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Towards a common definition of surgical prehabilitation: a scoping review of randomised trials. BACKGROUND: There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition. METHODS: The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis. RESULTS: We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is 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.' CONCLUSIONS: A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

We conducted a scoping review to synthesise a common definition of surgical prehabilitation. This review was performed in accordance with the framework suggested by Arksey and O'Malley12 and recommendations of Levac and colleagues,13 which include the following five essential steps: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarising, and reporting the results. A multidisciplinary team composed of prehabilitation health researchers and practitioners designed, charted, analysed, and interpreted the results of this study. Reporting of our findings followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.14 A detailed description of the methodology, including the search strategy, study selection, and data charting has been published.15,16 The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across RCTs and (2) consolidate a common definition for future research.

We conducted a scoping review to synthesise a common definition of surgical prehabilitation. This review was performed in accordance with the framework suggested by Arksey and O'Malley12 and recommendations of Levac and colleagues,13 which include the following five essential steps: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarising, and reporting the results. A multidisciplinary team composed of prehabilitation health researchers and practitioners designed, charted, analysed, and interpreted the results of this study. Reporting of our findings followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.14 A detailed description of the methodology, including the search strategy, study selection, and data charting has been published.15,16 The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across RCTs and (2) consolidate a common definition for future research. We focused our search on published ‘prehabilitation’ labelled (in title, abstract or keywords) trials, in which the participants were randomised to different groups (independent of the type and method of randomisation). Prehabilitation labelled trials were then included if the following working definition of prehabilitation was met15, 16, 17, 18, 19: unimodal intervention consisting of exercise, nutrition, or psychological support, or a multimodal intervention that includes exercise, nutrition, or psychological support with or without other interventions, undertaken for ≥7 days before surgery to optimise a patient's preoperative condition and improve postoperative outcomes. The search strategy was developed by a librarian (GG; Supplementary Appendix 1). The first search was conducted on March 25, 202215 and was updated using the same strategy and with the same librarian on February 22, 2023. Six bibliographic databases were searched: MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. No date restrictions were applied. The reference lists of relevant systematic reviews and narrative reviews were hand searched for additional relevant articles.

y and with the same librarian on February 22, 2023. Six bibliographic databases were searched: MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. No date restrictions were applied. The reference lists of relevant systematic reviews and narrative reviews were hand searched for additional relevant articles. Two independent reviewers used the Rayyan web application (www.rayyan.ai; Rayyan Systems Inc., Cambridge, MA, USA) to screen titles and abstracts for inclusion (in the initial search DE and GDT, for the updated search CG and CFG). Studies were considered for the full-text review if the following criteria were met: (1) studies delivering a ‘prehabilitation’ labelled programme before surgery for adult patients (aged ≥18 yr) and in accordance with the aforementioned definition, and (2) were primary RCTs (including pilot and feasibility RCTs) with interventions lasting at least 7 days (a period consistent with enhanced recovery after surgery initiatives, not prehabilitation). Exclusion criteria were narrative reviews, editorials, systematic reviews, meta-analyses, scoping reviews, pooled analyses, secondary analyses, study protocols, consensus guidelines, conference abstracts, publications not in English or French, and isolated medical treatments (e.g. medication management alone). The full-text review was performed independently (in the initial search by DE and GDT, for the updated search by CG and CFG). All disagreements between reviewers were addressed by discussion until a consensus was reached.

ions not in English or French, and isolated medical treatments (e.g. medication management alone). The full-text review was performed independently (in the initial search by DE and GDT, for the updated search by CG and CFG). All disagreements between reviewers were addressed by discussion until a consensus was reached. Charting of the data (CFG and NB) included baseline study characteristics (author, year of publication, surgical speciality, and cancer type) published elsewhere.16 Intervention characteristics along with explicit and implicit definitions of surgical prehabilitation were extracted from the main manuscript and entered into the data charting sheet (MS Excel 2010, Microsoft, Redmond, WA, USA).

(author, year of publication, surgical speciality, and cancer type) published elsewhere.16 Intervention characteristics along with explicit and implicit definitions of surgical prehabilitation were extracted from the main manuscript and entered into the data charting sheet (MS Excel 2010, Microsoft, Redmond, WA, USA). Intervention characteristics and definition components were quantified using counts and proportions. The qualitative text was analysed by two independent coders (CFG and NB) using summative content analysis, which involves familiarisation with the text; coding, counting, and comparisons of codes; and interpretation of the underlying meaning of the content.20,21 Definition components, as words or small phrases, were assigned codes using two approaches: pre-determined codes (i.e. deductive approach) and ‘ground-up’ codes based on the data set (i.e. inductive approach).20 The occurrence of each identified code was tabulated.20 Investigator and method triangulation was used to ensure the trustworthiness of the analysis by reducing the influence of individual biases.22 That is, two independent coders and two content analysis approaches (inductive and deductive) were used to form the common definition. The first coder used an inductive coding strategy that prioritised the most prevalent keywords in the explicit and implicit definitions provided by the study authors.20 Codes with similar meanings were grouped under an overarching category.21 The categories with ≥10 counts were included in the final inductive definition, representing the most frequently stated words of each category. The threshold of 10 counts was pre-specified (arbitrarily) to denote commonality across trials. The second coder used a deductive approach by pre-specifying important categories before analysis (purpose or goal, descriptor of the intervention, intervention type, timing, and target population) guided by the Template for Intervention Description and Replication (TIDieR) reporting guidelines for interventions.23 In the deductive approach, the TIDieR framework was prioritised regardless of the frequency of the individual codes. The inductive and deductive definitions were then compared to form a consolidated extensional definition (i.e. lists all things that are applicable to the defined subject) that represents typical surgical prehabilitation programmes.24

We conducted a scoping review to synthesise a common definition of surgical prehabilitation. This review was performed in accordance with the framework suggested by Arksey and O'Malley12 and recommendations of Levac and colleagues,13 which include the following five essential steps: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarising, and reporting the results. A multidisciplinary team composed of prehabilitation health researchers and practitioners designed, charted, analysed, and interpreted the results of this study. Reporting of our findings followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.14 A detailed description of the methodology, including the search strategy, study selection, and data charting has been published.15,16

We focused our search on published ‘prehabilitation’ labelled (in title, abstract or keywords) trials, in which the participants were randomised to different groups (independent of the type and method of randomisation). Prehabilitation labelled trials were then included if the following working definition of prehabilitation was met15, 16, 17, 18, 19: unimodal intervention consisting of exercise, nutrition, or psychological support, or a multimodal intervention that includes exercise, nutrition, or psychological support with or without other interventions, undertaken for ≥7 days before surgery to optimise a patient's preoperative condition and improve postoperative outcomes. The search strategy was developed by a librarian (GG; Supplementary Appendix 1). The first search was conducted on March 25, 202215 and was updated using the same strategy and with the same librarian on February 22, 2023. Six bibliographic databases were searched: MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. No date restrictions were applied. The reference lists of relevant systematic reviews and narrative reviews were hand searched for additional relevant articles.

Two independent reviewers used the Rayyan web application (www.rayyan.ai; Rayyan Systems Inc., Cambridge, MA, USA) to screen titles and abstracts for inclusion (in the initial search DE and GDT, for the updated search CG and CFG). Studies were considered for the full-text review if the following criteria were met: (1) studies delivering a ‘prehabilitation’ labelled programme before surgery for adult patients (aged ≥18 yr) and in accordance with the aforementioned definition, and (2) were primary RCTs (including pilot and feasibility RCTs) with interventions lasting at least 7 days (a period consistent with enhanced recovery after surgery initiatives, not prehabilitation). Exclusion criteria were narrative reviews, editorials, systematic reviews, meta-analyses, scoping reviews, pooled analyses, secondary analyses, study protocols, consensus guidelines, conference abstracts, publications not in English or French, and isolated medical treatments (e.g. medication management alone). The full-text review was performed independently (in the initial search by DE and GDT, for the updated search by CG and CFG). All disagreements between reviewers were addressed by discussion until a consensus was reached.

Charting of the data (CFG and NB) included baseline study characteristics (author, year of publication, surgical speciality, and cancer type) published elsewhere.16 Intervention characteristics along with explicit and implicit definitions of surgical prehabilitation were extracted from the main manuscript and entered into the data charting sheet (MS Excel 2010, Microsoft, Redmond, WA, USA).

Our search identified 1257 unique articles (Fig. 1). After the abstract screening, 149 articles were suitable for the full-text review. A total of 79 articles were excluded because of publication type (n=36), population (n=13), study design (n=9), additional duplicates (n=17), language (n=2), and intervention type (n=2), leaving 70 articles. Hand searching produced six additional articles. A total of 76 articles were thus included in the final review.5,8,25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98Fig 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.Fig 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Our search identified 1257 unique articles (Fig. 1). After the abstract screening, 149 articles were suitable for the full-text review. A total of 79 articles were excluded because of publication type (n=36), population (n=13), study design (n=9), additional duplicates (n=17), language (n=2), and intervention type (n=2), leaving 70 articles. Hand searching produced six additional articles. A total of 76 articles were thus included in the final review.5,8,25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98Fig 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.Fig 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. A total of 76 RCTs met the inclusion criteria.16 Trials included abdominal (26/76, 34%), orthopaedic and spinal (24/76, 32%), thoracic (14/76, 18%), cardiac (7/76, 9%), and other types (5/76, 7%) of surgeries. Surgical prehabilitation was explicitly defined in more than one-half of the RCTs (42/76, 55%; Table 1). Trials that did not report an explicit definition provided an explicit description of the intervention such as ‘ … maintaining good exercise capacity using aerobic and inspiratory muscle training program’75 or ‘short-term HIIT program was intended to augment preoperative physiological reserves and to facilitate postoperative functional recovery’.57 More than one-half of the explicit definitions (n=42) were from exercise-only trials (22/42, 52%) and about one-third originated from multimodal intervention trials (15/42, 36%). Together, nutritional-only and psychological-only prehabilitation accounted for 12% (5/42) of the RCTs providing an explicit definition. One-half of the trials with an explicit definition stemmed from the oncology literature (21/42). Only 14% (6/42) and 5% (2/42) of definitions were derived from RCTs of thoracic and cardiac surgical populations, respectively.Table 1Baseline study characteristics.Table 1CharacteristicsNumber of trials (n=76), n (%)Trials with an explicit definition (n=42), n (%)Type of prehabilitation program Exercise only41 (54)22 (52) Multimodal25 (33)15 (36) Nutrition only3 (4)2 (5) Psychological support only3 (4)3 (7) Respiratory only3 (4)0 (0) Pelvic floor training only1 (1)0 (0)Population included Oncological surgery35 (46)21 (50) Non-oncological surgery33 (43)17 (41) Mixed cohort8 (11)4 (10)Type of surgical population Abdominal surgery26 (34)18 (43) Orthopaedic and spinal surgeries24 (32)14 (33) Thoracic surgery14 (18)6 (14) Cardiac surgery7 (9)2 (5) Other surgeries∗5 (7)2 (5)∗Including breast-only and mixed cohorts.

gical surgery35 (46)21 (50) Non-oncological surgery33 (43)17 (41) Mixed cohort8 (11)4 (10)Type of surgical population Abdominal surgery26 (34)18 (43) Orthopaedic and spinal surgeries24 (32)14 (33) Thoracic surgery14 (18)6 (14) Cardiac surgery7 (9)2 (5) Other surgeries∗5 (7)2 (5)∗Including breast-only and mixed cohorts. Baseline study characteristics. ∗Including breast-only and mixed cohorts.

gical surgery35 (46)21 (50) Non-oncological surgery33 (43)17 (41) Mixed cohort8 (11)4 (10)Type of surgical population Abdominal surgery26 (34)18 (43) Orthopaedic and spinal surgeries24 (32)14 (33) Thoracic surgery14 (18)6 (14) Cardiac surgery7 (9)2 (5) Other surgeries∗5 (7)2 (5)∗Including breast-only and mixed cohorts. Baseline study characteristics. ∗Including breast-only and mixed cohorts. For both inductive and deductive qualitative methods, identified categories and predominant codes across all explicit definitions and descriptions are shown in Table 2. Findings from the inductive approach revealed 23 different categories (i.e. codes with similar content or meaning). Nearly three-quarters (n=55) of trials included ‘physical activity’ in their definition and used the codes ‘exercise/exercise therapy’ (n=25, 33%) most often. Forty-two percent (n=32) of trials used a ‘descriptor of prehabilitation’ category with the most prevalent code being ‘intervention’ (n=16, 21%). The category of ‘increasing function’ was reported in more than one-third (n=28, 37%) of trials with the code ‘enhance functional capacity’ being the most prevalent (n=17, 22%). When using the deductive approach, similar results were observed: the codes ‘enhance functional capacity/aerobic capacity/physical fitness’ (n=28, 37%) and ‘exercise’ (n=42, 55%) were also the most frequently reported (after the code ‘preoperative’). Ten inductive categories were excluded from the definition as they were infrequently (<10 counts) reported, including ‘rehabilitation’, ‘treatment benefits’, ‘cost’, ‘attenuate deterioration’, ‘education’, ‘medical management’, and ‘lifestyle modification’. The two qualitative approaches produced separate definitions (Table 3). There were two discrepancies observed between the inductively and deductively derived definitions: the inductive definition did not include medical optimisation nor education. As medical optimisation and education categories were reported rarely (n=5, 7% and n=3, 4%, respectively) across the 76 trials, these uncommon codes did not meet the proposed criteria for the inductive definition.

uctively derived definitions: the inductive definition did not include medical optimisation nor education. As medical optimisation and education categories were reported rarely (n=5, 7% and n=3, 4%, respectively) across the 76 trials, these uncommon codes did not meet the proposed criteria for the inductive definition. Figure 2 represents the most frequently reported codes of each category across trials using the inductive method.Table 2Identified inductive and deductive categories and their most reported codes using a summative content analysis approach.Table 2CategoryTotal category count and frequency∗ (n=76), n (%)Most reported code(s)Code count and frequency† (n=76), n (%)Inductive approach Surgical period74 (97)Preoperative37 (49) Physical activity55 (72)Exercise/exercise training25 (33) Descriptor of prehabilitation32 (42)Intervention16 (21) Increase function28 (37)Enhance/improve/augment functional capacity17 (22) Withstand stress20 (26)Withstand a stressful event/stressor of surgery11 (15) Continuous (from diagnosis to treatment)18 (24)Process12 (16) Improve reserve18 (24)Enhance/increase/optimise physiological reserve8 (11) Optimise nutrition13 (17)Nutrition/nutrition support6 (8) Delivery modal13 (17)Multimodal6 (8) Improve outcomes11 (15)Improve postoperative outcomes4 (5) Respiratory training10 (13)Pulmonary rehabilitation3 (4)Inspiratory muscle training3 (4) Psychological10 (13)Anxiety-reducing strategies2 (3)Psychological intervention2 (3)Reduce stress and anxiety2 (3) Recovery10 (13)Facilitate recovery of functional capacity2 (3) Rehabilitation7 (9)Rehabilitation4 (5) Medical optimisation5 (7)Optimisation of medical conditions1 (1)Smoking cessation1 (1)Medical support1 (1)Medical management1 (1)Weight loss1 (1) Treatment benefits4 (5)Benefits/beneficial effect3 (4) Attenuate deterioration4 (5)Reduce patient disability1 (1)Reduce the incidence or severity of future impairments1 (1)Ameliorate the post-surgical physiologic deterioration1 (1)Prevent or attenuate functional decline1 (1) Behavioural support4 (5)Behavioural support2 (3) Education3 (4)Education/education program3 (4) Personalised to population3 (4)For patients with lower fitness1 (1)Varies according to context and the patient's needs1 (1)Older patients with frailty1 (1) Baseline function2 (3)Establish a baseline functional level1 (1)Identify impairments1 (1) Cost1 (1)Reduce financial burden on the health system1 (1) Lifestyle modification1 (1)Lifestyle modification1 (1)Deductive approach Purpose/goal104

according to context and the patient's needs1 (1)Older patients with frailty1 (1) Baseline function2 (3)Establish a baseline functional level1 (1)Identify impairments1 (1) Cost1 (1)Reduce financial burden on the health system1 (1) Lifestyle modification1 (1)Lifestyle modification1 (1)Deductive approach Purpose/goal104 (137)Enhance functional capacity/aerobic capacity/physical fitness28 (37)Improve postoperative outcomes17 (22)Combat surgical stressors15 (20) Intervention type77 (101)Exercise/physical activity42 (55)Nutrition12 (16)Psychological7 (9)Medical optimisation5 (7)Education3 (4) Timing51 (67)Before surgery/preoperative47 (62) Descriptor47 (62)Program14 (18)Process12 (16)Intervention8 (11) Target population4 (5)Patients with lower preoperative fitness1 (1)Older patients with frailty1 (1)Individualised to patients' needs and context1 (1)Surgical patients1 (1)∗Total category count and frequency: number of times codes within a specific category was reported across 76 trials.

Process12 (16)Intervention8 (11) Target population4 (5)Patients with lower preoperative fitness1 (1)Older patients with frailty1 (1)Individualised to patients' needs and context1 (1)Surgical patients1 (1)∗Total category count and frequency: number of times codes within a specific category was reported across 76 trials. †Total code count and frequency: number of times a code was reported across 76 trials; studies may report multiple codes in one category.Table 3Surgical prehabilitation definitions using inductive and deductive qualitative approaches. TiDER: Template for Intervention Description and Replication.Table 3MethodDefinitionInductive qualitative approach using the most common keywords‘Prehabilitation is a process from diagnosis to treatment that consists of an unimodal or multimodal preoperative intervention including exercise, nutrition, psychological strategies and/or respiratory training, and aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes and facilitate recovery.’Deductive qualitative approach using the TiDER checklist‘Prehabilitation can be defined as a program delivered prior to surgery that may consist of a number of interventions including exercise therapy, nutritional optimisation, psychological strategies, respiratory training, medical optimisation, and education, and aims to enhance functional capacity and physiological reserve to allow a patient to withstand surgical stressors and improve postoperative outcomes.’Proposed common definition‘Prehabilitation is 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.’Fig 2Word cloud using an inductive qualitative approach to define surgical prehabilitation. The scaling of each code is proportional to the number of times it was reported across the 76 trials included.Fig 2

erve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.’Fig 2Word cloud using an inductive qualitative approach to define surgical prehabilitation. The scaling of each code is proportional to the number of times it was reported across the 76 trials included.Fig 2 Identified inductive and deductive categories and their most reported codes using a summative content analysis approach. ∗Total category count and frequency: number of times codes within a specific category was reported across 76 trials. †Total code count and frequency: number of times a code was reported across 76 trials; studies may report multiple codes in one category. Surgical prehabilitation definitions using inductive and deductive qualitative approaches. TiDER: Template for Intervention Description and Replication. Word cloud using an inductive qualitative approach to define surgical prehabilitation. The scaling of each code is proportional to the number of times it was reported across the 76 trials included.

A total of 76 RCTs met the inclusion criteria.16 Trials included abdominal (26/76, 34%), orthopaedic and spinal (24/76, 32%), thoracic (14/76, 18%), cardiac (7/76, 9%), and other types (5/76, 7%) of surgeries. Surgical prehabilitation was explicitly defined in more than one-half of the RCTs (42/76, 55%; Table 1). Trials that did not report an explicit definition provided an explicit description of the intervention such as ‘ … maintaining good exercise capacity using aerobic and inspiratory muscle training program’75 or ‘short-term HIIT program was intended to augment preoperative physiological reserves and to facilitate postoperative functional recovery’.57 More than one-half of the explicit definitions (n=42) were from exercise-only trials (22/42, 52%) and about one-third originated from multimodal intervention trials (15/42, 36%). Together, nutritional-only and psychological-only prehabilitation accounted for 12% (5/42) of the RCTs providing an explicit definition. One-half of the trials with an explicit definition stemmed from the oncology literature (21/42). Only 14% (6/42) and 5% (2/42) of definitions were derived from RCTs of thoracic and cardiac surgical populations, respectively.Table 1Baseline study characteristics.Table 1CharacteristicsNumber of trials (n=76), n (%)Trials with an explicit definition (n=42), n (%)Type of prehabilitation program Exercise only41 (54)22 (52) Multimodal25 (33)15 (36) Nutrition only3 (4)2 (5) Psychological support only3 (4)3 (7) Respiratory only3 (4)0 (0) Pelvic floor training only1 (1)0 (0)Population included Oncological surgery35 (46)21 (50) Non-oncological surgery33 (43)17 (41) Mixed cohort8 (11)4 (10)Type of surgical population Abdominal surgery26 (34)18 (43) Orthopaedic and spinal surgeries24 (32)14 (33) Thoracic surgery14 (18)6 (14) Cardiac surgery7 (9)2 (5) Other surgeries∗5 (7)2 (5)∗Including breast-only and mixed cohorts.

For both inductive and deductive qualitative methods, identified categories and predominant codes across all explicit definitions and descriptions are shown in Table 2. Findings from the inductive approach revealed 23 different categories (i.e. codes with similar content or meaning). Nearly three-quarters (n=55) of trials included ‘physical activity’ in their definition and used the codes ‘exercise/exercise therapy’ (n=25, 33%) most often. Forty-two percent (n=32) of trials used a ‘descriptor of prehabilitation’ category with the most prevalent code being ‘intervention’ (n=16, 21%). The category of ‘increasing function’ was reported in more than one-third (n=28, 37%) of trials with the code ‘enhance functional capacity’ being the most prevalent (n=17, 22%). When using the deductive approach, similar results were observed: the codes ‘enhance functional capacity/aerobic capacity/physical fitness’ (n=28, 37%) and ‘exercise’ (n=42, 55%) were also the most frequently reported (after the code ‘preoperative’). Ten inductive categories were excluded from the definition as they were infrequently (<10 counts) reported, including ‘rehabilitation’, ‘treatment benefits’, ‘cost’, ‘attenuate deterioration’, ‘education’, ‘medical management’, and ‘lifestyle modification’. The two qualitative approaches produced separate definitions (Table 3). There were two discrepancies observed between the inductively and deductively derived definitions: the inductive definition did not include medical optimisation nor education. As medical optimisation and education categories were reported rarely (n=5, 7% and n=3, 4%, respectively) across the 76 trials, these uncommon codes did not meet the proposed criteria for the inductive definition.

Currently, there is no standardised, universally accepted definition for surgical prehabilitation. Harmonised definitions in clinical research give rise to more robust evidence by facilitating the use of consistent designs, interventions, and reported outcomes, which can improve the pooling of data for future meta-analysis, leading to higher levels of evidence certainty.11 In fact, scoping reviews of surgical prehabilitation intervention15 and outcome reporting16 reveal significant heterogeneity, and this lack of consensus has impeded the ability to draw strong conclusions regarding the effectiveness of surgical prehabilitation.11 Given that prehabilitation is a complex intervention99, involving different components, targeted behaviours, and levels of provider expertise, consolidating a definition is an important step to inform standardised and rigorous research. Ultimately, the adoption of a common intervention definition, in addition to a core outcome set, could enhance the ability to develop, evaluate, and implement preoperative interventions that support optimal patient recovery after surgery.11 As a first step towards standardisation, this scoping review proposes a common extensional definition of surgical prehabilitation, developed by qualitatively triangulating and synthesising prehabilitation definitions across 76 primary RCTs.

eoperative interventions that support optimal patient recovery after surgery.11 As a first step towards standardisation, this scoping review proposes a common extensional definition of surgical prehabilitation, developed by qualitatively triangulating and synthesising prehabilitation definitions across 76 primary RCTs. Using both inductive and deductive approaches, we identified consistent surgical prehabilitation components across 76 trials, including timing (before surgery), modalities (exercise, nutrition, psychological, and respiratory training), and objectives (enhancing functional capacity and physiological reserve to improve outcomes and recovery), which inform our proposed common definition. Given the heterogeneity of the included study interventions and definitions, our proposed definition should be seen as an initial step towards the foundational work required to finalise a widely accepted definition that can be adopted internationally by the multidisciplinary and intersectoral field of prehabilitation.

Given the heterogeneity of the included study interventions and definitions, our proposed definition should be seen as an initial step towards the foundational work required to finalise a widely accepted definition that can be adopted internationally by the multidisciplinary and intersectoral field of prehabilitation. We acknowledge that uncertainty and possible controversy remain about whether medical optimisation100,101 and education are components of surgical prehabilitation interventions. Our findings suggest that these components are not common interventions in prehabilitation. That said, the modalities included in our proposed definition might be enhanced by medical optimisation (e.g. anaemia correction) and inherently involve modality-specific education102 (i.e. education or counselling related to anxiety management, nutrition, exercise, and breathing techniques). The exclusion of ‘medical optimisation’ and broad ‘education’ across trials of prehabilitation, and therefore our proposed definition, might reflect the distinct nature of prehabilitation modalities. For example, medical optimisation (and the related concept of medical clearance) and preoperative education (e.g. procedure-specific logistics, expectations of surgery, carbohydrate loading) are well-established and long-standing practices, often led by perioperative care clinicians (anaesthesiologists, surgeons, internal medicine specialists, nurses, or others) as part of standard care, independent of prehabilitation.103 Conceptually, the prehabilitation modalities included in our definition would be expected to supplement and occur in parallel with medical optimisation and preoperative education. Prehabilitation interventions focus primarily on healthcare professionals supporting change in patient behaviours with the specific purpose of building physiological reserve and psychological resilience before surgery. In contrast, surgery-specific medical optimisation focuses on healthcare professional-supported optimisation of long-term health conditions primarily involving pharmacological interventions and devices (e.g.

aviours with the specific purpose of building physiological reserve and psychological resilience before surgery. In contrast, surgery-specific medical optimisation focuses on healthcare professional-supported optimisation of long-term health conditions primarily involving pharmacological interventions and devices (e.g. diabetes mellitus control, blood pressure management, anaemia management, sleep apnoea diagnosis and management).103 Furthermore, medical optimisation is embedded within Enhanced Recovery After Surgery programmes.104 Education is also one of the pillars of Enhanced Recovery After Surgery programs, which are well-established, evidence-based perioperative care improvement interventions that are already embedded within surgical pathways.104,105 These education programmes provide information about the planned procedure, pain management, early mobilisation, and establishment of oral intake. The infrequent reporting of education and medical optimisation in prehabilitation trials may thus reflect that these interventions are already viewed as part of the routine perioperative pathway in many centres. Prehabilitation, by our definition, is complementary to the existing surgical preparation pathways inclusive of risk stratification, shared decision-making, medical optimisation, and patient education, and aims to confer additional benefits by improving both patient experience and postoperative outcomes.106 It is possible that sites lacking standardised medical optimisation and patient education services were more inclined to include these components in their definition of prehabilitation. Ultimately, broad collaboration between patients, clinicians, researchers, and health system leaders internationally, informed by robust knowledge synthesis, will be required to achieve a widely accepted definition.

ducation services were more inclined to include these components in their definition of prehabilitation. Ultimately, broad collaboration between patients, clinicians, researchers, and health system leaders internationally, informed by robust knowledge synthesis, will be required to achieve a widely accepted definition. The common definition produced from this scoping review is not without limitations. Firstly, the definition has been generated using only published definitions (in English and French), meaning it is limited to commonly reported components of surgical prehabilitation trials, which does not necessarily reflect validity nor consensus. Secondly, we must acknowledge that the cutoff of 10 used to denote commonality in the inductive summative content analysis was arbitrary and led to the exclusion of two modalities that remained in the deductive approach: medical optimisation (n=5) and education (n=3). A consultation exercise is required to achieve consensus in support of the inclusion or exclusion of medical optimisation and broad education as part of surgical prehabilitation. Thirdly, as observed in Figure 2, the consolidated definition is limited by the historical perspective of prehabilitation that has been predominantly described as ‘preoperative exercise’ even though multimodal models in cancer and surgery have expanded beyond exercise therapy alone.107 Fourthly, the trials that reported explicit definitions (n=42, 55%) were mainly from abdominal, orthopaedic, and spinal specialities; therefore, this common definition might not reflect the priorities of other surgery types. Given that the goal of this scoping review was to describe how surgical prehabilitation is currently being defined, we did not additionally consult a group of experts in the prehabilitation field for further input and consensus. We suggest that the next step is to consult international stakeholders and experts in the field to ensure the development of a comprehensive and globally accepted definition.

tion is currently being defined, we did not additionally consult a group of experts in the prehabilitation field for further input and consensus. We suggest that the next step is to consult international stakeholders and experts in the field to ensure the development of a comprehensive and globally accepted definition. There are many distinctive published definitions for surgical prehabilitation. This scoping review consolidated the available literature to suggest a common definition using a qualitative triangulation approach. The proposed common definition is the first step towards standardisation, which is needed to guide future high-quality RCTs and advance the prehabilitation field.

Using both inductive and deductive approaches, we identified consistent surgical prehabilitation components across 76 trials, including timing (before surgery), modalities (exercise, nutrition, psychological, and respiratory training), and objectives (enhancing functional capacity and physiological reserve to improve outcomes and recovery), which inform our proposed common definition. Given the heterogeneity of the included study interventions and definitions, our proposed definition should be seen as an initial step towards the foundational work required to finalise a widely accepted definition that can be adopted internationally by the multidisciplinary and intersectoral field of prehabilitation.

The common definition produced from this scoping review is not without limitations. Firstly, the definition has been generated using only published definitions (in English and French), meaning it is limited to commonly reported components of surgical prehabilitation trials, which does not necessarily reflect validity nor consensus. Secondly, we must acknowledge that the cutoff of 10 used to denote commonality in the inductive summative content analysis was arbitrary and led to the exclusion of two modalities that remained in the deductive approach: medical optimisation (n=5) and education (n=3). A consultation exercise is required to achieve consensus in support of the inclusion or exclusion of medical optimisation and broad education as part of surgical prehabilitation. Thirdly, as observed in Figure 2, the consolidated definition is limited by the historical perspective of prehabilitation that has been predominantly described as ‘preoperative exercise’ even though multimodal models in cancer and surgery have expanded beyond exercise therapy alone.107 Fourthly, the trials that reported explicit definitions (n=42, 55%) were mainly from abdominal, orthopaedic, and spinal specialities; therefore, this common definition might not reflect the priorities of other surgery types. Given that the goal of this scoping review was to describe how surgical prehabilitation is currently being defined, we did not additionally consult a group of experts in the prehabilitation field for further input and consensus. We suggest that the next step is to consult international stakeholders and experts in the field to ensure the development of a comprehensive and globally accepted definition.

There are many distinctive published definitions for surgical prehabilitation. This scoping review consolidated the available literature to suggest a common definition using a qualitative triangulation approach. The proposed common definition is the first step towards standardisation, which is needed to guide future high-quality RCTs and advance the prehabilitation field.

Study design, analysis of the data, and writing of the manuscript (equal contribution): CFG, NB, LD, CG Creation of tables and figures: CFG Study design, interpretation of data, and meaningfully revised the final manuscript and provided expertise in the fields of prehabilitation and perioperative medicine throughout: All authors

We thank Genevieve Gore, Liaison Librarian, Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University (Montréal, QC, Canada), for her assistance with developing and conducting the search strategy for this scoping review.