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Rehabilitation medicine
Protocol
Evaluations of virtual exercise programmes for adults with mobility limitations: a scoping review protocol incorporating an equity lens to inform the development of strategies to optimise participation of under-represented groups
  1. Renato Barbosa dos Santos1,
  2. Jing Lin1,2,
  3. Anchal Badwal2,
  4. Hardeep Singh3,4,
  5. Susan Brenda Jaglal1,2,4,
  6. Christina Sperling5,
  7. Nancy Margaret Salbach1,2,4
  1. 1Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
  2. 2Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
  3. 3Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
  4. 4KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
  5. 5March of Dimes Canada, Toronto, Ontario, Canada
  1. Correspondence to Renato Barbosa dos Santos; renatob.santos{at}utoronto.ca

Abstract

Introduction For individuals with mobility limitations, virtual exercise programmes can address the challenges of in-person participation in community exercise programmes. A synthesis of studies of virtual exercise programmes targeting mobility limitations provided outside of conventional rehabilitation services and strategies used to optimise equitable access and inclusivity in these programmes is lacking. We aim to characterise evaluations of virtual exercise programmes for adults with mobility limitations, and the nature of and extent to which equity, diversity and inclusion considerations are integrated in the research process.

Methods and analysis A scoping review following a six-stage methodological framework, including a consultation exercise, is proposed. A comprehensive strategy will be used to search Medline, Embase, PEDro, CINAHL and Scopus to identify peer-reviewed studies evaluating virtual exercise programmes for adults with mobility limitations living in the community. Three trained reviewers will select studies independently. Data (eg, study methodology, programme structure and content, participant characteristics) will be extracted using a standardised form, and collated and summarised using quantitative and qualitative methods. The PROGRESS-Plus and International Classification of Functioning, Disability and Health frameworks will be used to classify participant characteristics and study outcomes, respectively. During the consultation exercise, key knowledge users, including exercise participants, programme providers and coordinators, and members of community organisations for persons living with disabilities and under-represented groups, will be asked to provide insights regarding the applicability of review findings. A directed content analysis of data from the consultation exercise will be performed.

Ethics and dissemination The research ethics board at the University of Toronto approved the consultation exercise. Findings will be disseminated through peer-reviewed publications and conference presentations. Findings will enhance understanding of current research evaluating virtual exercise programmes and inform future research and strategies for promoting equitable access and outcomes for individuals with mobility limitations.

  • telemedicine
  • health equity
  • health services for the aged
  • neurology
  • physical therapy modalities
  • rehabilitation medicine
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2023-077961

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This protocol outlines a rigorous design that includes use of an established scoping review methodology, a comprehensive search strategy developed in consultation with an information specialist and a study selection and data charting process that adheres with methodological recommendations.

    • This review is strengthened by having input from a research team of authors with diverse backgrounds and characteristics, including ethnicity, language, gender and education. This diversity will contribute to a broader perspective during data analysis and interpretation.

    • The analysis approach will be guided by theoretical frameworks, such as the PROGRESS-Plus and International Classification of Functioning, Disability and Health frameworks, to ensure that findings are comprehensive.

    • Consulting with key knowledge users, including exercise participants, programme providers and coordinators, and organisations that support people with disabilities, will help identify gaps in the literature, further validate and disseminate the findings.

    • The review will only include peer-reviewed published literature, which limits the comprehensiveness of our findings.

    Introduction

    Globally, approximately 1.3 billion people experience disabilities,1 including mobility limitations, defined as difficulties in changing or maintaining body position, walking or moving around.2 Mobility limitations can be caused by chronic conditions such as stroke,3 osteoarthritis,4 multiple sclerosis,5 Parkinson’s disease6 or spinal cord injury.7 A variety of factors, including place of residence, race, gender/sex, socioeconomic status and age, can impact individuals’ experiences of mobility limitations.1 For instance, among individuals aged 65 years or above, a higher proportion of women report having mobility limitations than men.8 Racialised groups also experience disparities, as black people who have had a stroke are more likely to report requiring assistance with moving around the house and with shopping than white people who have had a stroke.9

    Benefits and challenges of in-person exercise programmes for people with mobility limitations

    Exercise programmes offered outside traditional healthcare settings (eg, gyms, community or leisure centres) have the potential to reduce mobility limitations.10–16 Task-oriented group-based programmes that focus on functional activities, such as sit to stand, stepping and walking, have shown potential in improving balance, walking capacity and overall mobility for people with conditions such as stroke,17 18 hip and knee osteoarthritis19 and multiple sclerosis.20 Several challenges, however, hinder participation in in-person exercise programmes. Personal barriers, such as fear of adverse events or infection, lack of motivation or time, along with environmental barriers such as transportation limitations, inadequate building or equipment access, inclement weather and the recent impact of pandemic-related programme closures, make it challenging to engage in centre-based exercise programmes.21–24 Additionally, for caregivers, the need to provide supervision or transportation can increase caregiving time, reducing available time for paid employment.25

    The role of virtual exercise programmes for people with mobility limitations

    Virtual exercise programmes can overcome personal and environmental barriers associated with in-person programmes.26 The effects of telerehabilitation services on everyday activities and mobility outcomes (including balance and gait) appear similar to the effects of in-person or usual care in people post-stroke27 and with multiple sclerosis.28 Delivery of exercise programmes may be completely remote, a hybrid model (a combination of virtual and in-person sessions), with synchronous (ie, a real-time approach),29 30 asynchronous (ie, no real-time interaction) format31 32 or a combination of synchronous and asynchronous activities (ie, participants completing some classes on their own).33 Researchers have used a variety of technology platforms for exercise delivery, including bidirectional technology (eg, Zoom),29 30 or pre-recorded videos31 34 accessed by participants via email, phone31 34 or a website.32

    Equity, diversity and inclusion (EDI) considerations in virtual exercise programmes for people with mobility limitations

    Although the use of technology is promising to provide equitable health services, people with disabilities face challenges accessing and using virtual services.35 These challenges stem from the lack of age and disability-appropriate technology and the failure to account for sociocultural diversity within communities.35 For example, language barriers can limit access to exercise programme information and resources, and communication with exercise participants may not include consideration of cultural beliefs.36 Hence, it is crucial to integrate EDI considerations into the design and implementation of clinical trials. Equity refers to the removal of systemic barriers and biases, enabling all individuals to have equal access to and to benefit from any aspect of society, accounting for everyone’s different and unique identities, lived experiences and backgrounds, and reflectively allocates for resources needed to reach an equal outcome.37 Diversity refers to individuals’ (eg, exercise participants and providers) differences in race, place of origin, religion, immigrant and newcomer status, ethnic origin, ability, sex, sexual orientation, gender identity, gender expression, age and other aspects of identity.37 Inclusion is the practice of creating an environment that ensures the all individuals are treated equitably, have access to the same opportunities and feel welcome and respected. Inclusion means actively fostering conditions in which everyone can fully participate and maximise their creativity and contributions without bias or discrimination.37

    Several guidelines have been developed to help researchers integrate EDI considerations into their research.38–42 In addition, the PROGRESS-Plus framework43 has been used to examine equity in exercise-based interventions for adults with rheumatoid arthritis,44 in rehabilitation interventions after hip fracture45 and in primary-care-based physical activity interventions.46 The framework can be used to examine equity-related variables, health opportunities and health outcomes of study populations.38 43 PROGRESS-Plus outlines factors, such as race/ethnicity, gender/sex and socioeconomic status, which are understood to influence health opportunities, including participation in physical activity.43 47–50

    A literature review on virtually delivered exercise programmes51 synthesised findings from seven studies of remotely supervised telehealth interventions involving activities undertaken in weight-bearing or standing positions, including 179 people who had a stroke. In this review, most studies specified a minimum mobility requirement for participation, and high-speed internet, in-person training regarding the telehealth system, telehealth support from a healthcare professional or technician via phone or in person, and caregiver assistance, as strategies to overcome technological barriers. This scoping review, however, was limited to interventions supervised by a health professional for people after stroke. Also, studies included in the review were conducted prior to the start of the COVID-19 pandemic, after which the use of technology to deliver exercise programmes has expanded rapidly.52 Additionally, the scoping review did not include a consultation exercise with key knowledge users, for example, persons living with disabilities from under-represented groups such as racialised and LGBTQIA2S+ (ie, lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, asexual and two-spirit) communities, to provide insights on the applicability of review findings. Thus, our understanding of the extent and nature of exercise programmes virtually delivered for adults with mobility limitations, including the EDI-related considerations implemented in the design and conduct of these programmes, is limited.

    To date, previous reviews have assessed the effects, feasibility or safety of interventions, including exercise, virtually delivered to people who had a stroke,27 51 53–56 multiple sclerosis,28 Parkinson’s disease57 and knee osteoarthritis.58 59 To our knowledge, a synthesis of evaluations of virtual exercise programmes targeting mobility limitations provided outside of conventional healthcare or rehabilitation services has not been completed. Previous reviews did not apply an equity lens to describe how researchers embedded EDI principles into the design and conduct of virtual exercise programmes for adults with mobility limitations. Thus, the overarching aim of this study is to characterise evaluations of virtual exercise programmes for adults with mobility limitations, and the nature of and extent to which EDI considerations are integrated in the research process

    Methods and analysis

    Protocol and registration

    We will conduct a scoping review that follows the six-stage methodological framework by Arksey and O’Malley60 and Levac et al61: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting the results and (6) consultation. We have chosen scoping review methodology as it enables mapping the research evidence and identifying gaps in the current literature while providing a source of knowledge translation.60 61 Additionally, our consultation exercise will empower knowledge users to provide insights beyond those in the literature, meaning and applicability of the review findings. In the absence of a guideline for a scoping review protocol,62 this protocol was drafted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews63 and is registered on Open Science Framework.64 We began this review in June 2023 and anticipate completion of the consultation phase by May 2024.

    Patient and public involvement

    Knowledge users

    The scoping review protocol was developed with input from directors of two national organisations that support people with disabilities (ie, March of Dimes Canada and Heart and Stroke Foundation of Canada) and one person who had a stroke. These individuals have made contributions to the development of the review protocol and will be involved with the interpretation and dissemination phases of this study.

    Positionality

    Our research team is comprised of individuals diverse in place of residence/origin (eg, newcomers, immigrants and non-immigrants to Canada), race and ethnicity (ie, white and members of racialised groups), language (eg, non-native English speakers), occupations/positions (ie, undergraduate and graduate students, researchers), genders (ie, men and women), education (ie, MSc, PhD), socioeconomic status, social capital, age and sexual orientation.

    Stage 1: identifying the research questions

    The overarching question is: What are the characteristics of evaluations of virtual exercise programmes for adults with mobility limitations, and what is the nature of and extent to which EDI considerations are integrated into the research process?

    Specific objectives are:

    1. To describe the structure, content, mode of delivery, effects of the interventions by study outcome and characteristics of programme providers in virtual exercise programmes for adults with mobility limitations.

    2. To characterise the study methodology (eg, study design, recruitment strategies, eligibility criteria, study outcomes and outcome measures).

    3. To describe the characteristics of participants using an equity lens, including the reasons for participant withdrawal, and EDI considerations reported within each stage of the research process (eg, research questions, design of the study, methodology and data collection, analysis and interpretations).

    4. To identify gaps in evaluations of virtual exercise programmes for adults with mobility limitations with respect to methodological strategies for optimising participation of members of under-represented groups.

    Stage 2: identifying relevant studies

    Search

    We will identify peer-reviewed literature using a search strategy developed through an iterative process in collaboration with an Information Specialist and Health Science librarian. The terms used were informed by the search filter developed by the Canadian Agency for Drugs and Technologies in Health65 and other relevant reviews.66 67 The search included subject headings and text words related to the following concepts: adults with mobility limitations, exercise programmes and telehealth. The OVID Medline search conducted on 07 June 2023 is available in online supplemental file 1. For comprehensiveness, no date, language or design limitations were imposed.

    Information sources

    The search strategy was created and finalised in OVID Medline and then translated to OVID Embase, Physiotherapy Evidence Database, CINAHL and Scopus. We have chosen these information sources in consultation with an Information Specialist and Health Science librarian, and deemed them appropriate to achieve the review objectives. We will not search for grey literature (eg, conference abstracts, books and trial registers) due to possible data incompleteness. We will supplement our research by hand-searching the reference lists of included articles, relevant systematic and scoping reviews and consult with experts in the field60 to identify studies that may have been missed in the above search strategies. Following the search, we will export all identified records to EndNote68 to remove duplicates following a systematic method.69 After removing duplicates, the unique records will be uploaded to Covidence70 for study selection.

    Stage 3: study selection

    Inclusion criteria

    Peer-reviewed studies meeting the following inclusion criteria (organised according to the Population, Context and Concept framework)71 will be included in the review.

    Population

    • The study includes adults (age ≥18 years) living in the community.

    • The study sample is composed of (at least 75%) people with health conditions associated with mobility limitations (eg, stroke, osteoarthritis, Parkinson’s disease, frailty, multiple sclerosis, cancer, cerebral palsy and lower extremity amputation).

    Context and concept

    • The study objective is to evaluate virtual exercise programmes, defined as a planned, structured, repetitive physical activity (eg, aerobic, balance, flexibility, strength, or task-oriented training),72 lasting longer than one session, and delivered (at least 50%) using bidirectional technology (eg, live interaction with programme facilitators or other participants) with participants exercising in their homes.

    • The exercise programme must target some aspect of mobility, defined as tasks or activities involving changing or maintaining body position (ie, static and dynamic balance), walking or moving around.2

    Types of study designs

    • The study design is a randomised or non-randomised trial, or a before and after single group study, including quantitative, qualitative or multiple methods of data collection.

    Exclusion criteria

    Studies will be excluded from the review if they meet one of the following exclusion criteria:

    • The study includes adults from long-term care or assisted living settings, as the review focuses on non-institutionalised adults.

    • Authors describe the exercise programme as rehabilitation or therapy, as the review focuses on exercise programmes provided outside of traditional healthcare settings and available through community or recreation centres.

    • The intervention is limited to prescribing or recommending the practice of exercise and/or physical activity, as the review focuses on planned, structured, repetitive physical activity.

    • The exercise programme is primarily aimed at improving arm activity, due to the review focus on exercise programmes focusing on mobility.

    • If an interaction between participants and programme facilitators only happens for data collection for research evaluation purposes.

    • The study is published only as an abstract, conference abstract, letter or protocol, due to possible data inaccuracy and incompleteness.

    • The study is a systematic or scoping review, due to the review focus on primary studies.

    • The study only reports qualitative data not linked to an experimental study (eg, randomised or non-randomised trial, before and after single group studies).

    Selection of sources of evidence

    To ensure systematic and reproducible study selection, the reviewers (RBdS, JL and AB) will start with a calibration exercise that involves reviewing the same subset of a random sample of abstracts (n=50) and full-text (n=10) articles.

    Level 1 screening

    We will develop an initial screening form and guide based on guidelines73 for title and abstract screening. The reviewers (RBdS, JL and AB) will pilot the form and guide on 50 records, including studies that are definitely eligible, potentially eligible and definitely ineligible. Reviewers (RBdS, JL and AB) will then meet and discuss any conflicts and clarify the eligibility criteria with the goal of achieving 80% agreement among reviewers.63 Adjustments will be made to the initial screening form and guide if needed. Reviewers will then proceed with screening the title and abstract in duplicate.

    Level 2 screening

    Similar to the previous stage, the reviewers (RBdS, JL and AB) will first pilot the full-text screening form on 10 articles to ensure 80% consensus.63 Again, reviewers (RBdS, JL and AB) will meet and discuss any conflicts and clarify the discrepancies with necessary adjustments made to the full-text screening form and guide. Reviewers will then proceed with full-text review in duplicate.

    As recommended for rigorous evidence syntheses,74 throughout level 1 and 2 screening, reviewers (RBdS, JL and AB) will meet regularly to discuss and resolve any discrepancies, update the review forms and guides and consult with a third reviewer (NMS) if necessary.

    Stage 4: charting the data

    Data charting process

    Following best practices recommendations,74 the reviewers (RBdS, JL and AB) will develop a data charting guide and form and pilot the data charting process on 5% of included articles to optimise accuracy. Once piloting is complete, data charting will be conducted in duplicate (RBdS, JL and AB) using Covidence.70 Throughout the data charting process, we will use Google Translate for abstracting data from non-English-language studies75 and contact corresponding authors to confirm unclear information relevant to the review.

    Data items

    Information charted from the included articles will comprise:

    Characteristics of the exercise programme, effects of interventions and characteristics of programme providers: modes of delivery (eg, completely remote methods or in a hybrid format), devices (eg, smartphone, tablet, laptop and desktop computer) used in the intervention, including those provided (eg, loaned or given) to participants; programme duration, programme frequency, session duration, programme aim (eg, improve balance, strength, etc), exercise components, language of delivery and whether any part is translated, whether caregivers can support person participating in programme, and cost. We will also chart sample size, and mean and SD of scores pre intervention and post intervention for each study outcome. Additionally, sociodemographic characteristics, qualifications and training of programme providers will be extracted verbatim.

    Study methodology: first author, year of publication, country where the study was conducted, study objectives, study design, terminology used to describe the intervention (eg, telehealth, e-health, telerehabilitation, virtual, remote), recruitment strategies, eligibility criteria for acceptance into the exercise programme, justification for exclusion criteria (when available), primary and secondary study outcomes, outcome measures, mode of administration of outcome measures (eg, in-person, remote or hybrid), timing of outcome assessment, collection of data (yes/no) on PROGRESS-Plus factors.43

    Characteristics of study participants and withdrawal, and integration of EDI considerations: sociodemographic characteristics including place of residence (rural/urban/inner city), race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital, personal characteristics associated with discrimination (eg, age, health condition) and time-dependent relationships (eg, time since diagnostic, time since discharged from hospital).43 In addition, we will extract reasons for participant withdrawal. We will chart verbatim information on the intentional use of EDI consideration in the design and conduct of the study (eg, research questions, design of the study, methodology and data collection, analysis and interpretations). We define intentional use as any instance in which the authors explicitly report the integration of EDI considerations (ie, any report by authors to address barriers and promote equal opportunities for participation in the study and create a more inclusive and equitable environment).37

    Stage 5: collating, summarising and reporting the results

    Data will be summarised descriptively, using frequencies and percentages for categorical data (eg, race and gender of participants); and mean, SD and minimum to maximum for data measured using a ratio scale (eg, age in years, sample size).

    Characteristics of the exercise programme, effects of interventions and characteristics of program providers

    We will summarise and report the mode of programme delivery (eg, completely remote methods or in a hybrid format), devices (eg, smartphone, tablet, laptop, desktop computer) used in the intervention, programme duration (in weeks), programme frequency (number of sessions per week), session duration (converted to minutes) and exercise components (eg, aerobic, balance, flexibility, strength or task-oriented training). We will calculate effect sizes for each primary outcome measure using Cohen’s d method76 to describe the effects of interventions. We will consider a small effect as d≥0.2, a medium effect as d≥0.5 and a large effect as d≥0.8.76 A forest plot will present the effect sizes and 95% CIs. Computations and plots will be conducted using RStudio (RStudio, PBC, Boston, USA). Table 1 lists the operational definitions for classifying the type of exercise and personnel delivering the exercise.

    View this table:
    Table 1

    Operational definitions to classify exercise components and personnel delivering the exercise

    Study methodology

    To characterise study outcomes, we will classify them using International Classification of Functioning, Disability and Health (ICF) terminology as (1) body structure and function or impairment; (2) activity or activity limitation; (3) participation or participation restriction; (4) personal factor and (5) environmental factor.2 Non-ICF outcomes, such as participant health-related quality of life, caregiver outcomes (eg, assistance, emotional health), cost, safety, feasibility and acceptability, will also be documented. Classification will be conducted by listing each outcome, the outcome measure used and ICF classification in a table using the ICF browser77 to verify the classification. Where classification is unclear, the measurement tool used for the specific outcome will be examined. The classification table will be verified for appropriateness by the coauthors, each with experience in using the ICF in research.

    Characteristics of study participants and withdrawal, and integration of EDI considerations

    We will classify eligibility criteria and characteristics of participants according to the PROGRESS-Plus.43 Classification will be conducted by mapping each eligibility criteria and characteristics of participants reported in the studies into a table containing the PROGRESS-Plus equity factors.43 The table will be verified for appropriateness by the coauthors. Once classification is completed, the frequency and percentage of studies reporting each PROGRESS-Plus equity factor will be calculated. Diversity of participants will be described as the proportion of diversity in ethnicity (eg, % of white, black or Asian), language, sex (eg, per cent of female or male) and gender identity, education level, socioeconomic status, age and health condition within each study.

    The Natural Sciences and Engineering Research Council of Canada (NSERC) guidance39 and other relevant literature40–42 will be used to inform the development of an appraisal checklist to describe the extent to which EDI considerations are explicitly reported in the design and conduct of the studies. In the analysis, one reviewer (RBdS) will appraise (yes/no) each stage of the studies (eg, research questions, study design, methodology and data collection, analysis and interpretations) as promoting EDI. Examples of EDI considerations include: Were members from the population/community of interest invited to help shape the objectives of the study? Was the programme delivered in different languages? Were exercise facilitators trained to work with diverse populations? EDI considerations will be categorised as intentional when authors provide a justification for their integration. Members of the research team will subsequently review and provide input on the appraisal. We will report the frequency of strategies across studies, the specific EDI strategies and justification, where provided by the authors.

    Stage 6: consultation exercise

    Gaps in current methodological strategies for optimising participation of members of under-represented groups

    A panel of knowledge users including two directors of organisations that support people with disabilities (ie, March of Dimes Canada and Heart and Stroke Foundation of Canada) has been formed for the scoping review. We will consult with panel members at different phases of the review process.

    In addition, we will conduct a consultation exercise with a group of exercise participants, programme providers and coordinators, members of community organisations for persons living with disabilities, racialised and LGBTQIA2S+ groups. The purpose of the consultation will be to identify considerations for optimising participation of members of under-represented groups, which may not have been captured in the current review findings and to maximise the knowledge translation of our findings by reaching relevant knowledge users.

    Individuals meeting the following inclusion criteria will be considered eligible for this consultation exercise: (1) programme providers and coordinators from community-based organisations that deliver community interventions, programmes or resources for persons living with disabilities, under-represented groups such as racialised and LGBTQIA2S+, or adults with self-reported balance and/or mobility limitations and (2) able to speak and read English to participate in the meeting.

    We will organise two 1.5-hour online focus groups, five participants per group, using Zoom. In the case of a schedule conflict, we will give individuals the option to participate in an interview instead. In advance of the meeting, we will email participants a summary of the review findings that will be discussed during the focus group. This approach will give participants the opportunity to read and prepare any questions or comments in advance. During the focus groups, a semistructured guide based on the preliminary review findings will be used. During the focus groups, RBdS and NMS will share the review findings with participants and explore participants’ views regarding aspects of the design and conduct of the studies and exercise programmes that may enable or prevent the participation of under-represented groups. The interview guide may be modified to further explore new ideas raised in the first focus group. Participants will be encouraged to participate in the discussion using the Zoom chat feature, if they wish, and forward any comments by email after the focus groups.

    The focus groups will be digitally recorded and transcribed verbatim. In the transcripts, the names of individuals will be replaced with pseudonyms. A conventional content analysis approach will be used.78 Two reviewers (RBdS and NMS) will independently code one transcript and meet to discuss and develop a coding scheme. One reviewer will then apply the coding scheme to the remaining transcripts using NVivo V.11.0 software and meet with the research team to review and cluster similar codes to identify emerging categories. Relationships between categories will be explored to identify themes. An audit trail will be maintained and quotes will be used to support themes. The research team will review and confirm the themes. In the final manuscript, we aim to provide a list of considerations for optimising participation of under-represented groups in studies evaluating virtual exercise programmes for adults with mobility limitations, highlighting the inputs and contributions derived from the consultation exercise.

    By engaging these individuals, we will be following scoping review best practices in which knowledge user involvement is encouraged to provide additional value to the study.60 79 In the final report, we aim to provide a list of considerations for optimising participation of under-represented groups in studies evaluating virtual exercise programmes for adults with mobility limitations, highlighting the inputs and contributions derived from the consultation exercise.

    Conclusion

    This scoping review protocol outlines a plan to characterise the extent, range and nature of evaluations of virtual exercise programmes for adults with mobility limitations, the effects of interventions and the nature of and extent to which EDI considerations are integrated in the research process. We also describe our plan to consult with community organisations for people living with disability to determine what considerations for optimising participation of members of under-represented groups are not captured in the current review findings. In doing so, the proposed research findings will guide subsequent development and evaluations of exercise programmes virtually delivered to adults with mobility limitations. Understanding how to improve the equitable design and access to virtually delivered exercise programmes is crucial for people with mobility limitations, particularly for under-represented groups commonly excluded from clinical trials.

    Ethics and dissemination

    The research ethics board at the University of Toronto has approved the consultation exercise (protocol number 45730). Individuals will be required to provide informed verbal consent to participate prior to participating in the consultation exercise. The findings of this review will be disseminated through peer-reviewed journal publications, presentations to relevant knowledge users (eg, programmes providers and coordinators) at conferences and meetings and integrated into the team’s future research.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    We gratefully acknowledge the contribution of Ms Katie Merriman, information specialist at the University of Toronto, for her invaluable advice in designing the search strategy.

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    Supplementary materials

    • Supplementary Data

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    Footnotes

    • Twitter @nancysalbach

    • Contributors All authors made significant intellectual contributions to the protocol. RBdS and NMS conceived the idea for the scoping review. RBdS conceptualised and drafted the research questions and study selection criteria, while NMS and HS contributed to their further development. RBdS developed the study methodology with JL, AB, CS, HS, SBJ and NMS providing feedback for refinement. All authors contributed to the drafting and editing and approved the final manuscript.

    • Funding RBdS is supported by the Physiotherapy Foundation of Canada through the Ann Collins Whitmore Memorial Scholarship. NMS holds the Toronto Rehabilitation Institute Chair at the University of Toronto.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods and analysis section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.