered as a bundle is difficult to disentangle from existing trial designs – most trials test bundled interventions.
The PROOF trial (Barberan-Garcia et al., 2018) is the most-cited RCT, demonstrating a marked reduction in post-operative complications in high-risk patients undergoing elective major abdominal surgery randomised to a structured personalised prehab programme vs standard care [5]. The Michigan Surgical and Health Optimization Program (MSHOP) provides large-scale real-world implementation data, with cost-savings demonstrated alongside clinical benefit [20].
The six pillars – clinical content
Pillar 1 – Physical conditioning
Aerobic and resistance training across 4-8 weeks. Suggested target: 30-45 minutes of moderate-intensity aerobic exercise (50-70% age-predicted maximum heart rate) most days, plus resistance training 2-3 times weekly. Cardiopulmonary exercise testing (CPET) where available provides individualised intensity targets; in its absence, conversational-pace effort is a reasonable proxy.
Evidence: structured exercise prehab improves functional capacity, reduces complications, and shortens length of stay across multiple major surgical populations [5, 9, 21].
Practical referral targets: physiotherapy, community exercise programmes, structured cardiac rehabilitation pathways where eligible. Patients with significant mobility limitations benefit from adapted programmes – exclusion from prehab on the basis of frailty is the opposite of the evidence; frail patients gain the largest absolute benefit [22].
Pillar 2 – Nutritional optimisation
Target intake: 1.2-1.5 g/kg/day of protein (higher than general adult recommendation), spread across meals. Oral nutritional supplementation appropriate for patients with weight loss >5% in the preceding 6 months or BMI <20 kg/m² or other markers of malnutrition. ESPEN guidance is the standard reference [17].
Specific interventions worth considering:
• Correction of iron-deficiency anaemia – oral iron if mild and time permits; intravenous iron if severe or oral intolerance. Interpretation of the PREVENTT trial [13] should be nuanced: primary endpoint negative, but secondary endpoints and selected populations may benefit. Decision should be individualised.
• Vitamin D, B12, and folate replacement where deficient.
• Preoperative carbohydrate loading per ERAS protocols where surgical pathway adopts ERAS [3].
• Alcohol reduction or cessation – meaningful improvements in immune function, coagulation, and metabolic state within 4 weeks of cessation [23].
Referral to a dietitian is high-yield where available. In its absence, a structured patient handout (such as the foundational article on this site) is a reasonable alternative for the average-risk patient.
Pillar 3 – Psychological preparation
Often the least-delivered pillar in practice and arguably the most undervalued. Evidence supports reduced preoperative anxiety and improved quality of recovery from brief structured interventions including cognitive-behavioural anxiety management, mindfulness-based stress reduction, and psycho-education [15, 16].
Active management of pre-existing anxiety or depression is warranted. Adjustment of existing antidepressant medication, brief cognitive behavioural therapy, and structured psychological support all have a place. The combination of impending major surgery and untreated mental health symptoms is a high-risk profile for both perioperative complications and longer-term recovery [24].
Sleep hygiene, mindfulness practice, and structured information provision are simple interventions that primary care can advise without specialist referral.
Pillar 4 – Medical optimisation
The core primary-care contribution to prehab. Specific items:
• Diabetes – aim for HbA1c <69 mmol/mol (<8.5%) where possible before major elective surgery. Higher HbA1c associated with increased surgical site infection and adverse cardiac outcomes [25].
• Hypertension – optimise where uncontrolled. Avoid surgery on the day with systolic >180 / diastolic >110 mmHg, per most peri-operative guidance.
• Anaemia – investigate and treat per local pathways. Target Hb ≥130 g/L pre-operatively where feasible.
• COPD – optimise inhaler regimen, treat any active exacerbation, refer to respiratory if uncontrolled.
• OSA – screen with STOP-Bang if not already diagnosed; ensure CPAP-adherent in confirmed cases.
• Cardiac disease – known IHD, valvular disease, or heart failure warrants cardiology input in pre-operative planning; do not assume the surgical team will arrange this.
• Medication review – formal review of every medication and supplement, with deprescribing or adjustment where appropriate. Particular attention to antithrombotics, antiplatelets, ACE inhibitors and ARBs, SGLT2 inhibitors, GLP-1 agonists, oral hypoglycaemics, herbal supplements, and immunosuppressants.
A pre-operative review appointment specifically scheduled for this purpose – not a routine check – is higher-yield than opportunistic optimisation [26].
Pillar 5 – Smoking, alcohol, and substance use
Smoking cessation is the single highest-impact perioperative intervention available [10, 27]. Benefits accrue rapidly: improved tissue oxygenation within days; reduced wound and pulmonary complications with 4+ weeks of cessation. Nicotine replacement therapy, varenicline, and structured cessation counselling all have evidence; combinations outperform individual modalities. Vaping is not an evidence-based substitute and is best stopped where possible.
Alcohol – heavy intake (>14 units/week, with sex-specific thresholds) increases perioperative complications including bleeding, infection, and delirium [23]. Reduction over 4 weeks improves outcomes; cessation in patients with dependence requires supervised withdrawal.
Cannabis use is increasingly prevalent globally and affects anaesthetic dose requirements and post-operative analgesia [28]. Honest disclosure to the anaesthetic team is essential; cessation for 2+ weeks pre-operatively is recommended where possible.
Pillar 6 – Social and practical preparation
The least medically-flavoured pillar, but a meaningful determinant of post-discharge recovery. Older patients living alone, patients without informal carer support, patients with low health literacy, and patients with insecure housing or financial stress are all at elevated risk of post-discharge adverse outcomes including readmission [29].
Practical primary-care contributions:
• Identify the carer / next-of-kin and engage them in the planning
• Refer to social work or occupational therapy where home environment is a concern
• Discuss advance care planning, particularly for high-risk procedures or elderly patients
• Connect the patient to local patient support organisations relevant to their condition
• Provide written patient information – the foundational article on this site is one resource, alongside specialty-specific information from the surgical team and relevant patient charities
For family members and caregivers, see our dedicated companion article.
Risk stratification – who needs prehab most
Whilst every patient facing major elective surgery benefits to some degree, the absolute benefit is greatest in:
• Low cardiorespiratory fitness – CPET VO₂ peak <15 mL/kg/min, anaerobic threshold <11 mL/kg/min, or inability to climb 2 flights of stairs without dyspnoea
• Frailty – Clinical Frailty Scale ≥4, or formal frailty assessment scores in the at-risk range (Edmonton Frail Scale, Fried criteria, Rockwood index)
• Sarcopenia – clinically identified (e.g. low handgrip strength, low gait speed) or radiologically (psoas muscle index on staging imaging)
• Multimorbidity, particularly poorly-controlled diabetes, anaemia, COPD, or untreated OSA
• Active smoking or hazardous alcohol use
• Significant pre-operative anxiety, depression, or sleep disturbance
• Age >70 with any of the above
• Major surgery – defined here as anticipated length of stay >3 days, anticipated significant blood loss, anticipated ICU/HDU admission, or any HPB, oesophageal, major cardiac, or major vascular procedure
The Duke Activity Status Index, METs-based screening, and CPET (where available) all provide objective fitness assessment. The Risk Analysis Index and Edmonton Frail Scale provide validated frailty screening. In primary care, simple clinical observation (gait speed, ability to manage stairs, recent functional decline) is a reasonable substitute when formal tools are unavailable.
Delivery models – with or without an established service
Established prehab pathway
Refer. Most established pathways accept primary care referrals directly or via the surgical team. Provide a brief summary of the patient’s comorbidities, baseline function, social context, and anticipated surgery. Continue your own optimisation work in parallel – the prehab service does not absolve primary care of the medical-optimisation pillar.
No formal prehab pathway available
Most healthcare systems are still in this position. A workable primary-care prehab approach in the absence of a formal service:
1. Schedule a dedicated pre-operative review appointment (not a general check-up).
2. Risk-stratify using the criteria above. Document.
3. Address each pillar systematically:
• Physical: written exercise advice (daily walking + simple resistance); refer to physiotherapy if mobility-limited.
• Nutritional: assess weight trajectory and intake; prescribe oral nutritional supplements if indicated; refer to dietitian if available.
• Psychological: screen for anxiety/depression (PHQ-9, GAD-7); offer brief intervention or refer.
• Medical: formal medication review; optimise chronic conditions; arrange any needed bloods (FBC, U&E, HbA1c, ferritin, B12, folate, vitamin D); correct deficiencies.
• Lifestyle: smoking cessation (offer NRT or varenicline + counselling); alcohol reduction; cannabis discussion.
• Social/practical: assess home environment, carer availability, transport, financial stress; refer to social work / OT if concerns.
4. Provide written patient information (this site is one resource).
5. Document the prehab plan in the patient’s record; share with the surgical team.
6. Schedule a brief follow-up review at 2-3 weeks to check progress and a final review at 1 week pre-surgery.
Total primary-care time investment: 2-3 appointments of 15-20 minutes across the prep window. This is a meaningful but proportionate commitment for the benefit obtained.
Documentation and handoff to the surgical team
A brief structured handoff to the surgical team adds value disproportionate to the time required. Suggested handoff content:
• Pre-existing comorbidities and current control status (HbA1c, BP, current Hb)
• Functional baseline (METs, frailty score, mobility status)
• Identified deficiencies addressed in prep window (e.g. corrected anaemia, optimised diabetes control, smoking cessation achieved)
• Outstanding concerns or unresolved optimisations
• Medication changes made in the prep window, with rationale
• Social context – carer support, anticipated discharge environment, advance care planning status
• Patient’s psychological state and engagement with the prep process
A brief structured letter or shared electronic record entry of this content arriving with the patient at the surgical pre-assessment clinic is high-value for the anaesthetic team in particular.
Resources to share with patients
This site (prehabforsurgery.com) is structured to be patient-readable and complements clinical input. The foundational patient-facing article – “What is prehab? A complete guide for patients preparing for surgery” – covers the six pillars in plain language and includes a downloadable first-week starter checklist. Disease-specific articles for HPB conditions (liver resection, Whipple, distal pancreatectomy, cholangiocarcinoma, hepatocellular carcinoma, colorectal liver metastases, neuroendocrine tumour metastases, total pancreatectomy) extend the framework to individual surgical pathways.
Other resources worth knowing about for HPB and adjacent populations:
• Macmillan Cancer Support – Principles and guidance for prehabilitation (the foundational UK-anchored framework document, widely referenced internationally)
• ERAS Society – clinical guidelines for various surgical specialties (eras-society.org)
• WHO Healthy Ageing framework – for older surgical patients
• National and international patient organisations relevant to the specific condition (e.g. AMMF for cholangiocarcinoma; Neuroendocrine Cancer UK / INCA / Carcinoid Cancer Foundation for NETs; Pancreatic Cancer UK / PanCAN for pancreatic cancer)
A closing note
Prehab is not a perfect intervention; the evidence base, while strong overall, is not uniformly robust across populations, pillars, and outcomes. But the direction of evidence is consistent, the interventions are mostly safe and low-cost, and the systematic delivery of even modest structured prep – across the six pillars – is materially better than the unstructured advice most patients still receive.
The constraint is rarely scientific. It is operational. Primary care, anaesthetic pre-assessment, surgical teams, and patients themselves rarely co-ordinate a structured plan in the 4–8 weeks before major surgery. Where they do, outcomes are demonstrably better. Where they don’t, patients arrive at theatre in a state that is sub-optimal in ways that were modifiable.
This article is intended to support clinicians taking the lead on closing that gap for individual patients, regardless of whether formal services exist in their setting. The patient-facing companion article and accompanying resources are designed to be shared directly with patients to support that work.
References
1. Macmillan Cancer Support. Principles and guidance for prehabilitation within the management and support of people with cancer. Macmillan, 2019 (and subsequent iterations).
2. Royal College of Anaesthetists (UK). Perioperative care of the elderly. Guidelines. RCoA, current version.
3. ERAS Society. Enhanced Recovery After Surgery guidelines (various surgical specialties). eras-society.org.
4. 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(6):750-768.
5. Barberan-Garcia A, Ubré M, Roca J, et al. Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomised blinded controlled trial (PROOF Trial). Ann Surg. 2018;267(1):50-56.
6. Gillis C, Buhler K, Bresee L, et al. Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and meta-analysis. Gastroenterology. 2018;155(2):391-410.
7. Bolshinsky V, Li MH-G, Ismail H, et al. Multimodal prehabilitation programs as a bundle of care in gastrointestinal cancer surgery: a systematic review. Dis Colon Rectum. 2018;61(1):124-138.
8. Hulzebos EHJ, Helders PJM, Favié NJ, et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA. 2006;296(15):1851-1857.
9. Valkenet K, van de Port IGL, Dronkers JJ, et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil. 2011;25(2):99-111.
10. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;(3):CD002294.
11. Mills E, Eyawo O, Lockhart I, et al. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124(2):144-154.
12. Muñoz M, Acheson AG, Auerbach M, et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia. 2017;72(2):233-247.
13. Richards T, Baikady RR, Clevenger B, et al. Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial. Lancet. 2020;396(10259):1353-1361.
14. Hijazi Y, Gondal U, Aziz O. A systematic review of prehabilitation programs in abdominal cancer surgery. Int J Surg. 2017;39:156-162.
15. Tsimopoulou I, Pasquali S, Howard R, et al. Psychological prehabilitation before cancer surgery: a systematic review. Ann Surg Oncol. 2015;22(13):4117-4123.
16. 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;(5):CD008646.
17. Weimann A, Braga M, Carli F, et al. ESPEN practical guideline: Clinical nutrition in surgery. Clin Nutr. 2021;40(7):4745-4761.
18. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations: 2018. World J Surg. 2019;43(3):659-695.
19. 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(1):72-80.
20. Englesbe MJ, Lussiez AD, Friedman JF, et al. Starting a surgical home. Ann Surg. 2015;262(6):901-903. [Michigan Surgical and Health Optimization Program — MSHOP.]
21. Moran J, Guinan E, McCormick P, et al. The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: a systematic review and meta-analysis. Surgery. 2016;160(5):1189-1201.
22. Milder DA, Pillinger NL, Kam PCA. The role of prehabilitation in frail surgical patients: a systematic review. Acta Anaesthesiol Scand. 2018;62(10):1356-1366.
23. Eliasen M, Grønkjær M, Skov-Ettrup LS, et al. Preoperative alcohol consumption and postoperative complications: a systematic review and meta-analysis. Ann Surg. 2013;258(6):930-942.
24. Ghoneim MM, O’Hara MW. Depression and postoperative complications: an overview. BMC Surg. 2016;16(1):5.
25. Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in non-cardiac surgery. Diabetes Care. 2010;33(8):1783-1788.
26. Edwards AF, Forest DJ. Preoperative laboratory testing. Anesthesiol Clin. 2018;36(4):493-507.
27. Lindström D, Sadr Azodi O, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008;248(5):739-745.
28. Echeverria-Villalobos M, Todeschini AB, Stoicea N, et al. Perioperative care of cannabis users. J Clin Anesth. 2019;57:41-49.
29. Glance LG, Osler TM, Mukamel DB, et al. Impact of the present-on-admission indicator on hospital quality measurement: experience with the Agency for Healthcare Research and Quality patient safety indicators. Med Care. 2008;46(2):112-119.
This article was written and reviewed by Mr Tom Gallagher, Consultant Hepatobiliary and Pancreatic Surgeon. It is intended for healthcare professional use to support patient care. Always interpret in the context of your own clinical judgement and local guidelines.
Last updated: 7 June 2026.