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Perioperative – Improves mental health and quality of life

Improving mental health and quality of life

Evidence summary

Abdominal surgery

Three moderate quality randomised controlled trials were identified in analysing the impact of prehabilitation on anxiety and depression scores (1, 4, 9).  Two studies used the Hospital Anxiety and Depression Scale (HADS) (4, 9) and one study used the SF-36 mental health domain (MH) (1).  One moderate quality randomised control trial incorporated relaxation breathing exercises as part of a trimodal prehabilitation strategy including alternating, home-based aerobic and resistance training three days per week.  The study did not demonstrate any significant change in anxiety score between the two groups (4).  One randomised controlled trial analysed pre-operative bicycle and resistance training in the pre-operative period as part of a unimodal prehabilitation strategy.  The study demonstrated no difference in anxiety scores between prehabilitation and control subjects.  It did however demonstrate reduced anxiety scores in both groups after surgery.  Depression scores improved over the prehabilitation period for the pre-operative bicycle and muscle strengthening group [mean difference (SE) from baseline to surgery depression scores − 0·8 (0·4), p = 0.045]( 9).  A good quality randomised control trial assessed pre-operative 30-minute interval exercise on a cycle ergometer as part of a unimodal prehabilitation intervention against control subjects.  They used the SF-36 mental health scores before and after the prehabilitation period and they demonstrated significantly better scores in the setting of prehabilitation [mean difference (SD) of 12 (1, 23), p = 0⋅038), with no change observed in the subjects who received standard care.  The same study also reported on overall quality of life scores using SF-36 and demonstrated a significant improvement in quality of life in the setting of prehabilitation [mean difference (SD) of 14 (1, 27), p = 0⋅027) (1).

Quality of evidence

Grade A/B – Good to moderate quality randomised control trials

Strength of recommendation

Grade 1. Strong recommendation. 


Pre-operative exercises have a positive role in improving mental health and overall quality of life following the period of prehabilitation. Specifically, there was a role for improved depression scores in patients undergoing mixed aerobic and muscle strengthening prehabilitation.   


1. Dunne DF, Jack S, Jones RP, et al. Randomized clinical trial of prehabilitation before planned liver resection. The British journal of surgery 2016;103(5):504-12. doi: 10.1002/bjs.10096

2. Heger P, Probst P, Wiskemann J, et al. A Systematic Review and Meta-analysis of Physical Exercise Prehabilitation in Major Abdominal Surgery (PROSPERO 2017 CRD42017080366). Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2020;24(6):1375-85. doi: 10.1007/s11605-019-04287-w

3. Yamana I, Takeno S, Hashimoto T, et al. Randomized Controlled Study to Evaluate the Efficacy of a Preoperative Respiratory Rehabilitation Program to Prevent Postoperative Pulmonary Complications after Esophagectomy. Digestive surgery 2015;32(5):331-7. doi: 10.1159/000434758 [published Online First: 2015/07/18]

4. Gillis C, Li C, Lee L, et al. Prehabilitation versus REHABILITATIONA randomized control trial in patients undergoing colorectal resection for cancer. The Journal of the American Society of Anesthesiologists 2014;121(5):937-47.

5. KIm DJ MN, Carli F, Montgomery DL, Zavorsky GS. Responsive Measures to Prehabilitation in Patients Undergoing Bowel Resection Surgery. Tohoku J Exp Med 2009;217(2):109-15.

6. Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol 2018;44(7):919-26. doi: 10.1016/j.ejso.2018.04.016

7. Hijazi Y, Gondal U, Aziz O. A systematic review of prehabilitation programs in abdominal cancer surgery. International journal of surgery (London, England) 2017;39:156-62. doi: 10.1016/j.ijsu.2017.01.111

8. Chen BP, Awasthi R, Sweet SN, et al. Four-week prehabilitation program is sufficient to modify exercise behaviors and improve preoperative functional walking capacity in patients with colorectal cancer. Support Care Cancer 2017;25(1):33-40. doi: 10.1007/s00520-016-3379-8

9. Carli F, Charlebois P, Stein B, et al. Randomized clinical trial of prehabilitation in colorectal surgery. The British journal of surgery 2010;97(8):1187-97. doi: 10.1002/bjs.7102

10. Bruns ER, van den Heuvel B, Buskens CJ, et al. The effects of physical prehabilitation in elderly patients undergoing colorectal surgery: a systematic review. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2016;18(8):O267-77. doi: 10.1111/codi.13429

11. Bousquet-Dion G, Awasthi R, Loiselle SE, et al. Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial. Acta Oncol 2018;57(6):849-59. doi: 10.1080/0284186X.2017.1423180