The validation of manual proceeded via two stages: Stage 1 was the development stage and stage 2 were the expert judgement stage. With a thorough examination of the literature, the manual was created in three steps constituting a section of exercise which is further divided into morning, afternoon and evening exercise, the diet plan for morning, afternoon and evening along with the patient education instructions. (11) The regimen was particularly designed for knee arthroplasty patients 12 weeks post-surgery, ranging from 45 to 70 years, both male and female. The manual is staged in a manner that accommodates the patient's functional needs and community mobility. A predetermined sequence of exercises in terms of mobility, stability and muscle performance makes up the TKR life style modification rehabilitation protocol. Musculoskeletal physical therapists, orthopedic surgeons, nutritionist were chosen for the validation process. The Institutional Ethics Committee of Riphah International university gave its approval for this validation study.
Life style modification manual
The three sections of the structured lifestyle modification manual [Annexure-1] include the exercise section targeting advanced function phase (activity phase) in which exercises are categorized in the morning, afternoon and evening times.
Specific therapeutic exercise components, such as general exercises, mobility exercises, stretching, muscular activation, and functional training, are included in the exercise section. Mobility, stretching, strengthening, closed-chain exercises, balance training, functional training, and aerobic conditioning are all included in the advanced function rehabilitation phase. The exercise section aims to improve essential muscle strength, mobility, stability and muscle performance. Further goals included restoring a normal gait pattern. The morning phase constitute stretching exercises of major muscle groups hamstrings, quadriceps and gastro-soleus. The after-noon phase targets mobility exercises while the evening phase focuses on the balance, gai and stability exercises. The regimen is designed based on recent literature and impairments after TKR (10). Balance exercises were incorporated in the protocol as it was not mostly found in the researches.
The Diet plan section includes the division of nutritional chart in breakfast, mid-morning, lunch, evening, dinner and bed time. The plan is particularly designed keeping in mind the adequate caloric diet with necessary portions of carbohydrates, good lipids and proteins. A list of foods that are allowed and those that are not allowed is also given for convenience of patients.
The next section is about the patient education on pain, swelling, balance instructions, walking instructions, stretching information and knee mobility.
Process of validation
The researcher invited 10 independent experts with at least 10 years of experience in the field of musculoskeletal physical therapy experience. A minimum of five and a maximum of ten experts are needed for the validation procedure, according to Lynn MR's recommendations(12). Out of 10, eight specialists consented to take part. Four consultant physical therapist and three senior physical therapists and one nutritionist were among the professionals who all worked in the field of musculoskeletal physical therapy. The validation approach involved ranking experts on two criteria—relevance and performance ease—using a 5-point Likert scale. Scores on the scale ranged from 1 for strongly disagreeing to 5 for strongly agreeing. If the score fell below 3, experts were consulted for advice. Scores of 4 and 5 were considered acceptable for calculations. The prepared content was supplied via electronic means, along with some basic instructions. The amount of agreement, content validation index, and kappa value were calculated using expert input on the life style modification manual.
By dividing the number of experts who received a score of 4 or above by the total number of experts that took part, the content validation index was determined. According to a study (13)the threshold for approval is > 0.78, therefore six out of eight people approved the manual. This emphasizes the fact that the life style modification manual is considered to have solid expert consensus and should be included in supervised home-based protocol if the percentage of agreement is greater than 78%. To verify the applicability of the workout routine, a modified kappa was computed. The following was suggested as the kappa values interpretation: fair = 0.40 to 0.60, good = 0.60 to 0.74 and excellent = 0.75 to 1.00.