How Do Physical Therapists in the United Kingdom Manage Patients With Hip Osteoarthritis? Results of a Cross-Sectional Survey

'I saw it as a marriage-You can't have one without the other': A qualitative study of patient and physiotherapist experiences with a therapeutic combined strength and aerobic physical activity exercise programme for hip osteoarthritis

INTRODUCTION

To explore physiotherapist and patient experiences with, and acceptability of, a 12-week physiotherapist-guided combined strength and aerobic physical activity exercise programme for hip osteoarthritis (OA).

METHODS

A qualitative study using semi-structured interviews with 13 people with hip OA and four physiotherapists. Patients underwent a 12-week home exercise programme customised by weekly visits with one of the four physiotherapists. The programme aimed for patients to participate in 150 min of moderate-intensity aerobic physical activity, and 20-30 min of strengthening exercise 2-3 times per week in concordance with American College of Sports Medicine (ACSM) dosage guidelines. Following the programme, patients and physiotherapists participated in individual semi-structured interviews to explore the acceptability of the exercise programme and barriers and facilitators to participation. Data were audio-recorded, transcribed and analysed using a thematic approach.

RESULTS

Five over-arching themes (supporting subthemes) were identified from both patient and physiotherapist interviews: (i) positive outcomes (functional improvements, pain relief, empowerment through experience, commitment to continue); (ii) combined benefits of aerobic and strength exercises (complimentary effects, strengthening exercises key); (iii) valuing support from the physiotherapist (personalised care, skill performance feedback, coach effect, accountability); (iv) motivation and opportunity for exercise (positive symptom loop, integration into daily routine, prior exercise experience, Fitbit motivation); and (v) time-consuming commitment (physiotherapy visit frequency, travel inconvenience, time for exercise).

CONCLUSIONS

Experiences of participants in this study indicate that, although time-consuming, a combined aerobic physical activity and strengthening programme prescribed at ACSM dosage guidelines is acceptable and confers positive outcomes in individuals with hip OA.

Clinical reasoning in managing chronic hip pain: One in two Australian and New Zealand physiotherapists diagnosed a case vignette with clinical criteria for hip OA as hip OA. A cross-sectional survey

OBJECTIVES

Using a case vignette of an adult (George) presenting with hip pain consistent with hip OA, this study aimed to describe: (a) whether physiotherapists make diagnoses and identify bodily structures using either patient history and/or physical examination findings; (b) which diagnoses and bodily structures physiotherapists attribute to the hip pain; (c) how confident physiotherapists were in their clinical reasoning using patient history and physical examination findings; (d) what treatments physiotherapists would offer to George.

METHODS

We conducted a cross-sectional online survey of physiotherapists in Australia and New Zealand. We used descriptive statistics to analyse closed questions and content analysis for open-text responses.

RESULTS

Two hundred and twenty physiotherapists completed the survey (39% response-rate). After receiving the patient history, 64% diagnosed George's pain and 49% of these as hip OA; 95% attributed George's pain to a bodily structure(s). After receiving the physical examination, 81% diagnosed George's hip pain and 52% of these as hip OA; 96% attributed George's hip pain to a bodily structure(s). Ninety-six percent of respondents were at least somewhat confident in their diagnosis after the patient history, and 95% were similarly confident after the physical examination. Most respondents offered advice (98%) and exercise (99%), but fewer offered treatments for weight loss (31%), medication (11%), and psychosocial factors (<15%).

DISCUSSION

About half of the physiotherapists that diagnosed George's hip pain made a diagnosis of hip OA, despite the case vignette including clinical criteria for a diagnosis of OA. Physiotherapists offered exercise and education, but many physiotherapists did not offer other clinically indicated and recommended treatments, such as weight loss and sleep advice.

Physiotherapy for patients with hip and knee osteoarthritis in Germany: a survey of current practice

BACKGROUND

Osteoarthritis (OA) of the hip and the knee is common and leads to pain, stiffness and disability. Clinical practice guidelines (CPG) provide recommendations to assist healthcare professionals in clinical decision-making. Although evidence-based physiotherapy has been shown to be effective in the management OA, a gap between clinical practice and guideline recommendations exists. Little is known about OA management provided by physiotherapists in Germany and whether treatment aligns with CPGs. The objectives of this study were (1) to investigate the current physiotherapy practice in patients with hip and/or knee OA in Germany, (2) to evaluate physiotherapists' adherence to guideline recommendations and (3) to explore barriers and facilitators to guideline use.

METHODS

A cross-sectional online survey was conducted among physiotherapists. The questionnaire collected information on demographic characteristics, physiotherapists' management of hip and knee OA and the use of CPGs in clinical practice. Guideline adherence was evaluated by comparing the survey findings with guideline recommendations. Full adherence was assumed if all recommended treatment options were chosen.

RESULTS

In total, 447 (74.9%) of 597 eligible physiotherapists completed the survey. Data from 442 participants (mean age 41.2 ± 12.8 years; 288 female (65.1%)) were included in the analysis. The most common treatment choices for both hip and knee OA were exercise therapy (hip OA: 424/442, 95.9%; knee OA: 426/442, 96.4%), self-management advice (hip OA: 413/442, 93.2%; knee OA: 395/442, 89.4%) and education (hip OA: 325/442, 73.5%; knee OA: 331/442, 74.9%), followed by manual therapy (hip OA: 311/442, 70.4%; knee OA: 311/442, 70.4%) and joint traction (hip OA: 208/442, 47.1%; knee OA: 199/442, 45.0%). Full guideline adherence was found in 17.2% (76/442) of physiotherapists for hip OA management and in 8.6% (38/442) for knee OA. Less than half of the respondents (212/430, 49.3%) were aware of an OA guideline.

CONCLUSIONS

In accordance with current guideline recommendations, most physiotherapists provide exercise therapy and education for patients with hip and/or knee OA. Interventions with low or conflicting evidence were also frequently provided. The limited awareness of existing OA guidelines and the low guideline adherence indicate an insufficient implementation of CPGs in German physiotherapy practice.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00026702). Registered 14 October 2021.

Recommendations for the delivery of therapeutic exercise for people with knee and/or hip osteoarthritis. An international consensus study from the OARSI Rehabilitation Discussion Group

OBJECTIVE

To develop evidence-informed recommendations to support the delivery of best practice therapeutic exercise for people with knee and/or hip osteoarthritis (OA).

DESIGN

A multi-stage, evidence-informed, international multi-disciplinary consensus process that included: 1) a narrative literature review to synthesise existing evidence; 2) generation of evidence-informed proposition statements about delivery of exercise for people with knee and/or hip OA by an international multi-disciplinary expert panel, with statements refined and analysed thematically; 3) an e-Delphi survey with the expert panel to gain consensus on the most important statements; 4) a final round of statement refinement and thematic analysis to group remaining statements into domains.

RESULTS

The expert panel included 318 members (academics, health care professionals and exercise providers, patient representatives) from 43 countries. Final recommendations comprised 54 specific proposition statements across 11 broad domains: 1) use an evidence-based approach; 2) consider exercise in the context of living with OA and pain; 3) undertake a comprehensive baseline assessment with follow-up; 4) set goals; 5) consider the type of exercise; 6) consider the dose of exercise; 7) modify and progress exercise; 8) individualise exercise; 9) optimise the delivery of exercise; 10) focus on exercise adherence; and 11) provide education about OA and the role of exercise.

CONCLUSION

The breadth of issues identified as important by the international diverse expert panel highlights that delivering therapeutic exercise for OA is multi-dimensional and complex.

Conceptualising adherence to exercise for musculoskeletal pain: A concept mapping study

BACKGROUND

The concept of adherence to exercise for musculoskeletal (MSK) pain is poorly defined and inadequately measured. This study aimed to, (1) conceptualise adherence to exercise therapy for MSK pain, and (2) identify statements most representative of the new conceptualisation that could be developed into items for a new measurement tool.

METHODS

Concept mapping methodology was used, which is an integrated mixed methods approach. Focus groups with stakeholders generated statements describing adherence to exercise for MSK pain. Statements were grouped according to themes and rated for importance. Data analysis via multidimensional scaling and hierarchical cluster analysis produced a series of concept maps, which were refined during a further stakeholder workshop to produce the final conceptualisation of exercise adherence. Mean importance ratings established statements most suitable for future development.

RESULTS

Twenty-eight participants produced 100 unique statements concerning adherence, which were sorted and rated. Analysis of the sort data with further participant refinement concluded that adherence to exercise consists of six domains: communication with experts; targets; how exercise is prescribed; patient knowledge and understanding; motivation and support; and psychological approach and attitudes. Fifty-six statements were rated with above average importance for inclusion in a new measure of adherence to exercise for MSK pain.

CONCLUSION

Adherence to exercise for MSK pain is a complex and multi-dimensional construct represented by six distinct domains. Statements that best represent these domains have been identified by key stakeholders and will inform the development of a new measure of adherence to exercise for MSK pain.

Physiotherapists' experiences of osteoarthritis guidelines in primary health care - an interview study

BACKGROUND

Osteoarthritis is a common joint disease, globally. Guidelines recommend information, exercise and, if needed, weight reduction as core treatment. There is a gap between evidence-based recommended care for osteoarthritis and clinical practice. To increase compliance to guidelines, implementation was conducted. The aim of the study was to explore physiotherapists' experiences of osteoarthritis guidelines and their experiences of implementation of the guidelines in primary health care in a region in southern Sweden.

METHODS

Eighteen individual, semi-structured interviews with physiotherapists in primary health care were analysed with inductive qualitative content analysis.

RESULTS

The analysis resulted in two categories and four subcategories. The physiotherapists were confident in their role as primary assessors for patients with osteoarthritis and the guidelines were aligned with their professional beliefs. The Supported Osteoarthritis Self-Management Programme, that is part of the guidelines, was found to be efficient for the patients. Even though the physiotherapists followed the guidelines they saw room for improvement since all patients with hip and/or knee osteoarthritis did not receive treatment according to the guidelines. Furthermore, the physiotherapists emphasised the need for management's support and that guidelines should be easy to follow.

CONCLUSION

The physiotherapists believed in the guidelines and were confident in providing first line treatment to patients with osteoarthritis. However, information about the guidelines probably needs to be repeated to all health care providers and management. Data from a national quality register on osteoarthritis could be used to a greater extent in daily clinical work in primary health care to improve quality of care for patients with osteoarthritis.

A mixed-methods survey of physiotherapists who practice acupuncture and dry needling in Ontario, Canada: practice characteristics, motivations, and professional outcomes

Background

Physiotherapists (PTs) across the globe are increasingly incorporating filiform needling techniques (e.g., acupuncture, dry needling) into their clinical toolkits; and, the evidence base for these complementary therapies is becoming progressively more robust. However, to date, little is known about needling PTs themselves.

Methods

Using a cross-sectional survey design, PTs authorized to perform needling therapies in Ontario, Canada were recruited for anonymous participation (n = 2061) in an online survey. The survey asked providers about their demographics and practice characteristics, rationale for and views about therapeutic needling, and their related clinical and professional outcomes. The response rate was 20.7% (n = 426), and 22.3% (n = 95) of respondents provided textual responses to an open-ended qualitative question.

Results

While study respondents’ demographic features appear similar to their broader professional population, Ontario’s needling PTs are less likely to work in public sector settings. Most completed training in medical acupuncture rather than dry needling, and typically used needling in over one-third of patient visits. Almost all endorsed needling as an effective musculoskeletal treatment, the primary factor informing their adoption of the practice. While many viewed traditional Chinese medical theories as a useful explanatory framework, most relied on biomedical epistemology to drive their needling work. A majority of respondents reported that the inclusion of needling within their clinical toolkits had improved their likelihood of achieving excellent clinical results, helped support patient recruitment and retention, and heightened their professional satisfaction. While a few reported earning a higher income as a result, most reported that their clinical use of needling in addition to other PT modalities reduced their physical fatigue after a day’s work.

Conclusions

This study represents a first scholarly investigation into the motivations, training backgrounds and practice patterns of PTs who use acupuncture or dry needling. Additional research from other jurisdictions is needed to evaluate the transferability of study findings.

Improving osteoarthritis management in primary healthcare: results from a quasi-experimental study

Background

To improve quality of care for patients with hip and knee osteoarthritis (OA), general practitioners (GPs) and physiotherapists (PTs) in a Norwegian municipality initiated an intervention. The intervention aimed to increase provision of core OA treatment (information, exercise, and weight control) prior to referral for surgery, rational use of imaging for assessing OA and improve communication between healthcare professionals. This study assessed the effectiveness of this intervention.

Methods

Forty-eight PTs and one hundred one GPs were invited to the intervention that included two interactive workshops outlining best practice and an accompanying template for PT discharge reports. Using interrupted time series research design, the study period was divided into three: pre-implementation, transition (implementation) and post-implementation. Comparing the change between pre- and post-implementation, the primary outcome was patient-reported quality of OA care measured with the OsteoArthritis Quality Indicator questionnaire. Secondary outcomes were number of PT discharge reports, information included in GP referral letters to orthopaedic surgeon, the proportion of GP referral letters indicating use of core treatment, and the use of imaging within OA assessment. Analyses involved linear mixed and logistic regression models.

Results

The PT workshop had 30 attendees, and 31 PTs and 33 GPs attended the multidisciplinary workshop. Two hundred eight and one hundred twenty-five patients completed the questionnaire during pre- and post-implementation, respectively. The adjusted model showed a small, statistically non-significant, increase in mean total score for quality of OA care (mean change = 4.96, 95% CI -0.18, 10.12, p:0.057), which was mainly related to items on OA core treatment. Patients had higher odds of reporting receipt of information on treatment alternatives (odds ratio (OR) 1.9, 95% CI 1.08, 3.24) and on self-management (OR 2.4, 95% CI 1.33, 4.32) in the post-implementation phase. There was a small, statistically non-significant, increase in the proportion of GP referral letters indicating prior use of core treatment modalities. There were negligible changes in the number of PT discharge reports, in the information included in the GP referral letters, and in the use of imaging for OA assessment.

Conclusion

This study suggests that a primary care intervention including two inter-active workshops can shift the quality of care towards best practice recommendations.

Trial registration

ClinicalTrials.gov: NCT02876120.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-03959-6.

Patient-reported quality indicators to evaluate physiotherapy care for hip and/or knee osteoarthritis- development and evaluation of the QUIPA tool

BACKGROUND

There is no physiotherapy-specific quality indicator tool available to evaluate physiotherapy care for people with hip and/or knee osteoarthritis (OA). This study aimed to develop a patient-reported quality indicator tool (QUIPA) for physiotherapy management of hip and knee OA and to assess its reliability and validity.

METHODS

To develop the QUIPA tool, quality indicators were initially developed based on clinical guideline recommendations most relevant to physiotherapy practice and those of an existing generic OA quality indicator tool. Draft items were then further refined using patient focus groups. Test-retest reliability, construct validity (hypothesis testing) and criterion validity were then evaluated. Sixty-five people with hip and/or knee OA attended a single physiotherapy consultation and completed the QUIPA tool one, twelve- and thirteen-weeks after. Physiotherapists (n = 9) completed the tool post-consultation. Patient test-retest reliability was assessed between weeks twelve and thirteen. Construct validity was assessed with three predefined hypotheses and criterion validity was based on agreement between physiotherapists and participants at week one.

RESULTS

A draft list of 23 clinical guideline recommendations most relevant to physiotherapy was developed. Following feedback from three patient focus groups, the final QUIPA tool contained 18 items (three subscales) expressed in lay language. The test-retest reliability estimates (Cohen's Kappa) for single items ranged from 0.30-0.83 with observed agreement of 64-94%. The intraclass correlation coefficient (ICC) and 95% confidence interval (CI) for the Assessment and Management Planning subscale was 0.70 (0.54, 0.81), Core Recommended Treatments subscale was 0.84 (0.75, 0.90), Adjunctive Treatments subscale was 0.70 (0.39, 0.87) and for the total QUIPA score was 0.80 (0.69, 0.88). All predefined hypotheses regarding construct validity were confirmed. However, agreement between physiotherapists and participants for single items showed large measurement error (Cohen's Kappa estimates ranged from - 0.04-0.59) with the ICC (95% CI) for the total score being 0.11 (- 0.14, 0.34).

CONCLUSIONS

The QUIPA tool showed acceptable test-retest reliability for subscales and total score but inadequate reliability for individual items. Construct validity was confirmed but criterion validity for individual items, subscales and the total score was inadequate. Further research is needed to refine the QUIPA tool to improve its clinimetric properties before implementation.

An exploration of psychosocial practice within private practice musculoskeletal physiotherapy: A cross-sectional survey

BACKGROUND

Patients with pain associated with musculoskeletal disorders often seek treatment from physiotherapists, necessitating these practitioners' competence to practice within the biopsychosocial framework. Qualitative research suggests musculoskeletal physiotherapists may not have adequate proficiency in psychosocial practice to assess and address psychosocial factors effectively.

OBJECTIVE

To collect quantitative self-report data via an online survey from a large cross section of Australian musculoskeletal physiotherapists regarding their psychosocial practice.

METHODS

The study involved an iterative survey development process followed by the conduct of this survey. A provisional survey named the 'Triple P Questionnaire' was developed, informed by the knowledge and experience of the research team. This Questionnaire was piloted by experts (n = 6) to provide feedback on the instrument. Changes were made to the survey based on this feedback. The finalised Triple P Questionnaire was distributed to Australian musculoskeletal physiotherapists.

RESULTS

181 participants completed the full survey. Not all demographic characteristics were representative of the population. Most participants indicated that they 'agree' to most statements posed in the questionnaire including confidence, routine practice of specific psychosocial skills and barriers. Some questions presented a majority response of 'disagree' or a spread of responses, indicating some evidence-practice gaps, including the use of questionnaires, and explicit assessment of psychological factors. Inferential statistics revealed no significant correlations between demographic characteristics and psychosocial practice.

CONCLUSION

The Triple P Questionnaire identified musculoskeletal physiotherapists' general confidence in their psychosocial practice but highlights some apparent inconsistencies in reported practice and areas where confidence is not as strong, reflecting possible evidence practice gaps.

Identifying and Prioritizing Clinical Guideline Recommendations Most Relevant to Physical Therapy Practice for Hip and/or Knee Osteoarthritis

BACKGROUND

Physical therapists are key providers of conservative management for hip and/or knee osteoarthritis (OA), yet not all guideline recommendations are tailored to their scope of practice.

OBJECTIVE

To identify and prioritize the most important recommendations relevant to physical therapy practice for hip and/or knee OA.

METHODS

International physical therapists (n = 132) were invited to participate in an online modified Delphi survey, followed by a priority-ranking exercise. A total of 63 recommendations were extracted from 2 recent high-quality clinical guidelines. In 3 Delphi rounds, the panel identified those recommendations they considered to be most relevant to physical therapy practice for hip and knee OA. Any new recommendations were ascertained. For a recommendation to be included, at least 70% of respondents had to rate the recommendation as 7 or above on a numeric rating scale (0 is not important and 10 is extremely important). The panel prioritized recommendations that remained after the final round using decision-making software.

RESULTS

Of 132 therapists from 14 countries, 62 completed round 1, 52 completed round 2, 45 completed round 3, and 35 completed the priority-ranking exercise. From an initial list of 70 potential recommendations (including 7 new recommendations), 30 were included in the priority-ranking exercise. The top recommendations were related to providing education and prescribing exercise and weight loss as core treatments, followed by individualized OA assessment and treatment and communication strategies.

CONCLUSION

This study identified and ranked the most important recommendations relevant to physical therapy practice for hip and/or knee OA. J Orthop Sports Phys Ther 2019;49(7):501-512. doi:10.2519/jospt.2019.8676.

How do UK physiotherapists address weight loss among individuals with hip osteoarthritis? A mixed-methods study

BACKGROUND

Weight loss is recommended as a core treatment for individuals with hip osteoarthritis who are overweight or obese. Physiotherapists play an important role in managing patients with hip osteoarthritis, but little is known about how they address weight. We aimed to explore how UK-based physiotherapists currently address weight loss among individuals with hip OA.

METHODS

We carried out a mixed-methods study. A cross-sectional questionnaire was mailed to 3,126 UK-based musculoskeletal physiotherapists. Self-reported approaches to addressing weight loss among individuals with hip osteoarthritis were explored using a case vignette and associated clinical management questions. Semi-structured telephone interviews (n = 21) were completed with a purposeful sample of physiotherapists who returned the questionnaire and provided consent for further contact. Interview data were analysed thematically.

RESULTS

There was a 53% response rate to the questionnaires (n = 1,646), and 1,148 responders were eligible for analyses (based on having treated an individual with hip OA in the last 6 months). Eight-five per cent of physiotherapists reported that they would address the vignette patient's weight, usually via advice (70%). Interviews identified that advice often focused on the importance of weight loss, with some physiotherapists offering basic advice on how to achieve weight loss. Multiple factors influenced their approach, including confidence, perceived remit and patient receptiveness.

CONCLUSIONS

UK physiotherapists commonly address weight loss among patients with hip osteoarthritis, by offering advice relating to the importance of weight loss. However, provision of more specific guidance on how to achieve weight loss is variable. With additional training, physiotherapists could play an important role in supporting weight loss among patients with hip OA, thus potentially optimizing treatment outcomes.

A mixed methods exploration of physiotherapist's approaches to analgesic use among patients with hip osteoarthritis

OBJECTIVE

To explore how physiotherapists currently address analgesic use among patients with hip osteoarthritis, and their beliefs about the acceptability of prescribing for these patients.

METHODS

A cross-sectional questionnaire was mailed to 3126 UK-based physiotherapists. Approaches to analgesic use among patients with hip osteoarthritis were explored using a case vignette. Semi-structured telephone interviews were undertaken with 21 questionnaire responders and analysed thematically.

SETTING

UK.

PARTICIPANTS

Physiotherapists who had treated a patient with hip osteoarthritis in the previous 6 months.

RESULTS

Questionnaire response: 53% (n=1646). One thousand one hundred forty eight physiotherapists reported treating a patient with hip osteoarthritis in the last 6 months (applicable responses), of whom nine (1%) were non-medical prescribers. Nearly all physiotherapists (98%) reported that they would address analgesic use for the patient with hip osteoarthritis, most commonly by signposting them to their GP (83%). Fifty six percent would discuss optimal use of current medication, and 33%, would discuss use of over-the-counter medications. Interviews revealed that variations in physiotherapists' approaches to analgesic use were influenced by personal confidence, patient safety concerns, and their perceived professional remit. Whilst many recognised the benefits of analgesia prescribing for both patients and GP workload, additional responsibility for patient safety was a perceived barrier.

CONCLUSIONS

How physiotherapists currently address analgesic use with patients with hip osteoarthritis is variable. Although the potential benefits of independent prescribing were recognised, not all physiotherapist want the additional responsibility. Further guidance supporting optimisation of analgesic use among patients with hip OA may help better align care with best practice guidelines and reduce GP referrals.