The present protocol has been registered within the Open Science Framework platform https://osf.io/9fdsh/ and the study protocol is being reported in accordance with the reporting guidance provided in the PRISMA extension for scoping reviews (PRISMA-ScR) (Appendix A)
The methodology will involve conducting scoping review to map, explore and study the breadth of information available on the topic of prehab and identify gaps in the literature. A scoping review methodology will be best suited as it will allow for a rapid review of a comprehensive range of literature which includes all levels of evidence which can then be described in a detailed manner. It will, however, exclude opinion papers, review papers and commentaries. The scoping review strategy as described by Arksey and O’Malley19 which details five stages will be used. The five steps in the following sequence will guide the manner in which the scoping review will be conducted: (1) defining the research question, (2) identifying the relevant studies, (3) selecting the main theme for this study, (4) charting and collecting the data and (5) summarising and reporting the results19.
Defining and pinpointing the research question
The main research question for the scoping purpose will be “Prehabilitation interventions for patients undergoing Primary Joint Arthroplasty.”
The areas of consideration and the sub-questions under the umbrella research question will include the following:
- What are the types of exercises included in prehabilitation programmes?
- In the exercise prescription of the prehabilitation intervention what is intensity, frequency, duration of the program?
- What other aspects are considered in a prehabilitation program?
Information Sources and Search Strategy
Identification of studies relevant to this review will be achieved through the utilization of the search strategy as recommended by the Joanna Briggs Institute. In the search for literature computer databases like google scholar, CINAHL, Medline, Pubmed, Ebsco, and Cochrane Library will be used. Any studies done between 2009 to 2020 will be included in the search strategy. The Boolean terms “AND”; “OR”; “NOT” will be used to separate keywords. Additional potentially relevant studies will be identified by conducting a search of the references of the included articles, and further searches on websites such as the World Health Organization (WHO) and the Directory of Arthroplasty. Relevant grey literature will be identified through targeted searches of dissertations/theses on ProQuest Dissertations and Theses Global, and conference abstracts on EMBASE Conference Abstracts and Conference Proceedings Citation Index-Science, Social Science and Humanities. Search terms that will be included will be knee, hip, joint replacement, arthroplasty, physiotherapy, physical therapy, exercise, rehabilitation, prehabilitation, preoperative, level of knowledge, patient education, foot deformities, osteoarthritis and patient compliance. Reference lists of retrieved articles will also be screened. Inclusion criteria for the scoping review will include exercise or education about prehab and studies will be selected based on how appropriate it is to the study question at hand however ensuring that the selection process will be iterative and inclusive of grey literature and diverse study designs 20.
Selection of eligible studies
The Population Concept Context (PCC) framework will guide the process of study selection and its link with the research question. To be included in the review, papers will need to have a sample population of adults 50 years and older as this is the common age for arthroplasty, whose participant in the study have had a lower limb joint replacement or are scheduled to have one, measure or focus on functional outcomes pre and post arthroplasty, interventions and exercise that incorporate pre-operative optimisation which may or may not include education as a preparation for joint arthroplasty as is contained in the proposed conceptual framework. The paper should describe the type of exercises prescribed such as aerobic exercise, anaerobic exercise, strengthening, flexibility, resistance, balance and functional activities and if any educational interventions were incorporated. The studies will also be scrutinised for the principles of exercise prescription used in terms of repetitions and frequency of interventions and its corelation to efficacy if described. Peer-reviewed journal papers will be included if they are written in English, involved human participants, and described measures for physical, psychological, and functional status of patients and contain physical activity/exercise and/or the recommendations prior to arthroplasty and post arthroplasty. Quantitative (e.g., randomized controlled trials, observational studies, cohort, case-control), qualitative, and mixed-method studies will be included if they consider the above aspects as the purpose of the study. Papers will be excluded if aims and the study population did not fit into the conceptual framework of the study or did not include any aspect of pre-operative optimisation.
Inclusion criteria
All articles or studies eligible for selection must meet the following inclusion criteria:
- Articles that include pre-operative optimisation in arthroplasty patients
- All published peer-reviewed research articles
- Articles written in English
Exclusion criteria
Articles or studies will be excluded if they have any of
the following criteria:
- Studies where full-text articles cannot be obtained
- Commentaries or opinion pieces
Eligible articles will be uploaded into Mendeley software for Windows 10 to ensure the identification and removal of all duplicated articles. Three reviewers who are familiar with the study proposal will be involved in the scoping review process. Title, abstract, and key words screening of all eligible articles will be conducted by the main author (PP) and second reviewer (HE). The process entails that the two reviewers (PP and HE) will initially screen the citations by title, abstract, and key words to ensure that the selected studies fall within the paradigm of the conceptual framework. Excluded citations will be reviewed and confirmed by a third reviewer (VC). The next step will consist of obtaining full texts of all selected articles by undertaking a thorough and exhaustive search of the web. In those instances where the full text cannot be obtained from the web a concerted effort will be made to obtain these full-text articles by engaging with the University subject librarian and or contacting the author/s as necessary. Full-text screening as to whether the selected articles meet the inclusion criteria will be conducted by both reviewers independently (PP and HE). Major discrepancies and lack of agreement in the inclusion for the scoping review between both reviewers will be resolved through discussion. However, should there still be no resolution, a third reviewer (VC) will be employed to ensure consensus. The degree of agreement between reviewers will be calculated and reported using Cohen’s kappa coefficient. A pilot study of the search and its result are depicted in Table 1.
Table 1: Results of a Pilot Search
Keywords Searched
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Date of Search
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Data Base
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Number of Publications Retrieved
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(“Adult” OR “ Aged +” OR “ Middle Aged”) AND ( “Arthroplasties” OR “Replacement” OR” Knee” OR “Arthroplasty” OR” Knee Replacement” OR “Knee Replacement Arthroplasties “ OR “Knee Replacement Arthroplasty “ OR “Replacement Arthroplasties” OR “Knee Arthroplasty “ OR “Total Arthroplasty” OR “Total Knee” OR “Total Knee Arthroplasty” OR “Replacement, Total Knee” OR “Total Knee Replacement “ OR “Knee Replacement, Total” OR “Replacement Arthroplasty”, Knee)) AND ( “Arthroplasties, Replacement, Hip “ OR “Arthroplasty, Hip Replacement “ OR “Hip Prosthesis Implantation” OR “Hip Prosthesis Implantations “ OR “Implantation, Hip Prosthesis” “Prosthesis Implantation, Hip” OR “Hip Replacement Arthroplasty” OR “Replacement Arthroplasties, Hip” OR “Replacement Arthroplasty, Hip” OR “Hip Replacement, Total” OR “Total Hip Replacement” OR “Total Hip Arthroplasty” OR “Total Hip Replacements”)) AND (• “Exercise, Preoperative” OR “Preoperative Exercises” OR “Pre-operative Conditioning “OR “Conditioning, Pre-operative” OR “Pre operative Conditioning” OR “Pre-operative Conditionings” OR “Pre-operative Rehabilitation” OR “Pre operative Rehabilitation” OR “Pre-operative Rehabilitations” OR “Rehabilitation, Pre-operative” OR “Preoperative Rehabilitation” OR “Preoperative Rehabilitations” OR “Rehabilitation, Preoperative” OR “Preoperative Conditioning” OR “Conditioning, Preoperative” OR “Preoperative Conditionings” OR “Pre-operative Exercise “ OR “Exercise, Pre-operative” OR “Pre operative Exercise” OR “Pre-operative Exercises” OR “Prehabilitation”)
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18/01/2021
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PubMed
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37 Results
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Charting the data
A standardized data charting table will be used to categorise and summarise the extracted information (Table 2). The tool will capture the relevant information on study design and other detailed information on the metrics used to describe pre-operative optimisation in arthroplasty patients. Information of interest will include the following:
- Demographic study characteristics: Authors, Year of publication, Journal, Topic, Setting, Country of origin
- Study characteristics: Study design, Aim/objective of the study, Sampling strategy, Sample Size
- Participant characteristics: Population, Sample, age (e.g., mean with standard deviation, range), Gender (e.g., percentage of male/female participants)
- Assessment tools: Anthropometric data, Outcome Measures used, Intervals of Assessment,
- Interventions: Exercise Prescription (e.g., type and duration or intensity), Types of Exercises, Education component, Intervals of exercises, Model of delivery
- Outcome results (e.g., findings relevant to study objectives).
- Key relevant findings and conclusions
- Other fields to capture data relevant to the assessment of study validity
- Scoping review authors analysis
Table 2: Data Extraction Table
Author
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Topic
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Methods
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Sampling and size
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Assessment tools
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Outcomes
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Conclusion
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Scoping Authors Comments
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Gaps
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Other
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The data-charting form will be jointly updated by the two reviewers to capture all permutations and combinations possible of the research question and to determine which variables to extract for example study design, population, sample characteristics etc. The two reviewers will independently chart the data and any disagreements will be resolved through discussion between the two reviewers or further adjudication by a third reviewer.
Collation, summarization, and reporting of the results
The data collection and extraction will be guided by the main research questions with the assimilation of the secondary questions within it. The data will be presented in a narrative format with the main categories like physical and psychological interventions and containing subcategories like for instance, physical intervention, will be further described as exercise prescription strategies and will comprise description of exercises used to improve strength, flexibility, balance, function and other similar intervention. The psychological interventions subcategories will explore the contents of the education components of pre-optimisation like health, pain, lifestyle education. The review will also try to identify if the literature alludes to or describes the anecdotal challenges faced from clinical and experiential practice like the impact of concurrent joint deformities on post-operative recovery and if pre-operatively it can be addressed and mitigated yielding and allowing for further exploring of unknow concepts and gap identification. In summary all the information will be synthesised, and the information will be presented in a narrative format which will include numerical information, thematically information on the various types of interventions used and finally the gaps that were identified.
Quality appraisal
The quality of the studies selected from the search strategy will be appraised using the Mixed Methods Appraisal Tool (MMAT) version 2018. Categories within the MMAT allows for the inclusion of qualitative studies in category one, category two includes quantitative randomized control trial, category three comprises non-randomized trials, category four includes quantitative descriptive studies, and category 5 mixed methodologies studies. Three reviewers (PP, HE and VC) will be involved in the quality appraisal process. Two reviewers (PP, HE) will capture the methodological quality of the selected studies as per the criteria outlined in the MMAT, while a third reviewer (VC), who has vast experience in the application of MMAT in the quality appraisal process, will oversee the process. Prior to performing a comprehensive charting process a trail of methods will be done to enhance the methodology of a scoping study as recommended by 21.