"I've been to physical therapy before, but not for the knees." A qualitative study exploring barriers and facilitators to physical therapy utilization for knee osteoarthritis

General practitioners experience multi-level barriers to implementing recommended care for hip and knee osteoarthritis: a qualitative study

BACKGROUND

General practitioners (GPs) play a key role in managing osteoarthritis, including referring to appropriate management services. Physiotherapist-led osteoarthritis management programs and advanced practice triage services are effective, but GPs views on them are largely unknown. This study aimed to explore general practitioner perspectives on: (1) managing patients with hip and knee osteoarthritis, and (2) physiotherapy-led osteoarthritis care and referral pathways.

METHODS

Interview topic guides were developed based on the theoretical domains framework. Twenty-five semi-structured interviews with GPs were conducted. All data were coded independently by at least two researchers and analysed inductively using thematic analysis, with barrier themes mapped to the socioecological model.

RESULTS

Two interrelated themes were identified: (i) GPs had good general knowledge of recommended osteoarthritis care, but (ii) they faced multi-level challenges facilitating or directly providing evidence-based care. Nearly all GPs identified exercise as first-line care and surgery as a last resort. Most were aware imaging was not required to diagnose osteoarthritis, yet reported often referring for imaging. Many GPs expressed challenges facilitating patient engagement in physiotherapy due to patient, environmental/social and system level barriers. Key barriers included: perceived patient expectations and lack of motivation to attend physiotherapy, a lack of knowledge of available physiotherapy services, a lack of affordable physiotherapy services, and lengthy waiting times for public orthopaedic appointments. Having private health insurance was perceived as an enabler.

CONCLUSIONS

Despite having good knowledge of guideline-recommended care, GPs in our study experienced multi-level barriers to implementing this care in practice. Public health information and strategies to address patient's beliefs and lack of motivation to exercise may help reduce barriers to engaging in appropriate care. Urgent health system funding reforms are needed to allow GPs to appropriately manage patients with hip and knee osteoarthritis.

Challenges in rehabilitation and continuum of care provision after knee replacement: a mixed-methods study from a low- and middle-income country

PURPOSE

Continuum-of-care is crucial following knee replacement. This is an understudied area in the context of low- and middle-income countries. We report findings of a mixed-methods study conducted to understand patient's postoperative experiences in following unsupervised home-based physiotherapy protocols and healthcare provider's experiences in providing rehabilitation care.

METHODS

Consecutive adults (n = 79) scheduled or had undergone knee replacement, attending an urban tertiary care hospital in India completed a 22-item questionnaire to gauge attitude towards physical rehabilitation. We conducted in-depth interviews with nine patients, ten physiotherapists, and three surgeons using a phenomenology approach. Data were interpreted using the capability, opportunity, and motivation-behaviour (COM-B) framework.

RESULTS

Patients were motivated to do exercises and valued family support during the recovery period. However, they desired physiotherapy support, especially during the early recovery period due to post-operative pain. Healthcare providers reported poor adherence with the exercise regimen and desired a mechanism to monitor patient progress after discharge. Patients and health care providers identified accessibility to rehabilitation centre as a major barrier in availing affordable and reliable physiotherapy services.

CONCLUSION

There is a need for a continuum of care to improve patient experience during recovery and for health care providers to monitor progress and provide personalised progressive exercise therapy.

Delayed timing of physical therapy initiation increases the risk of future opioid use in individuals with knee osteoarthritis: a real-world cohort study

OBJECTIVE

We assessed whether late versus early initiation of physical therapy (PT) was related to greater risk of future opioid use in people with knee osteoarthritis (OA) who receive PT.

METHODS

We used Commercial and Medicare Advantage claims data from 1999 to 2018 from American adults with incident knee OA referred for PT within 1 year of diagnosis. We categorised people as opioid naïve or opioid experienced based on prior prescriptions. We examined the association of timing of PT initiation with any and chronic opioid use over 1 year.

RESULTS

Of the 67 245 individuals with incident knee OA, 35 899 were opioid naïve and 31 346 were opioid experienced. In the opioid naïve group, compared with PT within 1 month, PT 1 to <3, 3 to <6, 6 to <9, 9-12 months from diagnosis was associated with adjusted risk ratio (aRR (95% CIs)) for any opioid use of 1.18 (1.10 to 1.28), 1.49 (1.37 to 1.61), 1.73 (1.58 to 1.89) and 1.93 (1.76 to 2.12), respectively; aRRs (95% CIs) for chronic opioid use were 1.25 (1.01 to 1.54), 1.83 (1.48 to 2.26), 2.29 (1.82 to 2.89) and 2.50 (1.96 to 3.19). Results were similar among opioid experienced; aRRs (95% CIs) for any opioid use were 1.19 (1.14 to 1.24), 1.32 (1.26 to 1.37), 1.39 (1.32 to 1.45) and 1.54 (1.46 to 1.61); aRRs (95% CIs) for chronic opioid use were 1.25 (1.17 to1.34), 1.43 (1.33 to 1.54), 1.53 (1.41 to 1.66) and 1.65 (1.51 to 1.80).

CONCLUSION

Compared with PT initiation within 1 month, delayed PT initiation was associated with higher risk of opioid use in people with incident knee OA. The longer the delay in PT initiation, the greater was the risk.

Variation in the utilisation of physiotherapy in patients with advanced knee osteoarthritis prior to total knee arthroplasty a systematic review

INTRODUCTION

Due to demographic changes and increasing knee osteoarthritis (KOA) prevalence, the incidence of total knee arthroplasties (TKA) is constantly rising. Clinical practice guidelines for the treatment of KOA unanimously recommend non-surgical interventions such as exercise, education, and weight reduction in overweight patients. The aim of this systematic review is to determine the proportion of patients with end-stage KOA who attended physiotherapy (PT) prior to TKA.

METHODS

A systematic literature search was carried out in the medical databases MEDLINE (via Pubmed), PEDro, and EBSCO in August of 2022. Studies were included regardless of their design, if they reported the proportion of patients with a diagnosis of primary KOA, who participated in PT prior to undergoing TKA. Study quality assessment was performed by two independent authors using the Joanna Briggs Institutes Checklist for studies reporting prevalence data. Results were presented by using a narrative synthesis.

RESULTS

Eighteen studies, comprising 579,718 patients, were identified in this systematic review. PT utilisation prior to TKA ranged from 10% to 73% for patients with advanced KOA. Only two studies showed PT utilisation rates of 60% or higher. Female gender, higher income, better socioeconomic status, higher education levels, older age were associated with PT utilisation. Data for other predicting factors was conflicting.

DISCUSSION

This review shows substantial variation in the utilisation of PT in patients with end-stage KOA. This is concerning, considering the uniform recommendation from clinical practice guidelines for non-surgical treatments like exercise and education in patients with KOA, which are mostly provided by physiotherapists.

Effect of Information Content and General Practitioner Recommendation to Exercise on Treatment Beliefs and Intentions for Knee Osteoarthritis: An Online Multi-Arm Randomized Controlled Trial

OBJECTIVE

To evaluate effects of general osteoarthritis (OA) information in addition to a treatment option grid and general practitioner (GP) recommendation to exercise on treatment beliefs and intentions.

METHODS

An online randomized trial of 735 people 45 years old or older without OA who were recruited from a consumer survey network. Participants read a hypothetical scenario about visiting their GP for knee problems and were randomized to the following: i) 'general information', ii) 'option grid' (general information plus option grid), or iii) 'option grid plus recommendation' (general information plus option grid plus GP exercise recommendation). The primary outcome was an agreement that exercise is the best management option (0-10 numeric rating scale; higher scores indicating higher agreement that exercise is best). The secondary outcomes were beliefs about other management options and management intentions. Linear regression models estimated the mean (95% confidence interval [CI]) between-group difference in postintervention scores, adjusted for baseline.

RESULTS

Option grid plus recommendation led to higher agreement that exercise is the best management by a mean of 0.4 units (95% CI: 0.1-0.6) compared with general information. There were no other between-group differences for the primary outcome. Option grid led to higher agreement that surgery was best, and x-rays were necessary, compared with general information (mean between-group differences: 0.7 [CI: 0.2-1.1] and 0.5 [CI: 0.1-1.0], respectively) and option grid plus recommendation (0.5 [CI: 0.1-0.9] and 0.9 [CI: 0.4-1.3]).

CONCLUSION

Addition of an option grid and GP exercise recommendation to general OA information led to more favorable views that exercise was best for the hypothetical knee problem. However, differences were small and of unclear clinical importance.

Understanding the management of osteoarthritis: A qualitative study of GPs and orthopaedic surgeons in Tasmania, Australia

Objective

Using a qualitative design this study aimed to 1) explore the attitudes towards and understanding of osteoarthritis (OA) held by Tasmanian general practitioners (GPs) and orthopaedic surgeons, 2) gain a deeper understanding of conservative and surgical management and 3) identify key barriers and challenges.

Design

Purposive sampling was used to recruit 17 ​GPs and 10 surgeons from Tasmania, Australia. Semi-structured interviews were audio-recorded, transcribed, coded, and thematically analysed to document understanding of OA, management and treatment decision making.

Results

GPs and surgeons had a shared understanding of the cause and management of OA which aligned well with evidence-based best practice. Most GPs acknowledged that severity of disease on an X-Ray does not correlate well with symptoms, although some GPs reported always using imaging to support their diagnosis. Conservative management was highly supported by all interviewees, focussing on exercise and/or physiotherapy. Key treatment barriers included managing poor patient understanding of OA, unrealistic expectations for treatment, lack of patient motivation and scepticism towards exercise, and cost and accessibility of conservative treatment options. Surgery was considered a suitable option when conservative management options had been exhausted.

Conclusion

This study uniquely interviewed GPs and surgeons from the same population, capturing two crucial areas of OA management. Some key barriers to treatment were identified and options for improving treatment include creating opportunities for increased patient education about OA, enhanced accessibility to OA conservative management programs along with improved reimbursement models supporting conservative management as first-line OA treatment.