Types of Studies Analyzed

The preliminary screening process identified 177 full-text articles for evaluation. Following full-text review, 24 articles were excluded due to irrelevance or lack of reported outcomes, yielding a final cohort of 153 studies for comprehensive analysis (Supplementary Table 1). Of these, 45% were randomized controlled trials, 37% were prospective non-randomized cohort studies, 10% were retrospective reviews, and 5% represented other study designs. Although most studies evaluated perioperative outcomes broadly, pain-specific endpoints were variably reported and infrequently designated as primary outcomes.

Publication Timeline

Among the 153 included studies, 124 (81%) were published between 2017 and 2020, and 29 (19%) between 2021 and 2025. The earliest clinical trial meeting the inclusion criteria was published in 2008. Publication volume increased substantially over time, with 12 studies published between 2009 and 2012, 17 between 2013 and 2016, and 123 between 2017 and 2025 (Fig. 1A). This growth reflects expanding academic interest in prehabilitation, though the inclusion of standardized pain-related outcomes and implementation metrics has not increased proportionally over time.

Fig. 1The alternative text for this image may have been generated using AI.

Temporal trends, specialty distribution, and modality composition of prehabilitation manuscripts. A Prehabilitation manuscripts between 2008 and 2025 (x-axis) indicate an increase in prehabilitation modality usage (y-axis). The x-axis representing the year of publication was divided into three-year increments. In 2008, there was 1 publication, increasing to 12 between 2009–2012, 17 between 2013–2016, and a surge between 2017–2020 with 94 manuscripts applying prehabilitation modalities. B Pie chart highlighting the specialty composition of the 153 studies analyzed. General surgery (red) comprised the greatest proportion at 46.7%, followed by orthopedic surgery at 20.9% (yellow), cardiothoracic surgery at 10.8% (blue), urology at 9.6% (green), and the Other category (ENT, obstetrics/gynecology, vascular, and multispecialty) at 12.1% (tan). The “Other” category included studies spanning more than one specialty. C Representation of the number of prehabilitation modalities employed in the analyzed studies by specialty. The use of one, two, or three or more prehabilitation modalities is represented by grey, purple, and blue bars, respectively. The percentage of studies employing these modalities is shown on the y-axis. D Pie chart visual representation of the number of modalities used in the analyzed studies in aggregate. 42.7% of studies used one modality, 29.8% used two, and 27.4% utilized three or more modalities

Demographic Characteristics

Across all studies, the mean patient age was 62.4 years (SD = 11.6; range 23.0–80.6), representing a population at heightened risk for postoperative pain, prolonged opioid exposure, and chronic postsurgical pain. Orthopedic surgery studies included the youngest patients (mean = 60.3 years; SD = 14.7), while urology studies included the oldest (mean = 65.8 years; SD = 4.7). Cardiothoracic and general surgery studies reported mean ages of 64.0 years (SD = 5.8) and 61.8 years (SD = 12.8), respectively.

The mean sample size was 130.9 patients (SD = 230.8), with wide variability driven by differences in study design. Sample sizes ranged from six patients in small interventional trials to 2,187 in retrospective analyses. Orthopedic surgery studies demonstrated the greatest variability in sample size (SD = 351.3), while cardiothoracic surgery studies showed the least (SD = 85.7). Gender distribution favored male participants overall (male-to-female ratio 1.4:1.0), with cardiothoracic surgery exhibiting the highest male predominance (2.1:1.0) and orthopedic surgery the lowest (0.8:1.0).

Adherence, Follow-up, and Engagement Reporting

Loss to follow-up was reported in 96 of the 153 studies, with a mean follow-up completion rate of 85.2% (SD = 14.7%). Cardiothoracic surgery studies demonstrated the highest follow-up completion rates (mean = 89.1%; SD = 11.2%), whereas studies spanning multiple surgical specialties reported the lowest (mean = 81.0%; SD = 21.8%). While follow-up completion serves as a pragmatic marker of retention, more granular measures of adherence to prehabilitation interventions—such as session attendance, completion of prescribed exercise regimens, or engagement with multimodal components—were inconsistently reported. When included, adherence and engagement metrics were variably defined, limiting cross-study comparison and quantitative synthesis. Nonetheless, reporting of follow-up and retention outcomes suggests that prehabilitation programs are feasible in selected populations, while highlighting the need for more standardized implementation metrics.

The mean duration of prehabilitation programs across studies was 5.8 weeks (SD = 4.7), a timeframe relevant to potential modulation of baseline pain, physical conditioning, and psychological readiness prior to surgery.

Oncologic Context

More than half of the included studies (56.3%) focused on patients undergoing surgery for malignancy, a population at increased risk for complex pain trajectories due to tumor burden, prior treatments, and psychological stressors. However, only 23.5% of studies explicitly included patients receiving neoadjuvant chemotherapy, which may further influence pain sensitivity, analgesic requirements, and engagement with prehabilitation programs. Orthopedic surgery studies did not include oncologic populations, whereas urology studies demonstrated the highest proportion of cancer-focused prehabilitation (80.0%), largely in prostate and bladder cancer resections.

Surgical Specialties

The most frequently represented surgical specialties were general surgery (46.7%), orthopedic surgery (20.9%), cardiothoracic surgery (12.1%), and urology (9.6%) (Fig. 1B; Supplementary Table 1). Studies from specialties with limited representation—including otolaryngology, vascular surgery, obstetrics and gynecology, and multidisciplinary cohorts (10.8%)—were grouped as “Other Studies.”

Within general surgery, colorectal procedures predominated (65.5%), representing a population commonly studied for functional recovery and postoperative pain but with heterogeneous pain outcome reporting. In orthopedic surgery, joint replacement (50.0%) and spine surgery (30.7%)—procedures with well-recognized pain burdens—were most frequently examined. Cardiothoracic studies focused primarily on pulmonary (33.3%) and esophageal resections (26.6%), while urologic studies centered on prostatectomy (58.3%) and cystectomy (41.6%). Less frequently studied procedures included organ transplantation, coronary artery bypass grafting, hepatopancreaticobiliary surgery, and hernia repair.

Patterns of Prehabilitation Modality Use Across Surgical Specialties

Studies were analyzed according to the number of prehabilitation modalities employed across surgical specialties (Fig. 1C). In cardiothoracic surgery, 67% of studies used a single modality, while 20% and 15% employed two or ≥ 3 modalities, respectively. General surgery demonstrated a more even distribution, with 31% using a single modality, 33% using two, and 37% employing ≥ 3 modalities—suggesting greater uptake of multimodal approaches that may address both physical conditioning and pain-related risk factors.

Orthopedic and urologic studies predominantly utilized single-modality interventions (approximately 60% each), despite these populations being at high risk for postoperative pain. In contrast, the pooled “other” specialties demonstrated the greatest use of ≥ 3 modalities (54%), exceeding single- and dual-modality approaches (22% each). Across the full cohort, 42.7% of studies employed a single modality, 27.4% used two modalities, and 29.8% utilized ≥ 3 modalities (Fig. 1D). While multimodal prehabilitation is conceptually aligned with multimodal pain management, its adoption remains inconsistent across specialties.

Types and Prevalence of Prehabilitation Modalities

Five categories of prehabilitation were identified: exercise, nutritional support, psychological interventions, substance cessation, and medical optimization. Exercise was the most employed modality, present in 87.1% of studies, followed by nutritional interventions (37.9%) and psychological support (32.6%)—both of which have established associations with pain perception, coping, and recovery. Medical optimization and substance cessation were each included in 11.2% of studies (Fig. 2A).

Fig. 2The alternative text for this image may have been generated using AI.

Distribution of prehabilitation modalities and utilization by surgical specialty. A Percentage of manuscripts that reported each prehabilitation modality (y-axis); bars were color-coded according to the following scheme: exercise (black, 87.1%), nutrition (green, 37.9%), psychological (light brown, 32.6%), digital (grey, 19.3%), substance cessation (dark brown, 11.2%), and medical optimization (orange, 11.2%); modalities were ordered by frequency, with exercise the most utilized. B Prehabilitation utilization subdivided by surgical specialty (x-axis: cardiothoracic surgery, general surgery, orthopedic surgery, urology, other) with the percentage of studies on the y-axis; bars were colored by modality according to the scheme in A and applied consistently across the panel

Overall, 59% of studies utilized a single modality (Supplementary Table 1). Multimodal prehabilitation—defined as the integration of two or more intervention categories—was employed in 20% of studies, with notable variation by specialty. General surgery had the highest use of multimodal regimens (27%), whereas cardiothoracic surgery had the lowest (10%) (Fig. 2B). The mean number of modalities per study was 1.98, ranging from 2.12 in general surgery to 1.46 in cardiothoracic surgery. Despite frequent inclusion of exercise and psychological components, few studies explicitly evaluated their effects on pain-related outcomes.

Economic Outcomes and Resource Use

Economic outcomes were infrequently reported across the included studies. When present, analyses varied substantially in scope and methodology, including measures of hospital length of stay, readmissions, direct costs, or cost-effectiveness. However, inconsistent reporting and heterogeneity in analytic approaches precluded quantitative synthesis of economic impact. These findings indicate that, despite increasing interest in prehabilitation, evidence regarding its financial implications and resource utilization remains limited and insufficiently standardized.

Proportion of Studies Reporting Improvement in Clinical and Pain-Related Outcomes

Across all included studies, 82% reported statistically significant improvement in at least one predefined clinical outcome, most commonly functional capacity, postoperative complication rates, or hospital length of stay (Fig. 3). Pain-related outcomes, including postoperative pain intensity, analgesic consumption, or pain-associated functional limitations, were reported less consistently and were infrequently designated as primary endpoints. When assessed, pain-related improvements generally occurred alongside gains in functional or recovery-related measures rather than as isolated outcomes. The proportion of studies reporting improvement in at least one clinical outcome varied by surgical specialty, with general surgery demonstrating the highest rate (93.1%), followed by urology (83.3%), cardiothoracic surgery (80.0%), and orthopedic surgery (73.0%) (Supplementary Table 1). These findings reflect outcome-specific improvements rather than uniform benefit across all measured domains.

Fig. 3The alternative text for this image may have been generated using AI.

Positive outcomes associated with prehabilitation by surgical specialty. A Proportion of included studies reporting positive outcomes (y-axis, %) presented overall and stratified by specialty (x-axis). Positive outcomes were observed in 82.3% overall; by specialty: cardiothoracic surgery, 80.0%; general surgery, 93.1%; orthopedic surgery, 73.0%; urology, 83.3%; and other, 61.5%. Percentages were calculated from the included dataset (n = 153); “other” comprised ENT, obstetrics/gynecology, vascular, and multispecialty studies

Short- and Long-Term Pain-Related Outcomes

To further characterize the temporal effects of prehabilitation, outcomes were stratified by follow-up duration. Short-term outcomes were defined as those assessed within 3 months postoperatively, while long-term outcomes were defined as those assessed beyond 3 months.

Among the 153 included studies, the majority (125/153; 82.3%) reported a statistically significant improvement in short-term pain-related outcomes following prehabilitation. Two studies (2/153; 1.3%) demonstrated neutral effects, while 21 studies (21/153; 13.7%) reported no significant short-term improvement in pain outcomes compared with control groups receiving no prehabilitation.

In contrast, long-term pain-related outcomes were reported far less frequently. Only 22 of 153 studies (14.4%) evaluated pain beyond 3 months postoperatively. Among these, 12 studies demonstrated significant long-term improvement in pain-related outcomes, while the remaining studies reported no significant differences compared with controls. The limited number of studies assessing long-term pain outcomes precluded formal synthesis and underscores a substantial gap in the existing literature.