Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review.

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Toomey" } ], "publisher": { "@type": "Organization", "name": "HRB Open Research", "logo": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 566, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 1200, "width": 127 }, "description": " Background Osteoarthritis (OA) has a significant impact on pain, mobility and affects over 528 million people worldwide (Hunter & Felson, 2006; Vos et al., 2020). Physical Activity (PA) is recommended to offset progression of OA however 40% of adults fail to meet the recommended PA guidelines (Wallis et al., 2013). OA management programmes which incorporate structured exercise and education have been implemented in different healthcare settings, showing significant impact on the management of hip and knee OA. Unfortunately, with cessation of exercise programmes, PA behaviour often declines, and the exercise benefits gained begin to diminish. Objectives This study aims to systematically review the barriers to and facilitators of maintaining PA behaviour for people with hip and knee OA. Methods The following databases will be searched throughout this review: APA PsycINFO, CINAHL Complete, Cochrane Library, Embase, Medline via PubMed, and the Web of Science. Only articles that meet the eligibility criteria and report on the barriers to and facilitators of maintaining PA behaviour for people with hip and knee OA will be included in this review. Articles will be screened, and quality assessment will be performed by two independent reviewers and verified by a third reviewer using Covidence and the Mixed-methods Appraisal Tool (MMAT). Key qualitative data will be managed using NVivo and a thematic synthesis of the findings will be performed using line-by-line coding. These will then be mapped to the quantitative findings and discussed as a narrative synthesis. Discussion PA plays a pivotal role in the management of hip and knee OA; however, further research is needed to identify the barriers to and facilitators of long-term engagement with PA behaviour. This study, which aims to address, analyse and consolidate these findings could help guide future long-term management of hip and knee OA. PROSPERO Registration CRD42024591820 " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/8-62", "name": "Barriers to and Facilitators of Maintaining Physical Activity Behaviour..." } } ] } Home Browse Barriers to and Facilitators of Maintaining Physical Activity Behaviour... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Hempenstall P, Hayes G, Woods C et al. Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review. [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :62 ( https://doi.org/10.12688/hrbopenres.14000.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review. [version 1; peer review: 1 approved] Peter Hempenstall https://orcid.org/0009-0007-2805-1618 1-3 , Grainne Hayes 2,4 , Catherine Woods 2-4 , Suzanne McDonough https://orcid.org/0000-0003-3758-3302 5 , Aoife Stephenson 5 , Clodagh M. Toomey 1-3,6 Peter Hempenstall https://orcid.org/0009-0007-2805-1618 1-3 , Grainne Hayes 2,4 , [...] Catherine Woods 2-4 , Suzanne McDonough https://orcid.org/0000-0003-3758-3302 5 , Aoife Stephenson 5 , Clodagh M. Toomey 1-3,6 PUBLISHED 23 May 2025 Author details Author details 1 School of Allied Health, University of Limerick, Limerick, County Limerick, Ireland 2 Physical Activity for Health Research Centre, University of Limerick, Limerick, County Limerick, Ireland 3 Health Research Institute, University of Limerick, Limerick, County Limerick, Ireland 4 Department of Physical Education and Sport Sciences, University of Limerick, Limerick, County Limerick, Ireland 5 School of Physiotherapy, Royal College of Surgeons in Ireland Faculty of Medicine and Health Sciences, Dublin, Leinster, Ireland 6 Participatory Health Research Unit, University of Limerick, Limerick, County Limerick, Ireland Peter Hempenstall Roles: Conceptualization, Methodology, Writing – Original Draft Preparation Grainne Hayes Roles: Conceptualization, Supervision, Writing – Review & Editing Catherine Woods Roles: Conceptualization, Supervision, Writing – Review & Editing Suzanne McDonough Roles: Supervision, Writing – Review & Editing Aoife Stephenson Roles: Supervision, Writing – Review & Editing Clodagh M. Toomey Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Osteoarthritis (OA) has a significant impact on pain, mobility and affects over 528 million people worldwide (Hunter & Felson, 2006; Vos et al. , 2020). Physical Activity (PA) is recommended to offset progression of OA however 40% of adults fail to meet the recommended PA guidelines (Wallis et al. , 2013). OA management programmes which incorporate structured exercise and education have been implemented in different healthcare settings, showing significant impact on the management of hip and knee OA. Unfortunately, with cessation of exercise programmes, PA behaviour often declines, and the exercise benefits gained begin to diminish. Objectives This study aims to systematically review the barriers to and facilitators of maintaining PA behaviour for people with hip and knee OA. Methods The following databases will be searched throughout this review: APA PsycINFO, CINAHL Complete, Cochrane Library, Embase, Medline via PubMed, and the Web of Science. Only articles that meet the eligibility criteria and report on the barriers to and facilitators of maintaining PA behaviour for people with hip and knee OA will be included in this review. Articles will be screened, and quality assessment will be performed by two independent reviewers and verified by a third reviewer using Covidence and the Mixed-methods Appraisal Tool (MMAT). Key qualitative data will be managed using NVivo and a thematic synthesis of the findings will be performed using line-by-line coding. These will then be mapped to the quantitative findings and discussed as a narrative synthesis. Discussion PA plays a pivotal role in the management of hip and knee OA; however, further research is needed to identify the barriers to and facilitators of long-term engagement with PA behaviour. This study, which aims to address, analyse and consolidate these findings could help guide future long-term management of hip and knee OA. PROSPERO Registration CRD42024591820 READ ALL READ LESS Keywords Hip and Knee Osteoarthritis, Physical Activity, Behaviour, Maintenance, Barrier, Facilitator, Long-term Corresponding Author(s) Peter Hempenstall ( [email protected] ) Close Corresponding author: Peter Hempenstall Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Hempenstall P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Hempenstall P, Hayes G, Woods C et al. Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review. [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :62 ( https://doi.org/10.12688/hrbopenres.14000.1 ) First published: 23 May 2025, 8 :62 ( https://doi.org/10.12688/hrbopenres.14000.1 ) Latest published: 23 May 2025, 8 :62 ( https://doi.org/10.12688/hrbopenres.14000.1 ) Introduction Osteoarthritis (OA) is a disease affecting the tissues surrounding the joint such as muscles, cartilage, bones, and ligaments and most commonly affects the hands, hips and knees. It often causes pain, hinders quality of sleep and interferes with activities of daily living ( Hunter & Felson, 2006 ). OA has become one of the fastest growing health problems in the world, having risen by 48% globally from 1990 to 2019 and now affects over 528 million people worldwide ( Vos et al. , 2020 ). People with OA experience a loss in function, increased joint pain, lower levels of physical activity (PA), more comorbidities and higher medication consumption than the general population ( French et al. , 2022 ; Gay et al. , 2019 ; Muckelt et al. , 2020 ). Although no cure exists for OA, the primary focus is to optimise the long-term management of OA, and this study aims to further address that. Management of hip and knee OA imposes a significant financial burden on the healthcare system. Costs are high globally for surgical interventions, hospital stays, and indirect factors like absenteeism, as well as presenteeism, productivity losses, early retirement, and premature death ( Hunter et al. , 2014 ). In 2014 OA-related expenses in Ireland equated to approximately €13.6 million, rising to €52.1 million in 2015 for Total Hip and Total Knee Arthroplasties (THA, TKA) alone ( Doherty & O'Neill, 2014 ; Jabakhanji et al. , 2021 ). Additionally, surgical treatments such as THA and TKA can also increase the risk of complications such as deep veinous thrombosis ( Liddle et al. , 2014 ). With a large OA-affected population and prevalent use of surgical interventions, long waiting lists persist. In 2018, 16–23% of patients waiting for a THA and TKA, respectively, faced delays of over 12 months ( Brick & Connolly, 2021 ). An international review and meta-analysis further revealed that roughly 65% of OA patients do not receive adequate education on exercise recommendations and self-management ( Hagen et al. , 2016 ). These statistics reveal and highlight the urgent need for improved access to healthcare for people with hip and knee OA and indeed, a better long-term and more viable management option is needed for OA. Recently studies have shifted to focus on self-management, and the benefits of PA for OA; to offer a more sustainable management pathway for lasting results. Although there are variations in PA dosage, both structured PA such as exercise programmes and un-structured activities such as unsupervised community walking programmes have shown to be beneficial in the management of OA symptoms and functional capacity ( Holden et al. , 2021 ; Juhl et al. , 2014 ; O'Connor et al. , 2015 ). Currently, the World Health Organisation (WHO) recommends 75–150 minutes of moderate-vigorous aerobic PA, which 40% of patients with hip or knee OA fail to meet ( Wallis et al. , 2013 ). Additionally, the WHO further recommends that older adults with chronic conditions should engage in muscle strengthening and balance exercises 2–3 times per week ( World-Health-Organisation, 2020 ). Increased levels of PA for people with OA has also shown lower rates of depression, an improved quality of life and a greater functional capacity ( Mesci et al. , 2015 ). A systematic review and meta-analysis of observational studies identified that 67% of people with OA present with at least one other chronic condition or comorbidity, compared to 56% of non-OA controls ( Swain et al. , 2020 ). Furthermore, for people with OA; the level of PA behaviour and physical performance outcomes (e.g., 30-second sit-to-stand and walking speed) decrease significantly with each additional comorbidity, highlighting the need for PA to offset progression of comorbidities ( Muckelt et al. , 2020 ). Interventions which offer a long-term change in PA behaviour could play a pivotal role in reducing the rate of disease progression and in the development of secondary conditions. The GLA:D® programme which consists of structured exercise and education, has shown increases of 110-120% on PA participation at 3 and 12-months post intervention, respectively and significant decreases in pain and medication consumption ( Baumbach et al. , 2023 ; Bell et al. , 2023 ; Skou & Roos, 2017 ). Unfortunately, the contrary is also true; people with OA that disengage in PA following cessation of activity programmes often negate the benefits of exercise developed, making their management of OA increasingly difficult ( Pisters et al. , 2010 ; Raposo et al. , 2021 ). It is clear the benefits PA can have on the management of OA and secondary conditions; however, a greater emphasis must be placed on identifying and promoting best practice for maintaining these activity levels. To better understand the determinants of behaviour, consideration should be attributed with the social cognitive theory (SCT); one of the most widely used theories for explaining motivation to maintain activity in health research ( Bandura, 2004 ). Various intrinsic factors are attributed to SCT such as a lack of motivation and poor self-efficacy which hinder both adherence and maintenance of PA behaviour for people with OA ( Hinman et al. , 2023 ). Furthermore, extrinsic factors such as a poor therapeutic alliance may deter this population from engaging in and maintaining long-term PA behaviour ( Moore et al. , 2020 ). Although research has identified various factors such as pain, stiffness and fear of worsening condition reducing adherence to PA behaviour ( Hunt & Papathomas, 2020 ), an extensive list of barriers to and facilitators of maintaining PA behaviour must be further developed and subsequently, their role in the long-term management of OA further explored. In understanding the term ‘maintenance’ with relevance to behavioural science and physical activity, there is a lack of consensus on determining an appropriate definition with differences in conceptual and operational definitions ( Dunton et al. , 2022 ; Rhodes & Sui, 2021 ). The most widely accepted conceptual definition is a period of sustained behavioural engagement above a threshold that improves health and well-being ( Dunton et al. , 2022 ; Seymour et al. , 2010 ). Operationally various thresholds (e.g. volume of physical activity) have been used in the maintenance literature e.g. meeting the physical activity guidelines of 150 minutes of moderate to vigorous physical activity or person-specific thresholds such as meeting a stated personal goal ( Dunton et al. , 2022 ). The duration indicating that the behaviour has been sustained has also varied e.g. for a period of at least 3- or 6-months ( Clarkson et al. , 2022 ; Dunton et al. , 2022 ; McDonough et al. , 2025 ; Prochaska & Velicer, 1997 ). For the purpose of this study, ‘maintenance duration’ will be defined in terms the Transtheoretical Model (TTM). The TTM, defines maintenance as a stage after behaviour has been performed consistently for ≥ 6-months ( Prochaska & Velicer, 1997 ). Although research for adherence to PA behaviour is growing; investigation into the maintenance of PA behaviour for people with OA remains under-researched. For example, a recent systematic review of digital tools to support PA maintenance across 18 long-term conditions identified 23 studies, but only four in OA, highlighting the gap for further research in maintaining PA for people with OA ( Howes et al. , 2024 ). There is currently no systematic review that compiles, analyses and forms a thematic synthesis on the barriers to and facilitators of maintaining PA behaviour for people with hip and knee OA. Furthermore, knowledge of these elements and their role in effective PA behaviour maintenance interventions will help to design future interventions for the long-term management of hip and knee OA. This may offer a more viable method for long-term OA management within the healthcare system. It will therefore be the purpose of this study protocol to design the methodology for an in-depth mixed-methods systematic review to identify and address the barriers to and facilitators of maintaining PA behaviour for hip and/or knee OA. This mixed-methods approach will capture both qualitative and quantitative studies enabling a greater understanding of barriers and facilitators to PA and shed light on the impact and persistence these factors have on OA management. It is anticipated that identification of these key elements affecting long-term engagement with PA will help in the design of future hip and knee OA management programmes. Methods This study has been registered on the PROSPERO database of systematic reviews (registration number: CRD42024591820). The reporting protocol for this systematic review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) checklist. Search strategy As this mixed-methods study addresses both qualitative and quantitative studies, the SPIDER (Sample, phenomenon of interest, design, evaluation and research type) tool was deemed as the most appropriate for guiding the development of the literature search strategy. SPIDER considers both aspects of the mixed-methods study, however, contributes a particular focus to the qualitative component of this study enabling experiences to be captured ( Cooke et al. , 2012 ). This will enable the identification of the barriers to and facilitators of PA behaviour from the perspectives of people with hip and knee OA while also incorporating quantitative studies with objective measurements. This search will be conducted on the database EBSCO Host for APA PsycINFO and CINAHL Complete. Additionally, the Web of Science, Medline via PubMed, Embase and the Cochrane library will also be searched. The search strategy will be first developed on PubMed and transcribed to the other databases. No date limit will be applied to facilitate a larger retrieval for synthesis. A Boolean search will be carried out using an exhaustive list of search terms such as ‘Osteoarthritis’ or ‘Hip Osteoarthritis’ or ‘Knee Osteoarthritis’ or ‘OA’ or ‘Lower-limb OA’ AND ‘Physical Activity’ or ‘Physical Inactivity’ or ‘Exercis*’ AND ‘Maintain*’ or ‘maintenance’ or ‘Adhere*’ or ‘sustain*’ or ‘long-term’ AND ‘Barrier*’ or ‘Obstacle*’ or ‘Challenge*’ or ‘issue*’ AND ‘Facilitat*’ or ‘Enable*’’. This search strategy aims to identify empirical studies that will inform this systematic review of identifying barriers to and facilitators of PA behaviour maintenance for people with hip or knee OA. For further details, see Table 1 . Table 1. Design of the review. Sample The sample or population of interest are people with hip and / or knee osteoarthritis who have participated in an intervention to increase physical activity at least 6 months previously. Furthermore, experiences as described by professionals who deliver physical activity programmes for the hip and knee osteoarthritis population will also be considered. Phenomenon of Interest This review will incorporate studies that obtain at least 6-month qualitative or quantitative follow- up of the correlates of maintaining physical activity for hip and/or knee osteoarthritis from the perspective of the person with osteoarthritis or those delivering the programme. This will facilitate a greater understanding of certain behaviours, motivators and drivers to maintaining physical activity behaviour. Design The study designs included will be quantitative (e.g. cohort studies which may be cross-sectional or longitudinal, randomised control trials, non-randomised trials, quasi-experimental trials, quasi- experimental trials, and other observational studies such as case-control and cross-sectional), qualitative studies (e.g. interviews, semi-structured interviews, and focus groups with both the osteoarthritis population and professionals who deliver the programmes) and mixed-methods studies (e.g., process evaluations, implementation studies and longitudinal cohort studies). Evaluation The qualitative experiences will be broken down using thematic synthesis as described below to allude to the barriers to and facilitators of maintaining physical activity behaviour for the osteoarthritis population. Quantitative outcomes will be summarised descriptively. Research Type This review will include quantitative, qualitative, and mixed-methods studies published in peer- reviewed journals. Studies that report on asynchronous long-term behavioural support will also be incorporated as elements of these interventions may inform how on-going support facilitates the long-term maintenance of physical activity. Eligibility criteria For inclusion and exclusion criteria, see Table 2. Table 2. Inclusion and Exclusion criteria. Criteria Inclusion Exclusion Language English Other Date range No date limit applied - Sample People with hip OA, knee OA or both. For studies with a sample of mixed chronic conditions at least 50% of the sample must present with hip or knee OA to be considered for inclusion. Other OA or other types of arthritis (Rheumatoid, Psoriatic) or other chronic conditions where hip or knee OA is not the majority. Phenomena of Interest The barriers to and facilitators of PA behaviour maintenance for people with hip and/or knee OA from both the perspectives of the clinicians and people with hip and/or knee OA. Studies that don’t incorporate a minimum 6-month follow-up period after an initial PA or exercise intervention. Context Qualitative interviews detailing the experiences of people with Hip and/or Knee OA and professionals who deliver the programmes on the barriers to and facilitators of behaviour maintenance to exercise or quantitative measures of PA behaviour maintenance for people with hip and knee OA. Studies that did not focus on the maintenance of PA behaviour for people with hip and/or knee OA. Study design Peer-reviewed: Qualitative, Quantitative, and mixed-methods Reviews, Reports, Protocols, Books, Abstracts, Case studies, Reviews, non peer- reviewed articles Type of intervention Studies detailing an at least a 6-month follow-up on experiences in maintenance for PA for people with OA. Studies which did not detail at least a 6-month follow-up for PA behaviour maintenance Due to much discretion on the basis of defining the term ‘maintenance’, the definition proposed in the TTM by Prochaska and Velicer (1997) whereby behaviour performed consistently for at least 6-months will be operationalised in this review. PA in this study, in conjunction with the concept of maintenance will be described as any bodily movement which requires energy yet; is not limited to one or more components of physical fitness ( Marley et al. , 2017 ). This definition incorporates activities of daily living, however, also considers structured forms of PA such as exercise programmes, offering a broader overview of PA for OA. Studies that implement a trial for promoting the maintenance of PA with follow-up at least 6-months post-intervention that report barriers and facilitators of PA behaviour maintenance will also be included. Studies that address the management of chronic conditions have shown that the management of OA is multi-faceted, containing various components and with large variability such as prescribed exercise and self-management strategies ( Brand et al. , 2014 ). This review therefore will aim to identify the various elements discussed that either facilitate or challenge the long-term engagement with PA for people with hip and knee OA in attempt to appropriate a paradigm for long-term OA management. Participants Adults with hip and/or knee OA that detail an at least 6-month follow-up on PA behaviour or professionals that deliver interventions to maintain PA behaviour for hip and knee OA will be eligible for inclusion in this review. Hip and knee OA participants in this study will be classified as diagnosed through either a general practitioner (GP), HCPs, or where participants have self-reported OA. Studies with other chronic MSK conditions will be included provided the higher proportion (i.e. ≥50%) of participants have diagnosed hip and/or knee OA. Study design Studies will be included if they undertake either (1) a qualitative approach (e.g., unstructured interviews, semi-structured interviews, structured interviews, and focus groups) addressing the barriers to and facilitators of maintaining PA behaviour for people with hip and/or knee OA or (2) quantitative studies that report on barriers and facilitators to maintaining PA behaviour for people with hip and/or knee OA such as surveys. Furthermore, mixed-method studies which incorporate either of the above qualitative or quantitative designs will also be included. Study selection The literature for this study will be stored and managed using the referencing software Endnote 21 (Version 21.2, Clarivate analytics, Australia). The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines will be used when identifying and selecting articles for review within this study and will be in compliance with the flow chart below. See Figure 1 . Articles will be imported to Endnote following the initial search and any duplicates removed. The remaining articles will be screened and reviewed using Covidence software (Covidence, Veritas Healthy Innovation, Melbourne, Australia) for their titles and abstracts by two independent reviewers ( PH , CT ) and any discrepancies which may arise will be resolved following discussion among authors. Furthermore, the remaining full-text articles will be retrieved and screened for eligibility using the eligibility criteria pre-determined in Covidence. The full-text articles will be divided amongst the team into two teams of two reviewers and a verifier in each team ( PH and Reviewer 2, Reviewer 3 and Reviewer 4 ). Any additional articles using an extended search through additional databases; or through citation tracking will also be included and screened for eligibility using the above process. To assess the articles for risk of bias, the Mixed-Methods Appraisal Tool (MMAT-version 2018) ( Hong et al. , 2018 ) will be used to address the qualitative, quantitative and mixed-methods studies for inclusion in this review and any discrepancies between authors will be solved using an additional verifier.to cross-check any inconsistencies and to reach a conclusion on study selection. Figure 1. PRISMA Flow chart diagram. Adapted by ( Page et al. , 2021 ). Data extraction and synthesis Given the heterogeneity of both qualitative and quantitative data to be analysed, a narrative synthesis as proposed by Yang et al. (2024) will be employed to conduct the data synthesis. This will facilitate the qualitative data to be synthesised using an appropriate thematic synthesis enabling an in-depth exploration of patient experiences that will be integrated with the quantitative findings through a narrative synthesis, allowing flexibility to compliment the findings as opposed to compare the findings. The descriptive statistics from each study such as author, year, country, study type (qualitative / quantitative), the study design, the key topics discussed, the methodology involved, the population (people with hip and/or knee OA or programme delivery professionals s) and the intervention setting (e.g. structured and semi-structured interviews) will be extracted and input into standardised data extraction tables using Microsoft Excel (Version 2405). This will be consistent for all included studies. The quantitative studies will be synthesised using an approach adapted by ( Clifford et al. , 2018 ) whereby the frequency of barriers and facilitators reported will be tallied and their importance weighted on a 3 point-scale. The factors that are most reported will be assigned a score of 3, those reported less / or of a moderate amount will be assigned a score of 2 and those least reported will be assigned a score of 1. If a barrier or facilitator is not reported, it will be assigned a score of 0. The total sum of barriers reported will be tallied which will give rise to the impact or importance of a barrier as presented in the identified studies. This same process will also be performed to tally identified facilitators to maintaining PA behaviour. The qualitative findings identified in the studies will be synthesised using thematic synthesis as proposed by Thomas and Harden (2008) . Data which addresses (1) the facilitators of PA behaviour maintenance from the perspectives of people with hip and/or knee OA and clinicians and (2) the barriers to PA behaviour maintenance from the perspectives of people with hip and/or knee OA and clinicians will be extracted and input into standardised data extraction tables. Thematic synthesis in this process offers transparency and is seen as a suitable method for the integration of qualitative study findings. The thematic synthesis will use both a data-driven or ‘an inductive’ approach in the early stages (stages 1 & 2) and re-introducing the research question of addressing the barriers to and facilitators of PA behaviour maintenance in the later stages implying ‘a deductive’ approach to develop the analytical themes. The three stages in the performance of this thematic synthesis will be (1) line-by-line coding of the evidence, (2) grouping of this code into varied ‘descriptive themes’ which may further allow studies to be compared in terms of the translation of conceptions in an iterative aspect. These ‘descriptive themes’ may be further broken down to incorporate sub-headings based on the translation of conceptions which may describe similar outputs across the studies and (3), the final construction of the analytical themes as suggested from this process. As this process will require continual re-visiting of the themes as more studies are analysed, it will allow for constant re-examination and re-construction of the analytical themes throughout the scope of this systematic review. These themes will be developed by one reviewer (PH) and cross-examined by a second author (Reviewer 2) to enhance the credibility of this study. The barriers to and facilitators of PA behaviour maintenance for people with hip and/or knee OA will be inferred from these descriptive themes which will lead the remainder of the study on the themes and aim to address the primary research question of this study. The descriptive themes developed may infer the incorporation of specific frameworks to aid the analysis such as the Theoretical domains framework (TDF) ( Cane et al. , 2012 ) however, this will be informed from the thematic synthesis and as per Cochrane qualitative and implementation methods group (CQIMG), and will not be prescribed ( Noyes et al. , 2018 ). The analytical themes will then be summarised and displayed in table form. Key quotes from personal experience and beliefs highlighted from these studies will be coded and stored using NVivo software (NVivo v15, QSR International, USA) and will be incorporated into this table summary under their designated themes. Furthermore, as this study will include both PA and structured exercise, a sub-group analysis will also be carried out using this same method on populations which engage in structured exercise. To facilitate a coherent synthesis of the mixed-methods review to address both the qualitative and quantitative findings, an integrative framework such as the Capability, Opportunity, Motivation – Behaviour (COM-B) model in conjunction with the TDF could be employed for curating the narrative synthesis of this review. The culmination of these frameworks could play a pivotal role in conducting this narrative synthesis as it will firstly; enact an understanding of the target behaviour (maintenance), aid in the identification of themes for assigning the barriers and facilitators appropriately and finally, assist in mapping the quantitative findings to the qualitative findings ( Michie et al. , 2014 ; Yang et al. , 2024 ). Although this appears to be the dominant integrative framework to perform this narrative synthesis, it is important to re-iterate that the framework will be inferred from the findings as opposed to prescribed. Discussion Currently, there is no cure for OA however; PA has shown to play a pivotal role in symptom relief and management of hip and knee OA; resulting in improvements in physical function and in joint pain relief ( Raposo et al. , 2021 ). There are many different opportunities and programmes available for promoting PA for people with hip and knee OA however, opportunities to sustain long-term adherence to PA appear less frequent. Unfortunately, for people with OA; the long-term opportunities are sparce and they often cease exercising once a programme comes to completion which diminishes the benefits gained ( Pisters et al. , 2010 ; Raposo et al. , 2021 ). A lack of moderate-to-vigorous intensity activity for people with OA not only reduces physical function but can nearly double the likelihood of deteriorating physical limitations ( Dunlop et al. , 2005 ). The focus of the research should therefore aim to address the determinants for long-term sustainability of PA to promote best practices for the management of hip and knee OA. To understand the determinants of PA behaviour maintenance, it is important to consider the factors both at the level of the individual such as behaviour guided factors and at the environmental level such as setting, accessibility or opportunities available. At the personal level, self-efficacy has shown to be a prominent theme. People with OA who engage in activity tend to reap the rewards more than those who chose to commit partially or not at all ( Hinman et al. , 2023 ). When addressing the barriers to and facilitators of PA for people with OA, there is quite a large overlap in both short-term adherence and in the long-term maintenance. In short-term adherence to exercise, personal barriers to exercise such as a lack of incentive to exercise during pain free periods, pain or other physical symptoms, a lack of motivation and lower levels of self-efficacy often influence maintenance of PA behaviour. Interestingly, these same factors affect long-term maintenance of PA behaviour however with the additional barriers of a lack of social support to exercise and on receipt of conflicting advice received from physiotherapists ( Moore et al. , 2020 ). Opposingly, participants who associate being ‘naturally active’ as part of their identity, have developed strong therapeutic alliances with their physiotherapist or those which have developed a strong motivation to prevent further pain often describe these elements as facilitators of PA behaviour maintenance ( Moore et al. , 2020 ). Although the presence of reviews on the barriers and facilitators of both adoption and adherence to PA for people with OA exist, an extensive review identifying their role in the maintenance of PA for people with OA remains, which this study aims to address. This knowledge in conjunction with understanding intervention elements to improve the maintenance of PA behaviour for people with hip and knee OA could be instrumental to long-term OA management. In an attempt to address the potential factors which, cause such a disparity in PA behaviour maintenance, this mixed-methods systematic review aims to identify the personal experiences through qualitative studies on both people with hip and/or knee OA and professionals who deliver PA programmes to greater illustrate the barriers to and facilitators of PA behaviour maintenance. Subsequently, this study also aims to quantitatively identify and evaluate the presence and influence of these barriers and facilitators for maintaining PA behaviour for people with hip and knee OA. It is anticipated that the personal experiences captured will represent the diverse intrinsic and extrinsic themes of engagement with long-term PA behaviour. Furthermore, through understanding the themes attributed to maintaining PA behaviour, it is anticipated these elements will be identified and facilitators enacted within OA interventions, creating a pivotal step in building a paradigm for the long-term management of OA. These findings could assist and guide the implementation of evidence-based practice for healthcare systems in the long-term management of hip and knee OA. Data availability Underlying data No data are associated with this article. Reporting guidelines Open Science Framework: PRISMA-P Checklist for “Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review”. https://doi.org/10.17605/OSF.IO/NV2QR ( Hempenstall, 2025 ). Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication). 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PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 23 May 2025 ADD YOUR COMMENT Comment Author details Author details 1 School of Allied Health, University of Limerick, Limerick, County Limerick, Ireland 2 Physical Activity for Health Research Centre, University of Limerick, Limerick, County Limerick, Ireland 3 Health Research Institute, University of Limerick, Limerick, County Limerick, Ireland 4 Department of Physical Education and Sport Sciences, University of Limerick, Limerick, County Limerick, Ireland 5 School of Physiotherapy, Royal College of Surgeons in Ireland Faculty of Medicine and Health Sciences, Dublin, Leinster, Ireland 6 Participatory Health Research Unit, University of Limerick, Limerick, County Limerick, Ireland Peter Hempenstall Roles: Conceptualization, Methodology, Writing – Original Draft Preparation Grainne Hayes Roles: Conceptualization, Supervision, Writing – Review & Editing Catherine Woods Roles: Conceptualization, Supervision, Writing – Review & Editing Suzanne McDonough Roles: Supervision, Writing – Review & Editing Aoife Stephenson Roles: Supervision, Writing – Review & Editing Clodagh M. Toomey Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 23 May 2025, 8:62 https://doi.org/10.12688/hrbopenres.14000.1 Copyright © 2025 Hempenstall P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Hempenstall P, Hayes G, Woods C et al. Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review. [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :62 ( https://doi.org/10.12688/hrbopenres.14000.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 23 May 2025 Views 0 Cite How to cite this report: Hall M. Reviewer Report For: Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review. [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :62 ( https://doi.org/10.21956/hrbopenres.15366.r47913 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-62/v1#referee-response-47913 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 19 Aug 2025 Michelle Hall , The Kolling Institute, The University of Sydney, Sydney, Australia Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15366.r47913 Abstract Background - please provide support references from guidelines recommending - 'Physical Activity (PA) is recommended to offset progression of OA'. Caution the interchange between 'exercise' and 'physical activity'. Is the objective specific ... Continue reading READ ALL Abstract Background - please provide support references from guidelines recommending - 'Physical Activity (PA) is recommended to offset progression of OA'. Caution the interchange between 'exercise' and 'physical activity'. Is the objective specific to PA inclusive of exercise? or just PA? Will 2 reviewers extract the data independently? Introduction Please acknowledge this work in OA conducted 9 years ago, and how it will differ or extend this evidence on 'exercise' (refer 1) Participant - will hip and knee OA be analysed seperate, Wallis et al suggests meeting PA guidelines more problematic for knee OA? "For hip osteoarthritis, 11 studies involving 325 participants averaged 160 min per week (95% CI = 114, 216) of MVPA when measured in bouts of ≥10 min, 189 min per week (95% CI = 166, 212) of MVPA, and 8174 daily steps (95% CI = 7670, 8678)." For the discussion, consider some evidence from the Glad program, than more PA may not always better.https://pubmed.ncbi.nlm.nih.gov/36272673/ Please note: I am not an expert is the mixed-methods approach of a systematic synthesis - as described everything appears well considered and thought through. I would recommend a framework such as the COMBI to guide synthesis. Hope this comments are helpful, look forward to this valuable contribution. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable References 1. Dobson F, Bennell K, French S, Nicolson P, et al.: Barriers and Facilitators to Exercise Participation in People with Hip and/or Knee Osteoarthritis. American Journal of Physical Medicine & Rehabilitation . 2016; 95 (5): 372-389 Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: osteoarthritis; exercise I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Hall M. Reviewer Report For: Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review. [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :62 ( https://doi.org/10.21956/hrbopenres.15366.r47913 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-62/v1#referee-response-47913 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 23 May 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 23 May 25 read Michelle Hall , The Kolling Institute, The University of Sydney, Sydney, Australia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Hall M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 19 Aug 2025 | for Version 1 Michelle Hall , The Kolling Institute, The University of Sydney, Sydney, Australia 0 Views copyright © 2025 Hall M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Abstract Background - please provide support references from guidelines recommending - 'Physical Activity (PA) is recommended to offset progression of OA'. Caution the interchange between 'exercise' and 'physical activity'. Is the objective specific to PA inclusive of exercise? or just PA? Will 2 reviewers extract the data independently? Introduction Please acknowledge this work in OA conducted 9 years ago, and how it will differ or extend this evidence on 'exercise' (refer 1) Participant - will hip and knee OA be analysed seperate, Wallis et al suggests meeting PA guidelines more problematic for knee OA? "For hip osteoarthritis, 11 studies involving 325 participants averaged 160 min per week (95% CI = 114, 216) of MVPA when measured in bouts of ≥10 min, 189 min per week (95% CI = 166, 212) of MVPA, and 8174 daily steps (95% CI = 7670, 8678)." For the discussion, consider some evidence from the Glad program, than more PA may not always better.https://pubmed.ncbi.nlm.nih.gov/36272673/ Please note: I am not an expert is the mixed-methods approach of a systematic synthesis - as described everything appears well considered and thought through. I would recommend a framework such as the COMBI to guide synthesis. Hope this comments are helpful, look forward to this valuable contribution. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable References 1. Dobson F, Bennell K, French S, Nicolson P, et al.: Barriers and Facilitators to Exercise Participation in People with Hip and/or Knee Osteoarthritis. American Journal of Physical Medicine & Rehabilitation . 2016; 95 (5): 372-389 Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise osteoarthritis; exercise I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Hall M. Peer Review Report For: Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review. [version 1; peer review: 1 approved] . HRB Open Res 2025, 8 :62 ( https://doi.org/10.21956/hrbopenres.15366.r47913) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-62/v1#referee-response-47913 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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