Digital Prehabilitation for Patients Undergoing Major Elective Surgery: a Single-arm Pilot Study
Phase: NA
Conditions: Surgery
Sponsor: Royal United Hospitals Bath NHS Foundation Trust

 
Digital prehabilitation for patients undergoing major elective surgery: 
a single-arm pilot study 
IRAS ID: 333460 
Study registration: NCT06137781 
Study protocol: v2.0 17/01/2024 
Study sponsor: Royal United Hospitals Bath NHS Foundation Trust 
Research team 
Name 
Research 
team role 
Professional role 
Contact 
Dr Alec Snow 
Chief 
Investigator 
Consultant in Intensive Care 
Medicine and Anaesthesia, 
PreActiv Co-founder 
alec.snow@nhs.net 
Dr Max 
Western 
Principal 
Investigator 
Senior Lecturer in Health 
m.j.western@bath.ac.uk  
Dr Rebecca 
Allam 
Co-Investigator 
PreActiv Co-founder 
rebecca.allam@preactiv.co.uk 
Dr Annabelle 
Emery 
Co-Investigator 
Research Lead at PreActiv 
annabelle.emery@preactiv.co.uk 
Alex Knopp 
Co-Investigator 
Tech Lead at PreActiv 
alex.knopp@preactiv.co.uk 
Adam Aspbury 
Co-Investigator 
Physiologist at PreActiv 
adam.aspbury@preactiv.co.uk 
Dr Oliver 
Perkin 
Co-Investigator 
Research Fellow in Exercise 
Physiology 
o.j.perkin@bath.ac.uk 
Dr Frankie 
Brown 
Co-Investigator 
Lecturer in Applied Science 
f.brown@napier.ac.uk 
Dr Helen Sims 
Researcher 
Care of the Elderly Registrar 
helen.sims@nhs.net 
Dr David Quinn 
Researcher 
Anaesthetic Registrar 
davidquinn@nhs.net 
Ian-Ju Liang 
Researcher 
Postdoctoral Research 
Associate 
ijl28@bath.ac.uk 
Leigh Ingham 
Researcher 
Preoperative Nurse 
leighingham@nhs.net 
Justine 
Archman 
Researcher 
Preoperative Nurse 
justine.archman@nhs.net 
 
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Protocol summary 
Study Title 
Digital prehabilitation for patients undergoing major elective surgery: a 
single-arm pilot study 
Short title 
Digital prehabilitation for patients undergoing major elective surgery 
Study Design 
Single-centre, single-arm, pilot study 
Study Participants 
Patients aged ≥50 years that are scheduled for major elective surgery in ≥10 
weeks 
Planned Sample 
Size 
N = 34 
Intervention  
Duration 
6 weeks 
  
Objectives 
Outcome Measures 
Primary 
  
Assess the 
feasibility of 
PreActiv’s digital 
prehabilitation. 
Recruitment 
rate, 
uptake 
rate, 
screen-pass 
rate, 
adherence, compliance, retention, safety, acceptability 
Secondary 
  
Assess the effect 
of PreActiv’s 
digital 
prehabilitation on 
fitness and 
wellbeing 
outcomes in 
patients awaiting 
major elective 
surgery. 
●​
Cardiorespiratory fitness 
●​
Functional fitness 
●​
Resting blood pressure and heart rate 
●​
Self-reported physical activity level 
●​
Quality of life 
●​
Mood 
●​
Economic impact 
●​
Environmental impact 
Intervention 
Digital prehabilitation including aerobic, resistance, and breathing exercises 
that are tailored to the patient's mobility and fitness level. 
Dose 
3 x 35-minute sessions per week. 
 
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1.​ Background 
The annual cost of surgical procedures within the National Health Service (NHS) in the UK is estimated at 
£9.5 billion (Abbott et al., 2017). The most recent estimation of surgical admissions to NHS hospitals 
between 2016-2019 – prior to disruptions caused by the Covid-19 pandemic – was 4,685,106 per year, of 
which 3,414,531 were defined as elective surgery scheduled with wait times ≥4 weeks (Dobbs et al., 
2021). Elective surgeries are non-emergency surgeries that are planned in advance, which provides the 
opportunity for patient optimisation prior to surgery with the aim of improving postoperative outcomes. 
Increasingly, cardiopulmonary exercise testing (CPET) is being implemented preoperatively to stratify 
surgical risk based on cardiorespiratory fitness (Levett et al., 2018). Indeed, numerous trials demonstrate 
that higher preoperative cardiorespiratory fitness is associated with reduced postoperative morbidity and 
mortality following major surgery (Ozova et al., 2022, Moran et al., 2016, West et al., 2014, Prentis et al., 
2012, Torchio et al., 2010, Wilson et al., 2010).  Based on these findings, the use of ‘formal prehabilitation 
pathways’ to improve fitness was recommended in the Royal College of Anaesthetists (RCoA) Guidelines 
for the Provision of Anaesthetic Services (2021).    
Prehabilitation is the process of preparing a patient for a medical intervention such as surgery. Effective 
prehabilitation programmes use surgery as a ‘teachable moment’ to introduce individualised, multi-modal 
lifestyle interventions with the aim of optimising modifiable risk factors for surgery, namely: physical 
activity, nutritional status, mental wellbeing, smoking status, alcohol intake, and pain management. Given 
the association between cardiorespiratory fitness and surgical outcomes, prehabilitation programmes are 
typically centred around exercise training. Evidence from systematic reviews demonstrates that 
prehabilitation interventions which include aerobic and/or resistance exercise training are effective at 
improving preoperative fitness and postoperative outcomes across a range of surgical populations 
(Clifford et al., 2023, Jain et al., 2023, Punnoose et al., 2023, McIsaac et al., 2022, Heger et al., 2020, 
Santa Mina et al., 2014). Specifically, measurements of cardiorespiratory fitness including V̇ O2PEAK, 
6-minute walk distance, and 1-minute sit-to-stand performance improve in response to prehabilitation 
(Bradley et al., 2023, Hall et al., 2022, West et al., 2015). Furthermore, prehabilitation has been shown to 
reduce postoperative complications, pain, length of hospital stay, and improve postoperative function, 
compared to usual care (Clifford et al., 2023, Punnoose et al., 2023, McIsaac et al., 2022, Moyer et al., 
2017, Wang et al., 2016, Santa Mina et al., 2014). 
In order to maximise the potential benefits from prehabilitation, including improved surgical outcomes and 
reduced costs to the NHS, accessibility is key. Commonly, prehabilitation is delivered via face-to-face 
sessions in hospital or community facilities. However, the most frequently reported barriers to 
engagement in prehabilitation programmes are lack of time and difficulty travelling to facilities on a regular 
basis (Gurunathan et al., 2023, van der Velde et al., 2023, Waterland et al., 2021). In addition to 
presenting a barrier to patients, face-to-face interventions are accompanied by high running costs to the 
healthcare provider, making the economic case for their implementation challenging (Barberan-Garcia et 
al., 2019). Furthermore, in-person interventions are vulnerable to disruption, e.g., during the Covid-19 
pandemic, with the target population of surgical patients susceptible to infection. As such, home-based 
interventions may provide an alternative approach. Indeed, a systematic review of prehabilitation studies 
identified home-based programmes as a strategy to overcome commonly-reported barriers of lack of time 
when scheduling prehabilitation around work, medical appointments, and practical tasks, plus lack of 
transport and parking (van der Velde et al., 2023).  
In prior studies, it has been shown that ~70% of patients would prefer to complete prehabilitation in their 
home (Gurunathan et al., 2023, Waterland et al., 2021). Furthermore, patients and/or their informal carers 
identify a tailored approach based on individual needs and preferences, access to resources, the ability to 
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monitor their progress, and motivation from achieving objective progressions as facilitators to engaging in 
prehabilitation (van der Velde et al., 2023, Agasi-Idenburg et al., 2020). Traditional paper handouts of 
exercises to perform at home may not provide scope for individually-tailored, progressive, and engaging 
exercise prescriptions, and have been shown to be inferior to digital home-based interventions (Lambert 
et al., 2017). Therefore, digital home-based prehabilitation interventions may overcome issues with 
face-to-face and traditional home-based interventions. 
There has been a rapid uptake of digital appointments since the Covid-19 pandemic – known as 
‘telemedicine’. Such strategies have been applied to prehabilitation – known as ‘teleprehabilitation’. 
Teleprehabilitation may involve remotely-supervised exercise sessions (e.g., via videoconferencing), 
which have been shown to be acceptable and effective for patients awaiting surgery (Parraguez et al., 
2023, An et al., 2021, Doiron-Cadrin et al., 2020). Notably, teleprehabilitation was shown to be similarly 
effective as in-person supervised prehabilitation (Doiron-Cadrin et al., 2020) and unsupervised 
teleprehabilitation (An et al., 2021). The equivalence to unsupervised teleprehabilitation is relevant, as 
supervised teleprehabilitation brings a high personnel burden and cost. For example, a three-week 
teleprehabilitation intervention delivered prior to total knee arthroplasty involved twice-daily 30-minute 
sessions on five days each week, each supervised by a physical therapist (An et al., 2021).  
Unsupervised teleprehabilitation involves providing patients with access to an online platform of 
prehabilitation resources, often supplemented with ‘check-in’ calls arranged weekly. Previous trials have 
demonstrated the acceptability and efficacy of unsupervised teleprehabilitation in onco-surgery 
(Drummond et al., 2022, Franssen et al., 2022, Wu et al., 2021, Piraux et al., 2020, Bruns et al., 2019), 
major elective surgery (van der Velde et al., 2022), lung transplant (Singer et al., 2018), and total joint 
arthroplasty (Chughtai et al., 2019). Only one trial, to our knowledge, has implemented unsupervised 
teleprehabilitation within the NHS in the UK (Wu et al., 2021). The four-week intervention included aerobic 
and resistance exercise, information on nutrition, and referral to smoking cessation, alcohol moderation, 
and psychological support services, plus weekly video calls (Wu et al., 2021). Whilst the resistance 
exercise training was delivered via exercise videos, no specific exercise prescription (i.e., frequency, 
intensity, time, type) was provided for aerobic exercise, and instead participants were advised to 
accumulate 150 minutes of moderate intensity aerobic activity per week (Wu et al., 2021). To improve 
cardiorespiratory fitness parameters associated with improved postoperative outcomes in the restricted 
preoperative time-frame, targeted exercise prescriptions such as high intensity interval training may be 
preferable (Weston et al., 2016). Furthermore, patients reported that they felt peer support was missing 
from the intervention (Wu et al., 2021). As such, there is space within the UK market for tailored, 
progressive, dynamic, evidence-based interventions that are aligned with patient preferences and are 
cost-effective for implementation within the NHS. 
PreActiv’s digital prehabilitation platform has been developed over the last two years by physicians, 
exercise physiologists, physiotherapists, software engineers, front-end developers, graphic designers, 
accessibility experts, and members of the public. PreActiv’s digital prehabilitation platform provides 
tailored, progressive, dynamic, evidence-based prehabilitation to patients within their own home via their 
computer, smartphone, or tablet. Exercise prescriptions are tailored to the patient's mobility level and 
fitness level, which are assessed via in-platform questionnaires and functional assessments. 
Subsequently, patients are enrolled onto an easy-to-follow programme of vigorous intensity aerobic and 
resistance exercise, plus breathing exercises in three 35-minute sessions per week for six weeks. The 
programme is adapted iteratively based on the patient’s fortnightly exercise test results, further tailoring 
the course to their needs and aiming to progress the intensity of the exercises over time. Within PreActiv’s 
digital prehabilitation platform, patients are enrolled into a managed community forum of patients and 
healthcare professionals where they can post their achievements and questions. Alongside access to 
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PreActiv’s digital platform, patients will be given educational materials that summarise the benefits of 
prehabilitation and how to realise them. At the end of the programme, patients are given a certificate and 
report which details their progress. 
The novel provision of tailored, progressive, dynamic, evidence-based, and home-based prehabilitation 
via a digital platform requires evaluation for feasibility, prior to a larger study investigating the efficacy of 
PreActiv’s digital prehabilitation platform to improve preoperative fitness and postoperative outcomes. 
2.​ Aims 
The primary aim of this study is to evaluate the feasibility of PreActiv’s digital prehabilitation, prior to a 
future larger study investigating its efficacy. The following outcomes measures will be evaluated during 
the study: 
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Recruitment rate (the proportion of patients invited that provide written informed consent) 
●​
Uptake (the proportion of patients invited that are willing to be screened for eligibility) 
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Screen-pass rate (the proportion of willing patients that pass screening for eligibility) 
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Adherence (the proportion of exercise sessions offered that are attended) 
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Compliance (the proportion of exercise sessions that are completed as prescribed) 
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Retention (the proportion of patients that enrol into the study who complete follow-up 
measurements) 
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Safety (the incidence and severity of adverse events) 
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Acceptability (Likert scale and open-ended survey questions, posts in community forum) 
The secondary aim is to assess the preliminary efficacy of PreActiv’s digital prehabilitation by measuring 
pre- to post-intervention changes to: 
●​
Cardiorespiratory fitness (VO2PEAK, ventilatory threshold) 
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Functional fitness (1-minute sit-to-stand test, 1-minute seated push-up test) 
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Resting blood pressure and heart rate 
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Self-reported physical activity level (International Physical Activity Questionnaire Short Form) 
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Quality of life (EuroQoL EQ-5D-5L Scale) 
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Mood (Hospital Anxiety and Depression Scale) 
An exploratory aim is to evaluate the economic/environmental impact of PreActiv’s digital prehabilitation: 
●​
Cost per patient to deliver PreActiv’s digital prehabilitation, with comparison to published costs for 
face-to-face and telemedicine prehabilitation programmes 
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●​
Environmental impact avoided by performing prehabilitation at home via PreActiv’s digital 
prehabilitation compared to the estimated hypothetical emissions associated with participants 
travelling to the hospital three times per week for six weeks for face-to-face prehabilitation. 
3.​ Study design 
A single-arm pilot study conducted at the Royal United Hospitals Bath NHS Foundation Trust (RUH). All 
participants will be allocated to receive PreActiv’s digital prehabilitation alongside usual care. Usual care 
at the RUH involves a digital preoperative assessment of surgical risk and relevant investigations such as 
electrocardiogram (ECG) and blood tests for all patients. For some patients, usual care may also include 
seeing an anaesthetist (depending on their risk factors) and seeing other allied healthcare professionals, 
e.g., dietician (depending on their individual requirements or the nature of the surgery). Prehabilitation is 
not standard of care at the RUH. Pre-intervention testing will be conducted in week 0 and 
post-intervention testing will be conducted in week 7. 
4.​ Participant eligibility 
The following inclusion criteria will define patients eligible for the study: 
●​
Planned for major elective surgery ≥10 weeks from time of recruitment 
o​
Major or complex surgery examples in NICE guideline NG45 ‘Routine preoperative tests 
for elective surgery’ provides appropriate examples that are relevant to the patient cohort 
at RUH. We have extrapolated from these examples a list of surgical procedures that 
qualify as major or complex surgery and are carried out at the RUH. This list is not 
exhaustive but provides a range of procedures that are applicable for example: 
laparotomy, joint replacement, total abdominal hysterectomy, nephrectomy, neck 
dissection, parotidectomy, endoscopic resection of prostate, thyroidectomy. 
●​
Aged ≥50 years 
Subgroups of patients will be excluded: 
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Surgery scheduled in <10 weeks  
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Any relative or absolute contraindications to undertake an exercise test as described by the 
American College of Sports Medicine (ACSM, 2022) and the American Heart Association 
(Fletcher et al., 2013) 
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Unsuitable to increase physical activity level as determined by Physical Activity Readiness 
Questionnaire (PAR-Q) 
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Uncontrolled or poorly-controlled lung condition, diabetes, or seizures 
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Recent (<12 months) cardiovascular events needing hospital admission  
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Ongoing infection or wound making this programme hazardous for the patient  
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Unable to access technology required to use the PreActiv digital platform 
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Currently meeting World Health Organisation (WHO) physical activity guidelines of 75-300 
minutes of moderate to vigorous intensity physical activity per week, plus twice-weekly muscle 
strengthening activities 
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Unable to understand explanations and/or provide informed consent 
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Unable to understand written or spoken English, and without ongoing access to an interpreter 
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Any condition and/or behaviour that would pose undue personal risk or introduce bias into the 
study 
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Currently enrolled in another research trial 
5.​ Study procedures 
a.​ Sample size 
A sample size of N = 34 has been selected, based on the primary aim of this pilot study to determine 
whether progression to a full-scale study is indicated, according to predefined progression criteria. 
Methodology for sample size estimation in external pilot studies published by Lewis et al. (2021) has been 
used to inform the sample size. A traffic light system (Avery et al., 2017) has been used to define 
progression criteria based on two key outcome measures - adherence and retention: 
 
Red  
stop 
Amber  
amend 
Green  
go 
Adherence 
0-50% 
51-74% 
75-100% 
Retention 
0-50% 
51-74% 
75-100% 
 
Based on these progression criteria, and aiming to test the hypothesis that feasibility outcomes will not fall 
within the red zone (stop) based on the expectation of being in the green zone (go) with 90% power and 
one-sided alpha of 0.05, we need to consent N = 34 participants. As such, recruitment will cease once N 
= 34 participants have provided written informed consent. 
b.​ Recruitment, screening & informed consent 
Participants will be recruited from the preoperative assessment clinic at the RUH. Preoperative 
assessment clinic is delivered predominantly via a virtual clinic (‘MyPreOp’) at the RUH, whereby patients 
complete questionnaires and provide consent for surgery online. However, all patients awaiting major 
elective surgery are required to attend the RUH for a blood test as a minimum, with patients aged ≥65 
years and/or those with systemic disease also required to attend for ECG, as per the NICE guidelines 
(NICE, 2016). Preoperative nurses will identify potentially eligible patients who are booked for a blood test 
and/or ECG appointment according to study inclusion criteria. Preoperative nurses will email (emailing 
patients is part of normal practice) the participant information sheet to potentially eligible patients a 
minimum of 48 hours prior to their appointment. A short period between provision of study information and 
follow-up by the research team is justified in the context of potentially short surgical pathways in the study 
population.  
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During their appointment, the patient will be asked by the preoperative nurse if they are interested in 
participating in the study. If they are interested, the patient will be introduced to a researcher who will be 
present in the preoperative clinic. For those patients who are not interested in being involved in the study, 
we are interested in capturing the reasons why for research reporting and to inform the design of a future 
RCT. We will explain to these patients that they do not need to give a reason as they are free to decline to 
answer, but that it would be really helpful if they could explain their reason for declining involvement, as 
this will contribute to research reporting and future study design of this project.  
Patients who are interested in participating will be invited to stay after their appointment to complete the 
study screening and consent visit. This approach is anticipated to reduce patient burden by avoiding an 
additional trip to the RUH for the study. Patients may also contact the researchers directly upon receipt of 
the participant information sheet, or agree with the researcher in the preoperative assessment clinic, to 
arrange a separate visit for screening and informed consent if preferred. 
Screening will be performed by a researcher - who is an RUH physician - against the inclusion/exclusion 
criteria via a bespoke health questionnaire completed by the patient (Appendix 1). The researcher will 
obtain verbal consent to access the patient’s medical record to validate the information provided in the 
health questionnaire. Indeed, as many of the exclusion criteria relate to very specific medical diagnoses, 
screening medical records to verify patient-reported medical conditions is anticipated to be the most 
comprehensive screening process. Patients will be asked to provide written informed consent in the 
presence of the researcher once patient eligibility has been confirmed and any questions about the study 
have been answered. If the patient does not have adequate understanding of written or spoken English, 
the informed consent process will be facilitated by a professional translator via Language Line. However, 
subsequent interpreting during the study will need to be provided by a non-professional interpreter (e.g., 
family member) as per the exclusion criteria: “Unable to understand written or spoken English, and 
without ongoing access to an interpreter”. 
c.​ Intervention 
Intervention tailoring 
Upon commencement of the intervention, participants will complete in-programme mobility and fitness 
assessments for tailoring of their programmes. 
The mobility assessment will involve answering the following questions: 
●​
Can you sit down and stand back up from a chair? - Yes, unsupported / Yes, supported / No 
●​
Can you walk with or without support? - Yes, unsupported / Yes, supported / No 
●​
Could you walk for more than 30 minutes? - Yes / No 
●​
Can you get down to and stand up from the floor? - Yes / No 
Based on participant responses, they will be allocated to one of four mobility groups: (i) seated, (ii) 
supported, (iii) standing, (iv) standing + floor. 
The fitness assessment will involve completing a 1-minute functional fitness assessment: 
●​
For those able to transition from seated to standing unsupported: a 1-minute sit-to-stand test, 
which measures the maximum number of times the participant can transition from a seated 
position to a standing position in 1-minute 
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For those unable, or requiring support, to transition from seated to standing: a 1-minute seated 
push-up test, which measures the maximum number of times the participant can lift their buttocks 
from the seat using their arms in 1-minute 
Based on participant performances, they will be allocated to one of three fitness groups: (i) low, (ii) 
intermediate, (iii) high. Allocation to fitness groups is based on the average normative score for males and 
females aged 70-79 years for 1-minute sit-to-stand test (Strassmann et al., 2013) whereby the 
‘intermediate’ group represents the 25th-75th percentile (Table 1). For the 1-minute seated push-up test, 
the ‘intermediate’ group represents the mean score with the standard deviation added and subtracted, 
from a published study in males and females aged ~75 years (Poncumhak et al., 2022) (Table 1). 
A dynamic course will be created for each individual participant based on the data they have submitted. 
Indeed, an appropriate programme will be created for weeks 1 and 2 based on the initial baseline 
responses to the mobility questionnaire and performance in the fitness assessment. In week 2 and week 
4, the fitness assessment will be repeated, and appropriate programmes will be allocated for weeks 3-4 
and weeks 5-6, respectively. 
The prehabilitation programmes are personalised to cater for differing mobility and fitness requirements 
and adapt on a fortnightly basis in line with the patient’s progress. Information on the allocation to mobility 
groups (seated/supported/standing/standing + floor) and fitness groups (low/intermediate/high) will be 
available to the researchers but blinded to the participant. 
Exercise dose 
All prehabilitation programmes consist of three ~35-minute sessions per week for a six-week period 
(Table 2). Rest days will be encouraged throughout the programme to facilitate recovery and reduce the 
likelihood of injury. Previous studies have found that six weeks of prehabilitation with three sessions per 
week improved 1-minute sit-to-stand test performance (Bradley et al., 2023), V̇ O2PEAK and ventilatory 
threshold (West et al., 2015). A multimodal approach to fitness will be taken, with each of the three 
sessions having an aerobic, resistance, and respiratory component, as recommended in the best practice 
guidelines for preoperative exercise (Tew et al., 2018).  
Exercises will be performed in a vigorous-intensity circuit-training format utilising body-weight and light 
external resistance. Previous research has shown circuit training with body-weight and dumbbell 
exercises reduced postoperative outcomes and length of hospital stay following elective abdominal aortic 
aneurysm repair (Barakat et al., 2016).  
The training sessions will commence with a 5-minute warm-up of dynamic mobility exercises performed at 
light intensity (rating of perceived exertion (RPE) 2-3/10 on a Borg CR10 scale) (Arney et al., 2019, 
Garber et al., 2011). Next, participants will complete aerobic exercise training for three sets of five 
exercises, where exercises are performed for 40 seconds followed by 20 seconds of passive rest, with a 
50-second passive rest between sets. After completing aerobic exercise training, participants will be 
guided through resistance training for major muscle groups, utilising bodyweight and light external 
resistance (e.g., food tins, water bottles) for two sets of five exercises, where exercises are performed for 
40 seconds followed by 20 seconds of passive rest, with a 50-second passive rest between sets. The 
target intensity for both aerobic and resistance exercise is vigorous-very vigorous, defined as RPE ≥5/10 
on a Borg CR10 scale (Arney et al., 2019, Garber et al., 2011). Finally, participants will complete two 
respiratory muscle training exercises for a total of ~4 minutes. 
The exercise prescription has been designed to achieve World Health Organisation physical activity 
guidelines for 75 minutes of vigorous intensity activity per week, whereby 25 minutes of vigorous intensity 
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exercise per session (excluding ‘set rest’) performed thrice weekly equals 75 minutes per week. Short 
20-second rest intervals have been selected so recovery is incomplete between exercises resulting in 
sustained intensity across the entirety of the aerobic and resistance exercise sections. Such an approach 
is adapted from Tabata training and repeated sprint training principles, but utilising multi-modal exercises 
as compared with uni-modal cycling or running-based exercise typically used in Tabata/repeated sprint 
training. 
Table 2. Summary of exercise prescription 
 
Number of 
exercises 
Sets 
Exercise 
interval 
Exercise 
intensity 
(RPE /10) 
Rest 
interval 
(seconds) 
Set rest 
(seconds) 
Warm-up 
6 
1 
2-6 reps 
2-3 
- 
- 
Aerobic 
5 
3 
40s 
5-10 
20 
50 
Resistance 
5 
2 
40s 
5-10 
20 
50 
Respiratory 
2 
1 
3 reps 
- 
5 
30 
 
Progression of the intervention  
The exercises will progress in complexity/difficulty every 2 weeks within the aerobic (e.g., increased 
speed, involvement of both upper and lower limbs) and resistance (e.g., bilateral to unilateral, introduction 
of isolation exercises where access to increasing loads may be restricted in the home-based setting) 
sections of each fitness group, with the aim of increasing intensity and providing a varied stimulus for 
adaptation and enjoyment.  
In addition to the progression which occurs every 2 weeks within each fitness group, functional fitness 
assessments (1-minute sit-to-stand test or 1-minute seated push up test) will be repeated at the end of 
weeks 2 and 4 to inform progression to a higher fitness group. For example, if a participant's 1-minute 
sit-to-stand exercise test result improves from 34 to 37 at the end of week 2, the patient will be assigned a 
high intensity programme for their mobility level for weeks 3 and 4. These edits will be refined 
automatically via adaptive algorithms using logic.  
Monitoring of exercise intervention 
Immediately after completing the aerobic exercise section, participants will be asked to report their overall 
RPE for aerobic exercise. The same process will be repeated immediately after the resistance exercise 
section. Participants will be asked to select the most appropriate score from 0-10 following the 
standardised prompt: “How much effort/exertion did you put into the workout? Where 0 would be no 
effort/exertion, and 10 would be the most effort/exertion you could possibly give.” 
Monitoring of participant engagement will also be conducted using the ‘back-end’ data from PreActiv’s 
digital platform.  
●​
Adherence: If participants have not performed a session in the past four days, a researcher will 
email them to remind them to log-in and complete their sessions. If there is no response to the 
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email after two days, a researcher will telephone the participant to explore reasons for low 
adherence and provide support to increase adherence. 
●​
Compliance: If participants report an RPE <5 for aerobic and/or resistance exercise on two 
occasions, they will be telephoned by a researcher to assess why they have scored their RPE <5. 
If poor  technique or lack of understanding is causing RPE <5, education on the importance of 
intensity and how to achieve higher intensities will be provided. If technique/understanding are 
not the issue, and the programme is too easy, the course would be adapted manually (in the 
future, the adaptation of the course would be partially automated). 
Non-exercise intervention 
General advice and information on services relating to alcohol consumption, smoking, and nutrition will be 
provided in the PreActiv eBook. Specific instruction or advice on alcohol, smoking, and nutrition is beyond 
the scope of this iteration of the PreActiv digital platform but will be included in subsequent versions.    
A community forum will be provided within the PreActiv digital platform, which will allow people 
undergoing similar surgeries to share experiences, discuss queries, and seek support from peers. 
Participants will have access to the community forum throughout their prehabilitation programme, and for 
one month post-surgery, to allow participants to share comments about their surgery and recovery 
experience. All comments made in the community forum will be archived for later analysis in order to 
further refine and evaluate PreActiv’s digital prehabilitation. 
There will be a check-in session on a Monday with a member of the research team via the community 
forum so users can access health professional support. This support is included in the implementation 
plan and is part of the intervention. 
d.​ Measurements 
Primary outcome measurements will be collected throughout the study (week 0-7). 
Feasibility 
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Recruitment rate: the proportion of patients invited that provide written informed consent 
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Uptake: the proportion of patients invited that are willing to be screened for eligibility 
●​
Screen-pass rate: the proportion of willing patients that pass screening for eligibility 
●​
Adherence: the proportion of exercise sessions offered that are attended, assessed based on the 
number of sessions completed on the PreActiv platform (note: subsequent exercise sessions only 
become available to participants once they have watched the previous video). 
●​
Compliance: the proportion of exercise sessions that are completed as prescribed: 
○​
Exercise intensity: comparing the RPE reported by participants to the target RPE 
prescribed (i.e., RPE 5-10/10 is the target, so RPE 6/10 would be compliant but RPE 
4/10 would be non-compliant). The proportion of aerobic and resistance sessions that are 
completed at the target intensity will be reported. It has been shown that an RPE score 
reported at the end of an exercise session is equivalent to the average RPE reported 
after each exercise (Day et al., 2004). 
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○​
Exercise type: after each session, participants will respond to the question: “how much of 
the session could you complete?” with options: all / most / some / none. If they select any 
option other than “all”, they will be asked to identify any exercises included in their 
session that they couldn’t complete from a list. Any sessions where ≥1 exercise was not 
completed will be deemed non-compliant to the type of exercise prescribed. The 
proportion of sessions where all exercises are completed will be reported. 
○​
Duration: after each session, participants will respond to the question: “how much of the 
session could you complete?” with options: all / most / some / none. If they select any 
option other than “all”, they will be asked to identify any exercises included in their 
session that they couldn’t complete from a list. If they do not select any specific exercise, 
then we infer that participants were unable to perform the exercises for the required 
duration. Any sessions where most / some / none is reported with no specific exercise 
identified will be deemed non-compliant to duration. The proportion of sessions where 
exercises were performed for the target duration will be reported. 
●​
Retention: the proportion of patients that enrol into the study who complete follow-up 
measurements 
●​
Safety: the incidence and severity of adverse events reported during the weekly check-in session 
with a member of the research team, and via a free-text response box after each exercise 
session to be completed if the participant indicates that they could not perform all exercises. 
●​
Acceptability (week 7 only): collected via a survey integrated within PreActiv’s prehabilitation 
platform containing a combination of Likert scale and open-response questions about participant 
experiences of using PreActiv’s digital prehabilitation (Appendix 2). Responses to the survey will 
be fully anonymised, meaning responses cannot be attributed to the participant by name or study 
ID. Additional feedback will be obtained from comments submitted by participants to the 
community forum throughout the intervention. 
Secondary outcome measurements will be conducted at the University of Bath during week 0 
(pre-intervention) and week 7 (post-intervention), with each visit lasting 1-hour: 
Participant characteristics 
●​
Baseline characteristics (week 0 only): age, sex, ethnicity, surgery type, comorbidities, 
medications, mobility, transport to hospital visits (Appendix 3). 
Physical assessments  
●​
Resting blood pressure and heart rate will be measured using an automated sphygmomanometer 
after 15 minutes of seated rest. 
●​
Cardiorespiratory fitness: Cardiopulmonary exercise tests (CPET) will be performed using a 
ramp-incremental protocol on a cycle ergometer. Body mass, height, and resting blood pressure 
will be measured prior to commencing exercise. After a 3-minute low-intensity warm-up, 
participants will be instructed to maintain a consistent cadence of 50-70 rpm during a ramp 
protocol whereby the resistance against the pedals increases incrementally over time. The rate of 
the incremental ramp protocol will range from 5-30 watts/minute, based on participant’s ability, 
with the aim of achieving maximal exertion within 8-12 minutes. Participants will be encouraged to 
exercise to maximal exertion. Heart rate, blood pressure, oxygen saturation, and rating of 
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perceived exertion (RPE) rated from 0-10 will be monitored throughout. A 5-minute low intensity 
cool-down will be completed after the ramp protocol with monitoring of heart rate and blood 
pressure recovery. Measurements of VO2PEAK and ventilatory threshold will be derived from 
CPETs. 
●​
Functional fitness: 1-minute sit-to-stand test (for participants able to transition from seated to 
standing unsupported) or 1-minute seated push-up test (for participants unable, or requiring 
support, to transition from seated to standing). 
○​
1-minute testing protocols have been selected to increase the emphasis on measuring 
endurance rather than muscular strength, due to the associations between 
cardiorespiratory fitness and surgical outcomes. The 1-minute sit-to-stand test has been 
shown to induce similar cardiorespiratory responses as cardiopulmonary exercise testing 
in COPD patients (Gephine et al., 2020), and has been implemented in prehabilitation 
trials (Bradley et al., 2023). The 1-minute seated push-up test is a relatively novel 
assessment, and has been shown to correlate with other functional fitness measures 
(Chokphukiao et al., 2023, Poncumhak et al., 2023). 
●​
Self-report physical activity: Participants will complete the IPAQ short-form questionnaire to 
self-report days per week and minutes per day of vigorous intensity physical activity, moderate 
intensity physical activity, walking, and sitting. ‘MET-hours’ (MET = metabolic equivalent of task) 
per week will be calculated. This information will be compared to the WHO guidelines on physical 
activity and sedentary behaviour. 
Psychological assessments 
●​
Quality of life: Participants will complete the EQ-5D-5L to provide insights into mobility, self-care, 
usual activities, pain/discomfort, and anxiety/depression. 
●​
Mood: Participants will complete the Hospital Anxiety and Depression Score 
Economic & environmental 
●​
Cost per patient to deliver PreActiv’s digital prehabilitation, with comparison to published costs for 
face-to-face and telemedicine prehabilitation programmes 
●​
Environmental impact avoided by performing prehabilitation at home via PreActiv’s digital 
prehabilitation compared to the estimated hypothetical emissions associated with participants 
travelling to the hospital three times per week for six weeks for face-to-face prehabilitation. 
Publicly-available carbon emissions data will be used for calculations. 
e.​ Data analyses 
The primary aim of this study is to test feasibility of the PreActiv’s digital prehabilitation. Feasibility will be 
assessed by reporting proportions and comparing to predefined progression criteria (for adherence and 
retention). This pilot study is not adequately-powered to investigate the statistical significance of pre- to 
post-intervention changes to secondary outcome measures. As such, data analyses will be predominantly 
descriptive. Effect sizes will be reported to convey the magnitude of pre- to post-intervention changes to 
secondary outcomes. 
6.​ Patient and public involvement (PPI) 
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We have undertaken two phases of PPI activities in the development of this study. Firstly, PreActiv’s 
digital prehabilitation has been co-designed with N=30 members of the public aged 50-96 years over a 
two-year period. Whilst these contributors were not all awaiting major elective surgery, they are otherwise 
reflective of the demographic of participants for this study. We also wanted to represent the views of 
surgical patients in our PPI activities. As such, secondly, we conducted a series of 1:1 interviews with N = 
4 aged 50-65 years patients awaiting major elective surgery at the RUH. These interviews involved 
discussions of the participant journey through the study, PreActiv’s digital prehabilitation intervention, 
measurements of interest to participants, incentives for participation, and the participant information 
sheet. Examples of iterations to the study design and intervention based on PPI are summarised below: 
PPI feedback 
Changes implemented 
PPI phase 1 
Originally, each exercise session was 60 minutes 
long, and users reported that was too long and 
that they couldn’t find the time for three 60-minute 
sessions per week. 
We have shortened each session to 35 minutes, 
which 
was 
deemed 
more 
accessible 
and 
achievable by users. The shorter sessions still 
meet our goal of achieving WHO physical activity 
guidelines for 75 minutes of vigorous intensity 
aerobic activity, plus two sessions of strength 
training, per week. 
Users reported that having one continuous 
exercise video was hard to follow and it was 
unclear how hard they should be working in each 
section. 
We have implemented separate exercise videos 
for each section - warm-up, aerobic, resistance, 
and breathing - with specific instructions on 
intensity and signs of exertion that are relevant to 
each section. 
Users reported that when asked for their RPE 
score at the end of the whole session, they were 
inclined to report how they were feeling at that 
moment. As they had just completed the 
low-intensity breathing exercises, the RPE scores 
were lower than expected. 
By splitting each of the sections into separate 
exercise videos, we were able to embed the RPE 
question directly after the aerobic and resistance 
exercise videos. Users then reported their RPE for 
each specific section directly after they had 
completed that section. As a result the RPE 
scores 
were 
higher 
and 
reflective 
of the 
effort/exertion experienced for that section.  
We originally used a modified Borg RPE scale 
with descriptions beside each number based on 
breathlessness. The higher the score, the more 
breathless you were with 9-10 being: ‘you are 
unable to talk and completely out of breath.’ Users 
reported that the RPE scale we had originally 
used was difficult to understand as each level 
included two numbers (1-2, 3-4 etc) with no way to 
differentiate between them. Users also reported 
that defining exertion based on breathlessness 
was inappropriate, as they associated being 
breathless with being unfit, and therefore were 
We have changed the wording accompanying our 
validated 
0-10 
Borg 
RPE 
scale 
to 
avoid 
mentioning breathlessness. The new phrasing is: 
“How much effort/exertion did you put into the 
workout? Where 0 would be no effort/exertion, 
and 10 would be the most effort/exertion you 
could possibly give.” The resulting scores have 
been 7-9/10 using this scale, compared to 2-4/10 
on the original scale. When combined with 
participants reporting that their heart rate was up 
and that they were sweaty, the new scale appears 
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more likely to rate their RPE lower, even though 
they reported that their heart rate was up and that 
they were sweaty. 
better at capturing their exertion than the original 
scale. 
 
Users reported that they were likely to follow the 
pace of the model in the exercise videos, even if 
they could exert themselves further and go faster. 
Users either stuck to the pace of the instructor or, 
if they weren’t able to keep up, would go at a 
slower pace. 
We have ensured the instructor's pace is set at an 
optimal speed during the exercise videos for the 
study. If this is too fast for some users, we are 
confident that they will self-regulate their speed, 
based on user feedback. 
Users reported that they weren’t always able to 
look at the video throughout the whole exercise 
(e.g., if they needed to be on the floor, or facing a 
wall), and therefore, they would miss out on visual 
encouragement or indications of how much time 
was left. 
We have added in audible motivational phrases to 
try to get users to work hard throughout their 
exercises. For example, “keep going”, “push 
yourself right to the end”, “see if you can up your 
speed for the last 10 seconds”.  We have also 
added in a beep and a flashing countdown timer 
for the last 5 seconds, to help achieve maximal 
exertion and so that users are aware that the end 
of the exercise rep is nearing, even if they cannot 
see the screen. 
Users reported that they didn’t have time to 
hydrate between exercises as they didn’t have 
water to hand. 
Before a user begins a session, they are informed 
of the equipment they will need e.g. chair, weights. 
We have now added a glass of water icon and 
description to this area so users will be prepared. 
PPI phase 2 
Some patients reported that they would like to 
meet the researcher at a time when they were 
already attending the hospital for a surgical 
appointment: “as your mind is on the surgery”. 
However, others reported that: “people might feel 
stressed [after their surgical appointment] and just 
want to get out”. Patients that preferred to stay for 
the screening and consent visit after their 
appointment raised that they would need to know 
the exact amount of time it would take, due to 
planning and paying for parking. 
We will send the participant information sheet to 
patients ahead of a routine appointment, with the 
aim of conducting screening and consent visits 
after their appointment. This approach will reduce 
the time and travel burden for patients. We have 
explained in the participant information sheet that 
the screening visit will last 45 minutes, and will 
reimburse participants for 1 hour of extra parking.  
We will also have an option for patients to arrange 
a separate visit to the hospital for screening and 
consent if that is their preference. 
When asked if two days’ notice was enough time 
to decide whether they would like to take part in 
the study, patients reported that this was similar to 
the amount of notice they had for other 
appointments. 
We will pursue a minimum two-day period 
between sending the participant information sheet 
and the patient’s routine appointment where they 
will be asked if they are interested in taking part. 
Patients were shown PreActiv’s prehabilitation 
website and eBook. Patients reported: “I think it is 
 
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a very good programme frankly” and they liked 
that the website was “extremely simple”. Patients 
found the eBook “interesting, particularly Food 
Fit”. 
When asked about attending the University of 
Bath for the measurement visit, patients reported 
that: “it is quite intimidating for people who haven’t 
been there”. 
We need to use equipment at the University of 
Bath for the study measurements, and as such, it 
was not possible to change the venue. We will 
provide participants with a detailed map and 
directions to the car park. The researcher will 
meet them in the car park and walk with them to 
the laboratory. Patients will also be given a 
contact number for the researcher if they have any 
issues. This approach has been successful in 
previous research studies. 
When asked about the benefits they would be 
hoping for if they took part in the intervention, 
patients reported that: “seeing fitness results 
improving during the programme” and “noticing an 
impact after surgery” were important to them. 
We 
explained 
to 
patients 
that 
measuring 
postoperative outcomes was outside the scope of 
this feasibility study, but that such measures 
would be included in a future study. The platform 
involves repeated assessments of fitness every 
two weeks, where participants can see their 
results progress in their user profile. 
When asked about incentives for taking part, 
patients reported: “a certificate of results would 
give a sense of achievement” and “money is not 
needed”. 
We will provide participants with a certificate of 
their progress during the intervention, plus a 
report of results from health, fitness, and wellbeing 
assessments performed at the University of Bath. 
We will provide money to cover the costs 
associated with taking part in the study. 
When asked for their feedback on the participant 
information sheet, patients reported that it looked 
professional and was easy to understand, but that 
it was quite long and a summary would be helpful. 
Patient’s proposed that they could talk to the 
researcher for more details. 
We have included a two-page executive summary 
within the participant information sheet, which 
contains the most important information for 
patients to decide whether to take part. The 
researcher will talk through the details of the 
participant information sheet during the screening 
and consent visit. 
 
7.​ Benefits of participating 
Participants will be provided with bespoke feedback on their test results after completing the study period. 
This will include physical activity level, blood pressure, cardiorespiratory fitness, and functional fitness, 
with reference to population norms and recommended guidelines – and highlighting any changes that 
occur between baseline and follow-up measures. Participants will also be awarded a certificate 
highlighting their progress throughout the digital prehabilitation intervention, including sessions performed 
and in-platform fitness test results. 
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Participants will receive free access to PreActiv’s digital prehabilitation for six weeks, which would 
otherwise cost £45. 
Participants will be reimbursed for their travel costs associated with taking part in the study, including 
parking costs, and fuel costs paid at 45p per mile for study visits. Payments will be made via BACS 
transfer. 
8.​ Risks of participating 
Risks of exercising: While exercise training provides long-term benefits that reduce the risk of adverse 
health events, the risk of acute injury and medical events is elevated whilst exercise is being performed. 
In particular, our exercise intervention is to be performed at vigorous to maximal exertion (i.e., a rating of 
perceived exertion 5-10/10), which increases the risk of adverse reactions if not appropriately prescribed. 
To mitigate these risks, all participants will be thoroughly screened for exercise contraindications as per in 
the inclusion/exclusion criteria, and people presenting with contraindications will be excluded from the 
study on safety grounds. Furthermore, the exercise prescription has been developed by physicians, 
physiotherapists, and clinical exercise physiologists, meaning the exercises that have been selected are 
deemed suitable for the population by a multidisciplinary team of experts. In addition, the exercise 
programme is tailored to the participants mobility and fitness level. The exercise videos embedded in the 
platform provide visual and verbal instructions for correct technique to reduce the risk of injury. 
Participants are also advised to separate their sessions with rest days to allow for recovery. As the risk of 
acute injury and medical events can be minimised, but not eliminated, participants will be provided with 
instructions for setting up a safe exercise space at home, and will be advised to stop exercising upon the 
onset of red-flag symptoms (e.g., pain, dizziness, light-headedness, feeling generally unwell) and to seek 
medical attention. Furthermore, there will be access to first aid and immediate life support (including 
defibrillator) during cardiopulmonary exercise testing.  
Time burden: In planning this research, the team has made careful consideration of the time burden 
involved. Indeed, part of the rationale for this study is that lack of time is a commonly-reported barrier to 
engaging with prehabilitation. The intervention requires participants to perform three 35-minute sessions 
per week, for a total time commitment of 1-hour 45 minutes per week. Whilst this time commitment only 
represents approximately 1% of their week, we acknowledge that there are competing priorities during the 
preoperative period, including medical appointments, making preparations, and seeing family/friends. As 
such, our intervention has been designed to be performed within the participant’s home, to avoid 
additional time required for travelling, and to provide flexibility with scheduling around other commitments. 
Our user testing revealed that 35 minutes was the optimum duration for sessions, so we modified our 
original 60-minute sessions to meet user preferences. We have also planned for the screening/consent 
visit to coincide with a time that the participant is already at the hospital for a blood test/ECG to reduce 
the number of visits required. 
Digital exclusion: This risk is not possible to completely mitigate. There is a minimum requirement that 
patients will need to be able to access a website and register their details. We have created navigation 
videos to help with onboarding patients and to enable easy use of the platform. Patients are encouraged 
to select a champion, usually a friend or relative, to help with adherence and onboarding. Accessibility 
experts have been consulted and user interface and user experience (UI/UX) developers have focussed 
on accessibility, which has been central to the design to ensure ease of use. 
Software bugs impact on usability: For example crashes, loss of data, or functionality errors. The 
involvement of an experienced lead developer and technical team will mitigate this risk by analysing user 
data every two weeks to identify bugs early.  
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Poor UI/UX: May reduce the accessibility of PreActiv’s digital prehabilitation, particularly in this patient 
group who commonly have less digital experience, and often sensory impairments. The platform interface 
has been designed with accessibility as a priority, drawing on the experience of PreActiv’s developers 
who have experience in UI/UX design that focuses on accessibility, and continuously engaging with user 
feedback to improve the UI/UX design. 
Changes to the regulatory frameworks may occur:  Including medical device standards and 
information governance. The platform is compliant with regulatory frameworks, and updates will be 
monitored closely by the research team to ensure continued compliance to regulatory requirements. 
9.​ Data management 
Manual files containing personal data (i.e., informed consent forms, health screening questionnaires) will 
be stored securely in the Clinical Trials Office at the Royal United Hospitals Bath NHS Foundation Trust. 
Electronic files containing personal data (i.e., a password-protected Excel spreadsheet that links the 
study-specific anonymisation code to the participant's personal data) will be stored securely on an NHS 
computer. 
Study data anonymised using a study-specific ID score will be stored securely in a locked filing cabinet at 
the University of Bath (manual files) or on a cloud-based platform (e.g., GoogleDrive) accessible via a 
password that will only be provided to members of the research team (electronic files). At the end of the 
trial, manual files will be transferred from the University of Bath to the Royal United Hospitals Bath NHS 
Foundation Trust. 
With regards to study data stored within PreActiv’s digital prehabilitation platform, data storage practices 
conform with GDPR and NHS data security guidelines. In-platform storage processes are as follows: 
●​
Personal data supplied by the participant to enrol onto PreActiv's digital prehabilitation platform 
(first name, surname, email address) will be stored in a Relational Database Management 
System (RDBMS) called MYSQL. The MySQL Database is made up of tables of data with 
relational keys to associate data between them. All user data is held within this database and the 
majority is stored in plain text, JSON, and serialised array format. The database is hosted on 
non-public facing infrastructure (i.e., it cannot be accessed via a URL). However, the participant is 
able to access their own data, and PreActiv’s tech lead is able to access all participant data, as 
described next. 
●​
When data are accessed from the database, they are sent and received via an encryption method 
called SSL/TLS. SSL/TLS stands for secure sockets layer and transport layer security. It is a 
protocol or communication rule that allows computer systems to talk to each other on the internet 
safely. SSL/TLS certificates allow web browsers to identify and establish encrypted network 
connections to web sites using the SSL/TLS protocol. 
●​
Participants can access their own data from the database via the application server (i.e., via 
PreActiv’s digital prehabilitation platform on a web browser) using stored credentials over a 
secure TLS connection. This connection requires a username, password, and a private / public 
key pair-based authentication method, which is only known by the participant.  
●​
PreActiv’s tech lead can access all participant data via PHPMyAdmin, which is a web-based 
database management tool that developers can use to view, edit, and delete not only the data 
stored in the database, but the schema of the database itself. This is also transferred over a 
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secure TLS connection, and requires a username and a password and can only be accessed via 
token-based authentication directly obtained from the administrative dashboard of our web host. It 
is not publicly available and can not be viewed through a normal web address or a public IP 
address. PreActiv’s tech lead will only use personal data to provide tech support to participants. 
 
10.​Definition of end of study 
The end of the study will be the date of the last visit of the last participant. 
 
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Grocott MPW; Perioperative Exercise Testing and Training Society (POETTS). Perioperative 
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10.1016/j.bja.2017.10.020. Epub 2017 Nov 24. PMID: 29452805. 
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Martin D, Mantziari S, Demartines N, Hübner M; ESA Study Group. Defining Major Surgery: A Delphi 
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McIsaac DI, Gill M, Boland L, Hutton B, Branje K, Shaw J, Grudzinski AL, Barone N, Gillis C; 
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testing as a risk-assessment method in patients undergoing intra-abdominal surgery: a systematic review. 
Br J Anaesth. 2016 Feb;116(2):177-91. doi: 10.1093/bja/aev454. PMID: 26787788. 
Moyer R, Ikert K, Long K, Marsh J. The Value of Preoperative Exercise and Education for Patients 
Undergoing Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev. 2017 
Dec;5(12):e2. doi: 10.2106/JBJS.RVW.17.00015. PMID: 29232265. 
NICE. Routine preoperative tests for elective surgery. 2016. 
https://www.nice.org.uk/guidance/ng45/chapter/recommendations Accessed 10-07-2023. 
Ozova M, Chomakhidze P, Poltavskaya M, Vychuzhanin D, Kopylov P, Saner H, Andreev D. 
Cardiopulmonary exercise testing for cardiovascular risk assessment in patients undergoing gastric and 
oesophageal cancer surgery: results from a prospective interventional cohort study. Open Heart. 2022 
Jul;9(2):e001932. doi: 10.1136/openhrt-2021-001932. PMID: 35840177; PMCID: PMC9295652. 
Parraguez LAL, Ribeiro IL, Hinojosa MP, Troncoso JP. Implementation of a teleprehabilitation program for 
oncosurgical patients during the COVID-19 pandemic: perspectives and user satisfaction. Support Care 
Cancer. 2023 May 22;31(6):346. doi: 10.1007/s00520-023-07799-z. PMID: 37212973; PMCID: 
PMC10201043. 
Piraux E, Caty G, Reychler G, Forget P, Deswysen Y. Feasibility and Preliminary Effectiveness of a 
Tele-Prehabilitation Program in Esophagogastric Cancer Patients. J Clin Med. 2020 Jul 9;9(7):2176. doi: 
10.3390/jcm9072176. PMID: 32660126; PMCID: PMC7408844. 
Poncumhak P, Wiyanad A, Siriyakul C, Kosura N, Amatachaya P, Amatachaya S. Validity and feasibility of 
a seated push-up test to indicate skeletal muscle mass in well-functioning older adults. Physiother Theory 
Pract. 2023 Mar;39(3):623-630. doi: 10.1080/09593985.2021.2023931. Epub 2022 Jan 6. PMID: 
34989326. 
Prentis JM, Manas DM, Trenell MI, Hudson M, Jones DJ, Snowden CP. Submaximal cardiopulmonary 
exercise testing predicts 90-day survival after liver transplantation. Liver Transpl. 2012 Feb;18(2):152-9. 
doi: 10.1002/lt.22426. PMID: 21898768. 
Punnoose A, Claydon-Mueller LS, Weiss O, Zhang J, Rushton A, Khanduja V. Prehabilitation for Patients 
Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open. 2023 Apr 
3;6(4):e238050. doi: 10.1001/jamanetworkopen.2023.8050. PMID: 37052919; PMCID: PMC10102876. 
Santa Mina D, Clarke H, Ritvo P, Leung YW, Matthew AG, Katz J, et al. Effect of total-body prehabilitation 
on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy. 2014 Sep 
1;100(3):196–207. 
Singer JP, Soong A, Bruun A, Bracha A, Chin G, Hays SR, Kukreja J, Rigler J, Golden JA, Greenland JR, 
Garvey C. A mobile health technology enabled home-based intervention to treat frailty in adult lung 
transplant candidates: A pilot study. Clin Transplant. 2018 Jun;32(6):e13274. doi: 10.1111/ctr.13274. Epub 
2018 Jun 20. PMID: 29742287; PMCID: PMC6066279. 
Strassmann A, Steurer-Stey C, Lana KD, Zoller M, Turk AJ, Suter P, Puhan MA. Population-based 
reference values for the 1-min sit-to-stand test. Int J Public Health. 2013 Dec;58(6):949-53. doi: 
10.1007/s00038-013-0504-z. Epub 2013 Aug 24. PMID: 23974352. 
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exercise training in patients awaiting major non-cardiac surgery. Anaesthesia. 2018 Jun;73(6):750-768. 
doi: 10.1111/anae.14177. Epub 2018 Jan 13. PMID: 29330843. 
Torchio R, Guglielmo M, Giardino R, Ardissone F, Ciacco C, Gulotta C, Veljkovic A, Bugiani M. Exercise 
ventilatory inefficiency and mortality in patients with chronic obstructive pulmonary disease undergoing 
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10.1016/j.ejcts.2010.01.032. Epub 2010 Mar 30. PMID: 20356758. 
van der Velde M, van der Leeden M, Geleijn E, Veenhof C, Valkenet K. What moves patients to 
participate in prehabilitation before major surgery? A mixed methods systematic review. Int J Behav Nutr 
Phys Act. 2023 Jun 21;20(1):75. doi: 10.1186/s12966-023-01474-6. PMID: 37344902; PMCID: 
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Peet DL, Aarden JJ, Veenhof C, van der Leeden M. Usability and Preliminary Effectiveness of a 
Preoperative mHealth App for People Undergoing Major Surgery: Pilot Randomized Controlled Trial. 
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PMC7819776. 
Wang L, Lee M, Zhang Z, Moodie J, Cheng D, Martin J. Does preoperative rehabilitation for patients 
planning to undergo joint replacement surgery improve outcomes? A systematic review and 
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10.1136/bmjopen-2015-009857. PMID: 26839013; PMCID: PMC4746481. 
Waterland JL, Ismail H, Amin B, Granger CL, Denehy L, Riedel B. Patient acceptance of prehabilitation 
for major surgery: an exploratory survey. Support Care Cancer. 2021 Feb;29(2):779-785. doi: 
10.1007/s00520-020-05547-1. Epub 2020 May 28. PMID: 32462351. 
West MA, Loughney L, Lythgoe D, Barben CP, Sripadam R, Kemp GJ, Grocott MP, Jack S. Effect of 
prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal 
cancer patients: a blinded interventional pilot study. Br J Anaesth. 2015 Feb;114(2):244-51. doi: 
10.1093/bja/aeu318. Epub 2014 Oct 1. PMID: 25274049. 
West MA, Lythgoe D, Barben CP, Noble L, Kemp GJ, Jack S, Grocott MP. Cardiopulmonary exercise 
variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded 
observational study. Br J Anaesth. 2014 Apr;112(4):665-71. doi: 10.1093/bja/aet408. Epub 2013 Dec 8. 
PMID: 24322573. 
Weston M, Weston KL, Prentis JM, Snowden CP. High-intensity interval training (HIT) for effective and 
time-efficient pre-surgical exercise interventions. Perioper Med (Lond). 2016 Jan 14;5:2. doi: 
10.1186/s13741-015-0026-8. PMID: 26770671; PMCID: PMC4712564. 
Wilson RJ, Davies S, Yates D, Redman J, Stone M. Impaired functional capacity is associated with 
all-cause mortality after major elective intra-abdominal surgery. Br J Anaesth. 2010 Sep;105(3):297-303. 
doi: 10.1093/bja/aeq128. Epub 2010 Jun 23. PMID: 20573634. 
Wu F, Rotimi O, Laza-Cagigas R, Rampal T. The Feasibility and Effects of a Telehealth-Delivered 
Home-Based Prehabilitation Program for Cancer Patients during the Pandemic. Curr Oncol. 2021 Jun 
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Appendix 1. Health questionnaire 
   
   
       
 
 
PreActiv digital prehabilitation project 
 
HEALTH SCREENING QUESTIONNAIRE 
 
Chief investigator:​  ​
Dr Alec Snow​
alec.snow@nhs.net    
Researchers:​
​
Dr Helen Sims​
helen.sims@nhs.net 
Dr David Quinn ​
davidquinn@nhs.net  
Ian-Ju Liang​ ​
ijl28@bath.ac.uk  
It is important that volunteers participating in research studies are currently in good 
health to exercise. This is to ensure (i) their own continued well-being and (ii) to avoid 
the possibility of introducing bias into the study outcomes. 
Please initial boxes: 
1.​ Are you scheduled to have surgery in 10 weeks or more from today? ​
​
​
Yes ☐​
No☐ 
2.​ Is the surgery you are scheduled for considered ‘major surgery’? Please consult 
with your surgical team if you are unsure. ​
Yes ☐​
No ☐ 
3.​ Are you aged 50 years old or older? ​
Yes ☐​
No ☐ 
 
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4.​ Are you able to understand written and spoken English, either independently, or 
with support from a family member or friend who can act as a translator 
throughout the study?​
Yes ☐​
No ☐ 
 
5.​ As far as you are aware, do you suffer or have you ever suffered from: 
a)​ Any heart condition (e.g., heart attack, angina, arrhythmia, vessel disease, 
valve 
disease, 
heart 
failure, 
inflammation, 
aortic 
dissection, 
cardiomyopathy) ​
Yes ☐​
No ☐ 
b)​ Blood pressure higher than 200/120 mmHg ​
Yes ☐​
No ☐ 
c)​ Pulmonary embolism or infarct​
Yes ☐​
No ☐ 
d)​ Deep vein thrombosis​
Yes ☐​
No ☐ 
e)​ Stroke or transient ischaemic attack​
Yes ☐​
No ☐ 
f)​ Uncorrected medical conditions such as significant anaemia, important 
electrolyte imbalance, and hyperthyroidism​
Yes ☐​
No ☐ 
g)​ Mental or physical impairment limiting exercise ​ Yes ☐​
No ☐ 
 
6.​ As far as you are aware, do you suffer from any of the following conditions: 
a)​ Lung condition(s)​
Yes ☐​
No ☐ 
If yes, are your lung condition(s) well-controlled​ Yes ☐​
No ☐ 
b)​ Seizures​
Yes ☐​
No ☐ 
If yes, are your seizures well-controlled​
Yes ☐​
No ☐ 
c)​ Diabetes​
Yes ☐​
No ☐ 
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If yes, is your diabetes well-controlled​
Yes ☐​
No ☐ 
d)​ Ongoing wound ​
Yes ☐​
No ☐ 
If yes, could the wound be made worse by exercise​
​
  
​
Yes ☐​
No ☐ 
e)​ Ongoing infection ​
Yes ☐​
No ☐ 
If yes, could the infection be made worse by exercise​
​
  
​
Yes ☐​
No ☐ 
 
7.​ Have you been hospitalised for a cardiovascular event within the past 12 
months?​
Yes ☐​
No ☐ 
 
8.​ The Physical Activity Readiness Questionnaire (PAR-Q) is a standard 
questionnaire used to identify risks that require consideration when increasing 
physical activity level. Please answer the following questions to the best of your 
knowledge: 
a)​ Has your doctor ever said that you have a heart condition, and should only 
do physical activity recommended by a doctor? ​ ​
​
​
​
Yes ☐​
No ☐ 
b)​ Do you feel pain in your chest when you do physical activity?​ ​
​
​
Yes ☐​
No ☐ 
c)​ In the past month, have you had chest pain when you were not doing 
physical activity? ​
Yes ☐​
No ☐ 
d)​ Do you lose your balance because of dizziness, or do you ever lose 
consciousness? ​
Yes ☐​
No ☐ 
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e)​ Do you have a bone or joint problem (for example back, knee or hip) that 
could be made worse by a change to your physical activity?​  ​
​
​
Yes ☐​
No ☐ 
f)​ Is your doctor currently prescribing drugs (for example water pills) for your 
blood pressure or heart condition? ​
Yes ☐​
No ☐ 
g)​ Do you know of any other reason that you should not do physical activity?​
​
Yes ☐​
No ☐ 
 
9.​ In the past week, did you perform: 
a)​ Physical activities for a total of 2 hours and 30 minutes or more that made 
you breathe slightly harder than normal? ​
Yes ☐​
No ☐ 
b)​ Physical activities for a total of 1 hour 15 minutes or more that made you 
breathe much harder than normal?​
Yes ☐​
No ☐ 
c)​ Muscle strengthening activities on two days or more? For example, lifting 
weights, using resistance bands, squats/push ups, heavy gardening​
​
Yes ☐​
No ☐ 
 
10.​PreActiv’s digital prehabilitation is delivered via a website that can be accessed 
on a computer, laptop, smart-phone, or tablet. Do you have access to any of 
these technologies to access PreActiv’s digital prehabilitation?​
​
​
​
Yes ☐​
No ☐ 
 
11.​Are you currently enrolled in any other research trials?​ Yes ☐​
No ☐ 
 
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If you have answered YES to questions 5-11, please provide details below (e.g., to 
confirm the problem was/is short-lived, insignificant or well controlled).  
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………………………………………………………………………………………………………
……………………………………………………………………………………………………… 
 
Participant Name: ________________________________________________ 
Participant Signature: _____________________________________________  
Date: ___________    
 
Participant ID: _____________ 
Researcher Signature: _____________________________________________  
Date: ___________                        
 
Thank you for your cooperation
 
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Appendix 2. Feedback survey 
Please tick one box per question that best represents your experience of PreActiv’s 
prehabilitation  
1= Strongly agree, 2 = Agree, 3 = Unsure, 4 = Disagree, 5 = Strongly disagree 
 
1 
2 
3 
4 
5 
N/A 
Website 
 
 
 
 
 
 
It was easy to register on the website 
 
 
 
 
 
 
The website was user friendly 
 
 
 
 
 
 
I am satisfied with the website 
 
 
 
 
 
 
The website was easy to navigate 
 
 
 
 
 
 
Aesthetically the website looked good 
 
 
 
 
 
 
Exercise prescription 
 
 
 
 
 
 
The exercises in the programme felt appropriate for me 
 
 
 
 
 
 
The exercise videos were easy to follow 
 
 
 
 
 
 
The exercises were challenging  
 
 
 
 
 
 
The rating of perceived exertion scale (0-10) was easy to 
understand 
 
 
 
 
 
 
It was easy to complete the fitness test in the programme  
 
 
 
 
 
 
I felt motivated to follow the exercise videos 
 
 
 
 
 
 
I enjoyed doing exercises at home 
 
 
 
 
 
 
Booklet/eBook - ‘A guide to prehabilitation’ 
 
 
 
 
 
 
The booklet contained useful information 
 
 
 
 
 
 
I felt motivated to follow the guidance in the booklet 
 
 
 
 
 
 
I was happy to access the information as an eBook, instead 
of it being printed 
 
 
 
 
 
 
Support 
 
 
 
 
 
 
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The community forum was a good source of support 
 
 
 
 
 
 
I received good tech support with using the platform (if 
required) 
 
 
 
 
 
 
I received good support from healthcare professionals 
through the platform 
 
 
 
 
 
 
Overall 
 
 
 
 
 
 
I would recommend the programme to a friend if they were 
having surgery 
 
 
 
 
 
 
I would continue to use the programme after the research 
ends 
 
 
 
 
 
 
I feel that the programme helped me to prepare for surgery 
 
 
 
 
 
 
Comments 
 
 
 
 
 
 
Please write any other comments or feedback here: 
 
 
The questions detailed above will be asked via PreActiv’s website, to allow responses to be fully 
anonymised. An example screen displaying the questions is shown below: 
 
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Appendix 3. Baseline characteristics 
Age (years) 
Please write here:  
Please tick one 
Sex 
Male 
 
Female 
 
Intersex 
 
Please tick one 
Ethnicity 
White 
 
Asian or Asian British 
 
Black, Black British, Caribbean or African 
 
Mixed or multiple ethnic groups 
 
Other ethnic group 
 
Reason for 
surgery 
(diagnosis) 
 
Please list: 
Surgery type 
 
 
 
Please list: 
 
 
Medical 
conditions 
Please list: 
 
 
 
Medications 
Please list: 
 
 
 
Please write yes or no 
Mobility 
Can you sit down and stand back up from a chair 
without pushing up on the arms of the chair, your 
legs, or a walking stick/frame? 
 
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How do you 
typically 
travel to the 
RUH? 
Please write (e.g., car, bus, taxi, walk, cycle etc): 
How far is it 
from your 
home to the 
RUH? 
Please give your best estimate of the total distance from home to the 
RUH and from the RUH back to home: 
If you travel 
by car, 
please 
answer 
these 
questions 
What is the year of your car? (e.g., 2013) 
What is the make of your car? (e.g., Ford):  
What is the model of your car? (e.g., Fiesta): 
What type of transmission does it have? (e.g., manual, automatic): 
What type of fuel does it use? (e.g., petrol, diesel, electric): 
Any further descriptions of the car? (e.g., engine size, turbo etc): 
 
 
 
 
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