Rehabilitation interventions to modify physical frailty in adults before lung transplantation: A systematic review protocol
Authors: McGarrigle Laura , Norman Gill , Hurst Helen , Todd Chris 
Published: August 2023

ABSTRACTIntroductionLung transplantation is the gold standard treatment for end-stage lung disease for a small group of patients meeting strict acceptance criteria after optimal medical management has failed. Physical frailty is prevalent in lung transplant candidates and has been linked to worse outcomes both on the waiting list and postoperatively. Exercise has been proven to be beneficial in optimising exercise capacity and quality of life in lung transplant candidates but its impact on physical frailty is unknown. This review aims to assess the effectiveness of exercise interventions in modifying physical frailty for adults awaiting lung transplantation.Methods and AnalysisThis protocol was prospectively registered on the PROSPERO database. We will search 4 databases plus trials registries to identify primary studies including adult candidates for lung transplantation undertaking exercise interventions and assessing outcomes pertaining to physical frailty. Studies must include at least ten participants. Article screening will be performed by two researchers independently at each stage. Extraction will be performed by one reviewer and checked by a second. The risk of bias in studies will be assessed by two independent reviewers using tools appropriate for the research design of each study; where appropriate we will use Cochrane risk of bias 2 or ROBINS-I. At each stage of the review process discrepancies will be resolved through consensus or consultation with a third reviewer. Meta-analyses of frailty outcomes, will be performed if possible and appropriate as will pre-specified subgroup and sensitivity analyses. Where we are unable to perform meta-analysis we will conduct narrative synthesis following SWiM guidance. The review will be reported using the PRISMA Checklist.Ethics and DisseminationNo ethical issues are predicted due to the nature of this study. Dissemination will occur via conference abstracts, professional networks, peer reviewed journals and patient support groups.Registration DetailsPROSPERO registration number CRD42022363730.Strengths and Limitations of this studyRigorous systematic review methods at all stages of the review combined with clinical expertise will allow us to produce a reliable first synthesis of the evidence for the effectiveness of rehabilitation in lung transplant candidates for physical frailty.A comprehensive search for relevant studies from multiple databases and other sources will allow us to identify relevant studies wherever published. The exclusion of non-English language studies is a limitation of this study but we will list these studies where we identify them.We will search for literature pertaining to “lung transplant candidates”, those on the “waiting list” or people “being assessed for lung transplant”. We have developed our search in consultation with an information specialist and it is likely to identify all studies where lung transplant candidates are a substantial proportion of the patient group. However it is not feasible to review every study of individuals with chronic lung disease, particularly where data are unstratified by disease severity or where the authors do not identify transplant candidates. It is therefore possible that we may miss some studies with some relevant data but this is unlikely to substantively impact the review outcomes.Using outcomes as a key criterion for inclusion risks missing some relevant studies due to the potential for reporting bias. To mitigate this, we will attempt to contact authors of all otherwise relevant studies to establish if any further outcomes were assessed but not reported and, where possible, obtain relevant data.