Patient and Public Involvement in Prehabilitation: A Systematic Review

Abstract

Objective

To systematically evaluate the extent and quality of patient and public involvement (PPI) reporting in prehabilitation programmes and research.

Data Sources

Keyword searches were conducted in MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane Central Register of Controlled Trials from 1 January 1994 to 22 October 2025.

Review methods

Using an a priori protocol registered with PROSPERO, a systematic review was conducted in accordance with PRISMA guidelines. A narrative synthesis approach was used to interpret findings across heterogeneous studies. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). A patient representative contributed to the study design and co-authored the review.

Results

From 14,078 records, 16 studies reporting PPI were included from the UK, Australia, Canada, USA and Spain. Most studies involved patients at multiple stages, using varied approaches including experience-based co-design. Reporting quality was suboptimal; only three studies met all items of the GRiPP2-SF checklist criteria, and none used a formal PPI reporting checklist tool.

Conclusion

Few prehabilitation programmes are designed with patient and public involvement; highlighting the need for collaborative approaches to improve acceptability and adherence. Although evidence of PPI is limited, several studies demonstrated sustained and meaningful involvement. Reporting remains inconsistent, underscoring the need for clearer reporting to strengthen the evidence base and support wider adoption. The findings highlight substantial opportunities for collaboration in future programmes, and further research should examine how PPI influences adherence, patient experience and the overall effectiveness of prehabilitation interventions.

Keywords

Patient and public involvement codesign prehabilitation optimisation systematic review

Introduction

Prehabilitation programmes have emerged as an innovative approach to optimise patients’ physiological and psychological preparedness before undergoing surgical or non-surgical interventions, such as surgery, chemotherapy or radiotherapy.¹ Prehabilitation prior to elective surgery may have beneficial effects, including fewer postoperative complications, enhanced functional capacity, reduced length of stay and improved quality of life,^1–6 although outcomes vary based on population and the certainty of evidence remains generally low, with the exception of exercise and nutritional prehabilitation.⁷ The certainty of evidence is limited by low-quality research, risk of bias, small sample size and studies pooling heterogeneous interventions.⁶ Whilst there is no universally accepted definition for prehabilitation, a recent definition of surgical prehabilitation has been proposed as the ‘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’.⁸ Prehabilitation programmes initially focused on single-component (unimodal) interventions to increase physical function and capacity, and later evolved to include multimodal aspects of care, including medical optimisation (i.e., management of preoperative anaemia, blood glucose optimisation), nutritional support, perioperative education and/or psychological support.⁹ However, patient adherence to these programmes, particularly those involving multiple components, has been identified as a challenge.¹⁰ Recent studies recommend stratified approaches to prehabilitation, including more patient-centred or personalised programmes to improve adherence.^11,12 Previous studies have also reported that patient adherence is enhanced by patient involvement and participation,¹³ although no reviews have examined the use and reporting of patient and public involvement (PPI) in prehabilitation research and design.

PPI in health services design and redesign has increased significantly over the past two decades and has been described as the ‘new Zeitgeist’ in healthcare.¹⁴ PPI is becoming widely recognised as a key factor in the design and improvement of safe, high-quality healthcare services¹⁵ and characterised by active engagement of patients and members of the public working with researchers and healthcare professionals to serve as ‘innovators, informants and distributors of health information’.¹⁶ Often conceptualised as partnerships or collaborations in the healthcare context, there is increasing recognition of the benefits of healthcare professionals, researchers and patients working together in healthcare research and improvement projects, and the importance of the ‘unique and precious’ knowledge and insights of patients which can be utilised to improve patient experiences, services and outcomes.¹⁷

Despite growing evidence of PPI benefits across related health fields such as cancer care, surgery and cardiac research,^18–21 no reviews have specifically examined PPI use and reporting within prehabilitation. This is notable given that prehabilitation relies on sustained and meaningful patient engagement and involves challenges such as time-sensitive delivery and multimodal design. Consequently, a focused review of PPI is warranted to determine whether current prehabilitation programmes and research are informed by patient and public perspectives and priorities. As Glasziou et al.²² have highlighted, failing to involve patients and the public in research design contributes to research waste and risks misalignment with the needs of those the research is intended to benefit. Embedding PPI is therefore essential, not only to ensure that researchers can optimally design future interventions and trials informed by patient insights, but also to promote responsible use of public research funds and align with best practice research guidance.²³

Thus, this review aimed to describe the extent of PPI in prehabilitation programme design, implementation and research, and the quality of reporting. Four key questions guided this review: (1) How and when are patients involved in the research and design of prehabilitation programmes? (2) What activities and approaches are used to involve patients and the public in researching and designing prehabilitation programmes? (3) What are the impacts and outcomes of PPI? (4) What is the quality of reporting on PPI in prehabilitation?

Methods

Study design

This systematic review of qualitative, quantitative, and mixed methods studies was conducted and reported to adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA and PRISMA-P) criteria.²⁴ The systematic review protocol was developed prior to the literature search and published online via PROSPERO (CRD42020221684).

Defining PPI and codesign

For the purpose of this review, we use the term ‘patient’ to collectively include patients, potential patients, patient representatives, carers, service-users, consumers and members of the public actively involved in the development and design of prehabilitation projects, including the planning and/or conduct of prehabilitation research. PPI specifically refers to research which is carried out ‘with’ or ‘by’ patients and members of the public, rather than ‘to’, ‘about’ or ‘for’ them.^25,26 One form of involvement, codesign, refers to active collaboration between patients, healthcare professionals, and/or researchers in designing solutions for a specific problem (i.e., a service or product improvement or innovation).²⁷ Both PPI and codesign have been included in this review to capture the active involvement of patients in both research and service design/ improvement activities across a wide spectrum of prehabilitation programmes. It is important to note that involvement often occurs along a continuum, ranging from consultation to shared leadership.²⁸

Definition of prehabilitation

To capture all potentially relevant projects and research related to prehabilitation, we included two different categories of prehabilitation: (1) interventions that aim to medically optimise functional capacity or nutritional status of patients before surgery or medical treatment, with the goal of improving or shortening recovery time, reducing perioperative complications and/or enhancing outcomes; and (2) interventions or practices to support the psychological preparedness of patients before surgery or medical treatment, such as cognitive coping strategies, facilitated peer support, or the use of educational resources.

Study eligibility

Inclusion criteria are outlined in Table 1. All relevant qualitative, quantitative or mixed methods studies that reported PPI or codesign in prehabilitation projects and research, including but not limited to medical optimisation (i.e., management of preoperative anaemia, blood glucose optimisation), physical exercise, nutritional support and/ or psychological support components prior to surgery or medical treatment, were included. To be eligible, articles had to be full-text studies and published in English between 1 January 1994 and 22 October 2025. The year 1994 was selected as this was when the earliest trial²⁹ was identified in one of the first systematic reviews on prehabilitation.³⁰ We excluded studies where involvement was limited to patient or the public being a research participant or ‘subject’ (i.e., individuals recruited as research participants for a clinical trial/data collection purpose or being an interview or focus group participant). Where interviews or focus groups were described as being part of a co-design or collaborative process shaping the prehabilitation programme or research, these studies were retained. Studies exclusively related to postoperative rehabilitation (e.g., enhanced recovery after surgery (ERAS), ICU mobilisation) or post-discharge settings (community rehabilitation) were also excluded, as were editorials, opinion pieces, abstracts, conference proceedings, dissertations and protocols.

Table 1.

Inclusion and exclusion criteria.

	Inclusion criteria	Exclusion criteria
Population	- Studies conducted in any healthcare setting with adult patients (>18 years of age)	- Studies which focus on children, adolescents
Study design	- Qualitative, quantitative, or mixed methods.	- Editorials, opinion pieces, abstracts/ conference proceedings, dissertations, protocols
Intervention	- Pre-habilitation programmes which included single or multi-modal interventions, such as medical optimisation (i.e., management of pre-operative anaemia, blood glucose optimisation), physical exercise, nutritional support, and/ or psychological support.	- Studies which focused entirely on postoperative rehabilitation, e.g., enhanced recovery after surgery (ERAS), ICU mobilisation; or post discharge setting/ community rehabilitation;
Outcome measures	- Studies reporting on patient involvement or codesign in adult prehabilitation programmes, including but not limited to patient involvement in prioritising, refining, shaping prehabilitation programme design, advising on any aspect of design, service delivery, implementation or evaluation.	- No outcomes of interest reported - Studies where patient involvement is limited to being a research ‘subject’ (i.e., recruited as a research participant for a clinical trial/ for data collection purposes), rather than involved in programme/research design or conduct; - Studies with a focus on the development of shared decision-making interventions and/ or the use of decision aids prior to surgery.
Other	- Published in English^a; - Published between 1994 and 2025; - Available in full text.	- Duplicate findings reported over several papers (in such cases, the primary paper presenting the main methodology and results was retained).

Non-English full-texts were excluded due to resource and time constraints.

Search strategy

Five online databases were searched (OVID MEDLINE, Elsevier EMBASE, EBSCO CINAHL, PsycINFO, Cochrane Central Register of Controlled trials). The search strategy was developed with an expert health librarian and reviewed by a patient representative (JC). Search terms covered: (1) public, patient, consumer, or service-user involvement; (2) involvement and codesign and (3) prehabilitation. This included international terminology variations, such as ‘consumer’ in Australia, and ‘PPI’ in the UK. Search terms were applied to titles, abstracts, key words and full texts. Reference lists of included studies were manually screened to identify additional articles. A pilot search in MEDLINE was conducted to refine the search strategy before the full search was undertaken (see Supplemental File 1).

Eligibility screening

Search results were imported into Rayyan QCRI systematic review web application,³¹ and duplicates removed. Two reviewers (RM, MR) independently screened title and abstract and full texts against inclusion and exclusion criteria (Table 1). If eligibility could not be determined through title and abstract screening, studies underwent full-text screening. Uncertainties were resolved through discussions with a third reviewer (FL).

Data extraction

A data extraction form was developed to capture key aspects of each study and was piloted and refined. Extracted data included study characteristics: year, design, country, methods, sample, setting, prehabilitation type and measurement. Involvement and codesign were classified using an adaptation of the International Association of Public Participation (IAP2) spectrum which included six levels of engagement (learn/inform, participate, consult, involve, collaborate, lead/support).³² Reporting quality was assessed using the Guidance for Reporting Involvement of Patients and the Public (GRiPP2) short form reporting checklist.³³ One reviewer (MR) extracted data, and a second reviewer (RM) checked 100% for accuracy. Discrepancies were resolved through consensus.

Data synthesis

Given heterogeneity in study design, setting, populations and incomplete reporting, findings were synthesised narratively to identify patterns, similarities and differences.³⁴

Quality appraisal

Methodological quality of each study was assessed using the Mixed Methods Appraisal Tool (MMAT),³⁵ suitable for qualitative, quantitative and mixed methods designs. Two reviewers (PAZ and MR) appraised each study, with disagreements resolved by a third reviewer (RM). No studies were excluded on the basis of quality; appraisal informed interpretation of the evidence.

Patient and public involvement

PPI was an integral component of this review to ensure it reflected both patient and healthcare professional perspectives. A member of the Consumer Advisory Group (JC) joined the review team as a patient representative, contributing valuable insights and building on an existing partnership.³⁶ Their involvement included helping establish review parameters, providing feedback on extraction tables, contributing to data analysis, reviewing the manuscript and co-authoring the paper. Full details, including aims, methods and reflections, on involvement are reported in accordance with the GRiPP2 short form checklist³³ (Supplemental File 2).

Results

Study inclusion

The search strategy yielded 14,078 articles, of which 79 were identified for full-text review.

We excluded 63 articles; the reasons for exclusion are outlined in the PRISMA flow diagram (Figure 1). Following full-text review, 16 articles met the eligibility criteria and were included in the review.

Figure 1.

PRISMA flow chart: identification of studies for the systematic review.²⁴

Study characteristics

Study characteristics of included studies are outlined in Table 2.^37–52 Study designs varied, four used Experience Based Co-Design (EBCD),^38,39,45,50 three were qualitative studies,^37,42,43 two were action research^47,48 and two were feasibility studies.^40,41 Additional designs included an exploratory randomised controlled trial,⁵¹ a feasibility clinical trial,⁴⁴ a participatory codesign/observational cohort study,⁴⁶ a cross-sectional study⁴⁰ and a Modified Delphi study.⁵² Most studies were published after 2017 (n = 14) with the earliest identified study in 2013. The majority of studies were conducted in the United Kingdom (n = 9),^{37,39,41,42,44,47,48,51,52} and Australia (n = 4),^45,46,49,50 the remaining studies were conducted in the United States (n = 1),³⁹ Canada (n = 1)⁴³ and Spain (n = 1).³⁸ Three studies involved a mixed population of patients and their carers,^48,50,51 with one study testing an intervention to indirectly support patients through their carers.⁵¹ Eleven studies focused on cancer prehabilitation (pre-operative and non-surgical).^38–42^,45,48–52 Five studies focused on the development of web-based, app-based or digitally enabled prehabilitation programmes.^{37,38,40,48,49} Four studies focused on developing non-surgical prehabilitation programmes (e.g., chemotherapy, fibromyalgia).^39,44,50,51 Two studies focused on pre-operative orthopaedic surgery (total knee replacement),^37,47 and one study focused on developing of criteria for evaluating and designing equitable prehabilitation before cancer surgery.⁵²

Table 2.

Study characteristics and quality assessment.

Author	Country	Study aim	Design	Context/sample	Pre-habilitation type	Quality assessment (MMAT)*
						D1	D2	D3	D4	D5
Anderson et al.³⁷	UK	To explore patients’ perspectives of potential barriers/ facilitators to engagement, and inform the development of a prototype intervention (Virtual Knee School).	Qualitative	Patients who were listed or had undergone total knee replacement (n = 14)	Unimodal: Pre-operative digital web-based education model	Y^a	Y^a	Y^a	Y^a	Y^a
Baltaxe et al.³⁸	Spain	To describe the co-creation process undertaken to achieve sustainable adoption of prehabilitation and facilitate site transferability	EBCD and QI	University hospital Not reported	Multimodal: Exercise training sessions, nutrition support, group based mindfulness sessions with psychologist, community-based physical activity plan	N^c	Y^c	Y^c	N^c	Y^c
Brady et al.³⁹	UK	To improve, in partnership with patients and staff, pre-treatment assessment service for patients with head and neck cancer undergoing chemoradiation	EBCD	Tertiary cancer hospital Not reported	Unimodal: Pre-treatment speech language therapy including prophylactic swallowing exercises	Y^a	Y^a	N^a	N^a	N^a
Bruce et al.⁴⁰	US	To develop and examine the feasibility of delivering web-based information to patients prior to a surgical consultation	Pilot feasibility	Community and academic breast surgery clinic Women newly diagnosed with breast cancer (n = 377)	Unimodal: Pre-operative psychological support/ web-based information	Y^b	Y^b	N^b	N^b	Y^b
Burnett et al.⁴¹	UK	To improve the outcomes of patients with lung cancer undergoing curative radiotherapy by modifying the standard of care radiotherapy pathway	Feasibility	Patients who were undergoing radiotherapy for curative lung cancer (n = 61)	Multimodal: tailored behaviour interventions, including smoking cessation, exercise, dietetic support and pulmonary rehabilitation	CT	CT	CT	CT	CT*
Cooper et al.⁴²	UK	To identify the factors influencing uptake, engagement and adherence to a presurgical home based physical activity and exercise intervention (ChemoFit) to establish feasibility and acceptability	Qualitative	Tertiary referral hospital Patients with oesophagogastric cancer (n = 22)	Unimodal: Pre-operative physical activity and strengthening exercises	Y^a	Y^a	Y^a	Y^a	Y^a
Corriveau et al.⁴³	Canada	To develop a logic model for prehabilitation programmes in tertiary care centres by exploring stakeholder perspectives of prehabilitation through interviews and focus groups.	Qualitative	Network of 3 tertiary hospitals Patients (n = 10), Healthcare professionals and staff (n = 51)	Multimodal: Pre-operative exercise training, nutrition therapy, psychosocial / behavioural support, including behaviour change techniques (goal-setting, motivation)	Y^a	Y^a	Y^a	Y^a	Y^a
Courel-Ibáñez et al.⁴⁴	UK (Northern Ireland)	To establish proof of concept of a 4-week prehabilitation education and behavioural change intervention for people with fibromyalgia	Feasibility clinical trial	Patients with a clinical diagnosis of fibromyalgia (n = 11)	Multimodal: education, behaviour change, self-paced exercise and weekly support	CT	Y^e	N^e	N^e	CT**
Hyatt et al.⁴⁵	Australia	To use a co-design process to develop video resources about immunotherapy that meet the needs of clinicians, patients and carers	EBCD	Public cancer centre service Subset of patients from Phase 4 (n = 10)	Unimodal: Pre-treatment psychological support/ video resources	Y^a	Y^a	Y^a	N^a	N^a
Linedale et al.⁴⁶	Australia	To codesign and assess the feasibility, acceptability and appropriateness of a community delivered prehabilitation approach (My PreHab Programme) prior to planned orthopaedic surgery	Participatory codesign and prospective observational cohort study	Metropolitan tertiary referral service with participating hospitals (n = 2) Patients referred for hip or knee surgery (n = 36)	Unimodel: Pre-operative digitally enabled pathway and website	N^c	Y^c	Y^c	Y^c	Y^c
Lucas et al.⁴⁷	UK	To develop, implement and evaluate an intervention to improve patient preparation for TKR surgery	Action research	Outer London acute NHS hospital Patients who had undergone TKR surgery (n = 23)	Bimodal: Pre-operative psychological support and exercise	Y^c	Y^c	Y^c	Y^c	Y^c
Poland et al.⁴⁸	UK	To evaluate preoperative education's impact on enhanced recovery by engaging patients, caregivers, and staff in recognising, implementing, and assessing improvements	Action research	NHS hospital in a small city in rural county Patients undergoing colorectal surgery (n = 97); Carers (n = 19)	Unimodal*: Pre-operative psychological support/ education resources	Y^a	Y^a	Y^a	Y^a	Y^a
Steffens et al.⁴⁹	Australia	To explore barriers, facilitators, and adoption of a preoperative prehabilitation intervention via an online app for patients undergoing gastrointestinal cancer surgery	Cross-sectional study	One tertiary hospital Patients in hospital after elective lower gastrointestinal cancer surgery (n = 30)	Multimodal: Pre-operative exercise, nutritional and psychological counselling delivered via an e-Health app	Y^b	N^b	Y^b	N^b	Y^b
Tang et al.⁵⁰	Australia	To collaboratively design and identify key components in a prehabilitation programme for people with prostate cancer	EBCD	Two metropolitan health services Patients who had completed treatment for prostate cancer (n = 8); Support person (n = 1)	Bimodal: Pre-operative psychological support, multidisciplinary team education, peer to peer support/education resources and exercise	Y^a	Y^a	Y^a	Y^a	Y^a
Tsianakas et al.⁵¹	UK	To test the feasibility and acceptability of a complex intervention for carers that was codesigned by staff and carers of patients starting chemotherapy	Exploratory RCT	Outpatient day unit in a large teaching hospital Chemotherapy patient carers; Intervention-received carers (n = 24); Non-intervention carers (n = 23); Intervention-delivering HCPs (n = 6)	Unimodal: Pre-operative psychological support, facilitated group education, peer to peer support/ video and education resources	Y^d	Y^d	Y^d	Y^d	Y^d
Wareing et al.⁵²	UK	To invite people with lived experience of cancer and healthcare professionals to define a set of criteria for quality and equitable prehabilitation interventions before cancer surgery	Modified Delphi study	UK-wide Prehabilitation professionals (n = 8) and people with lived experience of cancer (n = 14)	Multimodal: Pre-operative intervention criteria, focusing on emotional health, nutritional and physical health interventions, community based care, and addressing inequalities	Y^a	Y^a	Y^a	Y^a	Y^a

EBCD: experience based co-design; TKR: total knee replacement; QI: quality improvement.

*Mixed Methods Appraisal Tool (MMAT) [²¹]; Y = Yes, N = No, CT = Can’t Tell.

Section 1 of the MMAT for qualitative studies. ^b Section 4 of the MMAT for quantitative descriptive studies. ^c Section 5 of the MMAT for mixed methods studies. ^d Section 2 of the MMAT for quantitative randomised controlled trials. ^e Section 3 of the MMAT for quantitative non-randomised trials; Unimodal*: this study focused on pre-operative patient education as one component of an ERAS multimodal approach; CT* Can’t tell, this paper focused on reporting PPI and did not include complete methodological reporting, CT** Can’t tell, this study included limited reporting on the feasibility trial, and included qualitative methods: Y^a Y^a Y^a Y^a CT^a.

Characteristics of the prehabilitation interventions

Of the 16 studies, six employed multimodal interventions^{37,38,41,43,44,49,52} that included psychological support, exercise, nutrition support and smoking cessation in varying combinations across studies. Five used unimodal approaches focusing specifically on preoperative or pre-treatment psychological preparation.^{40,42,45,48,51} One unimodal study focused on preoperative speech and language therapy alongside prophylactic swallowing exercises,³⁹ while another unimodal study focused on preoperative psychological support for patients and carers.⁴⁸ Two studies adopted bimodal designs that combined psychological preparation with exercise.^47,50 Several studies included a focus on the development of educational support and resources to improve psychological preparedness. Of these, three studies provided in-person education sessions with multidisciplinary health care professionals,^44,47,50 three provided facilitated group sessions,^38,50,51 five produced web-based, app-based or digital information,^{37,38,40,46,49} two produced education resources in the form of a video or DVD^45,51 and one developed a patient information booklet.⁴⁷ Two of the studies included a focus on improving nutritional status and weight optimisation of patients prior to surgery.^38,46

Level of patient and public involvement

The majority of studies reported clearly on both the characteristics and number of those involved in the research process. A total of 192 individuals were involved across the 16 studies, with the majority identified as patients (n = 101). The remaining individuals were variously described as consumers (n = 38), carers (n = 15), experts by experience (n = 17), patient representatives or advocates (n = 8), public contributors (n = 7), service users (n = 5) and PPI member (n = 1). The terminology used to describe individuals varied considerably across studies, with some terms clearly defined and others used with limited or no explanation of what the term meant or how the role was conceptualised. Three studies involved a single patient,^43,44,48 while four studies involved between two and 10 patients and carers,^{38,39,47,48,50} and five studies engaged larger, mixed groups ranging from 14 to 38 individuals, involving patients, carers/ caregivers, consumer representatives, advocates and experts by experience.^{42,45,46,49,52} Two studies reported the involvement of ‘patients’ and ‘carers from a cancer service’ but did not provide specific numbers.^40,51 Five studies reported on aspects of diversity in relation to PPI^,^{41,42,45,46,52} and only one study incorporated an explicit equity focus.⁵² None of the included studies acknowledged intersectionality or overlapping identities such as gender, socioeconomic status, disability or Indigenous identity.

Fourteen of the 16 studies reported involving patients at multiple time-points,^37–41^,43–50,52 while two did not specify the stages at which patient involvement occurred.^42,51 The level of involvement varied from consulting to collaborating. Consulting typically involved seeking patient feedback on discrete aspects such as intervention feasibility, study procedures and materials.^{40,42,46,49,51} Collaboration entailed a more active and sustained partnership, where patients were members of the research team and contributed to decision-making throughout, including the design, development, implementation and dissemination of prehabilitation programmes and research.^41,47,48,50 More detail on the level of PPI in the included studies is described in Table 3.

Table 3.

Overview of PPI.

Study	Patients	PPI methods	PPI time points	PPI level of involvement
Anderson et al.³⁷	3 patient and public representatives with a range of relevant lived experiences, including TKR and barriers to using digital technology	Patient and public representatives served on the Project Advisory Group (PAG). Meetings were held every 6 months over the 39-month project. Patient representatives were involved in discussions on project planning, reviewing research materials, including participant information sheet, interview topic guide, and plain English summary of study findings. Two PPI representative were involved in planning and co-presenting the findings at a public dissemination event	Multiple time points	Involve (To work directly with the research team throughout the research process)
Baltaxe et al.³⁸	5 patients and their respective caregivers	Patient input, gathered through regular interviews and surveys, provided feedback on service workflow and technologies and provided material for the Design-Thinking sessions. Informal patient feedback to health professionals contributed to co-creation throughout the study	Multiple time points	Involve (To work directly with the research team throughout the research process)
Brady et al.³⁹	7 patients who had previous radical radiation treatment for head and neck cancer and 1 carer	Patients described their experiences and then reviewed interview data to identify priorities, refined content and worked with staff to identify joint priorities for improving services	Multiple time points	Involve (To work directly with the research team throughout the research process)
Bruce et al.⁴⁰	‘Patients’ no other details reported	Patients were consulted on how to incorporate pre-consultation delivery of web-based breast cancer information into routine care, and to identify anticipated implementation barriers	Multiple time points	Consult (To provide feedback and advice on specific research activities)
Burnett et al.⁴¹	8 radiotherapy patients who had competed lung cancer treatment	Patients were invited to be part of the study team and/or participate in a pre-study workshop; 2 patients were co-applicants on the grant, study team members, representatives on the trial management group, co-authors on all study outputs, and were involved in all aspects of the study; 6 further patients were involved in the pre-study workshop. Their lived experiences were used to guide intervention design and refine recruitment strategy	Multiple time points	Collaborate (To partner on equal footing with researchers in all aspects of the research)
Cooper et al.⁴²	14 patients from a local oesophago-gastric cancer support group and an unspecified number of patients recovering from surgery for oesophago-gastric cancer	Two activities were conducted to assess the study's worth and acceptability: i) a group presentation of the proposed study to seek feedback on acceptability; and ii) patients recovering from surgery were consulted about intervention feasibility, study procedures, and their willingness to participate. Patients were also consulted to inform the study protocol	Not reported	Consult (To provide feedback and advice on specific research activities)
Corriveau et al.⁴³	1 patient served on Steering Committee	One patient, as part of the 6-member Steering Committee, contributed to co-development of the project aims, research and interview questions, facilitated recruitment, supported interpretation of results, and co-developed the logic model	Multiple time points	Involve (To work directly with the research team throughout the research process)
Courel-Ibáñez et al.⁴⁴	1 PPI member from Fibromyalgia Support Northern Ireland (FMSNI)	One PPI member from FMSNI reviewed the protocol and participant facing document, and facilitated recruitment through the fibromyalgia support group	Multiple time points	Consult (To provide feedback and advice on specific research activities) Involve (To work directly with the research team throughout the research process)*
Hyatt et al.⁴⁵	3 consumer advocates, 23 patients receiving immunotherapy and 8 carers	Consumer advocates, patients and carers participated in discrete tasks, including sharing experiences; suggesting video topics and themes; identifying themes from interviews; mapping topics to filming plans; providing feedback on videos	Multiple time points	Involve (To work directly with the research team throughout the research process)
Linedale et al.⁴⁶	1 consumer representative, 7 consumers who had undergone surgery, 30 referred consumers in orthopaedics	Three activities: i) A consumer representative sat on the content development group responsible for mapping evidence-based resources and intervention codesign, and contributed to consumer engagement, manuscript review and co-authorship of the manuscript; ii) a 2-h in-person focus group gathered consumer perspectives on prehabilitation; iii) 2 rounds of user testing assessed functionality with consumers	Multiple time points	Involve (To work directly with the research team throughout the research process) Consult (To provide feedback and advice on specific research activities)
Lucas et al.⁴⁷	5 service users who had TKR surgery at the project site	Service users were part of the project team and involved in planning and reviewing the action cycles related to the development of the Knee Clinic, information booklet, and delivery of the intervention in group sessions. They were further involved in reflecting on the project progress and the change process	Multiple time points	Collaborate (To partner on equal footing with researchers in all aspects of the research)
Poland et al.⁴⁸	1 patient representative who had undergone colorectal surgery	The patient representative was a member of the research team and involved in all stages, including study design, implementation and dissemination	Multiple time points	Collaborate (To partner on equal footing with researchers in all aspects of the research)
Steffens et al.⁴⁹	5 patients and 1 cancer consumer involved in design/development of research and 30 postoperative gastrointestinal cancer surgery patients who provided feedback on the app	The 5 patients and 1 cancer consumer were involved in piloting the survey where their feedback identified key areas of focus, reworded items, and informed which questions were retained or dropped. The 30 postoperative patients navigated the app and completed a survey on their views, barriers/facilitators, expectations	Multiple time points	Consult (To provide feedback and advice on specific research activities)
Tang et al.⁵⁰	8 patients who had completed treatment for prostate cancer and 1 support person	Patients and the support person shared experiences, identified touchpoints and areas for improvement, discussed strategies for improvement and collaborated on the structure of the new prehabilitation model. This included participating in interviews and 4 × 2-h workshops	Multiple time points	Involve (To work directly with the research team throughout the research process) Collaborate (To partner on equal footing with researchers in all aspects of the research)
Tsianakas et al.⁵¹	‘Carers from a cancer service’ no other details reported	Carers co-designed the ‘Take Care’ intervention with HCP's and the project steering group	Not reported	Consult (To provide feedback and advice on specific research activities)
Wareing et al.⁵²	7 public contributors with lived experience as a patient, carer, or friend of a cancer patient were part of the PPI panel, and a further 17 ‘experts by experience’ (patients, carers, friends/family with lived cancer experience)	The PPI panel reviewed the final criteria after the Delphi concluded, contributed reflections on potential biases, study limitations, dissemination of results, reviewed comments to identify themes, and highlighted literacy and language complexity, leading to the development of simpler easy read versions. Experts by experience were involved in two co-design workshops to develop and refine statements for the Delphi questionnaire, and were subsequently involved in categorising statements into themes; they then took part in a three-round online modified Delphi process, rating statement importance and providing feedback that informed iterative revisions (Round 1: n = 14, Round 2: n = 13, Round 3: n = 14).	Multiple time points	Involve (To work directly with the research team throughout the research process)

*Limited reporting of PPI in this study, the description suggests consultation with elements of involvement rather than sustained involvement.

Activities and approaches to involve patients

Seven studies reported sustained and active involvement of patients across multiple phases of the research process,^{37,41,43,47,48,50,52} including participation as co-applicants on grants and publications,⁴¹ contributions to study design, implementation and dissemination,^37,48 involvement in substantive activities such as the delivery of interventions in group sessions,⁴⁷ and membership on expert and project advisory panels.^37,41,46,52 In four studies, patients shared their own experiences and identified key ‘touchpoints’ and areas for improvement as part of the experience-based co-design (EBCD) process.^38,39,45,50 In two studies, a prehabilitation intervention was co-designed with carers⁵¹ and patients,⁴⁶ and in two studies, patients collaborated in the design of a new prehabilitation model.^41,50 Most studies reported adequate detail on patient involvement in discrete activities within the research process, such as advising on the content and delivery of patient facing information such as plain English summaries, videos and booklets,^37–39^{,44,45,47,49,52} contributing to interview analysis,^39,41,43,45 advising on prehabilitation programme or model development,^41,43,50,51 and informing study protocol and procedures, including intervention feasibility and acceptability.^40,42,44 Several studies combined approaches,^{41,46,49,50,52} using involvement through advisory or steering groups to provide ongoing guidance, while also consulting additional patients for discrete, task focused activities such as usability testing and identifying barriers and facilitators to recruitment and engagement. This blended model allowed research teams to benefit from sustained partnership with a core group of patient advisors, alongside broader input from additional patients when specific perspectives or wider feedback was needed. The approaches used to involve patients are described in Table 3.

Outcomes and impact of patient involvement

There was variation across studies in how the impact of patient involvement and prehabilitation were reported (Table 4). Four EBCD studies reported the impact of patient involvement in the research process, noting that the co-design process generated rich insights and enabled clear identification of patient priorities, key topics, and ‘touchpoints’ which were important to patients in the development and delivery of prehabilitation services.^38,39,45,50 One EBCD study reached consensus on the development of a model of prehabilitation for patients with prostate cancer,⁵⁰ and one action research study reported the process facilitated identification of educational content and delivery preferences which were relevant for patients and linked to enhanced recovery.⁴⁸ One feasibility study reported the involving PPIE representatives led to significant and beneficial changes to the initial design of a prehabilitation programme, helping to maximising acceptance, recruitment and retention.⁴¹ A Delphi study similarly noted that patient involvement improved the clarity of statements and language, resulting in simpler, easy-read versions of Delphi statements and key materials.⁵² Only one study explicitly outlined predetermined patient outcomes measures, indicating statistically significant improvements in understanding symptoms, managing side effects and meeting patient information needs through the ‘Take Care’ intervention.⁵¹ Provider outcomes, assessed through surveys, focused on perceived implementation efficiency and burden.⁴⁰ Process outcomes were reported in eight studies, encompassing the acceptability of the prehabilitation intervention (n = 2),^40,51 the acceptability of the co-design process (n = 3),^39,45,50 methods and content of information sharing (n = 2)^40,48 and the change process (n = 1).⁴⁷ These examples illustrate the tangible impact that meaningful involvement can have on the quality and acceptability of prehabilitation interventions and programmes.

Table 4.

Summary of prehabilitation programmes and outcomes.

	Prehabilitation intervention			Intervention measurement
Study	Intervention	Description	Delivery/ MDT involvement	Key outcome measures	Screening tools	Measurement tools/ instruments
Anderson et al.³⁷	Unimodal: Pre-operative digital education model	Development of a pre-operative digital education intervention for TKR	Digital health information	Views on the programme; Barriers and facilitators to uptake	Not applicable*	Not applicable*
Baltaxe et al.³⁸	Multimodal – two preoperative physical activity and exercise training based programmes	The physical activity programme comprised: i) motivational interviewing; ii) a physical activity promotion plan; iii) nutritional optimisation; and iv) psychological support, using digitally enabled support tools. The exercise training programme added 2-3 hospital-based face-to-face supervised sessions per week	Not reported	Feasibility; service transferability and implementation	Not applicable*	Scirocco Maturity Model for Integrated Care; Consolidated Framework for Implementation Research (CFIR);
Brady et al.³⁹	Unimodal – non-surgical intervention and psychological support	Delivery of pre-treatment speech language therapy, prophylactic swallowing exercises and counselling	Speech-language therapists, radiation oncologist, clinical nurse specialists, head and neck dietitians	Not applicable*	Baseline pre-treatment speech and language assessment	Not applicable*
Bruce et al.⁴⁰	Unimodal –pre-operative educational intervention / psychological support	Delivery of web-based information to breast cancer patients prior to surgical consultation	Web-based health information	Feasibility of routine delivery of web-based information prior to surgical consultation, stakeholder acceptability	Not reported	Ottawa Practitioner Opinion Survey; pre-consultation survey to assess stakeholder acceptability
Burnett et al.⁴¹	Multimodal –- tailored behaviour interventions, including smoking cessation, exercise, dietetic support and pulmonary rehabilitation	Individually tailored programme during radiotherapy treatment, including exercise in the home environment.	Individually tailored programme, according to patient preferences	Acceptability and feasibility of the intervention, recruitment rates, adherence, practicability	Not reported	Not reported.
Cooper et al.⁴²	Unimodal – pre-operative physical activity and strengthening exercises	Delivery of a personalised home-based intervention consisting of daily step-based activity and strengthening exercises. Participants got a pedometer, resistance bands, and a weekly exercise diary	Engagement was encouraged through positive reinforcement and motivational discussion in weekly telephone calls with a researcher-clinician	Uptake, engagement and adherence; cardiopulmonary fitness	Multidisciplinary cancer staging process; cardiopulmonary exercise testing (CPET)	Borg Rating of Perceived Exertion (RPE); cardiopulmonary exercise testing (CPET)
Corriveau et al.⁴³	Multimodal – preoperative model	Development of a personalised in-person (with telemedicine follow-ups) risk-stratified prehabilitation programme combining individually tailored exercise, nutrition, and psychosocial /behaviour-change interventions delivered through a coordinated interdisciplinary team	The proposed model requires a coordinated team, including at least one Physician, Kinesiologist, Physiotherapist, Dietitian, Clinical lead / Registered Nurse, Administrative assistant, Psychosocial specialist (social worker)	No outcomes were measured in the study, but stakeholders proposed measuring process indicators, including cost, adoption, penetration, sustainability, adherence, acceptability, appropriateness, feasibility, fidelity, patient burden, inpatient workload, functional capacity, nutritional status, behaviour change	Not applicable*	Proposed tools that could be applied in the programme included: 6-minute walk test (6MWT), Cardiopulmonary exercise testing (CPET), Bioelectrical Impedance Analysis (BIA), DEXA (dual-energy X-ray absorptiometry), Patient-Generated Subjective Global Assessment (PG-SGA), Patient reported outcome measures (PROMs,) Montreal Cognitive Assessment (MoCA), discharge-related ADL measures
Courel-Ibáñez et al.⁴⁴	Multimodal: education, behaviour change, self-paced exercise and weekly support	Delivery of a 4-week prehabilitation intervention, combining education and skills training in exercise, physical activity, symptom flares, pacing, causes of symptoms and management, goal setting; followed by 6 weeks of self-paced exercise and weekly support via phone and WhatsApp messages	Weekly 1–1.5 h patient support group sessions over 4 weeks, facilitated by a physiotherapist and sports scientist, followed by 6 weeks of telephone and WhatsApp support	Acceptability and credibility, (primary outcomes) measured by number of sessions attended, number of drop-outs, reasons for early withdrawal, number of completed and returned questionnaires; secondary outcomes, FM severity	Screening and baseline assessment: Widespread Pain Index (WPI), Symptom Severity Scale (SS), Physical Activity Readiness Questionnaire, and medical/general history	Credibility/ Expectancy Questionnaire (CEQ), Revised Fibromyalgia Impact Questionnaire (FIQR), Sedentary Behaviour Questionnaire (SBQ), Pain Numeric Rating Scale (Pain NRS)
Hyatt et al.⁴⁵	Unimodal –non-surgical intervention psychological support	Development of video resources about immunotherapy	Video based health information	Not applicable*	Not applicable*	Not applicable*
Linedale et al.⁴⁶	Unimodal –pre-operative digitally enabled pathway and website	Development of a text message mediated digital pathway, screening for modifiable risk factors for post-operative complications and providing tailored information (on the website) to enable health optimisation prior to surgery. Information on the website related to 9 prehab focus areas¹	Patient completion of a digital health screening questionnaire, which could then be shared with GP and reviewed by nurses for ‘red flags’ and additional information	Acceptability, feasibility, appropriateness, and engagement with the programme	Digital health screening questionnaire for modifiable risk factors	Patient experience survey
Lucas et al.⁴⁷	Bimodal –re-operative psychological support and exercise	Development of a multidisciplinary knee clinic, and information resources	Information booklet and delivery of in-person education sessions with MDT health care professionals	Knowledge and preparation; self-efficacy beliefs; outcome expectations; exercise frequency and crutches use; post-operative mobility	Pre and post-operative physiotherapy assessment	Self-efficacy and outcome beliefs questionnaire; self-reported exercise frequency and crutches use
Poland et al.⁴⁸	Unimodal –pre-operative educational intervention/ psychological support	Development of pre-operative education process and resources	Not applicable	Not applicable* Notes that patients began to articulate the outcomes important to them	Not applicable*	Not applicable*
Steffens et al.⁴⁹	Multimodal –pre-operative intervention	Development of a multimodal app-based programme combining exercise, nutritional, and psychological components. The exercise module (StandingTall) provided gentle warm-ups, sit-to-stand and stepping exercises to build balance and strength, while the app also delivered preoperative nutritional advice and psychological counselling information to support overall surgical preparation	App-based (e-Health) programme	Views on the online programme; Barriers and facilitators to uptake; expectations	Assessment of cognitive status; screening tools not reported	Study-specific capturing patient outcomes, including self-reported nutritional status (PG-SGA Short Form), physical activity (IPAQ-SF), technology use, views on the programme, willingness to complete a preoperative programme
Tang et al.⁵⁰	Bimodal – non-surgical intervention exercise and psychological support	Development of a prehabilitation programme	Facilitated group sessions with physiotherapists, prostate cancer specialist nurse; comprising exercise, education, peer-to-peer support, one off pelvic-floor assessment and pelvic floor muscle training as required	Not applicable*	Not applicable*	Not applicable*
Tsianakas et al.⁵¹	Unimodal – non-surgical intervention psychological support	Delivery of pre-treatment resources, education and psychological support	Facilitated group sessions with chemotherapy nurses comprising 1 h group consultation, supportive/ educational DVD and booklet	Feasibility and acceptability of the intervention; knowledge of chemotherapy and side-effects, experience of care; satisfaction with out-patient services, coping and emotional well-being	Baseline questionnaires for carers	Investigator-developed series of nine 10 mm visual analogue scales (VASs); Supportive Care Needs Survey for Partners and Carers (seven items) (SCNS-P&C44); Experience of care (investigator designed); Perceived confidence in supporting friend/ relative (investigator developed); Emotional wellbeing (GHQ-12).
Wareing et al. ⁵²	Multimodal –Pre-operative intervention criteria, focusing on emotional health, nutritional and physical health interventions, community based care, and addressing inequalities	Development of 7 criteria statements for evaluating and designing equitable prehabilitation before cancer surgery, and 8 recommendations for equitable prehabilitation services	Criteria statements recommended shared decision making between the patient and prehabilitation team, including oncologists, physiotherapists, psychologists, anaesthetists and occupational therapists, personalised prehabilitation, and community link workers to help integrate community resources and assist vulnerable or frail patients	Not applicable*	Not applicable*	Not applicable*

* Key outcome measures/ measurement tools not applicable due to the study focus on co-design/action research process, and intervention development.

Focus areas included: Smoking, diabetes management, anaemia/low iron, emotional wellbeing, frailty, pain management, alcohol and drugs medication management, activity and exercise, and nutrition and weight optimisation; MDT: Multidisciplinary Team; TKR: Total knee replacement.

Quality of reporting for patient and public involvement

The quality of reporting on PPI in relation to GRiPP2 criteria varied (Table 5). All but three studies^40,44,47 clearly described the aim of involvement, and all 16 studies described patient involvement methods. Thirteen of the 16 studies, except for Corriveau et al.,⁴³ Courel-Ibáñez et al.,⁴⁴ and Tsianakas et al.,⁵¹ described patient involvement in the results. The majority of studies also included patient involvement in the discussion and conclusion.^{38,39,41,43–45}^,47–50,52 Demonstration of the final criterion was less evident, with only three studies,^38,41,50 providing a detailed reflection and critical perspective on patient involvement, four studies providing a partial reflection,^39,40,45,51 and nine studies providing no critical reflection/ perspectives.^37,42–44^,46–49,51 Table 5 provides a summary of reporting in relation to the GRiPP2 criteria.

Table 5.

Summary of reporting adherence with the GRiPP2 checklist.

Study	PPI aims	PPI methods	PPI results	PPI discussion and conclusion	PPI reflection critical perspectives
Anderson et al.³⁷	✓	✓✓	✓
Baltaxe et al.³⁸	✓✓	✓✓	✓✓	✓✓	✓✓
Brady et al.³⁹	✓✓	✓✓	✓✓	✓	✓
Bruce et al.⁴⁰		✓✓	✓✓		✓
Burnett et al.⁴¹	✓✓	✓✓	✓✓	✓✓	✓✓
Cooper et al.⁴²	✓✓	✓	✓✓
Corriveau et al.⁴³	✓	✓		✓
Courel-Ibáñez et al.⁴⁴		✓✓
Hyatt et al.⁴⁵	✓✓	✓✓	✓✓	✓✓	✓
Linedale et al.⁴⁶	✓✓	✓✓	✓✓
Lucas et al.⁴⁷		✓✓	✓✓	✓✓
Poland et al.⁴⁸	✓✓	✓✓	✓✓	✓✓
Steffens et al.⁴⁹	✓✓	✓✓	✓✓	✓✓
Tang et al.⁵⁰	✓✓	✓✓	✓✓	✓✓	✓✓
Tsianakas et al.⁵¹	✓	✓
Wareing et al.⁵²	✓✓	✓✓	✓✓	✓✓	✓

Note: ✓: Partial adherence with GRiPP2 criteria; ✓✓: Full adherence with GRiPP2 criteria.

Quality appraisal of included studies

Study quality varied, and half of the of the sixteen studies met all quality criteria.^{37,42,43,47,48,50–52} While six of the qualitative studies met all quality criteria, two studies did not have evidence that the interpretation of the results was substantiated by the data (Criteria 1.4), and there was a lack of coherence between qualitative data sources, collection, analysis and interpretation (Criteria 1.5). Two of the three mixed methods studies did not include an adequate rationale for using a mixed methods design (Criteria 5.1), and one of the studies did not address divergencies and inconsistencies between quantitative and qualitative results (Criteria 5.4). A summary of the quality appraisal is presented in Table 2.

Discussion

A growing interest in PPI within prehabilitation is evident, yet the limited number of studies reporting PPI suggests that this momentum has not fully translated into consistent practice within the field. The findings of this systematic review align with evidence from previous research, indicating that PPI is recognised as valuable but remains underutilised.^53,54

This suggests substantial scope and opportunity for future development and implementation within prehabilitation settings. It remains unclear, however, whether the limited use and reporting of PPI, particularly in areas such as prehabilitation, reflects a lack of awareness about its relevance and application, unfamiliarity with EQUATOR reporting guidance,³³ or broader barriers such as limited resources, time and skills. A recent systematic review identified multiple barriers to PPI in healthcare, including limited knowledge and institutional support, negative attitudes towards patient contributions, resistance to involvement, organisational constraints and inadequate training and accessibility.⁵⁵ Additionally, a recent BMJ study suggested that underreporting may not be solely due to a misunderstanding of reporting standards or structural barriers, but also from a lack of actual PPI activity and a reluctance to report unsuccessful or tokenistic PPI.⁵⁶ This suggests that a complex mix of contextual, attitudinal, and structural factors may contribute to the underutilisation and underreporting of PPI in prehabilitation. Greater use of established frameworks such as EBCD, and tools such as GRiPP2 can provide guidance and improve reporting of PPI. Journals also have a key role to play; some journals such as BMJ, now require PPI reporting at submission, a practice that could be more widely adopted.⁵⁷

In examining the characteristics of PPI reported within the included studies, further limitations are evident. Three studies involved a single patient,^43,44,48 four studies involved between two and 10 patients and carers,^{38,39,47,48,50} and five studies engaged larger mixed groups of 14–38 individuals, involving patients, carers/ caregivers, consumer representatives, advocates and experts by experience.^{42,45,46,49,52} While most studies demonstrated a clear commitment to involving patients and people with lived experience, reporting on the characteristics of those involved was limited. Five studies reported on aspects of diversity in relation to PPI,^{41,42,45,46,52} highlighting gaps in transparency and representation. Only one study included an explicit equity focus,⁵² and none acknowledged intersectionality or overlapping identities such as gender, socioeconomic status, disability or Indigenous identity.

The absence of diversity reporting is notable given the recency of the studies and longstanding concerns about the lack of diversity in PPI. Critics have observed that PPI often involves ‘well-behaved’ or ‘acquiescent’ people⁵⁸ with greater economic, social or cultural capital,⁵⁹ which can exclude marginalised groups, frequently described as ‘hard to reach’, ‘vulnerable’ or ‘high risk’.^60,61 The lack of intersectional perspectives further limits understanding of whether involvement reflects the experiences of people who may face additional barriers to accessing or engaging with prehabilitation. Ensuring that PPI captures a broad range of identities and experiences is essential for advancing equity,^52,62 and future studies should report more clearly on those involved so that diversity and representation can be assessed and strengthened.

Despite growing recognition of the value of PPI in health research, it is still rarely evaluated. Where evaluation does occur, the impact often remains unclear.^63,64 Most studies described involvement rather than assessing its effects on outcomes or service delivery, and none examined PPI impact on specific outcomes such as prehabilitation adherence. Few studies offered critical reflections on PPI processes, limiting insights into its unique contributions and challenges in the context of prehabilitation. Greater transparency and evaluation are needed, particularly regarding involvement processes, support structures, remuneration and power dynamics, to strengthen interpretation of PPI outcomes and advance learning in this emerging field.

Our findings reveal limited geographical representation in prehabilitation research, with most studies from the United Kingdom and Australia, and a limited number from Spain, Canada, and the United States, largely published after 2017. This pattern reflects broader developments in patient involvement,⁶⁵ likely driven by strong policy and funding incentives from organisations such as the National Health and Medical Research Council (NHMRC, Australia),⁶⁶ National Institute for Health and Care Research (NIHR, United Kingdom)⁶⁷ and Patient-Centered Outcomes Research Institute (PCORI, United States).⁶⁸ Cancer-focused prehabilitation was particularly prominent, likely reflecting funding priorities and public interest in oncology.¹⁸

To our knowledge, this is the first systematic review to specifically focus on PPI in prehabilitation. The findings highlight the need for improved reporting, particularly in relation to diversity, impact, challenges and critical perspectives. As expectations around PPI continue to grow, greater patient involvement is likely in future studies. Existing frameworks and guidance^33,69 can support authentic partnerships and promote greater transparency, but researchers and funders must use these resources critically and reflexively.⁷⁰

This review was informed by patient collaborators and established frameworks, including GRiPP2³³ and Manafo.³² A strength of the review is the inclusion of all prehabilitation studies from the first prehabilitation study in 1994–2025. However, several limitations should be acknowledged; inclusion was restricted to English-language articles, potentially excluding relevant non-English studies; PPI may have been under-reported in some studies or omitted from abstracts, limiting our ability to identify studies which may have included PPI; terminology differences across disciplines or regions may have led to missed studies.

Overall, we found limited but emerging use of PPI in prehabilitation, alongside clear examples of meaningful, sustained involvement. Reporting remains inconsistent, and strengthening the clarity and rigour of PPI reporting is essential to build the evidence base and support wider adoption. Addressing the challenges identified offers an opportunity to ensure prehabilitation programmes better reflect patient priorities and experiences. Future research should examine the outcomes of PPI, including its impact on adherence, patient-experience and the effectiveness of prehabilitation interventions.

Clinical messages

Prehabilitation before elective surgery can reduce complications, improve functional recovery and shorten length of hospital stays.

Patient-centred, personalised prehabilitation programmes improve adherence and engagement.

Greater integration of patient and public involvement in research and practice is needed to optimise patient outcomes.

Supplemental Material

sj-docx-1-cre-10.1177_02692155261450157 - Supplemental material for Patient and Public Involvement in Prehabilitation: A Systematic Review

Supplemental material, sj-docx-1-cre-10.1177_02692155261450157 for Patient and Public Involvement in Prehabilitation: A Systematic Review by Rachel Muir, Megan Rattray, Peta-Anne Zimmerman, Joan Carlini and Frances Fengzhi Lin in Clinical Rehabilitation

Footnotes

Acknowledgements

The authors would like to thank Griffith University Health Librarian, Bonnie Dixon and Queensland Health Librarian, Sarah Thorning, for support with development of the search strategy and searches. We would also like to thank Lauren Murray for helpful comments on an initial draft of this paper.

ORCID iDs

Rachel Muir

Megan Rattray

Peta-Anne Zimmerman

Contributions

Rachel Muir: funding acquisition, conceptualisation, methodology, formal analysis, writing – original draft and writing – review and editing. Megan Rattray: methodology, formal analysis, writing – original draft and writing – review and editing. Peta-Anne Zimmerman: conceptualisation, methodology, formal analysis and writing – review and editing. Joan Carlini: methodology, formal analysis and writing – review and editing. Frances Fengzhi Lin: conceptualisation, methodology, formal analysis and writing – review and editing.

Funding

A seed grant was provided by Griffith University School of Nursing and Midwifery for research assistant support.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

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