You Need Surgery. Now What? A Guide to Prehab and Preparation
By Dr. Matthew Wilson, DC, FIACA | Ashworth Chiropractic, Physical Therapy & Acupuncture | West Des Moines, Iowa
Getting told you need back surgery is a lot to process. There’s relief in finally having an answer — and fear about what comes next. The preparation, the procedure, the recovery. Whether it’s going to work. What your life looks like on the other side.
What most people don’t know — and what most surgeons don’t spend enough time on — is that what you do before the surgery significantly changes what happens after it. Not marginally. Significantly.
This post is about that window between the surgical decision and the operating room. It’s about prehabilitation — getting your body as strong, mobile, and well-conditioned as possible before surgery so you walk in with the best possible foundation for recovery. And it’s about what to realistically expect from the procedure itself, so you’re not blindsided on the other side.
Part 4 of this series covers what happens when surgery doesn’t provide the relief that was expected. If you’ve already had surgery and are still in pain, that post is for you.
BACK PAIN SERIES — PART 3 OF 4
This is Part 3 of a four-part series we are working on. Each will be linked as they are published online.
Part 1 covers what is the best non-surgical treatment for back pain.
Part 4 covers what happens if that surgery didn’t fix your pain.
The Question Most People Don’t Think to Ask
When a surgeon tells you that you need a procedure, the conversation usually focuses on the surgery itself — what they’re going to do, the risks, the expected recovery timeline. What rarely comes up is what you can do in the weeks before the procedure to meaningfully change those outcomes.
Think about it from a basic physiological standpoint. Your surgeon repairs the structural problem — the herniated disc, the stenotic canal, the unstable segment. But your recovery depends on everything around that structure: the muscles that support your spine, the cardiovascular conditioning that powers rehabilitation, the movement patterns you’ll need to rebuild. None of those things change on the operating table.
If those supporting systems are weak going in, you’re rebuilding from a weakened foundation. If they’re strong, you’re rebuilding from a position of advantage. The surgery is the same either way. The recovery is not.
The surgeon fixes the structural problem. Your body — your muscles, your conditioning, your movement capacity — determines how fast and how well you recover from it.
Prehabilitation is the deliberate investment in that part of the equation.
What the Research Shows
Based on articles retrieved from PubMed, the evidence for prehabilitation before spine surgery is building — and the signal is consistent across study types.
Prehabilitation for Lumbar Stenosis Surgery — An RCT
A 2025 pilot randomized controlled trial published in Clinical Spine Surgery (Takenaka et al.) enrolled 32 patients scheduled for lumbar spinal stenosis surgery and randomized them to a prehabilitation program or standard care. The results at 3 months post-surgery were meaningful: the prehabilitation group walked significantly further in the 6-minute walk test (446.8m vs 384.3m, p=0.01), had lower disability scores at 1 month post-operatively, and reported lower low back pain at 3 months. No adverse events were reported in either group.
In practical terms: patients who prepared for their surgery were moving better, hurting less, and had less disability in the months that followed — compared to patients who went into the same surgery unprepared.
Takenaka H, Kamiya M, Suzuki J. Prehabilitation Improves Early Outcomes in Lumbar Spinal Stenosis Surgery: A Pilot Randomized Controlled Trial. Clin Spine Surg. 2025;38(10):E480-E487. DOI: https://doi.org/10.1097/BSD.0000000000001779
Enhanced Recovery Protocols — 70% Lower Reoperation Rate
A 2024 retrospective cohort study published in Spine (Yung et al., Duke University Medical Center) analyzed 471 patients with adult structural spine disorder undergoing corrective surgery — comparing those who received an Enhanced Recovery After Surgery (ERAS) protocol including physical and psychological prehabilitation components against those who did not.
The adjusted findings are striking. Despite the ERAS group being older and having higher comorbidity profiles, they experienced:
- 70% lower likelihood of reoperation (OR: 0.3; 95% CI: 0.13–0.89)
- 60% lower likelihood of overall adverse events (OR: 0.4; 95% CI: 0.19–0.93)
- Significantly greater likelihood of achieving meaningful improvement in pain at 6 months and 1 year
- Significantly better physical function scores at 1 year
The authors concluded that ERAS following spinal surgery leads to faster functional recovery, reduced postoperative deconditioning, and improved quality of life — even in frailer patients with more medical complexity.
Yung A, et al. Impact of Enhanced Recovery After Surgery Protocols on Outcomes Up to Two Years After Adult Structural Spine Disorder Surgery. Spine. 2024;50(6):357-367. DOI: https://doi.org/10.1097/BRS.0000000000005213
Your Preoperative Pain Level Predicts Your Outcome
A 2021 study published in World Neurosurgery (Jacob et al., Rush University Medical Center) analyzed 740 patients undergoing minimally invasive lumbar fusion. The study found that patients with lower preoperative pain scores had significantly better postoperative outcomes across multiple measures — better functional scores, better pain relief, and higher patient satisfaction at virtually every postoperative time point measured.
This is important. It means the better your physical state going into surgery — less pain, better function, better conditioning — the better your state coming out of it tends to be. Prehabilitation is one of the tools that moves people in that direction.
Jacob KC, et al. The Effect of the Severity of Preoperative Back Pain on Patient-Reported Outcomes, Recovery Ratios, and Patient Satisfaction Following MIS-TLIF. World Neurosurg. 2021;156:e254-e265. DOI: https://doi.org/10.1016/j.wneu.2021.09.053
What Prehabilitation Actually Involves
Prehabilitation is not a single exercise program. It’s a coordinated preparation of your body for what surgery is going to put it through — and what recovery is going to demand of it. At Ashworth, we approach pre-surgical care across several domains:
Strength and Conditioning of the Surrounding Musculature
The muscles that support your spine — the deep core stabilizers, the hip extensors, the posterior chain — are the primary engines of your post-surgical recovery. They’re what powers your rehabilitation. They’re what allows you to get out of bed, walk the hallway, do the exercises your PT assigns you in the days and weeks after surgery.
Kelly Brown Gross, PT, MPT, WCS designs individualized pre-surgical strengthening programs that target the specific muscles most critical to your procedure and your recovery. This is not generic core work. It’s specific, progressive, and built around what you’re going to need.
Mobility and Range of Motion
Surgery and post-surgical immobility tighten everything. Hips, thoracic spine, hamstrings, hip flexors — the tissue that surrounds and loads your lumbar spine. Entering surgery with good mobility means less time in recovery working to get back to baseline, and more time making actual progress.
We use a combination of chiropractic mobilization, Graston soft tissue work, and specific mobility exercises to maximize your pre-surgical range of motion — so the surgical immobility period doesn’t start you from zero.
Movement Pattern Training
Post-surgical rehabilitation will teach you specific movement patterns — how to get up from a chair, how to roll in bed, how to walk with correct mechanics. Learning the foundations of these patterns before surgery means you’re not starting from scratch in the days immediately following the procedure, when pain and anesthesia effects make learning anything new harder.
Dr. Matt’s Postural Restoration training is particularly relevant here — identifying and correcting the asymmetrical movement patterns that contributed to the back problem in the first place, and training more balanced movement patterns before surgery so the post-surgical period isn’t fighting old habits.
Cardiovascular Conditioning
This is the most overlooked component of surgical preparation. Surgery is a significant physiological stress. Recovery from surgery is physically demanding. Patients who enter surgery with better cardiovascular conditioning recover faster, have fewer complications, and return to activity sooner.
We don’t need you to run a 5K before your spinal fusion. But walking more, moving more, and improving your aerobic base in the weeks before surgery consistently produces better outcomes. We’ll help you identify the right level of activity for your current presentation and build it appropriately.
Education — What to Actually Expect
Physical Therapy involves getting you ready for surgery. You wouldn’t run a race without warming up.
One of the most consistent findings in surgical outcomes research is that patient expectations shape patient outcomes. Patients who have realistic, accurate expectations of their recovery — what will hurt, what won’t, what the timeline looks like, what they’ll be asked to do — do better than patients who enter surgery without that understanding.
We spend real time on this. Not a pamphlet. An actual conversation about what your specific procedure involves, what the rehabilitation trajectory looks like, what red flags to watch for, and what realistic milestones look like at 2 weeks, 6 weeks, 3 months, and 6 months.
When Should You Start Prehabilitation?
The short answer: as soon as the surgical decision is made.
Most elective back surgeries have a waiting period of weeks to months between the decision and the procedure. That window is not dead time. It’s your opportunity. Even 4 to 6 weeks of targeted prehabilitation produces measurable improvements in the outcomes that matter — the Takenaka RCT used a 1-month program.
If your surgery is scheduled sooner than that, don’t assume there’s nothing worth doing. A few sessions of targeted preparation — even 2 or 3 — can establish the baseline movement patterns and begin the strength work that your post-surgical PT will build on.
And if you’re not yet certain surgery is in your future but you’re having serious conversations with a surgeon about it — that’s also the right time to call us. We can give you an honest assessment of whether conservative care has more to offer, help you go into any surgical consultation better informed, and begin preparing your body regardless of which direction the decision ultimately goes.
What Surgery Does — and Doesn’t — Fix
This is worth being direct about, because misaligned expectations after surgery are one of the primary drivers of disappointment — and of the ‘failed back surgery’ experience that Part 4 of this series covers.
Back surgery fixes the specific structural problem it was designed to address. A discectomy removes the herniated material pressing on the nerve. A decompression opens the narrowed spinal canal. A fusion stabilizes an unstable segment. These are real structural problems, and surgery is often the right solution for them.
What surgery does not fix:
- The muscle weakness and deconditioning that developed during years of pain-limited activity
- The movement pattern dysfunction and compensations the body built around the structural problem
- The central sensitization — the nervous system’s increased sensitivity to pain signals — that chronic back pain often produces
- Adjacent segment stress and degeneration that may have been building around the primary problem
- Psychological factors — fear avoidance, catastrophizing, sleep disruption — that significantly influence pain experience and recovery
None of these are reasons not to have surgery if surgery is indicated. They’re reasons to understand that surgery is the beginning of recovery — not the end of it. The post-surgical rehabilitation process addresses most of these things. Prehabilitation gives you a head start on all of them.
Surgery repairs the structure. Rehabilitation — before and after — rebuilds the function around it.
The patients who do best are the ones who understand this and invest in both sides of the equation.
A Few Things Worth Asking Your Surgeon Before You Commit
We’re not here to talk you out of surgery that’s appropriate for you. But we’ve seen enough post-surgical patients who went in without asking the right questions to know that the informed consent process doesn’t always cover everything worth knowing. A few questions worth having answered before you proceed:
What specifically are you repairing — and does the imaging finding directly match my symptoms? This is the most important question on this list. Based on articles retrieved from PubMed, a Mayo Clinic systematic review of 3,110 pain-free adults found disc degeneration in 37% of asymptomatic 20-year-olds and disc protrusion in 29% — rising significantly with age. An MRI finding is not automatically a pain generator. It is anatomy.
The clinical question — confirmed by a thorough neurological and orthopedic physical exam — is whether that finding is actually responsible for your symptoms, or whether it is an incidental finding that appears significant on imaging while the real pain generator lies elsewhere: a hip misalignment, piriformis syndrome, facet joint irritation, or sacroiliac dysfunction that mimics disc-related sciatica with remarkable accuracy. A good surgeon will correlate the imaging with the clinical picture. If that conversation hasn’t happened clearly, ask for it.
What is the evidence base for this specific procedure for my specific condition?
What does realistic improvement look like — and what’s the timeline?
What are the risks, and what are the rates of complications, reoperation, and adjacent segment disease for this procedure?
Have I had an adequate trial of conservative care? (The clinical standard is generally 6–12 weeks for non-emergency presentations)
Is a second surgical opinion appropriate before proceeding?
A good surgeon welcomes these questions. And if you want to talk through any of them before or after that conversation, we’re here for that too.
What Pre-Surgical Care Looks Like at Ashworth
We work with patients heading toward back surgery regularly. The team involved depends on what you need:
- Kelly Brown Gross, PT, MPT, WCS handles the physical therapy component — individualized strengthening, mobility work, movement pattern training, and education about what post-surgical rehabilitation will involve
- Dr. Matt Wilson addresses the chiropractic and soft tissue component — mobilization, Graston technique, postural restoration work, and any appropriate manual therapy appropriate to your presentation and procedure
- Shockwave therapy (ESWT) — for patients with chronic tendon, ligament, or soft tissue conditions in the region surrounding the surgical site, focused shockwave therapy before surgery can meaningfully improve the state of that tissue going into the procedure. The biological mechanism is well-established: shockwave stimulates neovascularization — the formation of new blood vessels — in chronically deprived tissue, upregulates vascular endothelial growth factor (VEGF), and triggers stem cell recruitment and activation in the surrounding connective tissue. For a patient heading into lumbar surgery with compromised paraspinal soft tissue, a chronic hip tendinopathy, or even a degenerative Achilles — getting that tissue into better biological condition before surgery means it is better equipped to support the rehabilitation load that comes after it. We use the Storz Medical Duolith SD1 Ultra for this — the same focused shockwave platform supported by the peer-reviewed literature on tissue regeneration and neovascularization.
- Laser therapy is used where appropriate to address active inflammation, increase blood flow and promote tissue health in the pre-surgical period
We coordinate with your surgical team when helpful, and we’ll be here for the post-surgical rehabilitation phase as well. The continuity of care — working with providers who already know your movement patterns, your history, and your goals — is one of the advantages of doing both sides of the surgery here.
No referral is needed for physical therapy in Iowa. You can call us directly.
Common Questions
My surgery is in three weeks. Is prehabilitation still worth it?
Yes. Three weeks is enough time to establish baseline movement patterns, begin targeted strengthening, and get the education that will inform your immediate post-surgical period. Even a compressed timeline is better than walking into surgery without preparation. Call us this week and we’ll make the most of the time available.
My surgeon didn’t mention prehabilitation. Should I bring it up?
Absolutely — and here’s something worth knowing before you do.
Most surgeons are genuinely supportive of prehabilitation when patients ask about it. The reason it often doesn’t come up is that a surgical consultation is focused on the procedure itself — the structural problem, the risks, the recovery timeline. Prehabilitation tends to fall outside that conversation unless the patient raises it.
What does sometimes come up is a referral to the hospital’s own physical therapy department. And we want to be straightforward about this: hospital outpatient PT is not a single standard of care. It varies considerably depending on the therapist, the caseload, and the level of specialization in the specific condition you’re dealing with. Many hospital systems staff outpatient PT positions with newer graduates — not because those clinicians aren’t capable, but because hospital employment is often how new graduates enter the profession.
What we offer is different. Between Dr. Matt Wilson and Kelly Brown Gross, PT, MPT, WCS, we have over 40 years of combined clinical experience — including specialized training that most outpatient hospital PT departments don’t have on staff: Postural Restoration, Graston Technique, Women’s Health Certification, focused shockwave therapy, laser therapy, and functional medicine. We regularly see patients who plateaued in other PT settings and achieve meaningful progress here. That’s not a claim — it’s what happens when highly specialized, experienced clinicians work with a patient who hasn’t found the right fit yet.
You are not obligated to go where your surgeon refers you. Iowa is an open-access state for physical therapy — you choose your provider. We’re not asking you to choose us without knowing more. We’re asking you to call us, have a conversation, and make an informed decision.
To bring it up with your surgeon: simply say “I’d like to do some physical therapy before the surgery to prepare — is there anything I should avoid given what you’re planning?” Most surgeons will support that. Then call us.
I’m in a lot of pain right now. Can I even do prehabilitation?
Yes — and this is actually the situation where it matters most. Kelly and Dr. Matt are experienced in working with patients in significant pain. The program is designed around your current tolerance, not some theoretical baseline. Even patients with significant pre-surgical pain can make meaningful progress in strength, movement quality, and conditioning with the right approach.
Will this affect my surgical timeline?
Prehabilitation does not delay surgery. It runs concurrently with the pre-surgical waiting period. If your surgery needs to happen urgently, that takes priority — and we’ll adapt accordingly.
Surgery is scheduled. Let’s make sure you’re ready for it.
➡️ Next in this series — Part 4: My Back Still Hurts After Surgery. What Do I Do Now? The complete guide to conservative care after failed back surgery.
Clinical References
The following peer-reviewed studies were retrieved from PubMed and cited in this article.
- Takenaka H, Kamiya M, Suzuki J. Prehabilitation Improves Early Outcomes in Lumbar Spinal Stenosis Surgery: A Pilot Randomized Controlled Trial. Clin Spine Surg. 2025;38(10):E480-E487. DOI: https://doi.org/10.1097/BSD.0000000000001779
- Yung A, et al. Impact of Enhanced Recovery After Surgery Protocols on Outcomes Up to Two Years After Adult Structural Spine Disorder Surgery. Spine. 2024;50(6):357-367. DOI: https://doi.org/10.1097/BRS.0000000000005213
- Jacob KC, et al. The Effect of the Severity of Preoperative Back Pain on Patient-Reported Outcomes, Recovery Ratios, and Patient Satisfaction Following MIS-TLIF. World Neurosurg. 2021;156:e254-e265. DOI: https://doi.org/10.1016/j.wneu.2021.09.053
- Rushton A, et al. Physical prognostic factors predicting outcome following lumbar discectomy surgery: systematic review and narrative synthesis. BMC Musculoskelet Disord. 2018;19(1):326. DOI: https://doi.org/10.1186/s12891-018-2240-2
- Hayashi D, et al. Low-energy extracorporeal shock wave therapy enhances skin wound healing in diabetic mice: a critical role of endothelial nitric oxide synthase. Wound Repair Regen. 2012;20(6):887-895. DOI: https://doi.org/10.1111/j.1524-475X.2012.00851.x
- Chen RF, et al. Modulation of vascular endothelial growth factor and mitogen-activated protein kinase-related pathway involved in extracorporeal shockwave therapy accelerate diabetic wound healing. Wound Repair Regen. 2018;27(1):69-79. DOI: https://doi.org/10.1111/wrr.12686
About the Author
Dr. Matthew Wilson, DC, FIACA, CCWP is the owner and lead clinician at Ashworth Chiropractic, Physical Therapy & Acupuncture in West Des Moines, Iowa. He is a Palmer College of Chiropractic honors graduate with advanced training in Postural Restoration (PRI), Graston Technique, acupuncture, dry needling, laser therapy, and functional medicine. He works alongside Kelly Brown Gross, PT, MPT, WCS to provide integrated pre- and post-surgical care for back pain patients.
