The Paradox of Surgical Recovery
Surgery presents us with a deeply rooted paradox. While postoperative rehabilitation is carefully planned and structured, patients often spend the weeks leading up to surgery simply waiting. But why allow valuable time to pass when the biological foundations for successful recovery could already be established? Recent research, particularly the large network meta-analysis published in the British Medical Journal (BMJ) by McIsaac et al. (2025), clearly demonstrates that prehabilitation can make a meaningful difference. As hand therapists, we know that every surgical procedure represents a traumatic event for biological tissue. This article explores why functional outcomes can be significantly improved when preparation begins days—or even weeks—before the first incision is made.
Exercise Is the Cornerstone of Prehabilitation
The findings of the BMJ meta-analysis are compelling. Targeted exercise before surgery can significantly reduce postoperative complications. The reported odds ratio of 0.50 suggests that the risk of complications may potentially be reduced by half. However, it is important to acknowledge that the certainty of this evidence is currently rated as very low because of potential bias in the included primary studies. Nevertheless, the clinical relevance of the question remains substantial.
McIsaac et al. (2025) conclude:
"Consistent and potentially meaningful effect estimates suggest that exercise prehabilitation […] may benefit adults preparing for surgery."
For hand surgery, this concept is particularly relevant. Consider complex tendon reconstruction procedures: success often depends on the patient's biological reserve. Individuals with better systemic fitness generally exhibit improved tissue oxygenation, more efficient metabolism, and enhanced physiological resilience. These factors promote postoperative tendon gliding while reducing the risk of adhesions. Exercise increases overall physical capacity, which directly translates into a faster return of function. This is an insight that deserves to become routine practice before elective tendon and joint surgery.
Nutrition – The Forgotten Foundation of Healing
Nutritional prehabilitation is often treated as a secondary consideration, yet it provides the biochemical foundation for wound healing. The BMJ analysis demonstrated that targeted nutritional optimization before surgery may reduce the average hospital length of stay by approximately one day (0.99 days). Although the certainty of the evidence is likewise considered very low, the isolated effects remain noteworthy.
Potential benefits of nutritional prehabilitation include:
- Reduced complication rates: An odds ratio of 0.62 indicates a protective effect of nutritional prehabilitation.
- Faster recovery: Average hospital length of stay may be reduced by approximately 0.99 days.
- Optimized anabolism: Adequate protein intake and nutritional supplementation ensure that the body has sufficient building blocks available for tissue regeneration following surgical trauma.
Within hand therapy, nutrition deserves far greater attention. Adequate protein availability is essential for maintaining the structural integrity of repaired tendons and ligaments during the postoperative healing process.
The "Seven-Day Window"
Prehabilitation has a clearly defined meaning and should not be confused with short-term perioperative interventions. According to the reviewed literature, an intervention must begin at least seven days before surgery to qualify as prehabilitation. This minimum timeframe distinguishes prehabilitation from perioperative protocols such as Enhanced Recovery After Surgery (ERAS) programs and provides the body with sufficient time to initiate meaningful physiological adaptations. Only with this preparation period can measurable improvements in postoperative resilience be expected.
Synergistic Effects: One Plus One Is More Than Two
Current evidence suggests that exercise and nutrition may work synergistically. Multimodal prehabilitation programs combining exercise, nutritional optimization, and psychosocial support produced the greatest improvements in both health-related quality of life (HRQoL) and physical capacity. For example, participants receiving multimodal interventions improved their 6-minute walking distance by an average of 43.43 meters, reflecting a considerable increase in overall physical resilience—an important prerequisite for successful healing of the upper extremity.
Intervention | HRQoL (SF-36 Physical Component, MD) | Physical Recovery (6-Minute Walk Test, MD) |
Exercise alone | 2,29 | 25.73 meters |
Nutrition alone | 3,28 | 3.37 meters |
Multimodal (exercise + nutrition + psychosocial support) | 3,48 | 43.43 meters |
MD = Mean Difference
The Gap Between Expert Consensus and Clinical Practice
Despite the encouraging evidence, a considerable implementation gap remains within hand therapy. Babiker-Moore et al. (2025) reported broad expert consensus that preoperative interventions—including massage, splinting, therapeutic ultrasound, and corticosteroid injections—represent valuable treatment options. Nevertheless, these interventions are not routinely implemented in everyday clinical practice. A clear discrepancy therefore exists between expert recommendations and real-world care. As hand therapists, we should take the growing body of evidence from surgical research seriously. Prehabilitation is not merely a "nice-to-have" concept reserved for major abdominal surgery—it represents an evidence-informed strategy that patients undergoing elective hand surgery equally deserve.
A New Standard for Hand Surgery
Prehabilitation is the logical extension of evidence-based hand therapy. Current evidence indicates that at least one week of structured preparation, primarily through exercise and nutritional optimization, has the potential to reduce postoperative complications while improving recovery and quality of life. Although the scientific certainty of the available evidence still needs to improve, the potential benefits for our patients are simply too significant to ignore.
References
Babiker-Moore T., Clark C.J., Kavanagh E., Crook T.B. (2025). The effect of preoperative interventions on postoperative outcomes following elective hand surgery: A systematic review. In: Hand Ther. 2025 Mar; 30(1):19-33. doi: 10.1177/17589983241301449
McIsaac D.I., Kidd G., Gillis C., Branje K., Al-Bayati M., Baxi A., Grudzinski A.L., Boland L., Veroniki A.A., Wolfe D., Hutton B. (2025). Relative efficacy of prehabilitation interventions and their components: systematic review with network and component network meta-analyses of randomised controlled trials. In: BMJ 2025; 388 :e081164 doi:10.1136/bmj-2024-081164
This article is intended for the professional development of hand therapists and rehabilitation professionals. It does not replace individualized clinical assessment or medical advice. All references were reviewed to the best of our knowledge (June 2026).
The IHHC Editorial Team is responsible for creating, reviewing, and continuously updating the content published by the International Hand Health Community (IHHC). Its mission is to present current knowledge from hand therapy, occupational therapy, physiotherapy, rehabilitation, and medicine in a way that is evidence-based, practical, and easy to understand.