Exercise in Perioperative Care

Prehabilitation is a process undertaken before surgery to enhance functional capacity and optimise modifiable risk factors, with the aim of improving recovery afterwards. It is defined by that preparation, rather than by any guarantee of fewer complications. Programmes are individualised and often multimodal, combining several strands such as exercise to build fitness and strength, nutrition to support the body's reserves, psychological preparation to reduce anxiety and improve engagement, and, where relevant, smoking cessation, alcohol reduction and medical optimisation. Exercise is a central component, because raising a person's cardiorespiratory fitness and muscle strength increases the physiological reserve they can draw on to withstand the stress of an operation and recover from it. Prehabilitation has been studied across many types of surgery, from colorectal and orthopaedic to cardiac procedures, and it can improve fitness and may reduce complications or shorten the length of stay, although the certainty of the evidence varies and is often low for individual comparisons. Because complications tend to be more common in less fit people, those who are least fit generally have the most to gain. The waiting period before surgery, rather than being dead time, becomes a valuable chance to prepare, and starting activity early makes a meaningful and lasting difference to recovery and long-term health.

Because fitness strongly influences how a person copes with major surgery, it is sometimes formally measured. Cardiopulmonary exercise testing (CPET) is used selectively, particularly before major or higher-risk surgery and alongside clinical assessment and validated risk-stratification tools, rather than for every patient. In it, the person exercises on a bike or treadmill while their heart, lungs and metabolism are monitored. Two measures from CPET are particularly useful: the anaerobic threshold, the point at which the body starts to rely more heavily on anaerobic metabolism, and the peak oxygen uptake, the highest rate of oxygen use reached during exercise. These are important measures, though not the only relevant variables, and together with clinical assessment they help estimate the risk of complications, contribute to decisions about the most appropriate level of perioperative care such as a normal ward or critical care, inform shared decision-making and consent, and direct referrals to optimise other conditions before surgery. Simpler functional tests, such as the six-minute walk test, are also used where formal testing is not available. Measuring fitness in this way not only stratifies risk but also identifies the people who stand to benefit most from prehabilitation, allowing exercise to be targeted where it will help the most.

Activity after an operation is just as important as preparation before it, and getting patients moving early is a central principle of modern surgical care. Early mobilisation is a core component of enhanced recovery after surgery (ERAS) pathways, which bundle together evidence-based steps before, during and after an operation to speed recovery, and early activity is one of the most important parts of an ERAS pathway. Getting up, sitting out of bed and walking soon after surgery, rather than lying in bed, is an important part of recovery. As a component of the whole enhanced recovery pathway, it is associated with fewer chest infections and blood clots, a quicker return of bowel function and a shorter hospital stay, although the evidence isolating early mobilisation on its own from the rest of the pathway is less certain. This is the same principle that prevents hospital deconditioning, applied to the surgical patient, and it counters the rapid loss of strength and fitness that immobility causes. Activity is then progressed gradually as recovery allows, building back towards normal function and, ideally, beyond a person's preoperative fitness. Framed simply, the goal is to prepare well, then get moving again as soon as it is safe.

Perioperative exercise is individualised to the person, their fitness and the surgery planned, and built up gradually from their current level. A rounded prehabilitation programme combines aerobic exercise to raise cardiorespiratory fitness, resistance training to build and preserve muscle strength, and, for selected patients at higher risk of chest complications, inspiratory muscle training, which strengthens the breathing muscles. Programmes are started as early as possible in the surgical wait to allow time for fitness to improve, but they must never inappropriately delay time-critical surgery, and they are adapted to the person's symptoms, frailty, nutritional status, cardiovascular risk, coexisting conditions such as anaemia, and the planned procedure. Delivery is a genuinely multidisciplinary effort, drawing on the anaesthetist, surgeon, physiotherapist, dietitian and enhanced recovery team, and it is supported by national resources such as the Royal College of Anaesthetists Fitter Better Sooner toolkit and the Centre for Perioperative Care. The overarching message is encouraging and evidence-based: preparing the body and mind before surgery, and mobilising early afterwards, is a safe and effective way to reduce complications, shorten recovery and improve long-term health, and patients should be actively supported to take part.

• •Prehabilitation is preparation before surgery to improve fitness and optimise modifiable risk factors, often combining exercise, nutrition and psychological support.
• •Fitter patients tend to recover better; complications tend to be more common in physically inactive people, though the size of the effect varies.
• •Cardiopulmonary exercise testing, used selectively before major surgery, measures the anaerobic threshold and peak oxygen uptake to help estimate risk and guide care alongside clinical assessment.
• •Use the surgical wait as a preparation window, starting exercise early; the least fit gain the most.
• •After surgery, early mobilisation as part of enhanced recovery pathways is associated with fewer chest infections and clots and a shorter stay.
• •Prehabilitation is multidisciplinary and individualised, often including aerobic and resistance work, with inspiratory muscle training for selected higher-risk patients, and must not delay time-critical surgery.