Prehab shows promise in improving health, reducing complications after surgery

A new study published in The BMJ suggests that prehabilitation (also called prehab) may be able to reduce complications and length of hospitalization after surgery, while also improving quality of life and physical recovery. The systematic review and meta-analysis, which is the largest of its kind, examined data from more than 15,000 patients who participated in 186 randomized controlled clinical trials around the world.

The researchers looked at various kinds of prehab, including exercise, nutritional enhancement, psychological support, cognitive training and various combinations of these. They found that exercise was the most promising component, followed by nutritional enhancement.

“If you are going to be having surgery, it is always a good idea to ask about prehabilitation,” said lead author Dr. Daniel McIsaac, anesthesiologist and senior scientist at The Ottawa Hospital and Clinical Research Chair in Perioperative Innovation at the University of Ottawa. “If you are willing and able to regularly increase your activity levels and protein intake for a few weeks before surgery, you are likely to experience a noticeably shorter recovery time after surgery.”

The researchers note, however, that many of the prehabilitation trials were conducted in single hospitals, and therefore it is unclear how well the results would translate to other hospitals or outside of tightly controlled research settings.

“Prehabilitation is very promising, but we still don’t know how best to implement it across hospitals and health systems,” said Dr. McIsaac. “We’re pretty sure that if patients can do the work of prehabilitation, they are likely to benefit. The big question is how do we deliver prehabilitation that works for all surgical patients at a system-level?  Ongoing multi-centre trials should provide more rigorous evidence to support broader implementation.”

Fitness impacts recovery

The term “prehabilitation” dates back to World War II, when the British Army used it to refer to approaches for improving the general health and fitness of military recruits. The term was later adopted by the medical community, and prehab has become a major area of research in the last 30 years.

“We know that people who are more physically fit tend to recover faster from surgery and suffer fewer complications,” said Dr. McIsaac. “While many patients, with encouragement from their doctors, want to improve their fitness before surgery, patients often aren’t sure where or how to start. The goal of our research program is to develop a simple and effective approach to prehabilitation that can benefit the largest number of patients in meaningfully improving their surgical recovery and help patients get home faster after surgery.”

More than 300 million surgeries are performed around the world each year. Unfortunately, more than 20 per cent of major surgery patients suffer from post-operative complications, which can increase the length of hospitalization and delay recovery.

Large prehab trials underway, guided by patients

Although most of the prehab clinical trials reported so far have taken place at single hospitals with a small number of patients, The Ottawa Hospital’s Aging Innovation In Perioperative Medicine & Surgery (AIMS) Research Group is currently conducting two large multi-centre prehab trials. The first trial has finished enrolling patients and results are expected to be published in March of 2025.

The second trial, which is focused on virtual home-based prehab, is currently enrolling patients across Canada who have a planned surgery that requires at least one night in hospital. People who are interested in participating can download this poster to learn more or contact the trial coordinator at strive@toh.ca or 1-877-372-7316.

Clinicians, scientists and patient partners across Canada are contributing to these trials though the Canadian Prehabilitation Knowledge Network and the Canadian Perioperative Anaesthesia Clinical Trials (PACT) Group. Patient engagement is being prioritized at all stages to ensure that results will be relevant to patients and the health-care system.

Gurlie Kidd, a retired social worker who has gone through a major surgery, has been a patient partner on the team since 2020. Her feedback has helped to ensure that the patient voice is central to all prehab trials at The Ottawa Hospital.  

“It is very empowering to know that there’s something you can do to prepare for surgery that will help your recovery. Patients are hungry for this,” said Kidd. “I hope that one day, prehab will be the standard of care before all major surgeries.”

Full reference: Relative efficacy of prehabilitation interventions and their components: systematic review with network and component network meta-analyses of randomised controlled trials. The BMJ. Daniel I McIsaac, Gurlavine Kidd, Chelsia Gillis, Karina Branje, Mariam Al-Bayati, Adir Baxi,Alexa L Grudzinski, Laura Boland, Areti-Angeliki Veroniki, Dianna Wolfe, Brian Hutton. DOI: 10.1136/bmj-2024-081164.

Funding and support: This study was funded by the Canadian Institutes of Health Research. Additional support was provided the Department of Anesthesiology & Pain Medicine at The Ottawa Hospital, the University of Ottawa Faculty of Medicine, Physician Services Inc., The Ottawa Hospital Anesthesia Alternate Funds Association, the Ottawa Hospital Research Institute and the Ottawa Methods Centre.

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