Enhancing postoperative recovery with multimodal prehabilitation: the journey begins before surgery

Multimodal prehabilitation

Article information

Korean J Anesthesiol. 2025;78(5):401-417

Publication date (electronic) : 2025 July 18

doi : https://doi.org/10.4097/kja.25320

Ah-Reum Cho ¹^,²^,³

, Wariya Vongchaiudomchoke ¹^,⁴

, Detlef Balde ¹^,⁵

, Do Jun Kim ⁶

, Francesco Carli^,¹

¹Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, QC, Canada

²Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University School of Medicine, Yangsan, Korea

³Medical Research Institute, Pusan National University Hospital, Busan, Korea

⁴Department of Anesthesiology, Siriraj Hospital, Mahidol University Faculty of Medicine, Bangkok, Thailand

⁵Department of Anesthesia, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile

⁶Department of Physiotherapy, McGill University Health Center, Montreal, QC, Canada

Corresponding author: Francesco Carli, M.D., M.Phil., FRCA, FRCPC Department of Anesthesia, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L10-112, Montreal, QC H3G1A4, Canada Tel: +1-514-934-1934 (ext. 43728) Fax: +1-514-934-4446 Email: franco.carli@mcgill.ca

Received 2025 April 21; Revised 2025 June 5; Accepted 2025 June 15.

Abstract

This narrative review explores multimodal prehabilitation, a patient-centered, evidence-based, and multidisciplinary approach to enhance postoperative recovery. It shifts the focus from traditional intraoperative and postoperative care to a comprehensive process beginning at diagnosis. Multimodal prehabilitation integrates exercise, nutrition, and psychological strategies to improve preoperative functional capacity and physiological reserve, enabling better management of surgical stress. The review examines prehabilitation’s clinical efficacy, highlighting enhanced functional capacity as a key outcome. It details prehabilitation components: exercise (aerobic, resistance, and respiratory muscle training), nutritional optimization targeting modifiable risk factors such as malnutrition and sarcopenia, and psychological support to lower anxiety and boost patient motivation and adherence. Individualized approaches are emphasized due to significant patient variability. This review also presents a successful multimodal prehabilitation program implemented at the Montreal General Hospital, which has a strong track record in this area. The program is structured around four key phases: screening, assessment, intervention, and follow-up. It also discusses the barriers to implementation and the roles of stakeholders, including the government, hospitals, healthcare professionals, and patients and their families, within the context of South Korea’s unique healthcare system and socio-cultural environment.

Keywords: Multidisciplinary care team; Nutritional support; Prehabilitation; Preoperative care; Preoperative exercise; Psychosocial support

Introduction

Numerous efforts have been made to enhance postoperative recovery. One of the most revolutionary strategies has been the implementation of the Enhanced Recovery After Surgery (ERAS) program. ERAS has shifted the paradigm from the traditional approach to a patient-centered, evidence-based, and multidisciplinary approach. The ERAS pathway provides a holistic approach throughout the perioperative period [1]. Since the first publication of the ERAS guidelines for colorectal surgery in 2005, more than twenty ERAS guidelines have been published or updated [2]. Although postoperative outcomes have been effectively improved by implementing the ERAS guidelines, there is still room for improvement [3–6].

The ERAS pathway mainly focuses on intraoperative and postoperative care, while preoperative components such as medical optimization, smoking cessation, patient education, and risk assessment remain similar to the traditional longstanding practices, as part of standard care [1]. Although this approach may be sufficient for fit patients, it can be suboptimal for older, frail, or high-risk individuals, for whom surgical decisions must take patient-specific vulnerabilities into account [7]. In addition, with the increasing complexity of surgical procedures and the expanding role of perioperative physicians in modern medicine, personalized preoperative care is becoming more important. Prehabilitation reflects this shift by aiming to optimize patients’ readiness for surgery through targeted, multidisciplinary interventions.

Also, the preoperative period offers the valuable teachable moment that surgical patients are most receptive to change. During this time, patients are at different stages of transtheoretical model of health behavior change, including precontemplation, contemplation, preparation, action, or maintenance, depending on their individual characteristics [8]. By encouraging patients to assess their current lifestyle habits and explaining the potential benefits of making positive changes before surgery, clinicians can effectively motivate them to progress to the ‘action’ or ‘maintenance’ stages [9]. Therefore, according to the recent definition, prehabilitation can be seen as the most effective way to capitalize on this teachable moment, encouraging positive behavior changes in patients. The recent definition is as follows: a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies, and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery [10].

In this context, anesthesiologists are well positioned to serve as perioperative physicians involved in collaborative decision-making with surgeons and allied health professionals. As the scope of anesthesiology expands to include preoperative risk assessment and patient optimization, prehabilitation aligns naturally with this evolution. With their expertise in perioperative care, anesthesiologists are uniquely suited to lead or support prehabilitation efforts, contributing to improved surgical outcomes and enhanced patient-centered care.

This narrative review explores the core components of multimodal prehabilitation, including exercise, nutrition, and psychological support, and summarizes current evidence on its clinical efficacy and cost-effectiveness. It then presents a practical example from a high-volume academic center with extensive experience in implementing prehabilitation [11–16]. Finally, it discusses the potential clinical application of prehabilitation in South Korea, where preoperative clinic and ERAS programs have not yet been fully established [17,18]. The review examines the barriers to implementing prehabilitation and provides a detailed analysis of the roles that the government, hospitals, healthcare professionals, and patients and their families must play in overcoming these challenges.

How does prehabilitation enhance postoperative recovery?

A recent scoping review aiming to establish a standardized definition of prehabilitation identified ‘enhanced functional capacity’ as the most frequently reported concept across trials [10]. Over time, the concepts of preoperative functional assessment and postoperative functional recovery have significantly evolved [19]. Historically, preoperative functional assessment became a component of guidelines in the 1990s, particularly as organizations like the American College of Cardiology/American Heart Association recognized its value in evaluating overall cardiac risk and planning appropriate preoperative testing [20]. Presently, several international guidelines emphasize the importance of preoperative functional capacity assessment in estimating patients’ risks for major morbidity and mortality following surgery [21,22].

The definition of postoperative recovery has evolved alongside the development of ERAS. Traditionally, the definition of postoperative recovery was limited to the early and intermediate phase of recovery, from operating room to discharge from care, as an outcome measure for factors associated with the length of hospitalization [23,24]. However, this definition is unidimensional and may not adequately reflect the complete process of recovery. More recently, postoperative recovery has been redefined as the return to, or improvement of, a patient’s preoperative function, encompassing multiple dimensions and physiological, psychological, social, and habitual functions [25–28].

Functional capacity generally refers to an individual’s ability to endure physiological stress that demands sustained aerobic metabolism [29]. This multifaceted physiological response requires the coordinated function of the cardiopulmonary, musculoskeletal, neuromuscular, and metabolic systems [30]. The potential mechanisms underlying multimodal prehabilitation are built upon this foundation. Factors influencing functional capacity can be categorized into modifiable and non-modifiable factors. Non-modifiable factors include age, gender, and comorbidities. In contrast, modifiable factors, such as low cardiopulmonary reserve [31,32], sarcopenia [33,34], malnutrition [35,36], frailty [37,38] and low psychological reserve [39,40], serve as primary targets for multimodal prehabilitation. Addressing these factors through key components of multimodal prehabilitation, including exercise training, nutritional optimization, and psychosocial support, plays a critical role in improving functional capacity before surgery (Fig. 1). This enhancement in preoperative functional capacity translates into better postoperative recovery outcomes, underscoring the clinical significance of multimodal prehabilitation in perioperative care [15,41].

Fig. 1.

Multimodal prehabilitation improves preoperative functional capacity and enhances postoperative outcomes by addressing modifiable surgical risk factors, such as low cardiopulmonary reserve, reduced physical activities, malnutrition, sarcopenia, frailty, and low psychological reserve.

The components of multimodal prehabilitation

Exercise

Prehabilitation aims to enhance functional capacity, with early efforts focusing on unimodal, exercise-based interventions to improve cardiorespiratory fitness, muscle strength, and muscle mass [10,42]. Currently, exercise remains the cornerstone of prehabilitation, incorporating various modalities such as aerobic exercise, resistance training, respiratory muscle training (RMT), or a combination of these approaches [43–46]. Aerobic and resistance exercises are often combined due to their complementary effects on different physiological systems. Aerobic exercise primarily targets the improvement of cardiorespiratory reserve by increasing peak oxygen consumption and endurance, whereas resistance exercise enhances metabolic flexibility by promoting muscle strength and mass [47]. Despite targeting distinct systems, these modalities share a synergistic relationship: gains in muscle mass and strength enhance physical performance, facilitating more effective aerobic exercise, while improved cardiorespiratory reserve supports higher-intensity resistance training, further augmenting muscle mass and strength [48,49]. Notably, a minimum of four weeks of training is typically required to achieve measurable improvements in peak oxygen consumption and muscle strength [50].

Surgery induces not only localized tissue injury but also systemic stress responses, including increased oxygen demand, inflammation and ischemia-reperfusion injury, and hyperglycemia and insulin resistance [51,52]. Previous studies underline that preoperative exercise can increase physiologic and metabolic reserve to mitigate those surgical stress responses and show improved postoperative outcomes. Aerobic exercise increases maximal rate of oxygen consumption and anaerobic threshold that indicates the circulatory and respiratory systems’ ability to supply tissues with oxygen, to meet the increased oxygen demand caused by surgical stress and healing [53,54]. Because of the self-regulated and progressively incremental nature of exercise, cells are exposed to intermittent hypoxia. With the concept of hormesis in mind, this repeated and transient exposure to cellular hypoxia increases factors that respond to cellular hypoxia and oxidative stress triggered by surgery [54]. Moderate, sustained exercise conditioning induces the endogenous antioxidative system and provides protection against oxidative stress [55]. Studies on endurance exercise training and cardiac myocytes have demonstrated a phenotype that is resistant to ischemia-reperfusion injury [56].

Exercise also improves insulin sensitivity and enhances the capacity of muscles to utilize both glucose and fatty acids for energy that is central to metabolic flexibility [57]. During surgery, the stress-induced increase in counter-regulatory hormones (cortisol, glucagon, and catecholamines), known as the catabolic response, promotes protein breakdown and glucose production through gluconeogenesis. Meanwhile, this response inhibits insulin secretion and induces insulin resistance, leading to perioperative hyperglycemia [51,58]. By improving metabolic flexibility, preoperative exercise may reduce these adverse metabolic effects, leading to fewer complications and better postoperative outcomes [59,60]. Furthermore, efficient energy utilization supports tissue repair and wound healing, facilitating faster recovery. Exercise also helps maintain and build muscle mass that is essential for preserving strength, enhancing functionality, and promoting overall recovery following surgery.

RMT in prehabilitation is gaining attention, as the simplicity and safety of the intervention further outweigh its effects on postoperative outcomes. A pragmatic, international, multicenter randomized controlled trial (RCT) demonstrated that a 30-minute preoperative education and breathing exercise training session, delivered by a physiotherapist within six weeks before surgery, halved the incidence of postoperative pulmonary complications (PPCs) after upper abdominal surgery [61]. Additionally, a Cochrane systematic review and meta-analysis, including 12 trials, showed that preoperative inspiratory muscle training was associated with a reduction in postoperative PPCs and length of stay (LOS) compared with usual care [62]. It is most likely to work by strengthening the respiratory muscles, thereby improving lung function, and reducing postoperative complications [63].

Nutrition

Surgery creates a catabolic environment that modulates metabolic processes to mobilize energy reserves (glycogen, adipose tissue, and skeletal muscle) to provide substrates for metabolic fuel, tissue repair, and the synthesis of proteins involved in the immune response [51,52]. These changes are exacerbated in patients with depleted energy reserves and reduced metabolic capacity, such as those with malnutrition and sarcopenia. Nutritional intervention plays a crucial role in this context by providing dietary protein as a source of amino acids, the building blocks of muscle. If a patient cannot obtain sufficient protein through diet alone, whey protein—an animal-based protein—is prescribed, as it contains significantly higher levels of leucine compared to plant-based proteins. Leucine, a branched-chain amino acid essential for muscle growth, activates mechanistic Target of Rapamycin Complex 1, a key regulator of protein synthesis [64,65]. It also ensures adequate calorie intake to meet metabolic needs and supplies essential micronutrients (vitamins and minerals) necessary for energy production and protein metabolism [66].

Although numerous studies have demonstrated that nutritional status is a key determinant of surgical outcomes, and various medical associations emphasize the importance of perioperative nutritional intervention [66,67], it remains under-recognized in clinical practice. A previous systematic review and meta-analysis found that nutritional intervention alone significantly shortened the LOS by two days after colorectal surgery [68]. Recognizing the critical role of nutrition, multimodal prehabilitation programs have incorporated this evidence, acknowledging that malnutrition is a key modifiable preoperative risk factor associated with poor surgical outcomes. The nutritional component of multimodal prehabilitation is primarily designed to prevent and treat malnutrition and muscle loss [69,70].

While exercise remains the cornerstone of multimodal prehabilitation, severely malnourished patients are highly vulnerable to muscle loss when engaging in physical activity, as their protein reserves are insufficient to maintain and build muscle mass. A significant increase in energy expenditure from exercise, particularly with aerobic training, can lead to further muscle wasting and a worsening of their physiological reserve [71]. A pooled analysis of prehabilitation trials revealed that multimodal prehabilitation was ineffective in enhancing preoperative functional capacity in severely malnourished patients [35]. Another study found that well-nourished patients were significantly more likely to improve their physical function after resistance training [72]. Given this evidence, it is essential to identify malnourished individuals early and initiate nutritional intervention as soon as possible before introducing exercise treatments. This approach helps minimize muscle breakdown while promoting gradual recovery with proper nutritional support.

Psychological support

Although surgical patients often experience psychological distress during the perioperative period, there is limited direct evidence on how psychological interventions lead to improved postoperative outcomes [73]. However, research in psychoneuroimmunology has highlighted the central role of chronic stress in activating the hypothalamic-pituitary-adrenal axis, stimulating the sympathetic nervous system, suppressing the parasympathetic nervous system, and impairing immune function [74]. Several trials have demonstrated that preoperative psychological interventions can significantly reduce surgical patients’ anxiety, potentially enhancing perioperative immune response and inflammatory protection [75,76]. Additionally, these interventions may mitigate chronic hyperactivation of the stress response, thereby reducing hypertension, inflammatory cascades, vascular injury, hemodynamic compromise, and the imbalance between oxygen supply and demand [51]. Psychological interventions aimed at reducing perioperative anxiety and enhancing surgical stress resilience encompass a wide range of techniques, including procedural information, behavioral instruction, cognitive interventions, relaxation techniques, guided imagery, stress management, and psychotherapeutic interventions [77,78].

Another critical role of psychological support is to enhance patient motivation and adherence to the prehabilitation program [74]. Since the success of multimodal prehabilitation depends largely on compliance, ensuring that patients adhere to exercise and nutritional regimens is highly recommended. Cancer patients, in particular, frequently experience overwhelming fatigue, low energy, and diminished willpower due to extensive medical evaluations and treatments before surgery. Within the context of research trials, the delivery setting of behavior change strategies in multimodal prehabilitation programs varies [79]. While many studies do not explicitly detail the strategies, some have briefly mentioned approaches such as motivational interviewing [80], patient experience-based co-design [81], and weekly phone calls with feedback [82].

A Cochrane review encompassing 105 studies across various surgical specialties under general anesthesia found that psychological preparation had only small beneficial effects on all measured outcomes, with no evidence of harm [77]. However, significant heterogeneity in intervention types, outcome measures, and timing of assessments prevented a quantitative synthesis. Additionally, methodological limitations such as lack of blinding, absence of stratification, and insufficiently powered studies were prevalent. These findings highlight the need for larger, well-designed trials to assess the efficacy of psychological prehabilitation in improving postoperative outcomes.

One size does not fit all

Several systematic reviews evaluating the effectiveness of multimodal prehabilitation have reported its positive impact on postoperative outcomes, including functional recovery, rates and severity of complication, LOS, and readmission rates. However, the evidence supporting these benefits has been classified as low or very low quality [41,42,44,45]. One of the key reasons for this low level of evidence is heterogeneity. Multimodal prehabilitation is a complex intervention consisting of multiple components that require significant behavioral changes from participants, rely on the expertise of healthcare professionals, and necessitate skill development by patients. As a result, the effectiveness of prehabilitation varies depending on which patients receive which components and how those components are delivered.

Patients present with diverse preoperative conditions; some are malnourished, some are sarcopenic, and others exhibit reduced physical functioning, with many experiencing overlapping characteristics (Fig. 2). Thus, individualized intervention is essential. For instance, a severely malnourished patient should primarily receive nutritional (protein and energy) support, supplemented with an exercise regimen as tolerated. Conversely, a patient with severely impaired physical function but adequate nutrition should focus on exercise training while maintaining their current diet with basic nutritional education. If a patient shows both low muscle strength and low muscle quantity or quality, indicative of sarcopenia [83], a combination of nutritional support and resistance exercise should be prioritized.

Fig. 2.

Targeted patient care in multimodal prehabilitation programs: one size does not fit all. A severely malnourished patient should primarily receive nutritional support, supplemented with an exercise regimen as tolerated. Conversely, a patient with severely impaired physical function but adequate nutrition should focus on exercise training while maintaining their current diet with basic nutritional education. If a patient is sarcopenic, both nutritional and resistance exercise interventions should be prioritized.

Previous studies further support the importance of individualized approaches. Patients with higher baseline fitness showed less improvement in functional walking capacity with prehabilitation than those with lower fitness levels and were less likely to recover their baseline six-minute walking distance (6MWD) at four weeks postoperatively [84]. Similarly, a study investigating the impact of preoperative nutritional status on multimodal prehabilitation outcomes found that patients with severe malnutrition or without any nutritional deficits did not exhibit significant improvements in 6MWD or fat-free mass index (FFMI) compared to controls after four weeks of intervention [35].

Beyond patient characteristics, the type of disease and surgery also influences prehabilitation strategies. For cancer patients, preoperative muscle loss and weight reduction are common concerns, and multimodal prehabilitation aims to minimize these losses or ideally promote muscle mass and weight gain. In particular, studies suggest that prehabilitation is highly beneficial for patients undergoing neoadjuvant therapy, as this population is vulnerable to rapid muscle wasting and deconditioning due to direct treatment toxicity and systemic side effects. Prehabilitation may help mitigate physical deterioration and maintain skeletal muscle mass. Ultimately, these positive effects can increase the likelihood that patients complete the full course of neoadjuvant therapy [85,86]. Additionally, the period of neoadjuvant therapy generally provides a window of two to three months before surgery that can be utilized as an opportunity to implement structured prehabilitation interventions [85].

Conversely, in patients with early-stage breast or endometrial cancer, as well as those undergoing orthopedic or hernia surgery, a weight loss strategy focused on reducing body fat while maintaining or increasing muscle mass may be preferable, particularly in patients with overweight or obesity [87–90]. Since obesity is a known risk factor for recurrence in these conditions, prehabilitation can serve as a foundation for long-term lifestyle modifications aimed at preventing postoperative weight regain and reducing disease recurrence risks.

These examples highlight that a one-size-fits-all approach is not applicable to multimodal prehabilitation. To maximize the effectiveness of prehabilitation, multimodal prehabilitation must be customized to individual patient needs rather than applying a uniform intervention for all.

Evidence for multimodal prehabilitation outcomes

Improvements in postoperative clinical outcomes

Recent large-scale meta-analyses and umbrella reviews (systematic reviews of systematic reviews) have been conducted to evaluate the evidence regarding the effects of prehabilitation on clinical outcomes, including LOS, incidence and severity of postoperative complications, functional recovery, and quality of life [41,44,45].

Skořepa et al. [41] analyzed data from 3339 frail and high-risk patients undergoing major abdominal surgery across six RCTs and 10 cohort studies. Their meta-analysis of nine studies indicated that the prehabilitation groups experienced a reduction in LOS by one day. Additionally, a meta-analysis of 10 studies addressing severe complications suggested a 44% lower risk of developing severe complications in the prehabilitation groups. Furthermore, four studies reported preoperative six-minute walk test (6MWT) results, demonstrating a 40-metered improvement before surgery.

An umbrella review including 55 systematic reviews assessed the effects of prehabilitation programs in elective adult patients undergoing various types of surgery [44]. Pooled effect estimates suggested that prehabilitation may reduce postoperative complications and hospital LOS in mixed, cardiovascular, and cancer surgeries, although the evidence was of low to very low certainty. However, moderate-certainty evidence supported the benefits of prehabilitation for functional recovery in cancer surgery patients.

A more recent meta-analysis aimed to estimate the relative efficacy of individual prehabilitation components and their combinations on postoperative outcomes [45]. The analysis included 186 RCTs involving 15 684 patients. Multimodal prehabilitation, particularly those incorporating exercise, was found to be the most effective in reducing complication rates (Odds Ratio: 0.64) and shortening LOS (mean difference: −1.91 days). Additionally, it was associated with improvements in health-related quality of life (mean difference in 36-Item Short Form Health Survey: + 3.48) and physical recovery (mean difference in 6MWD: + 43.4 m) in adults undergoing major surgery.

Despite the significant associations observed between prehabilitation and improved outcomes, the certainty of the available evidence remains low or very low. This limitation is primarily attributed to the inability to blind participants and caregiver, as well as the substantial heterogeneity in population, surgical procedures, and prehabilitation programs. Moreover, studies investigating patient-reported outcomes (PROs), including quality of life and psychological well-being, remain scarce. Conducting further multicenter trials with low risk of bias and a specific focus on PROs will be essential to establish a more robust evidence base for the benefits of prehabilitation.

Cost impacts of multimodal prehabilitation to the health care system

The hypothesis that overall healthcare costs may decrease despite the additional expenses of multimodal prehabilitation is supported by the notion that major complications, that prehabilitation can help reduce, significantly drive increased healthcare costs by admission to intensive care unit (ICU) and prolonged LOS [91]. A recent retrospective, propensity score-matched research on 294 lung cancer patients demonstrated a significant reduction in major complication rates (13.6% vs. 27.9%, P = 0.003) and ICU admission rates (2.7% vs. 8.2%, P = 0.040) in the prehabilitation group [16]. Similarly, an international, multicenter RCT on colorectal cancer surgery reported significantly lower major complication rates in the prehabilitation group compared to standard care (17.1% vs. 29.7%, P = 0.02) along with reduced ICU admissions (3.3% vs. 10.9%, P = 0.02) [15]. However, the cost-effectiveness of prehabilitation remains inconclusive [92,93].

A recent retrospective cohort study conducted in a regional Dutch hospital analyzed the clinical outcomes and effects on hospital resources for colorectal surgery [94]. The study found lower overall complication rates (31% vs. 40%, P = 0.04) and severe complication rates (20% vs. 31%, P = 0.01) in the prehabilitation group compared to standard care. Additionally, LOS was shorter in the prehabilitation group (mean 5.80 vs. 6.71 days). In-hospital cost savings amounted to €1109 per patient, with the calculated investment for prehabilitation being €969.

Another cost-analysis study was conducted in a tertiary-care university hospital in Spain to assess health outcomes and the cost implications of prehabilitation [95]. The analysis, that included 328 patients in both the prehabilitation and control groups, did not show significant differences in overall outcomes. However, a per-protocol analysis including only program completers (n = 112, 34%) demonstrated a significant reduction in mean LOS (9.9 [7.2] vs. 12.8 [12.4] days; P = 0.035). For completers undergoing highly aggressive surgeries (n = 60), there was also a reduction in mean ICU stay (2.3 [2.7] vs. 3.8 [4.2] days; P = 0.021), resulting in mean cost savings per patient of €3092 (32% cost reduction) (P = 0.007).

These findings suggest a strong correlation between improved clinical outcomes and reduced healthcare costs. The aforementioned Spanish study highlights the importance of patient compliance, indicating that higher compliance rates can independently contribute to cost reduction. Enhancing patient access and adherence to prehabilitation through home-based, community-based, or digitally supported programs should be explored [96,97]. Additionally, conducting further cost analyses in such settings will be essential. Furthermore, tailoring prehabilitation prescriptions based on a patient’s preoperative risk profile and the level of surgical aggression can optimize resource allocation and maximize economic benefits [95].

Nevertheless, systematic reviews of economic evaluations indicate a significant risk of bias and low methodological quality in existing studies [92,93]. Future cost-analysis research should address these limitations. First, most current studies have been conducted in specific regions such as Europe and Canada that limits the generalizability of findings due to variations in healthcare systems. Conducting studies across different regions will enhance applicability. Second, the dose of prehabilitation (frequency, duration, and intensity) may have a considerable impact on cost-analysis outcomes. Effective prehabilitation doses must balance the need for clinical impact with tolerability for the target population [98].

Multimodal perioperative program at McGill University Healthcare Center

The introduction of a new healthcare service is always a challenging endeavor. The Multimodal Perioperative Program (MPOP) at McGill University Healthcare Center has been established based on over a decade of research and clinical experience. This section outlines the objectives and processes of the successfully implemented MPOP, providing a reference for the introduction of prehabilitation programs [11,14,99].

Fully integrated within the preoperative center, the prehabilitation clinic delivers comprehensive, patient-centered, and multidisciplinary management of perioperative risk, from the initial consideration of surgery through to full recovery. Typically lasting four to 12 weeks, the program is based on team-based care and follows a structured framework consisting of screening, assessment, intervention, and follow-up (Fig. 3). These phases are seamlessly interconnected, ensuring a continuous and coordinated approach to perioperative care [99].

Fig. 3.

Multimodal prehabilitation program at Montreal General Hospital. Patients identified as high-risk during screening undergo assessment, intervention, and follow-up in the prehabilitation clinic while simultaneously following the ERAS pathway in the preoperative clinic, resulting in optimized preoperative status. DASI: Duke Activity Status Index, CNST: Canadian Nutritional Screening Tool, FFMI: Fat-Free Mass Index, HADS: Hospital Anxiety and Depression Scale, CPET: Cardiopulmonary Exercise Test, PG-SGA: Patient-Generated Subjective Global Assessment, ERAS: Enhanced Recovery After Surgery.

Screening

Surgeons refer patients to the prehabilitation clinic by selecting the appropriate criteria from the referral checklist; frailty, high medical risk, smoking, neoadjuvant therapy, significant weight loss or oral intake, body mass index ≤ 20 kg/m², or major surgery with expected duration ≥ 6 h (Supplemental Material 1). The purpose of screening is to stratify patients based on surgical risk and provide tailored assessments and programs accordingly. Screening includes physical, nutritional, and psychological evaluations that are conducted and assessed by the physician according to established guidelines on the patient’s first visit.

Physical screening includes the 6MWT, sit-to-stand test, handgrip strength assessment, arm curl test, and the Duke Activity Status Index (DASI). Patients who are unable to walk more than 400 m or have a DASI score below 34 are considered to have low physical status [100,101]. Nutritional risk is assessed using the Canadian Nutritional Screening Tool (CNST) and the FFMI, measured by a bioelectrical impedance analyzer (SECA mBCA 514). Patients with a positive CNST or reduced FFMI (< 17 kg/m² for males and < 15 kg/m² for females) require further nutritional assessment by a dietitian/nutritionist [102]. Psychological screening is conducted using the Hospital Anxiety and Depression Scale (HADS) and the Distress Thermometer. Patients with HADS-anxiety > 7, HADS-depression > 7, or a Distress Thermometer score > 3 are referred to a specially trained registered nurse for further evaluation [103,104]. Additionally, a motivational interview is conducted by a healthcare professional and the patient to collaboratively set personalized goals.

Patients who do not exhibit any risk factors in the physical, nutritional, or mental domains during the screening phase are deemed low-risk. These patients receive the standard universal recommendations. These include the management of comorbidities and medications, blood management, smoking cessation, patient education, and all components of the ERAS pathways. Additionally, general guidance on exercise, nutrition, and mental health resources is provided through group classes, informational handouts, or online platforms.

Assessment and intervention

Any patient who shows a high-risk profile in the screening are then referred for further assessment to specialized healthcare professionals. Patients with low physical status are referred to a kinesiologist or physiotherapist for further physical assessment. Cardiopulmonary exercise test (CPET) is the gold standard for the quantification of cardiorespiratory fitness [53,105]. If indicated, tolerance-limited, rapid-ramp CPET is conducted by a trained clinician on an electronically braked cycle ergometer (ViaSprint^TM 150P, Vyaire Medical Inc.) following standardized clinical guidelines [53]. Patients are offered either a home-based or supervised exercise program based on their conditions and personal preference, accompanied in both cases by a daily exercise diary. The training includes both aerobic and resistance exercises, with intensity and frequency adjusted according to each patient’s exercise capacity and needs.

For patients identified as high risk for malnutrition through nutritional screening, a registered dietitian conducts a comprehensive nutritional assessment. To ensure a standardized evaluation and tailor interventions to individual clinical needs, the Patient-Generated Subjective Global Assessment (PG-SGA) is utilized. This assessment considers dietary habits, nutrient intake and goals, physical and body composition status, underlying causes of malnutrition, and potential barriers to adequate food intake. If patients are severely malnourished (PG-SGA > 9), they are followed by the dietitian closely. The program is designed to optimize macronutrient balance, targeting a protein intake of 1.2–1.5 g/kg/day, along with a calorie intake of 25–30 kcal/kg/day to support overall energy needs. If necessary, whey protein supplements, vitamin D, multivitamin, and omega 3 supplements are prescribed.

Patients at high risk for mental distress receive a one-on-one session with a specially trained registered nurse who provides psychosocial support, tailored to the perioperative setting. Surgical stress resilience training, including deep breathing, progressive muscle relaxation, guided imagery, mindfulness meditation, body scanning, and present-focused attention, and goal setting, are introduced and practiced. If further specialized care is deemed necessary, referrals are made to social work, psychiatry, or geriatrics for additional support.

Follow-up

Multimodal prehabilitation is a personalized program that requires active patient participation. To ensure engagement and effectiveness, follow-up assessments are conducted every two to four weeks via phone or in-person before surgery, allowing for continuous monitoring and program adjustments based on patient progress and feedback. Postoperative recovery is assessed through a telehealth follow-up at four weeks and an in-person visit at eight weeks, during which the same measurements for functional capacity and body composition are repeated to evaluate recovery. At this stage, the program is formally concluded. If further management is needed after program completion, patients are referred to local cancer or rehabilitation facilities for continued care.

Implementing multimodal prehabilitation in South Korea: a multi-stakeholder perspective

Formal prehabilitation programs in South Korea are extremely limited. Only one feasibility study using the term ‘prehabilitation’ has been reported, conducted jointly by departments of physical education and obstetrics and gynecology [106], and no systematic implementation efforts or anesthesiology-led initiatives have been documented to date.

The barriers to implementing multimodal prehabilitation have been discussed in several previous studies [99,107,108]. However, introducing a new program should not follow a one-size-fits-all approach, as is true with the concept of multimodal prehabilitation itself. This section aims to examine the barriers that may arise from the perspectives of the government, hospitals, healthcare professionals, and patients and their families, considering the unique characteristics of South Korea’s healthcare system and socio-cultural background. Additionally, it discusses the efforts required to mitigate these barriers (Fig. 4).

Fig. 4.

A multi-stakeholder perspective on implementing multimodal prehabilitation in South Korea. The figure illustrates a stepwise strategy for identifying and overcoming barriers at the government, hospital, healthcare professional, and patient/family levels, based on South Korea’s unique healthcare system and socio-cultural context. VBHC: Value-Based Health Care, EBM: evidence-based medicine.

Government

South Korea’s healthcare system, established through government-led initiatives in the 1960s and 1970s, has evolved into a dual structure with limited financial resources. Approximately 90–95% of the healthcare services are provided by private institutions operating under the National Health Insurance Service (NHIS), a single, compulsory system regulated by the Ministry of Health and Welfare [109]. To maintain affordability and accessibility, ensuring benefits for all citizens, the government implemented a low reimbursement policy and introduced coinsurance with private health insurance. However, this has led to unintended consequences. Hospitals, facing financial pressure under the fee-for-service (FFS) system, often increase service volume and promote non-covered services like cosmetic procedures, advanced screenings, and treatments lacking strong evidence. Additionally, the expansion of private insurance since 2007 has fueled demand for unnecessary tests and treatments, contributing to inefficient healthcare spending [110]. Consequently, the practice of evidence-based medicine (EBM) remains limited in this environment.

Another significant barrier to EBM adoption in South Korea is the high prevalence of medical malpractice litigation. Compared to other countries, South Korea reports a far greater number of malpractice cases, with an average of 754.8 prosecutions annually; 14.7 times higher than Japan, 580.6 times higher than the UK, and 26.6 times higher than Germany [111]. This heightened legal risk has led to excessive defensive medicine practices that are not aligned with EBM.

Addressing these challenges requires collaborative efforts from the government and medical institutions to establish and promote evidence-based perioperative guidelines [112]. Such guidelines can enhance patient outcomes and provide legal support for clinical decisions, reducing litigation risks. Additionally, introducing an alternative payment model that considers both the quantity and quality of medical services is essential. A Value-Based Health Care (VBHC) system that incentivizes improved patient outcomes, essential medical services, and multidisciplinary care could shift the focus away from the volume-driven FFS system. Developing a VBHC model tailored to South Korea’s healthcare landscape would encourage physicians to prioritize complex patient cases, preventive care, and multidisciplinary management, ultimately improving overall healthcare quality.

Additionally, the government can encourage private insurance companies to implement incentive programs that provide financial benefits to patients who undergo ERAS and prehabilitation. Numerous studies have demonstrated that these programs effectively reduce LOS and complications [41,42,44]. More recently, increasing evidence suggests that they also contribute to lowering overall healthcare costs [93,94]. By incorporating such incentives, patients with private insurance would have greater awareness of ERAS and prehabilitation, increasing their access to these beneficial services.

The government can expand the Health Behavior Support Payment Program currently offered by the NHIS to surgical patients (https://www.nhis.or.kr/nhis/healthin/healthIncvInt.do). This program encourages individuals to proactively engage in healthy behaviors (such as walking, smoking cessation, blood pressure control, blood sugar control, and counseling/education), and points are awarded based on the level of participation and improvement. The points can be used for medical expenses or the purchase of health-related products. Similarly, if points were awarded to surgical patients participating in prehabilitation programs, it could increase participation and adherence, and improve postoperative recovery. Furthermore, patients can continue participating in the Health Behavior Support Payment Program after surgery that may help support the long-term maintenance of healthy lifestyle habits.

Hospitals

As hospitals grow larger and specialties become more segmented, surgical patients often face challenges in scheduling appointments with multiple departments that can be particularly burdensome for high-risk patients with multiple comorbidities. In cases where both surgical risk assessment and attenuation are needed quickly, early evaluation becomes crucial. Integrating a prehabilitation clinic within a preoperative clinic is an ideal approach [7,99].

Although South Korean hospitals are generally well-equipped, there is a noticeable shortage of multidisciplinary clinics where specialists from various fields, such as internists, anesthesiologists, surgeons, physiotherapists, and nutritionists, collaborate effectively. Establishing multidisciplinary clinics is challenging not only due to the lack of dedicated spaces but also the difficulty in securing specialized personnel. A recent survey of major hospitals in South Korea highlighted the scarcity of physiotherapists, nurses, and doctors as a key barrier to implementing ERAS programs that require similar multidisciplinary coordination as multimodal prehabilitation [17].

Decisions on resource allocation rely on evidence and cost-effectiveness data that may take time to gather. While multimodal prehabilitation has shown significant benefits, even unimodal approaches like exercise or nutritional support have outperformed usual care [45]. Starting with cost-effective programs such as unimodal or home-based prehabilitation during the data collection phase would be a practical step before fully investing in multimodal prehabilitation [96].

Even if prehabilitation is implemented, healthcare professionals may resist changing their practices. To overcome this, hospital-level efforts are essential to facilitate the transition [113]. Promoting and educating staff on the goals and benefits of multimodal prehabilitation is key. The shift from traditional postoperative outcome measures to PROs, reflecting functional recovery and quality of life, should be emphasized to gain medical professionals’ support. Additionally, establishing incentive systems for team-based care and quality engagement is necessary [114,115].

Healthcare professionals

The absence of established ERAS programs in South Korea further complicates the adoption of prehabilitation compared to countries where ERAS protocols are already in place. Implementing prehabilitation in this context demands additional time and effort to develop the necessary infrastructure and foster interdisciplinary collaboration. An encouraging development is the recent initiative by the Korean Ministry of Health and Welfare, in partnership with the Korean Society of Anesthesiologists and the Korean Surgical Society. Together, they have established a cooperative framework aimed at institutional improvements and have agreed to propose a pilot project introducing new incentive fees based on ERAS performance [18]. To further facilitate these efforts, healthcare professionals should actively participate in developing national guidelines for ERAS and prehabilitation, as well as take the lead in informing and educating their peers about these practices [107].

South Korea’s traditional Confucian culture has deeply ingrained hierarchical relationships based on age and rank. In such environments, it is common for directives to flow top-down, with limited room for open dialogue, even among professionals within the same field [116,117]. Furthermore, horizontal discussions between physicians and other healthcare professionals who assist in patient care often remain challenging. This rigid hierarchy can lead to conflicts among team members, hinder effective communication, and ultimately delay seamless patient care and timely treatment interventions.

To address these issues, fostering open communication through regular interdisciplinary meetings and encouraging feedback can create a more inclusive and collaborative environment. Establishing clear guidelines that define roles and responsibilities will further promote mutual understanding and respect among healthcare professionals [118]. Additionally, leadership and communication training programs can provide healthcare professionals with the necessary skills to engage in respectful dialogue and collaborative decision-making, thereby reducing hierarchical barriers and improving overall patient care [119].

Patients and their families

Multimodal prehabilitation requires active patient engagement that is influenced by three key domains: capability (psychological, physical), opportunity (physical, social), and motivation (automatic, reflective) [120]. Barriers to participation include a lack of information from healthcare professionals, limited awareness of prehabilitation, physical symptoms, comorbidities, financial constraints, and insufficient social support. These challenges often disproportionately affect high-risk patients who could benefit the most. To overcome these obstacles, healthcare professionals should provide personalized and adaptable programs, offering clear information, guidance, and continuous support. For those facing logistical or financial difficulties, home- or community-based prehabilitation and technology-based online programs present practical alternatives, with evidence supporting their effectiveness [96,97]. Facilitating patient participation in familiar environments can enhance adherence, promote long-term behavioral changes, and contribute to sustained postoperative benefits.

South Korea’s family-centered culture highlights the potential benefits of adopting multimodal prehabilitation programs. Medical decisions are often made collectively, with family members playing a significant caregiving role despite the sacrifices involved, viewing it as a moral obligation [121]. While Western societies are increasingly embracing relational autonomy, acknowledging the influence of social relationships on decision-making [122], this concept is already deeply embedded in Korean culture. Family involvement has been shown to enhance patient adherence to diet and exercise, reducing participation barriers and improving outcomes [123,124]. By providing financial, logistical, and emotional support, family members can further facilitate patient engagement in multimodal prehabilitation.

Conclusion

Multimodal prehabilitation aims to improve the preoperative functional capacity of surgical patients during the preoperative period that is considered an optimal teachable moment. By enhancing physiological reserve through exercise training, nutritional support, and psychological preparation, prehabilitation contributes to better management of surgical stress, faster recovery, and long-term maintenance of healthy behaviors. Although multiple studies have shown promising results, the overall certainty of the evidence remains of low to moderate due to heterogeneity and methodological limitations. Furthermore, research on the cost-effectiveness of these programs that is of interest to decision-makers is still lacking. More studies addressing these gaps are necessary.

The article introduces MPOP, one of the most successful prehabilitation programs globally. While benchmarking successful programs is important, it is equally crucial to adapt these programs to fit the specific medical systems and socio-cultural contexts of different regions. In South Korea, challenges such as a dual medical system, difficulties in implementing EBM, incomplete integration of preoperative clinics and ERAS programs, and hierarchical cultural norms hinder implementation. Nevertheless, several small but feasible interventions, such as brief preoperative nutrition consultations, simple home-based exercise programs, or the use of prehabilitation screening checklists in pre-anesthesia clinic, can serve as practical starting points. These efforts may help familiarize healthcare providers with multimodal prehabilitation and create momentum for broader implementation. Moving forward, building awareness among clinicians, piloting scalable models, and fostering multi-stakeholder collaboration will be key to advancing multimodal prehabilitation in South Korea.

Notes

Funding

None.

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Data Availability

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Author Contributions

Ah-Reum Cho (Conceptualization; Investigation; Methodology; Software; Visualization; Writing – original draft; Writing – review & editing)

Wariya Vongchaiudomchoke (Investigation; Validation; Writing – review & editing)

Detlef Balde (Investigation; Validation; Writing – review & editing)

Do Jun Kim (Investigation; Validation; Writing – review & editing)

Francesco Carli (Conceptualization; Methodology; Resources; Supervision; Writing – review & editing)

Supplementary Material

Supplementary Material 1.

Referral form for prehabilitation clinic.

kja-25320-Supplementary-Material-1.pdf

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