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Acad Med. 2014 Oct;89(10):1416-22. doi: 10.1097/ACM.0000000000000391.

Improving clinical performance using rehearsal or warm-up: an advanced literature review of randomized and observational studies.

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Dr. O'Leary is assistant professor, Department of Anesthesia, University of Toronto, and staff anesthesiologist, Hospital for Sick Children, Toronto, Ontario, Canada. Dr. O'Sullivan is research fellow, Department of Anesthesia, University College Cork, Cork, Ireland. Dr. Barach is anesthesiologist and visiting professor, University College Cork, Cork, Ireland. Professor Shorten is professor of anesthesia and dean, School of Medicine, University College Cork, Cork, Ireland.



To determine whether rehearsal (the deliberate practice of skills specific to a procedure) or warm-up (the act or process of warming up by light exercise or practice) prior to performing complex clinical procedures on patients can improve the task performance of operators and operating teams.


The authors performed an advanced literature search for clinical studies published between 1975 and October 2012 using MEDLINE, EMBASE, the Cochrane Controlled Trials Register, ISI Web of Knowledge, and They identified randomized controlled trials and observational studies that evaluated the effects of physical rehearsal or warm-up prior to performing complex clinical procedures. Two reviewers independently reviewed titles and abstracts and then full texts before abstracting data using a standardized form. They resolved disagreements by consensus.


The authors identified 1,886 potential articles and included 7 in their review (2 randomized controlled trials and 5 observational studies). All reported that rehearsal or warm-up by operators or operating teams is feasible. Only two clinical studies objectively demonstrated that warm-up can improve overall technical performance. Other objective evidence supporting the positive effects of rehearsal or warm-up for other team or nontechnical outcomes was limited.


The potential benefits of and optimal techniques for performing physical rehearsal and warm-up have not been established. Preliminary findings suggest that preoperative rehearsal or warm-up can improve the performance of operators or operating teams, but there is a paucity of objective evidence and comparative clinical studies in the existing literature to support their routine use.

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