Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients eligible for knee replacement: A qualitative interview study nested in the QUADX-1 trial

Rasmus Skov Husted, Thomas Bandholm, Michael Skovdal Rathleff, Anders Troelsen, Jeanette Kirk, Rasmus Skov Husted, Thomas Bandholm, Michael Skovdal Rathleff, Anders Troelsen, Jeanette Kirk

Abstract

Aim: Clinical guidelines recommend non-surgical treatment before surgery is considered in patients eligible for knee replacement. Surgical treatment is provided by orthopedic surgeons and exercise therapy is provided by physical therapists. The aim of this study was to identify perceived facilitators and barriers-among orthopedic surgeons and physical therapists-towards coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise.

Methods: This qualitative study is embedded within the QUADX-1 randomized trial that investigates a model of coordinated non-surgical and surgical treatment for patients eligible for knee replacement. Physical therapists and orthopedic surgeons working with patients with knee osteoarthritis in their daily clinical work were interviewed (one focus group and four single interviews) to explore their perceived facilitators and barriers related to pre-operative home-based exercise therapy with one exercise-only in patients eligible for knee replacement. Interviews were analyzed using thematic analysis.

Results: From the thematic analysis three main themes emerged: 1) Physical therapists' dilemma with one home-based exercise, 2) Orthopedic surgeons' dilemma with exercise, and 3) Coordinated non-surgical and surgical care.

Conclusion: We found that the pre-operative exercise intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons. The physical therapists were skeptical towards over-simplified exercise therapy. The orthopedic surgeons were skeptical towards the potential lack of (long-term) effect of exercise therapy in patients eligible for knee replacement. The consequence of these barriers and ambivalence in the professional role is important to consider when planning implementation of the model of coordinated non-surgical and surgical treatment.

Trial registration: ClinicalTrials.gov, ID: NCT02931058.

Conflict of interest statement

Dr. Troelsen reports personal fees from Zimmer Biomet, grants from Zimmer Biomet, personal fees from European Knee Society, outside the submitted work. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

References

    1. Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States–an alternative projection model. Osteoarthritis Cartilage. 2017;25: 1797–1803. 10.1016/j.joca.2017.07.022
    1. Pedersen A, Mehnert, Odgaard A, Schrøder HM. Existing data sources for clinical epidemiology: The Danish Knee Arthroplasty Register. Clin Epidemiol. 2012; 125 10.2147/CLEP.S30050
    1. Hubertsson J, Petersson IF, Thorstensson CA, Englund M. Risk of sick leave and disability pension in working-age women and men with knee osteoarthritis. Ann Rheum Dis. 2012; annrheumdis–2012.
    1. Roos EM, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS)-validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes. 2003;1: 17 10.1186/1477-7525-1-17
    1. Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, et al. Knee replacement. The Lancet. 2012;379: 1331–1340.
    1. Hawker G, Wright J, Coyte P, Paul J, Dittus R, Croxford R, et al. Health-Related Quality of Life after Knee Replacement: Results of the Knee Replacement Patient Outcomes Research Team Study*. J Bone Joint Surg Am. 1998;80: 163–173. 10.2106/00004623-199802000-00003
    1. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil OARS Osteoarthr Res Soc. 2014;22: 363–388. 10.1016/j.joca.2014.01.003
    1. Sundhedsstyrelsen—Knæartrose. Nationale kliniske retningslinjer og faglige visitationsretningslinjer. 1st ed Kbh; 2012.
    1. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev. 2015;9: CD004376 10.1002/14651858.CD004376.pub3
    1. Conaghan PG, Dickson J, Grant RL. Care and management of osteoarthritis in adults: summary of NICE guidance. BMJ. 2008;336: 502–503. 10.1136/
    1. Ravaud P. Management of osteoarthritis (OA) with an unsupervised home based exercise programme and/or patient administered assessment tools. A cluster randomised controlled trial with a 2x2 factorial design. Ann Rheum Dis. 2004;63: 703–708. 10.1136/ard.2003.009803
    1. Hurley MV, Walsh NE, Mitchell H, Nicholas J, Patel A. Long-term outcomes and costs of an integrated rehabilitation program for chronic knee pain: A pragmatic, cluster randomized, controlled trial. Arthritis Care Res. 2012;64: 238–247. 10.1002/acr.20642
    1. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Rasmussen S, et al. Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials. Osteoarthritis Cartilage. 2018;26: 1170–1180. 10.1016/j.joca.2018.04.014
    1. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med. 2015;373: 1597–1606. 10.1056/NEJMoa1505467
    1. Dabare C, Le Marshall K, Leung A, Page CJ, Choong PF, Lim KK. Differences in presentation, progression and rates of arthroplasty between hip and knee osteoarthritis: Observations from an osteoarthritis cohort study-a clear role for conservative management. Int J Rheum Dis. 2017;20: 1350–1360. 10.1111/1756-185X.13083
    1. Gwynne-Jones JH, Wilson RA, Wong JMY, Abbott JH, Gwynne-Jones DP. The Outcomes of Nonoperative Management of Patients With Hip and Knee Osteoarthritis Triaged to a Physiotherapy-Led Clinic at Minimum 5-Year Follow-Up and Factors Associated With Progression to Surgery. J Arthroplasty. 2020. [cited 10 Mar 2020]. 10.1016/j.arth.2020.01.086
    1. Calatayud J, Casaña J, Ezzatvar Y, Jakobsen MD, Sundstrup E, Andersen LL. High-intensity preoperative training improves physical and functional recovery in the early post-operative periods after total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2016;25: 2864–2872. 10.1007/s00167-016-3985-5
    1. Skoffer B, Maribo T, Mechlenburg I, Hansen PM, Søballe K, Dalgas U. Efficacy of Preoperative Progressive Resistance Training on Postoperative Outcomes in Patients Undergoing Total Knee Arthroplasty: Progressive Resistance Training Before TKA. Arthritis Care Res. 2016;68: 1239–51. 10.1002/acr.22825
    1. Cobos R, Latorre A, Aizpuru F, Guenaga JI, Sarasqueta C, Escobar A, et al. Variability of indication criteria in knee and hip replacement: an observational study. BMC Musculoskelet Disord. 2010;11 10.1186/1471-2474-11-11
    1. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee. Arthritis Rheumatol. 1986;29: 1039–1049. 10.1002/art.1780290816
    1. Slover J, Shue J, Koenig K. Shared Decision-making in Orthopaedic Surgery. Clin Orthop Relat Res. 2012;470: 1046–1053. 10.1007/s11999-011-2156-8
    1. Dell’Isola A, Steultjens M. Classification of patients with knee osteoarthritis in clinical phenotypes: Data from the osteoarthritis initiative. Lammi MJ, editor. PLOS ONE. 2018;13: e0191045 10.1371/journal.pone.0191045
    1. Mandl LA. Determining who should be referred for total hip and knee replacements. Nat Rev Rheumatol. 2013;9: 351–357. 10.1038/nrrheum.2013.27
    1. Dieppe P. Who should have a joint replacement? A plea for more ‘phronesis.’ Osteoarthritis Cartilage. 2011;19: 145–146. 10.1016/j.joca.2010.08.018
    1. Gossec L, Paternotte S, Maillefert JF, Combescure C, Conaghan PG, Davis AM, et al. The role of pain and functional impairment in the decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement. Osteoarthritis Cartilage. 2011;19: 147–154. 10.1016/j.joca.2010.10.025
    1. Mancuso CA, Ranawat CS, Esdaile JM, Johanson NA, Charlson ME. Indications for total hip and total knee arthroplasties. J Arthroplasty. 1996;11: 34–46. 10.1016/s0883-5403(96)80159-8
    1. Hofstede SN, Marang-van de Mheen PJ, Vliet Vlieland TPM, van den Ende CHM, Nelissen RGHH, van Bodegom-Vos L. Barriers and Facilitators Associated with Non-Surgical Treatment Use for Osteoarthritis Patients in Orthopaedic Practice. Coles JA, editor. PLOS ONE. 2016;11: e0147406 10.1371/journal.pone.0147406
    1. Klesges L, Estabrooks P, Dzewaltowski D, Bull S, Glasgow R. Beginning with the application in mind: Designing and planning health behavior change interventions to enhance dissemination. Ann Behav Med. 2005;April 1;29(2): 66–75.
    1. Glasgow R. What Types of Evidence are Most Needed to Advance Behavioral Medicine? Ann Behav Med. 2008;February;35(1): 19–25. 10.1007/s12160-007-9008-5
    1. Trompette J, Kivits J, Minary L, Cambon L, Alla F. Stakeholders’ perceptions of transferability criteria for health promotion interventions: a case study. BMC Public Health. 2014;14 10.1186/1471-2458-14-14
    1. Bunzli S, Nelson E, Scott A, French S, Choong P, Dowsey M. Barriers and facilitators to orthopaedic surgeons’ uptake of decision aids for total knee arthroplasty: a qualitative study. BMJ Open. 2017;7: e018614 10.1136/bmjopen-2017-018614
    1. Littlewood C, Mawson S, May S, Walters S. Understanding the barriers and enablers to implementation of a self-managed exercise intervention: a qualitative study. Physiotherapy. 2015;101: 279–285. 10.1016/j.physio.2015.01.001
    1. Miciak M, Mayan M, Brown C, Joyce AS, Gross DP. The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study. Arch Physiother. 2018;8 10.1186/s40945-018-0049-9
    1. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Semin Arthritis Rheum. 2014;43: 701–712. 10.1016/j.semarthrit.2013.11.012
    1. Bhattacharyya O, Reeves S, Zwarenstein M. What Is Implementation Research?: Rationale, Concepts, and Practices. Res Soc Work Pract. 2009;19: 491–502. 10.1177/1049731509335528
    1. Husted RS, Troelsen A, Thorborg K, Rathleff MS, Husted H, Bandholm T. Efficacy of pre-operative quadriceps strength training on knee-extensor strength before and shortly following total knee arthroplasty: protocol for a randomized, dose-response trial (The QUADX-1 trial). Trials. 2018;19: 47 10.1186/s13063-017-2366-9
    1. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation Hybrid Designs: Combining Elements of Clinical Effectiveness and Implementation Research to Enhance Public Health Impact. Med Care. 2012;50: 217–226. 10.1097/MLR.0b013e3182408812
    1. Newman S, Steed L, Mulligan K. Chronic physical illness: self-management and behavioural interventions Newman S, Steed L, Mulligan K. Chronic physical illness: self-maMaidenhead: Open University Press; 2009.
    1. Campbell R, Evans M, Tucker M, Quilty B, Dieppe P, Donovan JL. Why don’t patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. J Epidemiol Community Health. 2001;55: 132–138. 10.1136/jech.55.2.132
    1. McLean SM, Burton M, Bradley L, Littlewood C. Interventions for enhancing adherence with physiotherapy: A systematic review. Man Ther. 2010;15: 514–521. 10.1016/j.math.2010.05.012
    1. Picorelli AMA, Pereira LSM, Pereira DS, Felício D, Sherrington C. Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review. J Physiother. 2014;60: 151–156. 10.1016/j.jphys.2014.06.012
    1. Kitzinger J Chapter 3. Focus groups. 3rd edition Qualitative Research in Health Care. 3rd edition Blackwell Publishing Ltd; 2006.
    1. Krueger RA, Casey MA. Focus Groups. A Practical Guide For Applied Research. 3rd Edition Sage Publications, Inc; 2000.
    1. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Acad Med. 2014;89: 1245–1251. 10.1097/ACM.0000000000000388
    1. Horsburgh D. Evaluation of qualitative research: Evaluation of qualitative research. J Clin Nurs. 2003;12: 307–312. 10.1046/j.1365-2702.2003.00683.x
    1. Halkier B. Focus groups as social enactments: integrating interaction and content in the analysis of focus group data. Qual Res. 2010;10: 71–89. 10.1177/1468794109348683
    1. Crabtree BF, Miller WL. Depth Interviewing. Second Edition. Doing Qualitative Research. Second Edition. 1999.
    1. World Confederation for Physical Therapy W. Policy statement. Description of physical therapy. World Confederation for Physical Therapy; 2015.
    1. Higgs J, Refshauge K, Ellis E. Portrait of the physiotherapy profession. J Interprof Care. 2001;15: 79–89. 10.1080/13561820020022891
    1. Nowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis: Striving to Meet the Trustworthiness Criteria. Int J Qual Methods. 2017;16: 160940691773384 10.1177/1609406917733847
    1. Morse JM, Barrett M, Mayan M, Olson K, Spiers J. Verification Strategies for Establishing Reliability and Validity in Qualitative Research. Int J Qual Methods. 2002;1: 13–22. 10.1177/160940690200100202
    1. Dahlager L, Fredslund F . Hermeneutisk analyse–og forståelse og for-forståelse. 4th ed Forskningsmetoder i folkesundhedsvidenskab. 4th ed Kbh: Munksgaard Danmark; 2011.
    1. WMA. World Medical Association. WMA Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. 2017. Available: Available at: . Accessed November 15, 2017.
    1. Oxford Dictionary of English (3 ed). Oxford University Press; 2010.
    1. Wilensky HL. The Professionalization of Everyone? Am J Sociol. 1964;70: 137–158. 10.1086/223790
    1. Mintzberg H. Structure in fives. Englewood Cliffs, NJ: Prentice Hall; 1983.
    1. Klaber Moffett JA, Richardson PH. The influence of the physiotherapist-patient relationship on pain and disability. Physiother Theory Pract. 1997;13: 89–96. 10.3109/09593989709036451
    1. Abbott A. The system of professions: An essay on the division of expert labor. Chicago: University of Chicago Press; 1988.
    1. Folland S, Goodman A, Stano M. The Economics of Health and Health Care. New York: Routledge; 2016. Available: .
    1. The World Medical Association, Inc. Declaration of Geneva. The World Medical Association, Inc; 2005.
    1. Graves JE, Pollock ML, Leggett SH, Braith RW, Carpenter DM, Bishop LE. Effect of Reduced Training Frequency on Muscular Strength. Int J Sports Med. 1988;9: 316–319. 10.1055/s-2007-1025031
    1. Tucci JT, Carpenter DM, Pollock ML, Graves JE, Leggett SH. Effect of reduced frequency of training and detraining on lumbar extension strength. Spine. 1992;17: 1497–1501. 10.1097/00007632-199212000-00009
    1. Schaper NC, Nikolajsen A, Sandberg A, Buchs S, Bøgelund M. Timing of Insulin Injections, Adherence, and Glycemic Control in a Multinational Sample of People with Type 2 Diabetes: A Cross-Sectional Analysis. Diabetes Ther. 2017;8: 1319–1329. 10.1007/s13300-017-0317-9
    1. Farr JN, Going SB, Lohman TG, Rankin L, Kasle S, Cornett M, et al. Physical activity levels in patients with early knee osteoarthritis measured by accelerometry. Arthritis Rheum. 2008;59: 1229–1236. 10.1002/art.24007
    1. Dusik CJ, Buckley RE, Robertson-More C. Orthopedic surgeon perspectives on appropriate referral of trauma patients to physical therapy (PT). Arch Orthop Trauma Surg. 2013;133: 603–608. 10.1007/s00402-013-1706-9
    1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: The new Medical Research Council guidance. Int J Nurs Stud. 2013;50: 587–592. 10.1016/j.ijnurstu.2012.09.010
    1. Hawe P, Shiell A, Riley T. Complex interventions: how “out of control” can a randomised controlled trial be? BMJ. 2004;328: 1561–1563. 10.1136/bmj.328.7455.1561
    1. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing Provider Behavior: An Overview of Systematic Reviews of Interventions. Med Care. 2001;39: II-2–II–45. 10.1097/00005650-200108002-00002
    1. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Acad Med. 2014;89: 1245–1251. 10.1097/ACM.0000000000000388

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera