A Canada-based research team has found that patients who follow prehabilitation programmes before having major surgery fare better than their counterparts who do not.

After conducting an analysis of clinical trials, the team published the results in paper appearing in The BMJ earlier this month (22 January). The paper’s first author is Daniel McIsaac, from the Department of Anesthesiology and Pain Medicine at The Ottawa Hospital in Ontario.

Dr McIsaac and his colleagues found that actively preparing for major surgery – by exercising and improving diet, for example – is associated with fewer complications, less time in hospital, and improved recovery and quality of life in adults.

Though the paper does not mention the involvement of physiotherapists and dietitians, for example, in running such prehab programmes, it does go into some details about what prehab programmes might include.

Dr McIsaac and his colleagues stress that the certainty of evidence for all comparisons was generally low to very low, but they say prehabilitation based on exercise, nutrition, or exercise combined with other components, may be beneficial.

Existing evidence suggests that prehabilitation can improve outcomes after surgery, but there’s a lack of clarity about which components, or combinations of components, are most likely to be effective.

Researchers trawled databases

The researchers trawled databases for any randomised controlled trial involving adults preparing for major surgery who received prehabilitation interventions or usual care.

They found 186 relevant trials involving 15,684 participants (average age 62; 45 per cent women) that investigated individual or combinations of prehabilitation components (exercise, nutritional, cognitive, and psychosocial support) for seven or more days before surgery.

‘We found evidence for prehabilitation efficacy with moderate effect sizes in reducing complications rates, and potentially clinically meaningful improvements in length of stay, health related quality of life, and physical recovery for adults preparing for major surgery’ [Daniel McIsaac et al]

Critical outcomes of interest were complications up to 30 days after surgery, length of hospital stay, and health related quality of life and physical recovery (based on widely used tests) up to 90 days after surgery. The trials were of varying quality, but the researchers were able to assess their risk of bias and the certainty of evidence using established tools.

After accounting for other potentially influential factors including surgery type, they found that exercise was associated with a 50 per cent reduced risk of complications compared with usual care, while nutritional support was associated with a 38 per cent reduced risk. Combined exercise, nutritional, and psychosocial support was associated with a 36 per cent reduced risk.

Compared with usual care, combined exercise and psychosocial support was associated with 2.44 fewer days in hospital, while combined exercise and nutritional support was associated with 1.22 fewer days. Individually, exercise and nutrition were associated with 0.93 and 0.99 fewer days, respectively.

Combined exercise, nutritional and psychosocial prehabilitation was most likely to improve health related quality of life and physical recovery. Individually, exercise and nutrition were most likely to improve all critical outcomes.

Caveats and conclusions

Although this review was conducted according to best practices and was based on the latest trial evidence, the researchers acknowledge several limitations and stress that the certainty of evidence for all comparisons across all outcomes was generally low to very low due to bias and the high level of variation (heterogeneity) between trials.

However, Dr McIsaac and his colleagues say the results for exercise and nutritional prehabilitation were robust after excluding trials with a high risk of bias.

They conclude: ‘In a systematic review with network and component network meta-analyses at the treatment level, we found evidence for prehabilitation efficacy with moderate effect sizes in reducing complications rates, and potentially clinically meaningful improvements in length of stay, health related quality of life, and physical recovery for adults preparing for major surgery.

‘The strongest evidence supports isolated exercise and nutritional prehabilitation, as well as multicomponent interventions including exercise.’

To access the full version of the article – titled Relative efficacy of prehabilitation interventions and their components: systematic review with network and component network meta-analyses of randomised controlled trials doi: 10.1136/bmj-2024-081164 – see: https://www.bmj.com/content/388/bmj-2024-081164