Prepping for Success: The Three Pillars of Exercise, Nutrition, and Cognitive Training in Prehabilitation

Christian S. Guay, MD

Preparing patients for the physiological challenges of surgery represents a significant opportunity to improve outcomes. At the International Science Symposium, “Better Prepared, Better Recovered: Prehabilitation and Patient Optimization Before Surgery,” on Saturday, March 22, at the 2025 Annual Meeting, presented by IARS and SOCCA, three experts detailed complementary approaches to building patient resilience before surgical intervention, demonstrating how thoughtful preoperative preparation can significantly impact postoperative recovery.

Daniel I. McIsaac, MD, MPH, FRCPC, IARS Board Member, professor and vice chair (Research & Innovation) at University of Ottawa, and Director of Anesthesiology and Pain Medicine Research at The Ottawa Hospital, and Alexander Zarbock, MD, PHD, IARS Board Member, chair, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy at Westfälische Wilhelms University Hospital Münster, set the stage for this compelling discussion and moderated the session.

Alexander (Sandy) Jackson, MBChB, MSc, NIHR doctoral fellow, anaesthetics and intensive care doctor and clinician data scientist, at University of Southampton, began by exploring the role of exercise in prehabilitation. He started by distinguishing between physical activity — defined by the World Health Organization as “any bodily movement produced by skeletal muscles that requires energy expenditure” — and exercise, which represents “planned, structured, and repetitive activity with the objective to improve or maintain physical fitness.” Both higher physical activity and regular exercise correlate with better outcomes across numerous diseases, including cancer and heart disease.

Dr. Jackson described prehabilitation as a multimodal, personalized, needs-based intervention before and during treatment for various surgical diseases, most commonly cancer. This approach aims to improve resilience before surgery, keeping patients above critical functional thresholds despite the anticipated “insult” of surgery. Comprehensive prehabilitation programs incorporate physical activity and exercise, nutrition optimization, psychological support, and smoking and alcohol cessation. He emphasized that prehabilitation initiatives must begin well before surgery — not just days before in preanesthesia clinics — to be effective.

Research has demonstrated that preoperative exercise can help counteract the declines in maximal oxygen uptake capacity (VO₂) and six-minute walk test performance commonly seen after chemotherapy. Beyond improving fitness metrics, prehabilitation has been shown to reduce postoperative complications, enhance quality of life, and generate cost savings through shorter hospital stays. “Prehabilitation is a complex system, not a linear one,” Dr. Jackson concluded, highlighting the interplay between multiple intervention components.

Chelsia Gillis, RD, PhD, an assistant professor in the School of Human Nutrition, associate member in Surgery and Anesthesia and director of Perioperative Medical Research, Peri Operative Program at McGill University Health Center, continued the session by focusing on nutritional prehabilitation and its impact on surgical outcomes. “Malnutrition is associated with lower exercise capacity, functional capacity, and increased hospital length of stay,” Dr. Gillis explained, noting that it particularly increases the risk of postoperative infectious complications. She outlined two fundamental components of nutritional prehabilitation: avoiding malnutrition and supporting protein anabolism.

Dr. Gillis emphasized that malnutrition — defined as an unbalanced nutritional state resulting from poor food intake and/or disease that alters body mass/composition and diminishes function — cannot be identified by appearance alone. She recommended the Canadian Nutrition Screening Tool, which identifies at-risk patients by asking about unintentional weight loss in the past six months and reduced food intake for more than a week.

Intervention strategies should be stratified by risk level, ranging from standard handouts for low-risk patients to specialist interventions for high-risk individuals. Nutritional prehabilitation for at least seven days preoperatively has been shown to reduce hospital length of stay while increasing functional capacity and muscle mass. Dr. Gillis noted that resistance exercise plays an important role in the anabolic aspect of prehabilitation, while cardio exercise is typically avoided in malnourished patients.

James Jackson, PsyD, research professor of Medicine in the Division of Allergy, Pulmonary and Critical Care Medicine and director of Rehabilitation and Recovery at the Critical Illness, Brain Dysfunction, and Survivorship Center at Vanderbilt University Medical Center, concluded the session by addressing cognitive prehabilitation, which is particularly relevant for older surgical patients. “Annually, 1.4 million seniors survive the ICU,” Dr. Jackson noted, with many experiencing mild cognitive impairment that persists at three and nine months postoperatively. These impairments manifest in daily challenges with activities like driving and technology use.

Dr. Jackson distinguished between cognitive rehabilitation — therapy to improve or restore cognition after brain injury or illness — and cognitive prehabilitation, which involves brain training to enhance cognitive resilience before surgery. The latter is predicated on principles of neuroplasticity and shows growing evidence of effectiveness, particularly in reducing postoperative delirium.

Traditional cognitive prehabilitation typically employs computerized cognitive training, with attention appearing to be the cognitive domain most responsive to intervention. However, Dr. Jackson acknowledged controversy regarding whether improvements from these computerized games generalize across cognitive functions. He emphasized several practical considerations for implementation: interventions must be carefully assessed, well-tolerated by patients, reasonable in duration, and technologically feasible. Focus groups can provide valuable insight into patient preferences.

Dr. Jackson stressed the importance of the intervention “dose,” noting a typical dose-response relationship, and careful selection of cognitive outcome measures. He concluded with a pragmatic reminder that “perfect is the enemy of good” when implementing prehabilitation programs.

This comprehensive session highlighted how the integrated approach of exercise, nutrition, and cognitive prehabilitation can create a robust framework for optimizing patients before surgery, potentially transforming the trajectory of recovery and improving both short and long-term outcomes.