Prehabilitation for lumbar spinal stenosis: understanding mechanisms and contexts for enhanced engagement—a realist review

Background Neurogenic claudication (NC) due to lumbar spinal stenosis is the most common reason for spinal surgery in older adults. Prehabilitation may improve outcomes and reduce costs, but current evidence is conflicting. It remains unclear who benefits most, which mechanisms optimise outcomes and what outcomes matter to patients. This review aimed to develop a programme theory explaining what works, for whom, how and in what contexts for prehabilitation of NC surgical candidates. Methods An initial programme theory, comprising context-mechanism-outcome configurations (CMOCs), was developed through iterative mapping and consultation with experts (n=6) and patients (n=7). This theory was refined via two systematic literature searches and further stakeholder feedback. Studies were assessed for relevance, richness and rigour. Data were holistically coded using abductive and retroductive reasoning to create causal maps, which informed CMOC refinement. Results From 1422 records, 67 papers were included. The final programme theory included 14 CMOCs focused on patient engagement, a priority identified through patient consultation. Engagement was contingent on clear, consistent communication and addressing misconceptions among both patients and professionals. A shared understanding increased perceived value and avoided missed opportunities for preparation. Personalisation and collaborative goal-setting enhanced ownership and motivation. Ongoing support—via healthcare professional contact and peer input—helped counteract anxiety and feelings of abandonment during the surgical wait. Conclusions Engagement with prehabilitation for NC can be improved through clear communication, tailored interventions and sustained support. Further research is needed to test whether theory-informed programmes improve outcomes in this population.