Relative efficacy of prehabilitation interventions and their components: systematic review with network and component network meta-analyses of randomised controlled trials

Dear Editor,

With great interest we read the well-structured and highly significant systematic review of McIsaac et al. [1] that was conducted in collaboration with stakeholders, including patients. The review serves as a valuable contribution to spark critical discussion about prehabilitation and its modalities. We would like contribute to this important discussion.

As Johan Cruijff famously said; "You only see it once you get it". This insight resonates profoundly in healthcare evaluation, especially within the complex and evolving field of prehabilitation. The quality of the design and execution of complex interventions, such as multimodal prehabilitation can vary significantly resulting in markedly different outcomes. It has been proposed that studies utilizing aggregated synthesis should not only assess methodological quality but also evaluate the quality of the interventions themselves [2].

This is a critical limitation of the otherwise robust review of McIsaac et al. As highlighted in previous research [3], the reporting of intervention details in prehabilitation trials is frequently inadequate. While their methodology is commendable, the review falls short in exploring essential aspects of the interventions, such as their design, delivery context, compliance, supervision, titration, and behavioural strategies. Given that prehabilitation programs are often short in duration, achieving optimal outcomes requires high adherence and frequent titration of training response in combination with subsequent progression of training load is a necessity in personalizing physical exercise training and provide sufficient overload for each individual [4]. These principles of individualization likely extend beyond physical exercise training to other domains within multimodal prehabilitation, reaffirming the need to critically assess the intervention components themselves before pooling their results.

Behavioural components also deserve closer scrutiny. For instance, in many RCTs, interventions labelled as "physiotherapy-led" may reflect minimal engagement, with physiotherapists involved in as few as 1–4 patient contacts. This contrasts sharply with landmark trials such as Hulzebos et al. [5] and Van Berkel et al. [6], in which a small number of highly experienced physiotherapists treated over 130 and 25 high-risk patients, respectively, resulting in significant reductions in postoperative complications. In addition, the Coach2Move approach [7] illustrates how behaviourally intelligent, patient-centred and goal-oriented interventions can deliver real-world impact. These findings reaffirm the critical role of practitioner expertise, tailored interventions, and outcome measures that truly reflect patient priorities—going beyond predefined clinical endpoints or statistical significance, even when patient perspectives are nominally included, as in the work of McIsaac et al.

Lastly, systemic and organizational behaviours—such as clinician engagement, institutional readiness, and implementation support—are equally important for a prehabilitation intervention to be successful. Future reviews should account not only for methodological rigor but also for experiential fidelity and contextual nuances that define true intervention quality.

We also strongly advocate for greater international collaboration through research consortia—such as Fit4Surgery and iPOETTS—aiming to align standards for intervention design, implementation, outcome evaluation, and reporting. To truly advance the science and practice of prehabilitation, we must see—and act on—those crucial contextual details that only become visible with insight.

 
References:

1. McIsaac, D.I., et al., Relative efficacy of prehabilitation interventions and their components: systematic review with network and component network meta-analyses of randomised controlled trials. BMJ, 2025. 388: p. e081164.
2. Herbert, R.D. and K. Bo, Analysis of quality of interventions in systematic reviews. BMJ, 2005. 331(7515): p. 507-9.
3. Engel, D., et al., Reporting quality of randomized controlled trials in prehabilitation: a scoping review. Perioper Med (Lond), 2023. 12(1): p. 48.
4. Tew, G.A., et al., Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery. Anaesthesia, 2018. 73(6): p. 750-768.
5. Hulzebos, E.H., et al., Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA, 2006. 296(15): p. 1851-7.
6. Berkel, A.E.M., et al., Effects of Community-based Exercise Prehabilitation for Patients Scheduled for Colorectal Surgery With High Risk for Postoperative Complications: Results of a Randomized Clinical Trial. Ann Surg, 2022. 275(2): p. e299-e306.
7. de Vries, N.M., et al., The Coach2Move Approach: Development and Acceptability of an Individually Tailored Physical Therapy Strategy to Increase Activity Levels in Older Adults With Mobility Problems. J Geriatr Phys Ther, 2015. 38(4): p. 169-82.