Clinicians' beliefs and attitudes to physical activity and exercise therapy as treatment for knee and/or hip osteoarthritis: a scoping review

[Does patient communication influence kinesiophobia? A systematic review]

The aim of the present systematic review was to determine the effect of communication in the health care setting on kinesiophobia. To this end, a literature search was conducted in seven databases between November 2022 and February 2023. The review was carried out following the PRISMA statement and for the analysis of methodological quality we used: PEDro Scale, Van Tulder criteria and risk of bias analysis of the Cochrane Collaboration. A total of 13 articles were included with a mean methodological quality of 7.1 out of 10. Significant results were obtained for at least one variable (kinesiophobia, disability or level of physical activity) in 12 articles. There is strong evidence that communication can influence a subject's kinesiophobia. This influence is most likely to be in a negative or disabling sense, but it can also act in a positive sense by decreasing it.

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.

Comparing physical therapy students' attitudes and beliefs regarding chronic low back pain and knee osteoarthritis: an international multi-institutional comparison between 2013 and 2020 academic years

BACKGROUND

In 2013, physical therapy students demonstrated low guideline-adherent recommendations regarding chronic low back pain (CLBP) for spinal pathology, activity, and work.

OBJECTIVES

To assess the differences in physical therapy students' attitudes, beliefs, and adherence to guideline recommendations regarding CLBP and knee osteoarthritis between 2013 and 2020.

METHODS

In 2013 and 2020, second and fourth-year physical therapy students were recruited from 6 Belgian and 2 Dutch institutions. Attitudes and beliefs regarding CLBP and knee OA were evaluated using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), and a questionnaire regarding therapeutic exercise and knee osteoarthritis. A clinical vignette was used to measure guideline-adherent recommendations regarding spinal pathology, activity, and work.

RESULTS

In 2013, 927 second-year and 695 fourth-year students; in 2020, 695 second-year and 489 fourth-year students; were recruited to participate in the study. Compared to 2013, students had less biomedical and stronger biopsychosocial attitudes and beliefs regarding CLBP, more guideline-adherent recommendations for activity, and more biopsychosocial beliefs regarding the benefits of exercise for patients with knee osteoarthritis in both the second and fourth year. Only fourth-year students in 2020 scored significantly better on HC-PAIRS and guideline-adherent recommendation relating to spinal pathology. No differences were found regarding work recommendations.

CONCLUSIONS

Between 2013 and 2020, physical therapy students made a positive shift towards a more biopsychosocial approach to CLBP and knee osteoarthritis management. Guideline-adherent recommendations for CLBP concerning activity improved, however, concerning work and spinal pathology, it remained low.

Usage of guideline-adherent core treatments for knee osteoarthritis before and after consulting an orthopaedic surgeon: A prospective cohort study

Objective

To describe 1) the proportion of patients with knee osteoarthritis (OA) undergoing guideline-adherent core treatments until six months after primary referral to an orthopaedic surgeon, 2) which specific treatment pathways these patients undertake and 3) the characteristics of patients choosing different treatment pathways.

Design

This prospective cohort study consecutively invited patients referred to an orthopaedic surgeon due to knee OA at two Danish hospitals from October 2018 to December 2020. Before and six months after consulting the surgeon, patients answered a questionnaire reporting which treatments they had received for knee OA. The proportion receiving the combination of guideline-adherent treatments (i.e., exercise, education, and dietary weight management if needed) was determined. We evaluated the specific treatment usage before and until six months after the consultation and investigated characteristics of patients undertaking different pathways.

Results

Out of 5251 eligible patients, 2574 (49%) had complete data and were included in analyses. 23% received guideline-adherent treatments, 10% had no treatment. Patients underwent 1143 unique treatment pathways, 62% including treatments not recommended/recommended against. Those who underwent guideline-adherent pathways had similar characteristics to those who did not but tended to be females, retired, had longer-lasting knee problems, have comorbidities, and higher education levels.

Conclusions

Only one in four patients with knee OA received treatment adhering to clinical guidelines before and six months after consulting the surgeon. Patients used many different treatment pathways. There is a need for a structured effort to increase the use of guideline-adherent core treatments.

Trial Identifiers

Registration: NCT03746184, Protocol: PMID: 34233992.

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.

From sceptic to believer: Acceptability of cognitive muscular therapyTM , a new intervention for knee osteoarthritis

BACKGROUND

Cognitive Muscular TherapyTM (CMT) is an integrated behavioural intervention developed for knee osteoarthritis. CMT teaches patients to reconceptualise the condition, integrates muscle biofeedback and aims to reduce muscle overactivity, both in response to pain and during daily activities. This nested qualitative study explored patient and physiotherapist perspectives and experiences of CMT.

METHODS

Five physiotherapists were trained to follow a well-defined protocol and then delivered CMT to at least two patients with knee osteoarthritis. Each patient received seven individual clinical sessions and was provided with access to online learning materials incorporating animated videos. Semi-structured interviews took place after delivery/completion of the intervention and data were analysed at the patient and physiotherapist level.

RESULTS

Five physiotherapists and five patients were interviewed. All described a process of changing beliefs throughout their engagement with CMT. A framework with three phases was developed to organise the data according to how osteoarthritis was conceptualised and how this changed throughout their interactions with CMT. Firstly, was an identification of pain beliefs to be challenged and recognition of how current beliefs can misalign with daily experiences. Secondly was a process of challenging and changing beliefs, validated through new experiences. Finally, there was an embedding of changed beliefs into self-management to continue with activities.

CONCLUSION

This study identified a range of psychological changes which occur during exposure to CMT. These changes enabled patients to reconceptualise their condition, develop a new understanding of their body, understand psychological processes, and make sense of their knee pain.

Multidisciplinary Rehabilitation after Hyaluronic Acid Injections for Elderly with Knee, Hip, Shoulder, and Temporomandibular Joint Osteoarthritis

Osteoarthritis (OA) is a prevalent degenerative joint condition characterized by cartilage deterioration, joint inflammation, and functional limitations, particularly impacting the elderly population. Rehabilitation and hyaluronic acid (HA) injections are common therapeutic approaches routinely used in clinical practice, but their synergistic potential is far from being fully characterized. Thus, the aim of this narrative review was to elucidate the multilevel benefits and synergies of integrating these two approaches in multidisciplinary OA rehabilitation. This narrative review follows the scale for the assessment of narrative review articles (SANRA) criteria and involves a comprehensive literature search from July to August 2023. Two independent reviewers screened studies, including those involving human subjects with OA, rehabilitation strategies, and outcomes following HA injection, published in English. Results: HA injections might improve joint biomechanics, reducing friction, absorbing shocks, and potentially regulating inflammation. Rehabilitation plays a pivotal role in strengthening muscles, increasing the range of motion, and enhancing overall function. Optimizing rehabilitation following HA injection might provide additional benefits in joint health. OA management requires a multidisciplinary approach integrating HA injections, rehabilitation, and personalized care. Challenges in patient adherence and healthcare resources currently exist, but emerging technologies offer opportunities to enhance patient engagement and monitoring optimizing sustainability and outcomes of patients with knee, hip, shoulder, and temporomandibular joint OA.

"You're stuck in the middle here": a qualitative study of GPs' experiences of managing knee pain attributed to a degenerative meniscal tear

BACKGROUND

Exercise is the recommended first-line therapy for a degenerative meniscal tear (DMT). Despite this, knee pain attributed to DMTs are a common presentation to specialist orthopaedic clinics. In the primary care setting, the general practitioner (GP) plays a central role in managing patients with knee pain, but to date their perspective has not been explored in relation to DMTs. This study explored GPs' experiences of managing people with knee pain attributed to a DMT.

METHODS

A qualitative research design was adopted and practices in the South and Mid-West of Ireland were contacted via recruitment emails circulated through professional and research networks. Interested GPs contacted the researchers via email, and purposive and snowball sampling was used for recruitment. Semi-structured interviews were conducted online or over the telephone. Interviews were digitally recorded and transcribed. Data was analysed using an inductive approach to thematic analysis. Ethical approval was granted by the Irish College of General Practitioners (ICGP_REC_21_0031).

RESULTS

Seventeen semi-structured one-on-one interviews were conducted. Three main themes were identified with related subthemes: (1) GPs' experiences of relational aspects of care, (2) GP beliefs about what constitutes best care for patients with a DMT, and (3) how GP practice is enacted within the current healthcare setting. GPs described the challenge of maintaining a strong clinical alliance, while managing perceived patient expectations of a 'quick fix' and advanced imaging. They reported slowing down clinical decisions and feeling 'stuck' with limited options when conservative treatment had failed. GPs believed that exercise should be the core treatment for DMTs and emphasised engaging patients in an active approach to recovery. Some GPs believed arthroscopy had a role in circumstances where patients didn't improve with physiotherapy. Limited access to public physiotherapy and orthopaedic services hampered GPs' management plans and negatively impacted patient outcomes.

CONCLUSIONS

GP beliefs around what constitutes best care for a DMT generally aligned with the evidence base. Nonetheless, there was sometimes tension between these beliefs and the patient's own treatment expectations. The ability to enact their beliefs was hampered by limited access to conservative management options, sometimes leading to early escalation of care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

A pilot randomized controlled trial evaluating outdoor community walking for knee osteoarthritis: walk

OBJECTIVES

To determine the feasibility of a randomized controlled trial (RCT) examining outdoor walking on knee osteoarthritis (KOA) clinical outcomes and magnetic resonance imaging (MRI) structural changes.

METHOD

This was a 24-week parallel two-arm pilot RCT in Tasmania, Australia. KOA participants were randomized to either a walking plus usual care group or a usual care control group. The walking group trained 3 days/week. The primary outcome was feasibility assessed by changes being required to the study design, recruitment, randomization, program adherence, safety, and retention. Exploratory outcomes were changes in symptoms, physical performance/activity, and MRI measures.

RESULTS

Forty participants (mean age 66 years (SD 1.4) and 60% female) were randomized to walking (n = 24) or usual care (n = 16). Simple randomization resulted in a difference in numbers randomized to the two groups. During the study, class sizes were reduced from 10 to 8 participants to improve supervision, and exclusion criteria were added to facilitate program adherence. In the walking group, total program adherence was 70.0% and retention 70.8% at 24 weeks. The walking group had a higher number of mild adverse events and experienced clinically important improvements in symptoms (e.g., visual analogue scale (VAS) knee pain change in the walking group: - 38.7 mm [95% CI - 47.1 to - 30.3] versus usual care group: 4.3 mm [- 4.9 to 13.4]).

CONCLUSIONS

This study supports the feasibility of a full-scale RCT given acceptable adherence, retention, randomization, and safety, and recruitment challenges have been identified. Large symptomatic benefits support the clinical usefulness of a subsequent trial.

TRIAL REGISTRATION NUMBER

12618001097235. Key Points • This pilot study is the first to investigate the effects of an outdoor walking program on knee osteoarthritis clinical outcomes and MRI joint structure, and it indicates that a full-scale RCT is feasible. • The outdoor walking program (plus usual care) resulted in large improvements in self-reported knee osteoarthritis symptoms compared to usual care alone. • The study identified recruitment challenges, and the manuscript explores these in more details and provides recommendations for future studies.

Patient and public involvement to inform the protocol of a clinical trial comparing total hip arthroplasty with exercise: an exploratory qualitative case study

OBJECTIVE

To explore patient, clinician and decision-maker perceptions on a clinical trial evaluating the effectiveness of total hip arthroplasty (THA) compared with exercise to inform the trial protocol.

DESIGN

This is an exploratory qualitative case study using a constructivist paradigm.

SETTING AND PARTICIPANTS

Participants were enrolled into three key stakeholder groups: patients eligible for THA, clinicians, and decision makers. Focus group interviews were conducted in undisturbed conference rooms at two hospitals in Denmark, according to group status using semi-structured interview guides.

ANALYSIS

Interviews were recorded, transcribed verbatim and thematic analysed using an inductive approach.

RESULTS

We conducted 4 focus group interviews with 14 patients, 1 focus group interview with 4 clinicians (2 orthopaedic surgeons and 2 physiotherapists) and 1 focus group interview with 4 decision-makers. Two main themes were generated. 'Treatment expectations and beliefs impact management choices' covered three supporting codes: Treatment without surgery is unlikely to lead to recovery; Clinician authority impacts the management narrative; The 'surgery vs exercise' debate. 'Factors influencing clinical trial integrity and feasibility' highlighted three supporting codes: Who is considered eligible for surgery?; Facilitators and barriers for surgery and exercise in a clinical trial context; Improvements in hip pain and hip function are the most important outcomes.

CONCLUSIONS

Based on key stakeholder treatment expectations and beliefs, we implemented three main strategies to improve the methodological rigorousness of our trial protocol. First, we added an observational study investigating the generalisability to address a potential low enrolment rate. Second, we developed an enrolment procedure using generic guidance and balanced narrative conveyed by an independent clinician to facilitate communication of clinical equipoise. Third, we adopted change in hip pain and function as the primary outcome. These findings highlight the value of patient and public involvement in the development of trial protocols to reduce bias in comparative clinical trials evaluating surgical and non-surgical management.

TRIAL REGISTRATION NUMBER

NCT04070027 (pre-results).

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.

Putting the pieces together: A qualitative study exploring perspectives on self-management and exercise behavior among people living with multimorbidity, healthcare professionals, relatives, and patient advocates

Background Behavior change and exercise are considered critical for successful self-management in people with multimorbidity, however, little is known about people’s needs, experiences, and preferences. Purpose The aim of this study was to qualitatively explore the perspectives of people living with multimorbidity, healthcare professionals, relatives, and patient advocates in relation to self-management and exercise behavior. Research design Analysis was carried out by means of a hybrid inductive-deductive approach using Framework Analysis that enabled the subsequent use of the COM-B model in relation to the study of exercise behavior specifically. Study sample We conducted 17 interviews (9 focus groups; 8 key informants) with 48 informants from four groups (22 people living with multimorbidity, 17 healthcare professionals, 5 relatives, and 5 patient advocates). Data analysis Through an inductive Framework analysis, we constructed three themes: Patient education, supporting behavior change, and lack of a “burning platform.” Subsequent deductive application of the COM-B profile (applied solely to data related to exercise behavior) unveiled a variety of barriers to exercise and self-management support (pain, fatigue, breathlessness, lack of motivation, financial issues, accessibility, decreased social support). Results Overall, the four groups shared common understandings while also expressing unique challenges. Conclusions Future interventions and/or policies targeting exercise behavior in people living with multimorbidity should address some of the barriers identified in this study.

Deep Learning-Based CT Imaging to Evaluate the Therapeutic Effects of Acupuncture and Moxibustion Therapy on Knee Osteoarthritis

The study was aimed at analyzing the application value of deep learning-based computed tomography (CT) in evaluating the effect of acupuncture for knee osteoarthritis (KOA). Specifically, 124 patients with KOA were selected in the test group (warm acupuncture and moxibustion) and the control group (simple acupuncture), with 62 cases in each group. Deep learning-based CT scanning was performed before and after treatment to compare the Lequesne-Mery, Visual Analog Scale (VAS), Western Ontario and McMaster Universities (WOMAC), Hospital Special Surgery (HSS), and Knee Society Score (KSS) scores as well as the overall effective rate. The results showed that the trabecular thickness, quantity, bone mineral density (BMD), connection density, structural model index, and articular cartilage thickness were different significantly between the two groups (P < 0.05). After treatment, the Lequesne-Mery was 4.78, the VAS was 0.87, and the WOMAC score was 14.89 of the test group, which were reduced (P < 0.05). The KSS and HSS scores of the test group were improved significantly after treatment (P < 0.05). The total effective rate of the test group was 85.48%, and that of the control group was 51.61%; the former was significantly higher than the latter (P < 0.05). In conclusion, acupuncture could improve the clinical effect on KOA patients, and CT scanning under deep learning algorithm could evaluate the clinical effect of acupuncture for KOA.

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.