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BMC Musculoskeletal Disorders

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01-12-2022 | Knee Osteoarthritis | Research

Patients’ and clinicians’ experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

Authors: J. Knoop, J. W. de Joode, H. Brandt, J. Dekker, R. W. J. G. Ostelo

Published in: BMC Musculoskeletal Disorders | Issue 1/2022

Abstract

Background

We have developed a model of stratified exercise therapy that distinguishes three knee osteoarthritis (OA) subgroups (‘high muscle strength subgroup’, ‘low muscle strength subgroup’, ‘obesity subgroup’), which are provided subgroup-specific exercise therapy (supplemented by a dietary intervention for the ‘obesity subgroup’). In a large clinical trial, this intervention was found to be no more effective than usual exercise therapy. The present qualitative study aimed to explore experiences from users of this intervention, in order to identify possible improvements.

Methods

Qualitative research design embedded within a cluster randomized controlled trial in a primary care setting. A random sample from the experimental arm (i.e., 15 patients, 11 physiotherapists and 5 dieticians) was interviewed on their experiences with receiving or applying the intervention. Qualitative data from these semi-structured interviews were thematically analysed.

Results

We identified four themes: one theme regarding the positive experiences with the intervention and three themes regarding perceived barriers. Although users from all 3 perspectives (patients, physiotherapists and dieticians) generally perceived the intervention as having added value, we also identified several barriers, especially for the ‘obesity subgroup’. In this ‘obesity subgroup’, physiotherapists perceived obesity as difficult to address, dieticians reported that more consultations are needed to reach sustainable weight loss and both physiotherapists and dieticians reported a lack of interprofessional collaboration. In the ‘high muscle strength subgroup’, the low number of supervised sessions was perceived as a barrier by some patients and physiotherapists, but as a facilitator by others. A final theme addressed barriers to knee OA treatment in general, with lack of motivation as the most prominent of these.

Conclusion

Our qualitative study revealed a number of barriers to effective application of the stratified exercise therapy, especially for the ‘obesity subgroup’. Based on these barriers, the intervention and its implementation could possibly be improved. Moreover, these barriers are likely to account at least partly for the lack of superiority over usual exercise therapy.

Trial registration

The Netherlands National Trial Register (NTR): NL7463 (date of registration: 8 January 2019).

Available only for authorised users

Bijlsma JW, Berenbaum F, Lafeber FP. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011;377:2115–26. https://doi.org/10.1016/S0140-6736(11)60243-2.CrossRefPubMed

Felson DT. Identifying different osteoarthritis phenotypes through epidemiology. Osteoarthritis Cartilage. 2010;18:601–4. https://doi.org/10.1016/j.joca.2010.01.007.CrossRefPubMedPubMedCentral

Hay E, Dziedzic K, Foster N, Peat G, van der Windt D, Bartlam B, et al. Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials. Southampton (UK): NIHR Journals Library; 2018. PMID: 30048076.

Knoop J, van der Leeden M, Thorstensson CA, Roorda LD, Lems WF, Knol DL, et al. Identification of phenotypes with different clinical outcomes in knee osteoarthritis: data from the Osteoarthritis Initiative. Arthritis Care Res (Hoboken). 2011;63:1535–42. https://doi.org/10.1002/acr.20571.CrossRef

van der Esch M, Knoop J, van der Leeden M, Roorda LD, Lems WF, Knol DL, et al. Clinical phenotypes in patients with knee osteoarthritis: a study in the Amsterdam osteoarthritis cohort. Osteoarthritis Cartilage. 2015;23:544–9. https://doi.org/10.1016/j.joca.2015.01.006.CrossRefPubMed

Knoop J, Dekker J, van der Leeden M, de Rooij M, Peter WFH, van Bodegom-Vos L, et al. Stratified exercise therapy compared with usual care by physical therapists in patients with knee osteoarthritis: a randomized controlled trial protocol (OCTOPuS study). Physiother Res Int. 2019;28:e1819. https://doi.org/10.1002/pri.1819.CrossRef

Fransen M, McConnell S, Harmer AR, van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376. https://doi.org/10.1002/14651858.CD004376.pub3.CrossRefPubMed

Knoop J, van der Leeden M, van der Esch M, de Rooij M, Peter WF, Bennell KL, et al. Is a model of stratified exercise therapy by physical therapists in primary care feasible in patients with knee osteoarthritis? A mixed methods study. Physiotherapy. 2019. pii: S0031–9406(19)30033–1. https://doi.org/10.1016/j.physio.2019.01.013.

Knoop J, Dekker J, van Dongen JM, van der Leeden M, de Rooij M, Peter WFH, et al. No Added Value of Stratified Exercise Therapy compared to Usual Exercise Therapy in Patients with Knee Osteoarthritis: a Cluster Randomized Controlled Trial (OCTOPuSstudy); accepted for publication in Journal of Physiotherapy.

10.

Knoop J, Esser J, Dekker J, de Joode JW, Ostelo RWJG, van Dongen JM. Cost-Effectiveness of Stratified Exercise Therapy compared to Usual Exercise Therapy in Patients with Knee Osteoarthritis: Economic Evaluation alongside Cluster Randomized Controlled Trial. Under review.

11.

Green J, Thorogood N. Qualitative methods for health research. 4th Revised edition. London: Sage Publications Ltd; 2018.

12.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89:1245–51. https://doi.org/10.1097/ACM.0000000000000388 PMID: 24979285.CrossRefPubMed

13.

Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and therapeutic criteria committee of the American rheumatism association. Arthritis Rheum. 1986;29:1039–49.CrossRef

14.

Foster NE, Mullis R, Hill JC, Lewis M, Whitehurst DG, Doyle C, IMPaCT Back Study team, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med. 2014;12(2):102–11. https://doi.org/10.1370/afm.1625.CrossRefPubMedPubMedCentral

15.

Cherkin D, Balderson B, Wellman R, Hsu C, Sherman KJ, Evers SC, et al. Effect of low back pain risk-stratification strategy on patient outcomes and care processes: the MATCH randomized trial in primary care. J Gen Intern Med. 2018;33(8):1324–36. https://doi.org/10.1007/s11606-018-4468-9 Epub 2018 May 22. PMID: 29790073; PMCID: PMC6082187.CrossRefPubMedPubMedCentral

16.

Foster NE, Konstantinou K, Lewis M, Ogollah R, Saunders B, Kigozi J, et al. Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT. Health Technol Assess. 2020;24(49):1–130. https://doi.org/10.3310/hta24490.PMID:33043881;PMCID:PMC7681342.CrossRefPubMedPubMedCentral

17.

Delitto A, Patterson CG, Stevans JM, Freburger JK, Khoja SS, Schneider MJ, et al. Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial. EClinicalMedicine. 2021;34:100795. doi: https://doi.org/10.1016/j.eclinm.2021.100795. PMID: 33870150; PMCID: PMC8040279.

18.

Morsø L, Olsen Rose K, Schiøttz-Christensen B, Sowden G, Søndergaard J, Christiansen DH. Effectiveness of stratified treatment for back pain in Danish primary care: a randomized controlled trial. Eur J Pain. 2021;25(9):2020–38. https://doi.org/10.1002/ejp.1818 Epub 2021 Jul 2. PMID: 34101953; PMCID: PMC8518659.CrossRefPubMedPubMedCentral

19.

Lawford BJ, Delany C, Bennell KL, Bills C, Gale J, Hinman RS. Training physical therapists in person-centered practice for people with osteoarthritis: a qualitative case study. Arthritis Care Res (Hoboken). 2018;70:558–70. https://doi.org/10.1002/acr.23314 Epub 2018 Feb 26 PMID: 28686802.CrossRef

20.

Moore AJ, Holden MA, Foster NE, Jinks C. Therapeutic alliance facilitates adherence to physiotherapy-led exercise and physical activity for older adults with knee pain: a longitudinal qualitative study. J Physiother. 2020;66(1):45–53. https://doi.org/10.1016/j.jphys.2019.11.004 Epub 2019 Dec 13 PMID: 31843425.CrossRefPubMed

21.

Greenhalgh T, Howick J, Maskrey N, Evidence Based Medicine Renaissance Group. Evidence based medicine: a movement in crisis? BMJ. 2014;348:3725. https://doi.org/10.1136/bmj.g3725 PMID: 24927763; PMCID: PMC4056639.CrossRef

22.

Pisters MF, Veenhof C, van Meeteren NL, Ostelo RW, de Bakker DH, Schellevis FG, et al. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review. Arthritis Rheum. 2007;15(57):1245–53. https://doi.org/10.1002/art.23009 PMID: 17907210.CrossRef

23.

Nicolson PJA, Bennell KL, Dobson FL, Van Ginckel A, Holden MA, Hinman RS. Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis. Br J Sports Med. 2017;51:791–9. https://doi.org/10.1136/bjsports-2016-096458 Epub 2017 Jan 13 PMID: 28087567.CrossRefPubMed

24.

Bennell KL, Kyriakides M, Hodges PW, Hinman RS. Effects of two physiotherapy booster sessions on outcomes with home exercise in people with knee osteoarthritis: a randomized controlled trial. Arthritis Care Res (Hoboken). 2014;66:1680–7. https://doi.org/10.1002/acr.22350 PMID: 24757032.CrossRef

25.

Fitzgerald GK, Fritz JM, Childs JD, Brennan GP, Talisa V, Gil AB, et al. Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: a multi-center, factorial randomized clinical trial. Osteoarthritis Cartilage. 2016;24:1340–9. https://doi.org/10.1016/j.joca.2016.03.001 Epub 2016 Mar 10 PMID: 26973326.CrossRefPubMed

26.

Quicke JG, Holden MA, Bennell KL, Allison K. Where to from here? Is there a role for physical therapists in enacting evidence-based guidelines for weight loss in adults with osteoarthritis who are overweight? Phys Ther. 2020;23(100):3–7. https://doi.org/10.1093/ptj/pzz135 PMID: 31596467.CrossRef

27.

Allison K, Delany C, Setchell J, Egerton T, Holden M, Quicke J, et al. A qualitative study exploring the views of individuals with knee osteoarthritis on the role of physiotherapists in weight management: A complex issue requiring a sophisticated skill set. Musculoskeletal Care. 2019;17:206–14. https://doi.org/10.1002/msc.1391 Epub 2019 Mar 1 PMID: 30821904.CrossRefPubMed

28.

Tang CY, Pile R, Croft A, Watson NJ. Exploring physical therapist adherence to clinical guidelines when treating patients with knee osteoarthritis in Australia: a mixed methods study. Phys Ther. 2020;19(100):1084–93. https://doi.org/10.1093/ptj/pzaa049 PMID: 32239158.CrossRef

29.

Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019;27(393):1745–59. https://doi.org/10.1016/S0140-6736(19)30417-9 PMID: 31034380.CrossRef

30.

Wiertsema SH, van Dongen JM, Geleijn E, Beckerman H, Bloemers FW, Ostelo RWJG, et al. The Transmural Trauma Care Model (TTCM) for the rehabilitation of trauma patients is effective in improving patient related outcome measures: a non-randomized controlled trial. BMC Health Serv Res. 2019;8(19):819. https://doi.org/10.1186/s12913-019-4547-6.PMID:31703670;PMCID:PMC6842249.CrossRef

31.

de Rooij M, van der Leeden M, Cheung J, van der Esch M, Häkkinen A, Haverkamp D, et al. Efficacy of tailored exercise therapy on physical functioning in patients with knee osteoarthritis and comorbidity: a randomized controlled trial. Arthritis Care Res (Hoboken). 2017;69(6):807–16. https://doi.org/10.1002/acr.23013.CrossRef

32.

Briggs AM, Hinman RS, Darlow B, Bennell KL, Leech M, Pizzari T, et al. Confidence and attitudes toward osteoarthritis care among the current and emerging health workforce: a multinational interprofessional study. ACR Open Rheumatol. 2019;22(1):219–35. https://doi.org/10.1002/acr2.1032.PMID:31777798;PMCID:PMC6857979.CrossRef

33.

Leemrijse CJ, Barten JA, Kooijman MK, Verberne LDM, Veenhof C, Swinkels ICS. Omvang en kenmerken fysiotherapeutische zorg bij patiënten met artrose. NIVEL. 2016:24-31. https://www.nivel.nl/nl/publicatie/jaarcijfers-2012-en-trendcijfers-2008-2012-fysiotherapie.

34.

Nelligan RK, Hinman RS, Teo PL, Bennell KL. Exploring attitudes and experiences of people with knee osteoarthritis toward a self-directed ehealth intervention to support exercise: qualitative study. JMIR Rehabil Assist Technol. 2020;26(7):e18860. https://doi.org/10.2196/18860.PMID:33242021;PMCID:PMC7728537.CrossRef

35.

Cronström A, Dahlberg LE, Nero H, Ericson J, Hammarlund CS. “I would never have done it if it hadn’t been digital”: a qualitative study on patients’ experiences of a digital management programme for hip and knee osteoarthritis in Sweden. BMJ Open. 2019;24(9):e028388. https://doi.org/10.1136/bmjopen-2018-028388.PMID:31129601;PMCID:PMC6537991.CrossRef

36.

Hinman RS, Nelligan RK, Bennell KL, Delany C. “Sounds a Bit Crazy, But It Was Almost More Personal:” a qualitative study of patient and clinician experiences of physical therapist-prescribed exercise for knee osteoarthritis via skype. Arthritis Care Res (Hoboken). 2017;69:1834–44. https://doi.org/10.1002/acr.23218 Epub 2017 Nov 2 PMID: 28217864.CrossRef

37.

Lawford BJ, Delany C, Bennell KL, Hinman RS. “I was really skeptical…But it worked really well”: a qualitative study of patient perceptions of telephone-delivered exercise therapy by physiotherapists for people with knee osteoarthritis. Osteoarthritis Cartilage. 2018;26:741–50. https://doi.org/10.1016/j.joca.2018.02.909 Epub 2018 Mar 20. PMID: 29572130.CrossRefPubMed

38.

Kloek CJJ, Bossen D, Spreeuwenberg PM, Dekker J, de Bakker DH, Veenhof C. Effectiveness of a blended physical therapist intervention in people with hip osteoarthritis, knee osteoarthritis, or both: a cluster-randomized controlled trial. Phys Ther. 2018;1(98):560–70. https://doi.org/10.1093/ptj/pzy045.PMID:29788253;PMCID:PMC6016690.CrossRef

39.

Bennell KL, Nelligan R, Dobson F, Rini C, Keefe F, Kasza J, et al. Effectiveness of an internet-delivered exercise and pain-coping skills training intervention for persons with chronic knee pain: a randomized trial. Ann Intern Med. 2017;4(166):453–62. https://doi.org/10.7326/M16-1714 Epub 2017 Feb 21 PMID: 28241215.CrossRef

Title: Patients’ and clinicians’ experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study
Authors: J. Knoop
J. W. de Joode
H. Brandt
J. Dekker
R. W. J. G. Ostelo
Publication date: 01-12-2022
Publisher: BioMed Central
Keywords: Knee Osteoarthritis
Osteoarthrosis
Obesity
Obesity
Exercise Therapy
Osteoarthrosis
Care
Exercise Therapy
Knee Osteoarthritis
Published in: BMC Musculoskeletal Disorders / Issue 1/2022
Electronic ISSN: 1471-2474
DOI: https://doi.org/10.1186/s12891-022-05496-2

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Patients’ and clinicians’ experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

Abstract

Background

Methods

Results

Conclusion

Trial registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Trial registration

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