Barriers and enablers to uptake of a contemporary guideline-based management program for hip and knee osteoarthritis: A qualitative study

The social and organisational factors shaping acceptability of a self-management education and exercise intervention for people with hip or knee osteoarthritis in Greenland

This study aimed to explore the experiences and perspectives of people with osteoarthritis attending the "Osteoarthritis School" (OA School) in Nuuk, Greenland to generate insights and lessons that can inform the development of self-management education and exercise interventions for people with other lifestyle conditions in a Greenland context. We conducted a qualitative interpretive description (ID) study based on ten semi-structured interviews with people with hip or knee osteoarthritis. Interviews were audio-recorded, transcribed, and coded. Using ID, we identified three themes: 1) perceptions and experiences of how the OA School intervention was organised (time and place); 2) perspectives and experiences of the education and exercise components (social factors, motivation, and education); and 3) significant change stories (physical and mental improvements and increased knowledge of OA). Social and organisational factors, such as working out with peers and the time and place of the intervention, influenced the participants' acceptance of the OA School intervention. Knowledge from this study will help us gain insight into what to address when developing future self-management education and exercise interventions in the Greenlandic healthcare system.

Implementation barriers and facilitators for referral from the hospital to community-based lifestyle interventions from the perspective of lifestyle professionals: A qualitative study

PURPOSE

A lifestyle front office (LFO) in the hospital is a not yet existing, novel concept that can refer patients under treatment in the hospital to community-based lifestyle interventions (CBLI). The aim of this study was to identify implementation barriers and facilitators regarding the implementation of an LFO in the hospital from the perspective of CBLI-professionals and to develop evidence-based implementation strategies to reduce these identified barriers.

METHODS

We conducted semi-structured interviews until data saturation, with 23 lifestyle professionals working in the community. A semi-structured topic guide was used, inquiring about (1) community-based lifestyle interventions; (2) their views about referral from the LFO; and (3) their preferences, needs and recommendations for collaboration with the LFO in the hospital. The online interviews lasted on average 46 minutes, were audio-recorded and transcribed verbatim. A thematic content analysis was conducted. Found barriers and facilitators regarding the LFO where mapped using the consolidated framework for implementation research (CFIR) whereafter evidence based strategies were developed using the CFIR-Expert Recommendations for Implementing Change Strategy Matching Tool V.1.0 (CFIR-ERIC).

RESULTS

Barriers and facilitators were divided into two main themes: 1) barriers and facilitators related to the referral from LFO to CBLI (i.e. financial, cultural, geographical, quality) and 2) barriers and facilitators related to the collaboration between LFO and CBLI (i.e. referral, communication platform and partnership). Thirty-seven implementation strategies concerning 15 barriers were developed and clustered into six overarching strategies: identify referral options, determine qualifications lifestyle professionals, develop support tools, build networks, facilitate learning collaboratives, and optimize workflow.

CONCLUSIONS

In this study, barriers and facilitators for the development of the LFO were found and matching implementation strategies were developed. Practical improvements, like identifying specific referral options or develop support tools, can be implemented immediately. The implementation of other strategies, like connecting care pathways in basic services, primary, secondary and tertiary care, will take more time and effort to come to full potential. Future research should evaluate all implemented strategies.

Participants' perceived benefits from the GLA:D™ program for individuals living with hip and knee osteoarthritis: a qualitative study

BACKGROUND

The Good Life with osteoArthritis: Denmark (GLA:D™), an evidence-based education and exercise program designed for conservative management of knee and hip osteoarthritis (OA), has been shown to benefit participants by reducing pain, improving function, and quality of life. Standardized reporting in the GLA:D databases enabled the measurement of self-reported and performance-based outcomes. There is a paucity of qualitative research on the participants' perceptions of this program, and it is important to understand whether participants' perceptions of the benefits of the program align with reported quantitative findings.

METHODS

We conducted semi-structured telephone interviews with individuals who participated in the GLA:D program from January 2017 to December 2018 in Alberta, Canada. Data were analyzed using an interpretive description approach and thematic analysis to identify emergent themes and sub-themes associated with participants perceived benefits of the GLA:D program. We analyzed the data using NVivo Pro software. Member checking and bracketing were used to ensure the rigour of the analysis.

RESULTS

30 participants were interviewed (70% female, 57% rural, 73% knee OA). Most participants felt the program positively benefited them. Two themes emerged from the analysis: wellness and self-efficacy. Participants felt the program benefited their wellness, particularly with regard to pain relief, and improvements in mobility, strength, and overall well-being. Participants felt the program benefited them by promoting a sense of self-efficacy through improving the confidence to perform exercise and routine activities, as well as awareness, and motivation to manage their OA symptoms. Twenty percent of participants felt no benefits from the program due to experiencing increased pain and feeling their OA was too severe to participate.

DISCUSSION

The GLA:D program was viewed as beneficial to most participants, this study also identified factors (e.g., severe OA, extreme pain) as to why some participants did not experience meaningful improvements. Early intervention with the GLA:D program prior to individuals experiencing severe OA could help increase the number of participants who experience benefits from their participation.

CONCLUSION

As the GLA:D program expands across jurisdictions, providers of the program may consider recruitment earlier in disease progression and targeting those with mild and moderate OA.

Barriers and enablers to the implementation and sustainability of short-stay arthroplasty programs for elective primary total hip and knee replacement: A systematic review with qualitative evidence synthesis

INTRODUCTION

We aimed to systematically review contemporary evidence on the barriers and enablers to implementing and sustaining short-stay arthroplasty programs for elective primary total hip and knee replacement from the perspectives of patients, health professionals, carers, healthcare administrators, funders and policymakers and to map the findings to the Theoretical Domains Framework (TDF).

METHODS

Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and the Cochrane Central Register of Controlled Trials were searched (up to 19 August 2023). Primary qualitative or mixed-methods studies reporting on perspectives relating to the review aims that utilised a short-stay programme were eligible for inclusion. Study quality was assessed using the qualitative critical appraisal tool from the Joanna Briggs Institute. Data were analysed inductively. The final themes were mapped to the TDF. The confidence in the findings was assessed using GRADE CERQual.

RESULTS

Fifteen studies were included. Twelve barrier themes and twelve enabler themes were identified. Three themes were graded with high confidence, 10 were graded with moderate confidence, three were graded with low confidence, and eight were graded with very low confidence. The most pertinent domains that the themes were mapped to for patients were beliefs about capabilities, reinforcement, and the environmental context and resources. Health professionals identified knowledge, environmental context and resources as important domains. Two domains were identified for carers: (1) social/professional role and identity and (2) memory, attention, and decision processes.

CONCLUSION

We identified key barrier and enabler themes linked to the TDF that can be used to guide implementation initiatives and promote the sustainability of short-stay arthroplasty programs.

Implementing good life with osteoArthritis from Denmark (GLA:D®) in australian public hospitals. Part 1: Feasibility

BACKGROUND

Literature reporting positive outcomes from the Good Life with osteoArthritis in Denmark (GLA:D®) program in Australia mainly involves patients attending private physiotherapy services.

OBJECTIVE

Evaluate the feasibility of implementing GLA:D® in Australian public hospitals.

DESIGN

Implementation study in three metropolitan tertiary public hospitals over six months.

METHOD

Patients aged ≥18 years with knee or hip joint-related problems deemed appropriate for non-surgical care were invited to participate in GLA:D®. Feasibility was evaluated using RE-AIM framework components (Implementation, Effectiveness, Maintenance) using service-level metrics, patient-level data, and program fidelity assessment. Findings of qualitative interviews with service providers are presented in Part 2.

RESULTS

Implementation: 70 patients (69 with knee osteoarthritis) participated (13 cohorts). 55 (79%) patients attended both education sessions, and 49 patients (70%) attended 10-12 exercises sessions. Fidelity was met based on environmental, therapist, participant- and program-related criteria.

EFFECTIVENESS

At 3 months, patients reported lower average pain (visual analogue scale [0-100 mm]: effect size -0.56, 95% CI -0.88 to -0.23) and disability (HOOS/KOOS-12 [100-0]: 0.67, 0.28 to 1.05), and improved quality of life (EQ-5D overall score: 0.46, 0.11 to 0.80). No adverse events were reported. All patients who completed 3-month assessment (n = 52) would recommend GLA:D®. Maintenance: All participating services elected to continue delivering GLA:D® beyond the study.

CONCLUSIONS

Implementing GLA:D® in Australian public hospitals is feasible, safe, and acceptable to patients with knee osteoarthritis. Public hospital patients with knee osteoarthritis reported improvements in pain, disability, and quality of life similar to previous GLA:D® cohorts.

Use of Implementation Strategies to Promote the Uptake of Knee Osteoarthritis Practice Guidelines and Improve Patient Outcomes: A Systematic Review

OBJECTIVE

Translation of knee osteoarthritis (KOA) clinical practice guidelines (CPGs) to practice remains suboptimal. The primary purpose of this systematic review was to describe the use of implementation strategies to promote KOA CPG-recommended care.

METHODS

Medline (via PubMed), Embase, CINAHL, and Web of Science were searched from inception to February 23, 2023, and the search was subsequently updated and expanded on January 16, 2024. Implementation strategies were mapped per the Expert Recommendations for Implementing Change taxonomy. Risk of bias (RoB) was assessed using the Cochrane Effective Practice and Organisation of Care criteria. The review was registered prospectively (PROSPERO identifier: CRD42023402383).

RESULTS

Nineteen studies were included in the final review. All (100% [n = 4]) studies that included the domains of "provide interactive assistance," "train and educate stakeholders" (89% [n = 16]), "engage consumers" (87% [n = 13]), and "support clinicians" (79% [n = 11]) showed a change to provider adherence. Studies that showed a change to disability included the domains of "train and educate stakeholders," "engage consumers," and "adapt and tailor to context." Studies that used the domains "train and educate stakeholders," "engage consumers," and "support clinicians" showed a change in pain and quality of life. Most studies had a low to moderate RoB.

CONCLUSION

Implementation strategies have the potential to impact clinician uptake of CPGs and patient-reported outcomes. The implementation context, using an active learning strategy with a patient partner, restructuring funding models, and integrating taxonomies to tailor multifaceted strategies should be prioritized. Further experimental research is recommended to determine which implementation strategies are most effective.

'I do hope more people can benefit from it.': The qualitative experience of individuals living with osteoarthritis who participated in the GLA:D™ program in Alberta, Canada

INTRODUCTION

The Good Life with osteoArthritis: Denmark (GLA:DTM) is an evidence-based program designed for individuals with symptomatic hip and knee osteoarthritis (OA). This program has reported improvement in pain, quality of life and self-efficacy, as well as delays in joint replacement surgery for adults with moderate to severe hip or knee OA. Evaluations of GLA:DTM implementation in several countries have focused on effectiveness, training, and feasibility of the program primarily from the provider perspective. Our objective was to examine how the GLA:DTM program was perceived and experienced by individuals with hip and knee OA to inform on-going program refinement and implementation.

METHODS

Thirty semi-structured telephone interviews were conducted with participants who completed the GLA:DTM program in Alberta. An interpretive description approach was used to frame the study and thematic analysis was used to code the data and identify emergent themes and sub-themes associated with participants' experience and perception of the GLA:DTM program.

RESULTS

Most participants had a positive experience of the GLA:DTM program and particularly enjoyed the group format, although some participants felt the group format prevented one-on-one support from providers. Three emergent themes related to acceptability were identified: accessible, adaptable, and supportive. Participants found the program to be accessible in terms of location, cost, and scheduling. They also felt the program was adaptable and allowed for individual attention and translatability into other settings. Finally, most participants found the group format to be motivating and fostered connections between participants.

CONCLUSION

The GLA:DTM program was perceived as acceptable by most participants, yet the group format may not be useful for all individuals living with OA. Recommended improvements included adapting screening to identify those suited for the group format, providing program access earlier in the disease progression trajectory, modifying educational content based on participants' knowledge of OA and finally, providing refresher sessions after program completion.

A cross sectional study exploring the relationship of self-reported physical activity with function, kinesiophobia, self-efficacy and quality of life in an Asian population seeking care for knee osteoarthritis

BACKGROUND

Physical activity is a guideline-recommended first-line intervention for people with knee osteoarthritis. Physical activity levels, and its potential correlates, is underexplored in Asian populations with knee osteoarthritis.

METHODS

Participants enrolled in a longitudinal study in Singapore self-reported physical activity (UCLA activity score), function (Knee Osteoarthritis Outcome Score [KOOS-12]), kinesiophobia (Brief fear of movement [BFOM]), self-efficacy (ASES-8), and quality of life (EQ-5D-5 L). One-Way ANOVA was used to test the difference in outcomes between UCLA categories, while ordinal logistic regression was used to identify the associated factors to physical activity level.

RESULTS

Seventy-three percent of all enrolled participants (n = 311/425) reported either inactivity or low physical activity (median 4, IQR 3-5). Significant, weak, positive correlations were observed be-tween UCLA activity score and either KOOS-12 (Spearman's rho: 0.1961; p < 0.001), ASES-8 (0.1983; p = 0.004), or EQ-5D-5 L (0.2078; p < 0.001). A significant, weak, negative correlation was observed between physical activity and BFOM (-0.2183; p < 0.001). Significant differences in function between groups (moderate vs. inactive or low physical activity) were not clinically important. Participants with obesity, from the eldest age category (i.e. ≥75), or who identified as Malay or female, were less physically active than those with a healthy BMI, below the age of 54, or who identified as Chinese or male, respectively.

CONCLUSION

Healthcare professionals in Asia should be aware of the large proportion of people with knee osteoarthritis who are either inactive or have low physical activity levels. Screening for, and offering interventions to promote, physical activity and its correlates should be prioritised.

Development of a Digital Health Intervention to Support Patients on a Waitlist for Orthopedic Specialist Care: Co-Design Study

BACKGROUND

The demand for orthopedic specialist consultations for patients with osteoarthritis in public hospitals is high and continues to grow. Lengthy waiting times are increasingly affecting patients from low socioeconomic and culturally and linguistically diverse backgrounds who are more likely to rely on public health care.

OBJECTIVE

This study aimed to co-design a digital health intervention for patients with OA who are waiting for an orthopedic specialist consultation at a public health service, which is located in local government areas (LGAs) of identified social and economic disadvantage.

METHODS

The stakeholders involved in the co-design process included the research team; end users (patients); clinicians; academic experts; senior hospital staff; and a research, design, and development agency. The iterative co-design process comprised several key phases, including the collation and refinement of evidence-based information by the research team, with assistance from academic experts. Structured interviews with 16 clinicians (female: n=10, 63%; male: n=6, 38%) and 11 end users (age: mean 64.3, SD 7.2 y; female: n=7, 64%; male: n=4, 36%) of 1-hour duration were completed to understand the requirements for the intervention. Weekly workshops were held with key stakeholders throughout development. A different cohort of 15 end users (age: mean 61.5, SD 9.7 y; female: n=12, 80%; male: n=3, 20%) examined the feasibility of the study during a 2-week testing period. The System Usability Scale was used as the primary measure of intervention feasibility.

RESULTS

Overall, 7 content modules were developed and refined over several iterations. Key themes highlighted in the clinician and end user interviews were the diverse characteristics of patients, the hierarchical structure with which patients view health practitioners, the importance of delivering information in multiple formats (written, audio, and visual), and access to patient-centered information as early as possible in the health care journey. All content was translated into Vietnamese, the most widely spoken language following English in the local government areas included in this study. Patients with hip and knee osteoarthritis from culturally and linguistically diverse backgrounds tested the feasibility of the intervention. A mean System Usability Scale score of 82.7 (SD 16) was recorded for the intervention, placing its usability in the excellent category.

CONCLUSIONS

Through the co-design process, we developed an evidence-based, holistic, and patient-centered digital health intervention. The intervention was specifically designed to be used by patients from diverse backgrounds, including those with low health, digital, and written literacy levels. The effectiveness of the intervention in improving the physical and mental health of patients will be determined by a high-quality randomized controlled trial.

Does a consumer co-designed infographic increase knowledge of physical activity after total knee joint replacement? A randomised controlled trial

PURPOSE

To determine if a consumer co-designed infographic increased knowledge of physical activity and self-efficacy for exercise after total knee joint replacement surgery.

METHODS

Forty-four adults with primary knee joint replacement surgery were recruited from a public and a private hospital in Melbourne, Australia. Participants were randomly allocated to an experimental or control group. The experimental group received a consumer co-designed infographic. All participants received usual care. Primary outcome measures were knowledge of physical activity and self-efficacy for exercise. Outcomes were administered at baseline, week 1 and week 6. Semi-structured interviews with experimental group participants explored the acceptability, implementation and efficacy of the infographic.

RESULTS

There were no between-group differences for knowledge of physical activity at week 1 (MD -0.02 units, 95% CI -0.9 to 0.9) or week 6 (MD 0.01 units, 95% CI -0.9 to 0.9). Self-efficacy for exercise increased at week 1 (MD 14.2 units, 95% CI 2.9-25.4) but was not sustained. Qualitative data showed that the infographic was embraced by some participants but not by others.

CONCLUSIONS

A consumer co-designed infographic did not improve knowledge of physical activity but may have had a short-term positive effect on self-efficacy for exercise after knee joint replacement. Trial registration ACTRN12621000910808.

Association of baseline physical activity participation with participant characteristics and outcomes following education and exercise-therapy in people with knee osteoarthritis: A GLA:D® Australia prospective cohort study

OBJECTIVES

To investigate whether participants with knee osteoarthritis classified as 'more' or 'less' physically active at baseline differ in characteristics and/or outcomes at baseline and at 3 and 12 months following the commencement of an education and exercise-therapy program.

METHODS

Prospective cohort study using the GLA:D® Australia registry. The University of California, Los Angeles Physical Activity Scale (UCLA) participant data dichotomised as 'more' (≥7) or 'less' active (≤6). Groups were compared using chi-square (obesity [baseline only], comorbidity prevalence, medication consumption, fear of damage from physical activity); and linear mixed model regression (12-item Injury Osteoarthritis Outcome Score [KOOS-12], pain [visual analogue scale], health-related quality of life [QoL] [EQ-5D-5L]) statistics, adjusted for age, sex and baseline physical activity at 3 and 12 months.

RESULTS

We included 1059 participants (70% female). At baseline, 267 (25%) were classified as 'more' active, increasing to 29% and 30% at 3 and 12 months, respectively. At baseline, compared to the 'less' active group, the 'more' active group had a lower proportion of participants who were obese ('more' = 21% vs. 'less' = 44%), had comorbidities (58% vs. 74%) and consumed medications (71% vs. 85%); lower pain intensity (37 vs. 47); and higher KOOS-12 (59 vs. 50), and health-related QoL (0.738 vs. 0.665) scores. When accounting for age, sex and baseline physical activity, improvements seen in knee-related burden and health-related QoL were not different between groups at 3 or 12 months. Compared to the 'less' active group, the proportion of participants not consuming medication remained higher in the 'more' active group at 3 ('more' 45% vs. 'less' 28%) and 12 months (43% vs. 32%).

CONCLUSION

'More' active people with knee osteoarthritis were less likely to be obese, had fewer comorbidities, lower medication consumption, knee-related burden and pain intensity, and higher health-related QoL than 'less' active participants at all timepoints.

Implementing a guideline-based education and exercise program for people with knee and hip osteoarthritis-Practical experiences of providers and clinic leaders: A qualitative study

BACKGROUND

The Good Life with osteoArthritis: Denmark (GLA:DTM ) program is an evidence-based education and exercise program designed for individuals with symptomatic hip and knee osteoarthritis. Launched in Denmark, it has been implemented across Europe, Australia, and North America. The authors assessed the feasibility of GLADTM implementation in Canada (Alberta) by applying the RE-AIM framework. An evaluation objective was to identify factors impacting the implementation of the program in both publicly funded and private rehabilitation settings, based on the experience of the initial cohort of providers and clinic leaders who set up and delivered the program.

METHODS

Semi-structured telephone interviews were conducted with GLA:DTM -trained providers, managers, or directors of clinics across Alberta. Braun and Clarke's thematic approach was used to code the data and identify emergent categories and themes. Those relevant to the implementation were identified and by consensus, categorized as facilitators of and challenges to the implementation process.

RESULTS

Eighteen GLA:DTM -trained providers and three clinic leaders from a range of clinical settings completed an interview. Seven common themes emerged in relation to implementation across the study settings. Three themes reflect facilitators of implementation (program acceptability by providers, multi-level support mechanisms, and program flexibility) and four implementation challenges (direct and indirect costs, lack of external referrals, program access issues, and lack of suitable space). The initial implementation of the program was exploratory with limited focus on long-term sustainability.

CONCLUSIONS

The GLA:DTM program is a translatable program that can be implemented with relative ease in both public and private rehabilitation settings; however, costs, space constraints, and having an adequate referral base were noted challenges. Further work is warranted to explore equitable access across public and private settings and program sustainability.

The effect of geographic location and payor type on provincial-wide delivery of the GLA:D program for hip and knee osteoarthritis in Alberta, Canada

Objective

The Good Life with osteoArthritis: Denmark (GLA:D™) program for knee and hip osteoarthritis has been shown to be effective, but evaluations have yet to explore whether effectiveness differs by program context. The present study explores whether there are differences in effectiveness of the GLA:D™ program for treatment of hip and knee osteoarthritis across program location (i.e., rural, urban, metro) and program payor (i.e., public, private) within Alberta, Canada.

Design

The study population was adults with hip or knee osteoarthritis attending the 8-week GLA:D™ supervised exercise and education programme in Alberta between Sep 2017-Mar 2020. Outcomes of interest were joint-related pain and quality of life (HOOS/KOOS), health quality of life (EQ-5D-5L), and performance-based functional (30-s chair stand test; 40-m walk test) measures. Minimally clinically important changes were calculated for each outcome and ANOVA and chi-square tests were used to determine statistical significance by program location or payor.

Results

Of the 1321 eligible participants, 974 (73.7%) completed the baseline questionnaire, about 50% of participants participated in a metro area and 60% paid privately for the program. There were no statistically significant differences in improvements of joint-related pain, joint-related quality of life, health-related quality of life, or performance-based functional measures by program location or program payor, except for participants who received the program in a publicly covered primary care clinic who experienced significantly larger improvements in joint-related pain.

Conclusion

The implementation of the GLA:D™ program for the treatment of knee and hip osteoarthritis in Alberta is effective across a range of contexts.

Bringing the Walk with Ease Programme to the UK: a mixed-methods study to assess the relevance, acceptability, and feasibility of implementation for people with arthritis and musculoskeletal conditions

Developed in the United States (US), Walk With Ease (WWE) is a popular evidence-based, 6-week community walking programme for adults with arthritis, delivered in either an instructor-led or self-directed format. While WWE has expanded into communities across the USA, it is relatively unknown in other countries across the globe. This study, in collaboration with community and patient partners, aimed to examine the relevance, acceptability and feasibility of introducing WWE into a UK context. After initial cultural adaptation, participants were recruited into the study. Eligible (≥18 years, doctor diagnosed arthritis (confirmed or self-report), self-reported joint symptoms in last 30 days, BMI ≥25 kg/m2, and <150 min/week of moderate/vigorous PA) and consented participants were randomized into two groups: WWE programme or usual care. A mixed-methods analysis approach integrated quantitative data (physical performance assessment; baseline and post-six week programme questionnaire) and qualitative data (narrative interviews exploring participants' pre- and post-WWE experiences and stakeholders' perceptions). Of 149 participants, the majority were women (70%) aged ≥60 years (76%). Among the 97 receiving the programme, 52 chose instructor-led; 45 chose self-directed. Participants found WWE relevant and acceptable-99% indicating they would recommend WWE to family/friends. Within both WWE formats, mixed differences representing improvement were observed at 6 weeks from baseline for physical performance and arthritis symptoms. Emergent themes included improved motivation, health, and social well-being. WWE is a relevant and acceptable walking programme with scope for wider implementation to support UK health and well-being policy strategies.

Difficulties Experienced by Patients with Knee Osteoarthritis during the Conservative Treatment Process: A Qualitative Study

BACKGROUND AND OBJECTIVES

This study aimed to investigate the difficulties faced by patients with knee osteoarthritis during the conservative treatment process.

MATERIALS AND METHODS

We included twenty-one patients who were diagnosed with knee osteoarthritis and admitted to the orthopedics and traumatology outpatient clinic of the hospital where the researcher worked between January 2022 and April 2022. We interviewed each patient using semi-structured face-to-face interviews. To analyze the interviews, the researcher used the directed content analysis method. Data were analyzed using the NVIVO 10 software package. The authors and the expert trained in qualitative research who generously supported the authors continued the analysis independently of each other until they reached a consensus.

RESULTS

After analysis of the interviews held with the participants, the following three main themes emerged: lack of information about conservative treatment, frequent change of physicians, and non-compliance with lifestyle changes. Two sub-themes were identified within the theme of frequent change of physicians: distrusting health personnel, and not being able to make an appointment. In addition, most of the patients were not knowledgeable enough about either the definition of the disease or the treatment process. These patients stated that they were confused because they had to change physicians frequently; thus, they distrusted physicians because each physician they visited made a different plan for the treatment process.

CONCLUSIONS

At the end of the study, we determined that during the conservative treatment process of patients with knee osteoarthritis, a multidisciplinary approach should be adopted, and orthopedic surgeons, physical therapy and rehabilitation physicians, dietitians, and physiotherapists should be in harmony with the patient. In addition, health personnel should provide patients with detailed information to eliminate questions they have during the conservative treatment process. In order for healthcare team members to establish a trusting relationship between the patients, they should allocate enough time to the patient.

Comprehensiveness, accuracy, quality, credibility and readability of online information about knee osteoarthritis

BACKGROUND

People are increasingly using the Internet to retrieve health information about chronic musculoskeletal conditions, yet content can be inaccurate and of variable quality.

OBJECTIVE

To summarise (i) comprehensiveness, (ii) accuracy and clarity, iii) quality of information about treatment choices, (iv) credibility and (v) readability of online information about knee osteoarthritis.

METHOD

Systematic appraisal of website content. Searches for "knee osteoarthritis" and "knee arthritis" were performed using Google and Bing (October 2020). The top 20 URLs of each search were screened for eligibility. Comprehensiveness, accuracy and clarity of content were matched against 14 pre-defined topic descriptors. DISCERN and HONcode were used to measure quality of information about treatment choices and website credibility, respectively. Flesch Reading Ease and Flesch-Kincaid Grade Level tests were used to assess readability.

RESULTS

Thirty-five websites were included. Websites were generally comprehensive (median, range = 12, 0-14/14) with descriptors available for 67% (n = 330/490) of topics across all websites, but only 35% (n = 116/330) were accurate and clear. Quality of information about treatment choices was generally low (median DISCERN score, range = 40, 16-56/80). Credibility descriptors were present for 65% (n = 181/280) of items, with 81% (n = 146/181) of descriptors being clear. Median Flesch reading ease was 53 (range = 21-74), and Flesch-Kincaid grade level was 8 (range = 5-11).

CONCLUSION

Few websites provide accurate and clear content aligned to key research evidence. Quality of information about treatment choices was poor, with large variation in comprehensiveness, credibility and readability.

IMPLICATIONS

Careful consideration is required by clinicians to identify what online information people with knee osteoarthritis have accessed and to address misinformed beliefs.

Attitude and Belief of Healthcare Professionals Towards Effective Obesity Care and Perception of Barriers; An Updated Systematic Review and Meta-analysis

BACKGROUND

Obesity is a serious chronic disease that adversely affects health and quality of life. However, a significant percentage of people do not participate in or adhere to weight loss programs. Therefore, a multidisciplinary approach is needed to identify critical barriers to effective obesity management and to examine health practitioners' attitudes and behaviors towards effective obesity treatment.

METHODS

This systematic review was conducted in accordance with PRISMA 2020. Eligible studies were identified through a systematic review of the literature using Medline, Scopus, Cochrane, Google Scholar, Web of Science, and Embase databases from January 1, 2011 to March 2, 2021.

RESULTS

A total of 57 articles were included. Data on 12663 physicians were extracted from a total of 35 quantitative articles. Some of the most commonly perceived attitude issues included "obesity has a huge impact on overall health", "obesity is a disease" and "HCPs are to blame". Health professionals were more inclined to believe in "using BMI to assess obesity," "advice to increase physical activity," and "diet/calorie reduction advice." The major obstacles to optimal treatment of obesity were "lack of motivation", "lack of time" and "lack of success".

CONCLUSION

Although the majority of health care professionals consider obesity as a serious disease which has a large impact on overall health, counseling for lifestyle modification, pharmacologic or surgical intervention occur in almost half of the visits. Increasing the length of physician visits as well as tailoring appropriate training programs could improve health care for obesity.

The GLA:D® Canada program for knee and hip osteoarthritis: A comprehensive profile of program participants from 2017 to 2022

BACKGROUND

The Good Life with osteoArthritis in Denmark (GLA:D®) program was implemented in Canada in 2017 with the aim of making treatment guideline-recommended care available to the 4 million Canadians with knee and hip osteoarthritis (OA). This report describes the GLA:D® Canada program, registry and data collection procedures, and summarizes the sociodemographic and clinical profile of participants with knee and hip OA to inform the scientific research community of the availability of these data for future investigations and collaborations.

METHODS

The GLA:D® program consists of three standardized components: a training course for health care providers, a group-based patient education and exercise therapy program, and a participant data registry. Patients seeking care for knee or hip OA symptoms and enrolling in GLA:D® are given the option to provide data to the GLA:D® Canada registry. Participants agreeing to provide data complete a pre-program survey and are followed up after 3-, and 12-months. Data collected on the pre-program and follow-up surveys include sociodemographic factors, clinical characteristics, health status measures, and objective physical function tests. These variables were selected to capture information across relevant health constructs and for future research investigations.

RESULTS

At 2022 year-end, a total of 15,193 (11,228 knee; 3,965 hip) participants were included in the GLA:D® Canada registry with 7,527 (knee; 67.0%) and 2,798 (hip; 70.6%) providing pre-program data. Participants were 66 years of age on average, predominately female, and overweight or obese. Typically, participants had knee or hip problems for multiple years prior to initiating GLA:D®, multiple symptomatic knee and hip joints, and at least one medical comorbidity. Before starting the program, the average pain intensity was 5 out of 10, with approximately 2 out of 3 participants using pain medication and 1 in 3 participants reporting a desire to have joint surgery. Likewise, 9 out 10 participants report having previously been given a diagnosis of OA, with 9 out 10 also reporting having had a radiograph, of which approximately 87% reported the radiograph showed signs of OA.

CONCLUSION

We have described the GLA:D® Canada program, registry and data collection procedures, and provided a detailed summary to date of the profiles of participants with knee and hip OA. These individual participant data have the potential to be linked with local health administrative data registries and comparatively assessed with other international GLA:D® registries. Researchers are invited to make use of these rich datasets and participate in collaborative endeavours to tackle questions of Canadian and global importance for a large and growing clinical population of individuals with hip and knee OA.

Developing a framework for the implementation of recommendations for lifestyle factors for people with RMDs across Europe: assessment of current materials and implementation needs

Lifestyle factors (such as diet, physical activity or smoking habits, among others) are known to influence the progression of rheumatic and musculoskeletal diseases (RMDs). Despite contemporary improvements in RMD care, the management of lifestyle factors is suboptimal. In the context of a recent European Alliance of Associations for Rheumatology (EULAR) task force, existing informative materials regarding lifestyle factors for people with RMDs were collected from national organisations across European countries. Current materials show important limitations in terms of coverage, literature support and access, which may make the implementation of successful interventions difficult. In the present viewpoint, a roadmap to cover these gaps at the European level with the recent EULAR recommendations on lifestyle factors is discussed from an implementation perspective. This analysis may pave the ground for future implementation endeavours at the European level related to non-pharmacological interventions that may also be applicable beyond rheumatology.

Implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program via telehealth in Australia: A mixed-methods program evaluation

INTRODUCTION

We aimed to evaluate the implementation of the Good Life with osteoArthritis in Denmark (GLA:D^®) program via telehealth in Australia using Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation framework.

METHODS

Using a convergent mixed-methods design, semi-structured one-on-one interviews with physiotherapist adopters and nonadopters of GLA:D^® via telehealth were analyzed thematically alongside the examination of registry data (1 March 2020-10 February 2022) from patients with hip or knee osteoarthritis completing GLA:D^® via telehealth (telehealth-only) or combined with in-person care (hybrid). Effectiveness was determined as changes from baseline to 3-month follow-up (mean differences, 95% confidence intervals, effect size) for Knee injury and Osteoarthritis Outcome Score (KOOS-12)/Hip disability and Osteoarthritis Outcome Score-12 (HOOS-12), and chair stand test. Group- and individual-level changes were compared to published minimally clinically important change scores.

RESULTS

Twenty-three interviews (12 adopters, 11 nonadopters) found key barriers/facilitators to reach and adoption, high perceived effectiveness, and strategies to support sustainability. Of 2612 registered patients, 85 (3%) and 115 (4%) completed GLA:D^® via telehealth-only or hybrid model, respectively. Most effectiveness outcomes were associated with moderate-large improvements. Group-level changes exceeded minimally clinically important change values for KOOS/HOOS-quality of life and chair stand test. Nearly two out of three patients reached a minimally clinically important change for KOOS/HOOS-quality of life. With telehealth-only and hybrid delivery, 99% (n = 82) and 85% (n = 97) were satisfied/very satisfied. Physiotherapist adoption was limited (n = 128, 6%).

DISCUSSION

GLA:D^® delivered via telehealth is effective, had high patient satisfaction, and was perceived positively by physiotherapist adopters. Addressing low reach and adoption requires further implementation strategies to facilitate greater telehealth opportunities for patients and physiotherapists.

A survey of patient and medical professional perspectives on implementing osteoarthritis management programs for hip and knee osteoarthritis

BACKGROUND

Strategies are needed to improve referral into, and uptake of, osteoarthritis (OA) management programs. This survey investigated and compared patients' and medical professionals' views around hip and knee OA management and factors impacting implementation of an osteoarthritis management program.

METHODS

As part of a mixed-methods program of research, patients with hip or knee OA and medical professionals routinely involved in the management of OA, were invited to complete a comprehensive online survey. All data were analysed descriptively or using chi squared tests. Survey findings for factors perceived to impact implementation of an OA management programme were triangulated with previously reported qualitative data.

RESULTS

Fifty-three patients (38 females, 15 males) and 32 medical professionals (orthopaedic surgeons, sports physicians, rehabilitation physicians, rheumatologists and general practitioners) completed the survey. Twenty-eight patients (53%) had prior participation in the OA management programme (GLA:D^® ) and 19 medical professionals (59%) had previously referred patients to the programme. Of the participants with prior exposure, 21 patients (75%) and 15 medical professionals (79%) agreed the programme was beneficial. A higher proportion of medical professionals, compared to patients, believed weight loss (100% vs. 67%), injection therapy (50% vs. 21%), hip replacement (100% vs. 62%) and knee replacement (97% vs. 62%) were effective treatments, with no differences for all other treatments. The barriers and enablers identified for referral into, and participation in, an OA management programme mostly aligned to factors identified in previous related qualitative research. Divergent factors in the survey included patients concerns about doing exercise-therapy with 81% (higher than expected) not reporting any concerns about exercising, and 19% (lower than expected) concerned about their OA joint, such as making their pain worse.

CONCLUSIONS

This study has extended our understanding of barriers and enablers for referral into, and participation in, an OA management programme with a lower than expected number of patients being concerned about exercising due to their OA joint. Patients and medical professionals had positive views relating to the quality of the programme delivery, patient satisfaction and programme effectiveness. Medical professionals were more likely than patients to consider weight loss, injections and joint replacement as effective treatment options.

Implementation of physical activity interventions for people with inflammatory arthritis: an overview and future recommendations

Regular physical activity is important for both physical and mental health. This is particularly important for people with inflammatory arthritis, because of the benefits on both disease-specific and systemic outcomes and the increased risk of comorbidities such as cardiovascular disease. Despite a wealth of evidence supporting physical activity interventions, there remains a significant gap in implementation into routine care. This overview describes what implementation is, examines why it is important to consider implementation approaches to improve uptake of physical activity, highlights factors that influence successful implementation using exemplars from both osteoarthritis and inflammatory arthritis and recommends where future research is needed.

Advanced Practice Physiotherapists and the implementation of the JIGSAW-E model for the management of osteoarthritis in Scottish primary care settings: a qualitative case study

OBJECTIVE

To explore the acceptability, barriers and enablers of NICE guidelines for osteoarthritis in the Scottish primary care setting using the Joint Implementation of Guidelines for Osteoarthritis in Western Europe (JIGSAW-E) model and investigate the role of Advanced Physiotherapy Practitioners (APPs) in providing evidence-based care.

DESIGN

A qualitative case study comprised of semi-structured interviews followed by a workshop with participants.

SETTING

10 Scottish primary care practices.

PARTICIPANTS

Six general practitioners (GPs) and eight APPs were interviewed. Twenty-three practitioners attended the workshop including 22 physiotherapists and one GP.

RESULTS

While both GPs and APPs recognised the need to improve and standardise osteoarthritis care delivery, this study found that APPs were better situated to implement the evidence-based model. Barriers to implementation included lack of time for training, limited appointment time for GPs to consult and discuss medication use with patients, limitation of disease specific guidelines for patients with complex multimorbidity, and system-based barriers such as electronic data collection and high staff turnover. The key enabler was practitioners' motivation to provide optimal, standardised quality care for osteoarthritis. To increase acceptance, ownership and usability for both practitioners and patients, the JIGSAW-E model materials required adaptation to the local context.

CONCLUSION

This study provides evidence that the JIGSAW-E model is acceptable in Scottish primary care. Furthermore, the evolving roles of GPs and APPs within multidisciplinary primary care teams provides a platform to implement the JIGSAW-E model, where APPs are well placed to provide leadership and training in the delivery of evidence-based care for osteoarthritis.

Osteoarthritis management care pathways are complex and inefficient: A qualitative study of physiotherapist perspectives from specialised osteoarthritis services

OBJECTIVE

Hip and knee osteoarthritis guidelines internationally provide consistent first-line care recommendations. However, uptake of these recommendations remains suboptimal. This qualitative study explores factors influencing guideline-based care from the perspectives of physiotherapists working in specialised osteoarthritis services across different models of care.

METHODS

Nineteen semi-structured interviews were conducted with physiotherapists working in specialist osteoarthritis services across three different Australian models of care (OsteoArthritis Hip and Knee Service n = 10; OsteoArthritis Chronic Care Programme n = 4; Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services n = 5). Interviews were audio recorded and transcribed verbatim. Data were coded and analysed inductively using thematic analysis.

RESULTS

The overarching theme to emerge was that accessing first-line osteoarthritis care is complex and difficult, regardless of model of care. Subthemes indicated that: (i) services are either unavailable or inadequately funded, (ii) referral pathways are labyrinthine and lengthy, (iii) patients and other health professionals often believe that surgery is the only/best option and (iv) managing patient co-morbidities is challenging.

CONCLUSION

Physiotherapists working in specialised osteoarthritis services perceive multiple and complex factors influencing adherence to first-line care. Barriers occur at various levels in all models of care, including patient and health professional beliefs, health service, and system levels. These results suggest improving healthcare for people with osteoarthritis requires urgent system reform.

People With Knee Osteoarthritis Attending Physical Therapy Have Broad Education Needs and Prioritize Information About Surgery and Exercise: A Concept Mapping Study

OBJECTIVES

To (1) identify the education priorities of people with knee osteoarthritis, including perceived importance and confidence that a health care professional can address each, and (2) match priorities to education-specific content recommendations in knee osteoarthritis management guidelines.

DESIGN

Concept mapping methodology.

METHODS

Participants generated, sorted (based on themes), and rated (5-point Likert scales: importance and confidence) education priorities. Multidimensional scaling and hierarchical cluster analysis of sorting data produced a cluster map with overarching domains. Priorities were matched against education-specific content recommendations in knee osteoarthritis guidelines.

RESULTS

Participants (brainstorming, n = 43; sorting and rating, n = 24) generated 76 priorities. A 4-domain, 11-cluster map was the most useful representation of sorting data: (i) understanding treatment options (relationship of education and exercise with surgery, adjunct options, treatment decision making); (ii) exercise therapy (how to exercise, why exercise); (iii) understanding and managing the condition (symptom management, understanding symptoms, understanding the condition); and (4) surgical, medical, and dietary management (surgery, medications, diet and supplements). The "relationship of education and exercise with surgery" (3.88/5), "surgery" (3.86/5), and "how to exercise" (3.78/5) clusters were rated highest for importance. Few priorities identified by participants were clearly recommended as education-specific content recommendations in the American College of Rheumatology (3%, n = 2/76), European Alliance of Associations for Rheumatology (12%, n = 9/76), National Institute for Health and Care Excellence (16%, n = 12/76), and Osteoarthritis Research Society International (1%, n = 1/76) guidelines.

CONCLUSION

People with knee osteoarthritis presenting to physical therapists have broad education needs and prioritize information about surgery and exercise. J Orthop Sports Phys Ther 2022;52(9):595-606. Epub: 17 June 2022. doi:10.2519/jospt.2022.11089.

Patient and clinician perspectives of online-delivered exercise programmes for chronic musculoskeletal conditions: protocol for a systematic review

Background: Despite the growing economic and social impact of chronic musculoskeletal (MSK) conditions, there has been low uptake of clinical guidelines for management, owing partly to the negative perceptions of patients and clinicians of their appropriateness and accessibility. Online-delivered exercise programmes (ODEPs) offer an alternative that can reduce costs and offer convenience for those with mobility limitations. As such, investigating participants’ perceptions of such programmes provides insight into the complexity and interplay of factors associated with uptake and optimization of implementation strategies. Objectives: This study aims to systematically review of the literature of patients’ and clinicians’ perceptions of ODEPs for chronic MSK conditions. Methods: To ensure the likelihood of identifying all relevant published articles, the following databases will be searched from inception to end of the project: CINAHL Complete, MEDLINE, SportDiscus, AMED, APA PsycArticles, APA PsycInfo, Scopus, and Cochrane Library. Included articles will qualitatively and/or quantitatively report the perceptions of participants of ODEPs for chronic MSK conditions. ODEPs are defined as either (a) synchronous, users can exchange information simultaneously, or (b) asynchronous, with at least one synchronous feature, or (c) neither, where the authors investigate a user’s past experiences and/or likelihood of participating in such a programme. Article screening and quality assessment using the Critical Appraisal Skills Programme (CASP) checklists will be performed by two independent reviewers. All findings from included articles will be extracted and coded using a thematic synthesis approach. Discussion: It is important to offer diverse resources to address the growing public health burden of chronic MSK conditions. This study will explore patients and clinicians’ perceptions of ODEPs including needs, appropriateness and acceptability. Our findings could be used by policy makers, clinicians, and researchers to generate new models of care that could influence the uptake and long-term sustainability of ODEPs for chronic MSK conditions. PROSPERO registration: CRD42021273773.

[Effect of Auriculotherapy on Musculoskeletal Pain: A Systematic Review and Meta-Analysis]

PURPOSE

The aim of this study was to evaluate the effect of auriculotherapy on musculoskeletal pain in adults.

METHODS

A total of 885 studies were retrieved from nine databases (PubMed, Scopus, CINAHL, Web of Science, Ovid Medline, Cochrane Library, RISS, KMbase, and KISS). Sixteen studies were selected for meta-analysis, which satisfied the inclusion criteria and the evaluation of risk of bias. Demographic data, auriculotherapy types, intervention characteristics, auricular points, and outcomes related to pain (subjective pain scale, and amount of analgesic) were extracted from all included studies. The effect size of auriculotherapy was analyzed through comprehensive meta analysis 3.0, and the presence of publication bias was analyzed through a funnel plot and Egger's regression.

RESULTS

The results of the meta-analysis (n = 16) revealed that the auriculotherapy was significantly superior to the control group on present pain in adults (Hedges' g = -0.35, 95% Confidence Interval [CI] = -0.55~-0.15). According to the results of subgroup analysis, the effect size of auricular acupuncture therapy (Hedges' g = 0.45, 95% CI = -0.75~-0.15) was higher than the auricular acupuncture (Hedges' g = 0.27, 95% CI = -0.53~0.00): the longer the intervention period, the greater the effect size.

CONCLUSION

In this study, auriculotherapy demonstrates a significant reduction in musculoskeletal pain in adults. Therefore, it is necessary to refine the curriculum to include auriculotherapy as a nursing intervention to relieve musculoskeletal pain in adults and encourage its use in clinical settings.

Barriers and facilitators perceived by healthcare professionals for implementing lifestyle interventions in patients with osteoarthritis: a scoping review

OBJECTIVE

To provide an overview of barriers and facilitators that healthcare professionals (HCPs) perceive regarding the implementation of lifestyle interventions (LIs) in patients with hip and/or knee osteoarthritis (OA).

DESIGN

Scoping review.

DATA SOURCES

The databases PubMed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from inception up to January 2021.

ELIGIBILITY CRITERIA

Primary research articles with a quantitative, qualitative or mixed-methods design were eligible for inclusion if they reported: (1) perceptions of primary and/or secondary HCPs (population); (2) on implementing LIs with physical activity and/or weight management as key components (concept) and (3) on conservative management of hip and/or knee OA (context). Articles not published in English, German or Dutch were excluded.

DATA EXTRACTION AND SYNTHESIS

Barriers and facilitators were extracted by two researchers independently. Subsequently, the extracted factors were linked to a framework based on the Tailored Implementation for Chronic Diseases checklist.

RESULTS

Thirty-six articles were included. In total, 809 factors were extracted and subdivided into nine domains. The extracted barriers were mostly related to non-optimal interdisciplinary collaboration, patients' negative attitude towards LIs, patients' low health literacy and HCPs' lack of knowledge and skills around LIs or promoting behavioural change. The extracted facilitators were mostly related to good interdisciplinary collaboration, a positive perception of HCPs' own role in implementing LIs, the content or structure of LIs and HCPs' positive attitude towards LIs.

CONCLUSIONS

Multiple individual and environmental factors influence the implementation of LIs by HCPs in patients with hip and/or knee OA. The resulting overview of barriers and facilitators can guide future research on the implementation of LIs within OA care. To investigate whether factor frequency is related to the relevance of each domain, further research should assess the relative importance of the identified factors involving all relevant disciplines of primary and secondary HCPs.

PROSPERO REGISTRATION NUMBER

CRD42019129348.

Linking physical activity with clinical, functional, and structural outcomes: an evidence map using the Osteoarthritis Initiative

Physical activity is consistently recommended across clinical practice guidelines for managing knee osteoarthritis, yet prescription rates are low. Evidence mapping uses a systematic approach to visually illustrate and summarize published evidence, highlight gaps in the literature, and formulate research questions. The purpose of this study was to review and summarize evidence published from the Osteoarthritis Initiative (OAI) linking physical activity with clinical, functional, and structural knee osteoarthritis outcomes. Electronic databases were searched until June 2021. Studies from the OAI reporting subjective (Physical Activity Scale for the Elderly, PASE) or objective (accelerometry) physical activity data were included. Scatter plots were created to represent each outcome group (clinical, functional, structural) and physical activity measure (PASE, accelerometry) to map the evidence by the directional effect (positive, interaction, negative, or no effect) associated with physical activity. Forty-two articles were included in this review. Physical activity was quantified using PASE (n = 21), accelerometry (n = 20), or both (n = 1). Studies reported consistently positive physical activity effects on clinical (n = 22) and functional (n = 20) outcomes, with few exceptions. Structural (n = 15) outcomes were largely reported as interaction effects by physical activity intensity or sex, or as no significant effect. A network of interconnected outcomes emerged, with clinical and functional outcomes often reported together, and structural outcomes reported individually. This study provides an overview of current evidence linking physical activity to multiple interrelated knee osteoarthritis outcomes using an OAI-driven model. These evidence maps can be used as a framework to guide future investigations of the effects of physical activity on knee osteoarthritis.

Exploring views of orthopaedic surgeons, rheumatologists and general practitioners about osteoarthritis management

BACKGROUND

Delivery of recommended treatments for hip and knee osteoarthritis (OA) is known to be discordant with guideline recommendations. However, professional views related to OA management across medical and surgical disciplines are not well understood. The aim of this study was to explore the views of medical professionals about management of hip and knee OA.

METHODS

Qualitative study. Semistructured individual interviews were conducted with orthopaedic surgeons, rheumatologists and general practitioners routinely involved in the management of OA. Interviews were audiotaped, transcribed, member-checked, coded and thematically analysed.

RESULTS

Fifteen medical professionals were interviewed. Three main themes were: (i) recognition of the importance of nonsurgical management of hip and knee OA, focussed on self-management, exercise-therapy, weight management and analgesia; (ii) joint replacement being considered the 'last resort' for end stage disease not responding to nonsurgical management; and (iii) determination of management 'success' through patient perceptions was more common than the use of validated instruments. Views on management broadly converged across disciplines, except for the role of joint replacement, considered an adjunct in the overall management of OA by rheumatologists and as a definitive cure by orthopaedic surgeons.

CONCLUSIONS

Aligning with current guidelines, medical professionals recognised the importance of nonsurgical management focussed on exercise-therapy for hip and knee OA, and concurred that joint replacement surgery should be a last resort. A focus on patient education was less prominent, which along with implementation of validated outcome measures in routine medical practice, may require greater health system support.