Patient perspectives on home-based rehabilitation exercise and general physical activity after total hip arthroplasty: A qualitative study (PHETHAS-2) [version 4; peer review: 2 approved with reservations]

Background: Home-based rehabilitation exercise following Total Hip Arthroplasty (THA) shows similar outcomes compared to supervised outpatient rehabilitation exercise. Little is known about patients' experiences with home-based rehabilitation, and this study aimed to investigate how patients perceived home-based rehabilitation exercise and general physical activity after THA, focusing on facilitators and barriers. Methods: Semi-structured interviews of qualitative design were conducted with 22 patients who had undergone THA and who had performed home-based rehabilitation exercise. The study took place in a regional hospital in Denmark between January 2018 and May 2019. Data were analyzed using an interpretive doing the exercises. Both pain and the absence of pain were identified as barriers for doing home-based rehabilitation exercise. Pain could cause insecurity about possible medical complications, while the absence of pain could lead to the rehabilitation exercise being perceived as pointless. Conclusions: The overall goal of returning to the well-known everyday life served as a facilitator for undertaking home-based rehabilitation exercise after THA along with the flexibility regarding time and place for performing exercises. Boring exercises as well as both pain and no pain were identified as barriers to the performance of home-based rehabilitation exercise. Participants were motivated towards performing general physical activities which were part of their everyday life. Thank you for the opportunity to review this paper. This is a qualitative study exploring patients’ perspectives of unsupervised home-based rehabilitation exercise and general physical activity after a total hip arthroplasty. The sample includes patients enrolled in a pragmatic cohort study of unsupervised home-based exercise and patients not enrolled in the cohort study. All qualitative participants received the same exercise instructions and were interviewed at 10 weeks post-surgery. The data were synthesized into one main theme and a subtheme. Overall, this is a very interesting paper on a timely topic, and the methods are detailed and transparent. The findings have implications for clinical practice to support patients’ recovery after total hip arthroplasty. The study is strengthened by use of a theoretical concept and inclusion of participants external to the cohort study. Figure 1 is an excellent diagram that helps the reader understand the flow of the study procedures. The discussion has been significantly enhanced in this version of the manuscript. Additionally, the authors engage in thoughtful reflection on whether adherence to rehabilitation exercise is necessary if people have returned to everyday life. Degree of data availability is appropriate given the study design. I have a few questions and suggestions to further improve the clarity of reporting and richness of the findings. Thank you for the thorough review and highly valuable comments, improving the quality of the manuscript Patient perspectives on home-based rehabilitation exercise and general physical activity after total hip arthroplasty: A qualitative study (PHETHAS-2). Please find listed below the reviewer comments, our responses and subsequent actions taken to improve the manuscript. We find that working with your comments greatly improved the manuscript and we hope you will find that the revisions address the concerns and issues raised in the review. The study findings showed that returning to habitual everyday life was a common goal for patients rehabilitating after THA. Thereby, habitual everyday life became a crucial mental driving force during the rehabilitation period and served as a facilitator for performing the home-based rehabilitation exercise, which was perceived as a means to achieve their goal. Attention should be paid towards each patient's facilitators and barriers for home-based rehabilitation exercise, and it seems especially important to identify each individual's preferred activities in their habitual everyday life when planning and setting relevant goals for the rehabilitation period. Competing Interests: No competing interests were disclosed. This article addresses patients’ perspectives on home-based rehabilitation exercises following total hip arthroplasty (THA). The topic is investigated through a qualitative method using semi-structured interviews. Data were analysed using thematic analysis. The study found the theme: 'wishing to return to the well-known everyday life', and the subtheme 'general physical activity versus rehabilitation exercise'. The topic of the paper is interesting and overall the paper is well-written; however, there are a number of issues throughout the paper.