A qualitative study exploring the views of individuals with knee osteoarthritis on the role of physiotherapists in weight management: A complex issue requiring a sophisticated skill set

Alternative models to support weight loss in chronic musculoskeletal conditions: effectiveness of a physiotherapist-delivered intensive diet programme for knee osteoarthritis, the POWER randomised controlled trial

OBJECTIVES

To determine if physiotherapists can deliver a clinically effective very low energy diet (VLED) supplementary to exercise in people with knee osteoarthritis (OA) and overweight or obesity.

METHODS

88 participants with knee OA and body mass index (BMI) >27 kg/m2 were randomised to either intervention (n=42: VLED including two daily meal replacement products supplementary to control) or control (n=46: exercise). Both interventions were delivered by unblinded physiotherapists via six videoconference sessions over 6 months. The primary outcome was the percentage change in body weight at 6 months, measured by a blinded assessor. Secondary outcomes included BMI, waist circumference, waist-to-hip ratio, self-reported measures of pain, function, satisfaction and perceived global change, and physical performance tests.

RESULTS

The intervention group lost a mean (SD) of 8.1% (5.2) body weight compared with 1.0% (3.2) in the control group (mean (95% CI) between-group difference 7.2% (95% CI 5.1 to 9.3), p<0.001), with significantly lower BMI and waist circumference compared with control group at follow-up. 76% of participants in the intervention group achieved ≥5% body weight loss and 37% acheived ≥10%, compared with 12% and 0%, respectively, in the control group. More participants in the intervention group (27/38 (71.1%)) reported global knee improvement than in the control group (20/42 (47.6%)) (p=0.02). There were no between-group differences in any other secondary outcomes. No serious adverse events were reported.

CONCLUSION

A VLED delivered by physiotherapists achieved clinically relevant weight loss and was safe for people with knee OA who were overweight or obese. The results have potential implications for future service models of care for OA and obesity.

TRIAL REGISTRATION NUMBER

NIH, US National Library of Medicine, Clinicaltrials.gov NCT04733053 (1 February 2021).

Putting weight-related conversations into practice: Lessons learned from implementing a knowledge translation casebook in a disability context

BACKGROUND

Due to reported challenges experienced by healthcare providers (HCPs) when having weight-related conversations with children with disabilities and their families, a knowledge translation (KT) casebook was developed, providing key communication principles with supportive resources. Our aim was to explore how the KT casebook could be implemented into a disability context. Study objectives were to develop and integrate needs-based implementation supports to help foster the uptake of the KT casebook communication principles.

METHODS

A sample of nurses, physicians, occupational therapists and physical therapists were recruited from a Canadian paediatric rehabilitation hospital. Informed by the Theoretical Domains Framework, group interviews were conducted with participants to understand barriers to having weight-related conversations in their context. Implementation strategies were developed to deliver the KT casebook content that addressed these identified barriers, which included an education workshop, simulations, printed materials, and a huddle and email strategy. Participant experiences with the implementation supports were captured through workshop evaluations, pre-post surveys and qualitative interviews. Post-implementation interviews were analysed using descriptive content analysis.

RESULTS

Ten HCPs implemented the KT casebook principles over 6 months. Participants reported that the workshop provided a clear understanding of the KT casebook content. While HCPs appreciated the breadth of the KT casebook, they found the abbreviated printed educational materials more convenient. Strategies developed to address participants' need for a sense of community and opportunities to learn from each other did not achieve their aim. Increased confidence in integrating the KT casebook principles into practice was not demonstrated, due, in part, to having few opportunities to practice. This was partly because of the increase in competing clinical demands at the onset of the COVID-19 pandemic.

CONCLUSIONS

Despite positive feedback on the product itself, changes in the organisational and environmental context limited the success of the implementation plan. Monitoring and adapting implementation processes in response to unanticipated changes is critical to the success of implementation efforts.

'The fact that I know I can do it is quite a motivator now': a qualitative study exploring experiences maintaining weight loss 6 months after completing a weight loss programme for knee osteoarthritis

OBJECTIVE

To explore experiences maintaining weight loss 6 months after completing a multicomponent weight loss programme for knee osteoarthritis.

DESIGN

Qualitative study based on an interpretivist paradigm and a phenomenological approach that was embedded within a randomised controlled trial.

SETTING

Semistructured interviews were conducted with participants 6 months after completing a 6-month weight loss programme (ACTRN12618000930280) involving a ketogenic very low calorie diet (VLCD), exercise and physical activity programme, videoconferencing consultations with a dietitian and physiotherapist, and provision of educational and behaviour change resources and meal replacement products. Interviews were audio recorded, transcribed verbatim and data were analysed based on the principles of reflexive thematic analysis.

PARTICIPANTS

20 people with knee osteoarthritis.

RESULTS

Three themes were developed: (1) successfully maintained weight loss; (2) empowering self-management of weight (understand importance of exercise; increased knowledge about food and nutrition; resources from programme still useful; knee pain as a motivator; confidence in ability to self-regulate weight) and (3) challenges keeping on track (loss of accountability to dietitian and study; old habits and social situations; stressful life events or changes in health).

CONCLUSION

Participants had overall positive experiences maintaining their weight loss since completing the weight loss programme and were confident in their ability to self-regulate their weight in the future. Findings suggest a programme incorporating dietitian and physiotherapist consultations, a VLCD, and educational and behaviour change resources supports confidence maintaining weight loss in the medium term. Further research is required to explore strategies to overcome barriers like loss of accountability and returning to old eating habits.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

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

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05496-2.

Patient engagement in the design of an intervention to prevent muscle loss in individuals with knee osteoarthritis and a body mass index (BMI) ≥ 35

OBJECTIVE

Interventions for knee osteoarthritis (OA) in adults with a large body size (defined as a body mass index [BMI] ≥ 35 kg/m² ) often prioritise weight-loss, which may overshadow specific benefits for physical function, metabolic health, and body composition. As part of the development of a future clinical study, we gathered perspectives from individuals living with knee OA and a large body size to inform the proposed intervention design and delivery.

METHODS

Purposive and voluntary sampling was used to engage individuals ≥40 years of age with self-reported knee OA and a BMI ≥ 35 kg/m² . An anonymous electronic survey was distributed on social media between April 2020 and June 2020. Open-ended questions addressed a proposed 12-week multimodal intervention (involving targeted nutrition, resistance exercises, and self-management support). An optional semi-structured interview was offered upon completion, with interviews recorded and transcribed verbatim. Reflexive thematic analysis and interpretation guided by an acceptability framework was used to identify recommendations for the intervention design and delivery.

RESULTS

Twenty individuals living across Canada completed the survey (100% female; 18 aged <65 years and 2 ≥ 65 years). Ten individuals completed the interview. From aggregate survey and interview data, three recommendations were generated: (1) the effectiveness of the intervention for health improvement (specifically mobility and pain) must be emphasised to avoid perceived weight-loss expectations; (2) extend support beyond 12-weeks and consider terminology free from weight-bias to enhance acceptance; (3) include optional customisation of intervention delivery to reduce acceptability-related burden.

CONCLUSION

These female patient-derived recommendations may improve perceived intervention acceptability, and thereby may enhance participant enrolment and retention in clinical trials.

Obesity Hurts: The Why and How of Integrating Weight Reduction With Chronic Pain Management

Amongst adults with chronic pain, overweight and obesity are highly prevalent. The association between chronic pain and overweight is driven by several explanations, including increased biomechanical load, changes in the gut microbiome, and low-grade (neuro)inflammation. Moreover, the link between overweight, obesity and chronic pain can best be considered from a lifestyle perspective. Since conservative treatment for chronic pain is often limited to short-term and small effects, addressing important comorbidities within a lifestyle approach could be the next step towards precision medicine for these patients. Indeed, evidence shows that combining weight reduction with conservative pain management is more effective to reduce pain and disability, compared to either intervention alone. This perspective article aims to update the reader with the current understanding of the possible explanatory mechanisms behind the interaction between overweight/obesity and chronic pain in an adult population. Second, this paper applies this knowledge to clinical practice, including assessment and conservative treatment of overweight/obesity in adults with chronic pain. Henceforth, clinical recommendations and guidelines are provided based on available scientific evidence and the authors' clinical expertise.

IMPACT

This paper will guide clinicians in the implementation of weight reduction programs within pain management.

Reported practices related to, and capability to provide, first-line knee osteoarthritis treatments: a survey of 1064 Australian physical therapists

BACKGROUND

Physical therapists play a key role in providing first-line knee osteoarthritis treatments, including patient education and exercise therapy.

OBJECTIVES

Describe Australian physical therapists' awareness of guidelines; reported practices; and beliefs about capability, opportunity, motivation, and evidence.

METHODS

An online cross-sectional survey was completed by physical therapists prior to attending the Good Living with osteoArthritis from Denmark (GLA:D®) Australia training courses (March 2017 to December 2019). The survey instrument was developed by an expert panel and was informed by the Theoretical Domains Framework.

RESULTS

1064 physical therapists from all Australian states and territories participated. 11% (n = 121) could name an accepted guideline, 98% agreed it was their job to deliver patient education and exercise therapy, and 92% agreed this would optimise outcomes. Most reported providing strength exercise (99%), written exercise instructions (95%), treatment goal discussion (88%), and physical activity advice (83%) all or most of the time. Fewer provided aerobic exercise (66%), neuromuscular exercise (54%), and weight management discussion (56%) all or most of the time. Approximately one quarter (23-24%) believed they did not have the skills, knowledge, or confidence to provide education and exercise therapy recommended by guidelines, and just 48% agreed they had been trained to do so.

CONCLUSION

Australian physical therapists treating knee osteoarthritis typically provide strength-based home exercise with written instructions, alongside goal setting and physical activity advice. Just one in nine could name a guideline. Education and training activities are needed to support physical therapists to access, read and implement guidelines, especially for aerobic and neuromuscular exercise, and weight management.

"It's the single best thing I've done in the last 10 years": a qualitative study exploring patient and dietitian experiences with, and perceptions of, a multi-component dietary weight loss program for knee osteoarthritis

OBJECTIVE

Explore patient and dietitian experiences with a multi-component dietary weight loss program for knee osteoarthritis to understand enablers and challenges to success at 6-months.

DESIGN

Qualitative study embedded within a randomised controlled trial. Semi-structured individual interviews with 24 patients with knee osteoarthritis who undertook, and five dietitians who supervised, a weight management program (involving a ketogenic very low calorie diet (VLCD), video consultations, educational resources) over 6 months. Data were thematically analysed.

RESULTS

Five themes were developed: (1) ease and convenience of program facilitated adherence (structure and simplicity of the meal replacements; not feeling hungry on diet; convenience of consulting via video) (2) social and professional support crucial for success (encouragement from partner, family, and friends; guidance from, and accountability to, dietitian; anxiety around going at it alone) (3) program was engaging and motivating (determination to stick to program; rapid weight loss helped motivation) (4) holistic nature of program was important (suite of high-quality educational resources; exercise important to compliment weight loss) (5) rewarding experience and lifelong impact (improved knee pain and function; positive lifestyle change).

CONCLUSIONS

Patients and dietitians described positive experiences with the weight management program, valuing its simplicity, effectiveness, and convenience. Support from dietitians and a comprehensive suite of educational resources, incorporated with an exercise program, were considered crucial for success. Findings suggest this multi-component dietary program is an acceptable weight loss method in people with knee osteoarthritis that may benefit symptoms. Strategies for supporting long-term independent weight management should be a focus of future research.

Patient experiences with physiotherapy for knee osteoarthritis in Australia-a qualitative study

OBJECTIVE

Physiotherapists commonly provide non-surgical care for people with knee osteoarthritis (OA). It is unknown if patients are receiving high-quality physiotherapy care for their knee OA. This study aimed to explore the experiences of people who had recently received physiotherapy care for their knee OA in Australia and how these experiences aligned with the national Clinical Care Standard for knee OA.

DESIGN

Qualitative study using semistructured individual telephone interviews and thematic analysis, where themes/subthemes were inductively derived. Questions were informed by seven quality statements of the OA of the Knee Clinical Care Standard. Interview data were also deductively analysed according to the Standard.

SETTING

Participants were recruited from around Australia via Facebook and our research volunteer database.

PARTICIPANTS

Interviews were conducted with 24 people with recent experience receiving physiotherapy care for their knee OA. They were required to be aged 45 years or above, had activity-related knee pain and any knee-related morning stiffness lasted no longer than 30 min. Participants were excluded if they had self-reported inflammatory arthritis and/or had undergone knee replacement surgery for the affected knee.

RESULTS

Six themes emerged: (1) presented with a pre-existing OA diagnosis (prior OA care from other health professionals; perception of adequate OA knowledge); (2) wide variation in access and provision of physiotherapy care (referral pathways; funding models; individual vs group sessions); (3) seeking physiotherapy care for pain and functional limitations (knee symptoms; functional problems); (4) physiotherapy management focused on function and exercise (assessment of function; various types of exercises prescribed; surgery, medications and injections are for doctors; adjunctive treatments); (5) professional and personalised care (trust and/or confidence; personalised care) and (6) physiotherapy to postpone or prepare for surgery.

CONCLUSION

Patients' experiences with receiving physiotherapy care for their knee OA were partly aligned with the standard, particularly regarding comprehensive assessment, self-management, and exercise.