Prehabilitation Reimagined as Policy: A Multidimensional Framework to Reduce Pain, Opioid Use, and Surgical Risk

  • International Journal of Spine Surgery
  • October 2025,
  • 8807;
  • DOI: https://doi.org/10.14444/8807

Abstract

Background Traditional surgical prehabilitation emphasizes biomechanical conditioning. In a pain landscape shaped by opioid exposure, trauma histories, and psychosocial distress, this reductionist approach is insufficient.

Objective To propose a multidimensional, whole-person framework for perioperative readiness that integrates neurobiological mechanisms with practical clinical and policy levers.

Framework Five synergistic domains—biological, psychological, social, spiritual, and existential—address discrete readiness deficits linked to dopaminergic tone, central sensitization, stress reactivity, connection, and meaning. Each domain is mapped to mechanisms, evidence-based interventions (eg, physical therapy, cognitive behavioral therapy/screening, social support linkage, chaplaincy, reflective practices), and relevant billing structures (Current Procedural Terminology Healthcare Common Procedure Coding System, International Classification of Diseases, 10th Revision Z codes).

Implementation The model operationalizes a deliverables-based pathway—screen → triage → targeted interventions → outcome tracking—monitoring pain, function, opioid exposure (morphine milligram equivalents), length of stay/readmissions, depression and anxiety (Paitent Health Questionnaire-4), and pain catastrophizing (Pain Catastrophizing Scale). It aligns with risk-adjusted payment models and can be embedded within enhanced recovery after surgery programs.

Clinical Significance Reframing prehabilitation as neurobiologically informed whole-person readiness provides a low-risk, nonpharmacological strategy to reduce suffering, improve engagement, enhance postoperative pain control and recovery, and decrease opioid reliance.

Level of Evidence 5 (Expert Opinion). This perspective integrates neurobiological and behavioral theory with policy and billing frameworks to enable hypothesis-generating implementation and outcomes research.

Introduction

Despite advances in surgical techniques and perioperative protocols, postoperative pain remains a major challenge in spine surgery. Opioid analgesics, though effective for acute pain, remain the predominant management strategy,1 yet their widespread use has fueled growing concerns about dependence, prolonged consumption, and associated morbidity.2–4 The ongoing opioid crisis underscores an urgent need for effective, nonpharmacological strategies that can optimize recovery while reducing opioid exposure.5

Historically, prehabilitation has emphasized biomechanical conditioning—such as strength training, gait improvement, and flexibility exercises—to enhance physical readiness before surgery.6 While valuable, this narrow focus is increasingly inadequate in the context of modern surgical populations. Many patients now present with a complex biopsychosocial profile that includes chronic pain syndromes, prior opioid exposure, trauma histories, and comorbid psychological distress. These conditions often coincide with depleted neurochemical reserves, central sensitization, and disengaged affective states—factors that can impair surgical recovery as much as, if not more than, mechanical deconditioning.

The conviction to expand prehabilitation beyond its traditional biomechanical focus is grounded not only in scientific evidence but also in lived clinical experience. The second author, a spine surgeon who survived a prolonged COVID-19–related coma, underwent clinical pastoral education training at AdventHealth during his rehabilitation. AdventHealth—whose mission is “Extending the Healing Ministry of Christ” through care of body, mind, and spirit—provided an immersive, practical demonstration of whole-person healing that seamlessly integrated medical, psychological, social, and spiritual dimensions. Central to this approach is AdventHealth’s “spiritual wholeness” screening, adapted from the fruits of the Spirit in Galatians 5 (love, joy, and peace),7,8 which asks patients 3 simple yet revealing questions:

  1. Do you have someone who loves and cares for you?

  2. Do you have a source of joy in your life?

  3. Do you have a sense of peace today?

A “no” to any of these prompts initiates a referral—to chaplaincy in the inpatient setting or to the patient’s provider or the E-Spiritual Care Center in the outpatient setting. The latter connects callers directly with a pastoral counselor via phone, offering immediate spiritual support without requiring in-person or telemedicine appointments.9 Experiencing this structured, operationalized model of mind-body-spirit care firsthand reinforced the understanding that true readiness for healing must encompass the full spectrum of human needs. This encounter directly inspired key elements of the multidimensional prehabilitation framework proposed in this article.

We therefore propose reframing prehabilitation as a multidimensional, policy-ready intervention that addresses readiness across 5 synergistic domains: Biological, Psychological, Social, Spiritual, and Existential. Each domain is both evidence-informed and symbolically meaningful, targeting specific vulnerabilities while aligning with neurobiological and behavioral mechanisms known to influence pain modulation, stress resilience, and engagement (Figure 1).

Conceptual model illustrating prehabilitation as a multidimensional and policy-relevant model incorporating a whole-person readiness strategy organized across 5 synergistic domains—Biological, Psychological, Social, Spiritual, and Existential. Each domain addresses distinct preoperative readiness deficits while aligning with underlying neurobiological and behavioral mechanisms, working in concert to modulate central pain circuits, enhance patient engagement, and reduce perioperative risk.
Figure 1

Conceptual model illustrating prehabilitation as a multidimensional and policy-relevant model incorporating a whole-person readiness strategy organized across 5 synergistic domains—Biological, Psychological, Social, Spiritual, and Existential. Each domain addresses distinct preoperative readiness deficits while aligning with underlying neurobiological and behavioral mechanisms, working in concert to modulate central pain circuits, enhance patient engagement, and reduce perioperative risk.

This expanded framework draws from neuroscience, addiction medicine, rehabilitation science, and health policy to reposition prehabilitation from a purely physical “tune-up” into a whole-person readiness strategy.10 By embedding these domains into clinical pathways and reimbursement models, we offer a scalable redesign for health systems, payers, and policymakers— capable of improving perioperative outcomes, mitigating opioid reliance, and fostering recovery that is not only functional but also purposeful and sustained.

Biological Domain: Movement as Dopaminergic Medicine

Healing begins with movement—an active, intentional process that engages the body’s innate capacity to regulate pain, restore neurochemical balance, and rebuild functional resilience.

Interventions

To harness these benefits after spine surgery, a set of strategic, evidence-informed interventions can be implemented11–13 to activate the body’s dopaminergic and anti-inflammatory pathways by implementing the following:

  • preoperative physical conditioning (aerobic training, resistance exercise, and flexibility work)

  • targeted neuromuscular training for functional deficits

  • nutrition optimization and anti-inflammatory dietary strategies

  • smoking cessation and metabolic risk control

  • pain pathway recalibration via graded activity and non-opioid pharmacologic support

Outcomes

  • Increased functional reserve and surgical tolerance.

  • Improved wound healing and immune function.

  • Reduced perioperative complications and length of stay.

  • Lower postoperative opioid requirements.

Neuroscience Link

Voluntary physical activity initiates a cascade of neurochemical events that modulate both pain and craving circuits.14 Exercise activates the mesolimbic dopamine system15,16—including the nucleus accumbens17 and ventral tegmental area18—counteracting the reward deficiency commonly seen in chronic pain19–21 and opioid-exposed individuals.22–25 It enhances prefrontal cortical regulation, supporting executive function,26 motivation,27 and affective control.28 Simultaneously, movement reduces central sensitization,29–31 downregulates pro-inflammatory cytokines (eg, IL-6 and TNF-α),29,32,33 and increases levels of brain-derived neurotrophic factor,34,35 promoting neuroplasticity and resilience.36,37 In essence, movement is neurochemical medicine—it rewires, restores, and reinforces the brain’s natural capacity for reward and inhibition.38

The Symbolic Value of Movement

Movement is the first visible sign that healing is active, not passive. It shifts the patient identity from one of dependency to one of agency—restoring control over the body and recalibrating the narrative from “being treated” to “actively recovering.”

Movement as a Model for Neurochemical Recalibration and First Sign of Healing

In this model, physical therapy is elevated from biomechanical intervention to neurobiological therapy. For patients with chronic pain, trauma histories, or opioid exposure, movement is not just exercise—it is dopaminergic rehabilitation. Structured physical activity stimulates endogenous opioid release,39 upregulates D2 receptor expression,40 and reactivates hedonic tone,41 all while diminishing the neural underpinnings of craving and hyperalgesia.42 These observations position movement as a cornerstone treatment for both pain and addiction vulnerability.43 Importantly, the benefits extend beyond the biological to the behavioral: restoring agency, reinforcing self-efficacy, and transforming passivity into participation.

To ignore the central role of movement is to miss a primary opportunity for preoperative neurochemical recalibration. Reframed in this light, physical therapy should be reimbursed, prioritized, and delivered not merely as presurgical preparation but as dopaminergic medicine.

Psychological Domain: Rewiring Pain Through Cognitive Activation

From Coping to Cognitive Mastery

In the surgical setting, pain is never purely physical—it is amplified or attenuated by the stories the brain tells about it. Chronic pain can entrench maladaptive scripts of fear, helplessness, and avoidance. By engaging the mind before surgery, we can disrupt these loops and replace them with adaptive, recovery-focused narratives.

Interventions With Neurobiological Reach

Cognitive behavioral therapy (CBT), pain neuroscience education, and digital therapeutics activate the prefrontal cortex, strengthening top-down regulation over the limbic system. This shift dampens amygdala-driven hypervigilance, reduces catastrophizing, and restores a sense of agency—critical in both pain modulation and opioid risk reduction. These interventions include

  • CBT for pain and anxiety

  • mindfulness-based stress reduction

  • coping strategy enhancement and fear-avoidance reduction

  • reoperative counseling and expectation setting

  • resilience training and emotional regulation exercises

Outcomes

  • Reduced preoperative anxiety and catastrophizing.

  • Improved cognitive control over limbic reactivity.

  • Better adherence to rehabilitation protocols.

  • Lower postoperative pain scores and sedative use.

The Symbolic Shift

When patients participate in structured cognitive work, they move from being passive recipients of surgery to active co-authors of their recovery. This reframing transforms surgery from something “done to them” into a process they are helping to shape.

Illustrative Evidence

In a large multicenter randomized controlled trial of 770 adults with chronic low back pain on long-term opioid therapy, both mindfulness-based therapy and CBT produced significant and sustained improvements in pain, function, and quality of life, with concurrent reductions in opioid dosage at 6 and 12 months.44 While not a surgical cohort, these findings reinforce the neurobiological and behavioral rationale for embedding structured cognitive or mindfulness interventions into prehabilitation programs to enhance pain modulation and opioid stewardship. Relevant studies include Zgierska et al,44 Buvanendran et al,45 and Driscoll et al.46

Policy and Billing Pathways

Embedding cognitive activation into prehabilitation is not only clinically justified but also administratively feasible:

  • Current Procedural Terminology (CPT 96127—Brief emotional/behavioral assessment.47

  • CPT 96164—Group CBT delivery.48

  • CPT 99484—Collaborative care management billing.49

Why It Matters

Rewiring pain through cognitive activation is more than a mental exercise—it is a neurobiological intervention that primes both the brain and the patient for optimal surgical recovery. By recognizing the psychological domain as equally vital to the biological, we create a prehabilitation model that speaks to the whole person.

Social Domain: Bonding, Belonging, and Buffering Stress

From Isolation to Embedded Recovery

Surgical recovery is not a solo act—it unfolds within the patient’s social ecosystem. Strong relational ties act as biological buffers, reducing cortisol, improving immune function, and activating oxytocinergic and dopaminergic pathways. These neurochemical shifts dampen the stress response and enhance both engagement and adherence.

Interventions With Neurobiological Reach

Family-based coaching, structured peer support programs, and community health worker navigation can identify and address social vulnerabilities before they disrupt recovery. The following interventions may transform social connection into an active therapeutic agent:

  • identification of caregiver support and transportation plans

  • social work engagement for resource coordination

  • peer support group participation

  • family education for perioperative support roles

  • community-based rehabilitation partnerships

Outcomes

  • Increased adherence to postoperative care plans.

  • Reduced social isolation and stress load.

  • Improved patient-reported outcomes.

  • Shorter time to functional independence.

The Symbolic Shift

“No one heals alone” becomes more than a sentiment—it becomes a care principle. Integrating social resources into prehabilitation reframes recovery as a shared journey, reducing emotional burden and reinforcing the patient’s sense of belonging.

Illustrative Evidence

In a 2022 study by Holt-Lunstad et al, social isolation was found to rival smoking and obesity as a mortality risk factor.50 Additionally, Chan et al reported that peer-supported recovery reduced substance use and improved engagement in care.51

Policy and Billing Pathways

  • ICD-10 Z55–Z65—Z codes for social determinants of health.52

  • Healthcare Common Procedure Coding System (HCPCS) G9920/G9921—community health worker services under alternative payment models.53

Why It Matters

Identifying and strengthening a patient’s social web is as critical as optimizing their physical condition. Connection precedes recovery, and in the high-stress perioperative period, it may be the single most underutilized tool for improving both surgical and behavioral outcomes.

Spiritual Domain: Meaning, Mystery, and Transcendent Coping

From Distress to Sacred Ground

For many patients, surgery is more than a physical event—it is an encounter with vulnerability, uncertainty, and mortality. Spiritual engagement, whether religious or nonreligious, can transform this experience into one of meaning-making, hope, and inner steadiness.

Interventions With Neurobiological Reach

Chaplaincy consults, guided imagery, sacred ritual, and structured spiritual assessment engage cortical midline structures and dopaminergic reward systems. The following rituals and prayers regulate autonomic stress responses, lower cortisol, and activate neural pathways linked to trust, safety, and optimism:

  • chaplaincy or pastoral care engagement

  • structured spiritual wholeness screening (love, joy, and peace)

  • faith- or values-based rituals, prayer, or meditation

  • meaning and hope-focused counseling

  • access to spiritual care resources (eg, E-Spiritual Care Center)

Outcomes

  • Improved stress physiology modulation (lower cortisol and stable heart rate).

  • Greater emotional resilience and hope.

  • Reduced preoperative anxiety.

  • Enhanced patient satisfaction and coping.

The Symbolic Shift

When pain is framed as purposeful, suffering enters a sacred space—becoming part of a story larger than the surgical event. This reframing can restore identity, deepen resilience, and foster a sense of peaceful readiness.

Illustrative Evidence

In a study by Puchalski et al, integrating spiritual care improved quality of life in seriously ill patients.54 In another study, Jankowski et al, found that preoperative chaplain visits significantly reduced patient anxiety.55

Policy and Billing Pathways

  • CPT G0425–G0427—Chaplaincy services via telehealth.56

  • Facility-based chaplain documentation supporting accreditation standards and patient experience metrics.57

Why It Matters

Spiritual readiness is not merely a comfort—it is a modulator of stress physiology and a builder of hope. By recognizing and integrating spiritual care into prehabilitation, clinicians honor the human need for meaning while enhancing the biological readiness for recovery. An applied example of this integration between neurobiology and spiritual care is illustrated in the Hierarchical Neuro-Spiritual Model, developed by Dr. Morgan P. Lorio, which aligns stages of pastoral and spiritual intervention with corresponding neuroanatomical substrates,10 progressing from physiological stabilization to spiritual transformation including

  • Safety—Brainstem: Simple acts such as offering water, a blanket, or quiet presence regulate autonomic function and signal safety.

  • Connection—Limbic system: Active listening and empathic presence foster trust, relational security, and emotional regulation.

  • Integration—Diencephalon: Storytelling and spiritual reflection promote coherence, meaning-making, and internal balance.

  • Transcendence—Cortex: Rituals, blessings, prayer, or contemplative silence renew identity, inspire hope, and deepen spiritual insight.

A spiritual overlay is present at all levels, with divine presence—or its personal equivalent—mediated through the caregiver, environment, or inner stillness. Healing flows upward toward transcendence and cycles back to reinforce safety, forming a feedback loop of grace and neuroplasticity. This unified neuro-spiritual framework complements the Spiritual and Existential domains of our prehabilitation model (Figure 2).

Hierarchical Neuro-Spiritual Model applied to prehabilitation. Four stages align pastoral and spiritual care with neuroanatomy: Safety (Brainstem), Connection (Limbic), Integration (Diencephalon), and Transcendence (Cortex). A continuous spiritual overlay is present at all levels, with healing flowing upward toward transcendence and cycling back to reinforce safety through a feedback loop of grace and neuroplasticity.
Figure 2

Hierarchical Neuro-Spiritual Model applied to prehabilitation. Four stages align pastoral and spiritual care with neuroanatomy: Safety (Brainstem), Connection (Limbic), Integration (Diencephalon), and Transcendence (Cortex). A continuous spiritual overlay is present at all levels, with healing flowing upward toward transcendence and cycling back to reinforce safety through a feedback loop of grace and neuroplasticity.

Existential Domain: Narrative, Identity, and Dopaminergic Presence

From Fragmentation to Coherence

Major surgery can fracture a patient’s sense of identity—raising questions about capability, purpose, and the meaning of the ordeal. Addressing these existential concerns before surgery transforms recovery from a purely physical milestone into a deeply personal turning point.

Interventions With Neurobiological Reach

Chaplaincy consultations, narrative interviews, and meaning-making rituals are not peripheral gestures—they are neuroregulatory interventions. Emerging frameworks such as Neurospirituality conceptualize spiritual presence, ritual, and life-story integration as activators of dopaminergic reward circuits. These same neural pathways are implicated in trauma resolution, addiction recovery, and resilience-building, offering a biologically grounded rationale for existential readiness in prehabilitation. Patients may benefit from the following interventions:

  • screening for purpose or connection to something greater than self

  • life narrative and meaning-making exercises

  • legacy and values clarification work

  • post-traumatic growth facilitation

  • integration of recovery goals with personal identity

Outcomes

  • Stronger alignment of recovery with life purpose.

  • Activation of reward pathways through meaning-making.

  • Lower risk of postoperative depression and prolonged opioid use.

  • Greater long-term satisfaction and resilience.

The Symbolic Shift

When patients actively reassemble their narrative, the self becomes the author—not just the subject—of the healing story. Recovery gains purpose, and surgical preparation becomes a chapter in a larger life arc.

Illustrative Evidence

In Breitbart et al, meaning-centered therapy reduced distress and improved spiritual well-being in patients with advanced illness.58 Additionally, Wong highlighted that existential therapies enhanced dignity, purpose, and engagement.59,60

Policy and Billing Pathways

  • CPT 99483 – Cognitive assessment and care planning (can incorporate complex existential risk).61,62

  • Future development: Dedicated codes for narrative-based or meaning-focused interventions.

Why It Matters

Existential readiness aligns neurobiology with narrative, transforming surgery from an isolated event into a meaning-rich life transition. By embedding these practices in prehabilitation, clinicians can activate reward pathways, reinforce identity, and prepare patients for recovery that resonates far beyond the operating room.

Five Domains May Expose Upstream Vulnerabilities

These 5 domains are not abstract constructs—they are rooted in measurable neurobiology63 and practical economics. Chronic pain and reward-deficiency syndromes increasingly reflect dopaminergic dysregulation,64,65 epigenetic trauma,66 and psychosocial isolation.67 Addressing these upstream vulnerabilities before surgery improves recovery trajectories, reduces opioid reliance, and lowers complications—making multidimensional readiness both a clinical imperative and a cost-containment strategy.

Beyond Movement: The Multifaceted Role of Dopamine in Behavior and Recovery

While dopamine is traditionally recognized for its role in regulating voluntary movement through the nigrostriatal pathway, its broader neuromodulatory functions are increasingly central to understanding pain, addiction, emotional regulation, and behavioral health. Dopamine acts across diverse brain circuits to influence a wide array of neuropsychiatric and behavioral phenotypes (Table 1). In addition, dopamine modulates craving, reinforcement, and relapse vulnerability across substances such as alcohol, opioids, cannabis, psychostimulants, and nicotine—often through dysregulation of D1 and D2 receptor activity within the mesolimbic reward system. In affective and stress-related disorders, including post-traumatic stress disorder, major depressive disorder, bipolar disorder, and generalized anxiety, altered dopaminergic signaling contributes to emotional dysregulation, impaired salience attribution, and maladaptive stress responses.

View this table:
Table 1

Specific reward deficiency syndrome functions of dopamine across brain reward circuitry.

Moreover, dopamine dysfunction is implicated in impulse-control disorders (eg, hypersexuality, gambling, hoarding, shopping) and neurodevelopmental conditions such as ADHD, autism, and Tourette’s syndrome. These findings collectively support the concept of Reward Deficiency Syndrome, wherein hypodopaminergic tone leads to a heightened risk of maladaptive behaviors aimed at compensatory reward-seeking. Notably, these dopaminergic imbalances also impact cognitive control, identity formation, social bonding, and narrative coherence—functions intimately tied to the Psychological, Social, Spiritual, and Existential domains of the proposed prehabilitation framework.

By reframing dopamine not just as a motor neurotransmitter but as a central orchestrator of motivation, mood, and meaning-making, we illuminate its therapeutic potential across all 5 domains of readiness. This neurobiological perspective justifies the integration of dopaminergic-activating interventions—from structured movement and CBT to social connection and spiritual engagement—into a comprehensive prehabilitation model aimed at restoring whole-person resilience.

Translational work has begun to explore biochemical strategies to restore dopaminergic homeostasis directly.64,65 Dr Stephen DeFelice coined the term “Nutraceutical” from “Nutrition” and “Pharmaceutical” in 1989.98 Kenneth Blum and colleagues introduced nutraceutical formulations—such as KB220—specifically engineered to normalize dopamine signaling within the mesolimbic reward system.99 These pro-dopaminergic compounds exemplify how molecular modulation may complement behavioral and rehabilitative domains in a future precision-based prehabilitation model.

Economic Rationale and Return on Investment for Whole-Person Prehabilitation

Incomplete readiness for surgery carries a measurable economic burden for payers and health systems, driven by higher readmission rates,100,101 extended length of stay, excess opioid prescribing, and downstream treatment of preventable complications.102 In spine surgery, even a modest reduction in these adverse events translates into substantial savings—estimates place the cost of unplanned readmission between $12,000 and $20,000 per episode in the US,103 while prolonged opioid use adds both direct pharmacy costs and indirect expenditures from dependence-related care. A multidimensional prehabilitation model that addresses biological, psychological, social, spiritual, and existential readiness offers a favorable return on investment by reducing perioperative risk, shortening recovery timelines, and improving patient-reported outcomes. When operationalized within existing reimbursement frameworks and value-based purchasing arrangements, such an approach aligns financial incentives with whole-person, evidence-informed care—supporting both fiscal sustainability and improved quality metrics (Figure 3).

Cost and policy impact of whole-person prehabilitation. Incomplete readiness increases perioperative risk, readmissions, opioid use, and costs. Implementing multidimensional prehabilitation reduces these burdens, improves outcomes, and delivers return on investment (ROI) within value-based payment models. LOS, length of stay.
Figure 3

Cost and policy impact of whole-person prehabilitation. Incomplete readiness increases perioperative risk, readmissions, opioid use, and costs. Implementing multidimensional prehabilitation reduces these burdens, improves outcomes, and delivers return on investment (ROI) within value-based payment models. LOS, length of stay.

Discussion

The 5-domain model—Biological, Psychological, Social, Spiritual, and Existential—reframes prehabilitation from a purely biomechanical task into a multidimensional readiness strategy grounded in both neurobiology and human experience. Each domain targets specific preoperative vulnerabilities, yet none operates in isolation. Instead, they form a mutually reinforcing network of interventions that prepare the patient’s body, mind, relationships, values, and life narrative for the stress and recovery demands of surgery.

One practical illustration of this approach comes from structured “spiritual wholeness” screening models, such as those used at AdventHealth, which identify key readiness gaps through brief, values-based questions. While AdventHealth’s original 3 questions address love, joy, and peace,8 adding a fourth—“Do you have a sense of purpose or connection to something greater than yourself?”—could extend this method into the existential domain. A “no” response would prompt referral for targeted support, given that unaddressed existential anxiety has been linked to approximately 40% higher postoperative opioid use and greater sedative/anxiolytic requirements.104,105 Integrating such purpose-focused screening into spine surgery prehabilitation could facilitate early intervention, reducing downstream medication needs and improving recovery trajectories (Figure 4).

Spiritual Wholeness Screening process adapted for perioperative spine surgery prehabilitation. The screening begins with 4 brief questions assessing love and care, joy, peace, and—added for the existential domain—purpose or connection to something greater. Any “no” response triggers a referral to chaplaincy in inpatient settings or to the provider/E-Spiritual Care Center in outpatient settings. Early intervention addresses mind-body-spirit and existential needs, reducing anxiety and postoperative opioid/sedative use while improving recovery. In the spine surgery context, integrating purpose-focused screening bridges the Spiritual and Existential domains of the prehabilitation model, facilitating better overall outcomes. Periop, perioperative.
Figure 4

Spiritual Wholeness Screening process adapted for perioperative spine surgery prehabilitation. The screening begins with 4 brief questions assessing love and care, joy, peace, and—added for the existential domain—purpose or connection to something greater. Any “no” response triggers a referral to chaplaincy in inpatient settings or to the provider/E-Spiritual Care Center in outpatient settings. Early intervention addresses mind-body-spirit and existential needs, reducing anxiety and postoperative opioid/sedative use while improving recovery. In the spine surgery context, integrating purpose-focused screening bridges the Spiritual and Existential domains of the prehabilitation model, facilitating better overall outcomes. Periop, perioperative.

Evidence supports this approach: preoperative spiritual or religious interventions have been shown to reduce anxiety before surgery.104,106 Adapting this structured, values-based triage process for the perioperative setting ensures that existential readiness is screened and addressed alongside physical and psychological preparation—making it a practical bridge107 between the Spiritual and Existential domains in our framework.

From the Biological perspective, movement and targeted physical interventions act as dopaminergic medicine, recalibrating central pain pathways while building functional reserve. The Psychological domain complements this by rewiring maladaptive pain narratives, reducing fear and catastrophizing, and enhancing cognitive control over limbic reactivity. The Social domain provides the relational scaffolding necessary for adherence, buffering stress through oxytocinergic and dopaminergic circuits activated by connection and belonging. The Spiritual domain addresses the profound uncertainty of surgery by fostering meaning, hope, and transcendence—mechanisms shown to regulate stress physiology and improve resilience. Finally, the Existential domain integrates these threads into a coherent personal narrative, aligning recovery with the patient’s identity and life purpose, and activating reward pathways through meaning-making.

The power of this framework lies in its integration. Neurobiological mechanisms—from brain-derived neurotrophic factor-mediated neuroplasticity to dopamine and endogenous opioid release—cut across domains, reinforcing each other.108 Symbolic elements also overlap: movement restores agency, cognitive reframing reinforces identity, social connection affirms belonging, spiritual engagement provides purpose, and existential alignment ties recovery to life’s broader arc. Together, these layers form a readiness architecture that is both scientifically grounded and deeply human. Just as Enhanced Recovery After Surgery protocols apply multimodal,109 evidence-based practices to optimize the perioperative period, multidimensional prehabilitation serves as a presurgical analog—mitigating risk and accelerating recovery before the first incision.

Policy relevance is embedded throughout. Existing CPT, HCPCS, and ICD-10 Z codes demonstrate that most domains can already be operationalized and reimbursed within current systems (Table 2), while gaps—particularly for existential and meaning-based interventions—highlight opportunities for future code development. This positions the model not as an aspirational ideal but as a feasible, billable, and scalable redesign of perioperative care.

View this table:
Table 2

Implementation pathway for 5-domain prehabilitation and supportive CPT, HCPCS, and ICD-10 codes.

By uniting these domains under a single conceptual banner, prehabilitation becomes a whole-person, neurobiologically informed, policy-compatible intervention. This integrated approach has the potential to reduce perioperative risk, limit opioid reliance, enhance recovery, and return patients not only to baseline function but to a more resilient and purposeful postsurgical life.

Conclusion

Prehabilitation is no longer merely physical preparation—it is a neurochemical, relational, and existential intervention that can restore confidence, engagement, and meaning before a scalpel touches skin. The 5-domain framework we propose—Biological, Psychological, Social, Spiritual, and Existential—integrates neuroscience, spiritual anthropology, and policy reform into a coherent readiness model capable of reducing pain, limiting opioid use, and alleviating suffering.

Embedding these domains into payment structures and clinical pathways reframes surgical preparation from a mechanical “tune-up” into a whole-person return to agency. This is not just about getting patients ready for surgery—it is about preparing them for recovery that is resilient, purposeful, and sustained.

Prehabilitation is not a luxury add-on. It is a foundational, cost-effective intervention that reduces preventable suffering, preserves function, and strengthens the human capacity for recovery. By expanding readiness to include biological, psychological, social, and existential dimensions, institutions and payers can realize not only clinical gains but also spiritual, societal, and economic return on investment.

Footnotes

  • Funding The authors received no financial support for the research, authorship, and/or publication of this article.

  • Declaration of Conflicting Interests The authors report no conflicts of interest in this work.

  • CRediT Author Statement Kai-Uwe Lewandrowski, MD (Corresponding author) Conceptualization; Methodology; Investigation; Resources; Data curation; Writing – original draft; Writing – review & editing; Visualization; Supervision; Project administration;.Morgan P. Lorio, MD: Conceptualization; Methodology; Investigation; Resources; Writing – original draft; Writing – review & editing; Visualization; Supervision. Igor Elman, PhD, Validation; Formal analysis; Interpretation; Writing – review & editing. Kenneth Blum, PhD, Conceptualization; Methodology; Resources; Interpretation; Writing – review & editing; Supervision. Albert Pinhasov, PhD, Validation; Formal analysis; Interpretation; Visualization; Writing – review & editing. Panayotis K. Thanos, PhD, Validation; Formal analysis; Interpretation; Visualization; Writing – review & editing. Sergio Luis Schmidt, PhD, Methodology; Validation; Formal analysis; Writing – review & editing; Supervision. Rossano Kepler Alvim Fiorelli, MD, PhD, Resources; Investigation; Writing – review & editing; Supervision; Project administration. Accountability: All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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In this Issue
International Journal of Spine Surgery

Vol. 19, Issue 5

1 Oct 2025

Table of Contents Index by author

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Keywords

preoperative care/methods, multimodal therapy, holistic health, pain management/methods, health behavior, psychosocial support systems, opioid use disorder, substance craving/prevention and control, spinal surgery/preoperative rehabilitation, dopamine/neurobiology, central sensitization, neuroplasticity/physiology, spirituality