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Absence of Improvement With Exercise in Some Patients With Knee Osteoarthritis: A Qualitative Study of Responders and Nonresponders

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Arthritis Care & Research
Authors:
Rana S Hinman at University of Melbourne
Rana S Hinman
Sarah E. Jones
Sarah E. Jones
Sarah E. Jones
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Rachel Kate Nelligan at University of Melbourne
Rachel Kate Nelligan
Penelope K. Campbell
Penelope K. Campbell
Penelope K. Campbell
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Abstract and Figures

Objective To compare the perceptions of patients about why they did, or did not, respond to a physical therapist–supported exercise and physical activity program. Methods This was a qualitative study within a randomized controlled trial. Twenty‐six participants (of 40 invited) with knee osteoarthritis sampled according to response (n = 12 responders, and 14 nonresponders based on changes in both pain and physical function at 3 and 9 months after baseline) to an exercise and physical activity intervention. Semistructured individual interviews were conducted. Inductive thematic analysis was undertaken within each subgroup using grounded theory principles. A deductive approach compared themes and subthemes across subgroups. Findings were triangulated with quantitative data. Results (Sub)themes common to responders and nonresponders included the intervention components that facilitated engagement, personal attitudes and expectations, beliefs about osteoarthritis and exercise role, importance of adherence, and perceived strength gains with exercise. In contrast to responders who felt empowered to self‐manage, nonresponders accepted responsibility for lack of improvement in pain and function with exercise, acknowledging that their adherence to the intervention was suboptimal (confirmed by quantitative adherence data). Nonresponders believed that their excess body weight (supported by quantitative data) contributed to their outcomes, encountered exercise barriers (comorbidities, stressors, and life events), and perceived that the trial measurement tools did not adequately capture their response to exercise. Conclusion Responders and nonresponders shared some similar perceptions of exercise. However, along with perceived limitations in trial outcome measurements, nonresponders encountered challenges with excess weight, comorbidities, stressors, and life events that led to suboptimal adherence and collectively were perceived to contribute to nonresponse.
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Absence of Improvement With Exercise in Some Patients
With Knee Osteoarthritis: A Qualitative Study of Responders
and Nonresponders
Rana S. Hinman,
1
Sarah E. Jones,
1
Rachel K. Nelligan,
1
Penelope K. Campbell,
1
Michelle Hall,
1
Nadine E. Foster,
2
Trevor Russell,
3
and Kim L. Bennell
1
Objective. To compare the perceptions of patients about why they did, or did not, respond to a physical
therapist–supported exercise and physical activity program.
Methods. This was a qualitative study within a randomized controlled trial. Twenty-six participants (of 40 invited)
with knee osteoarthritis sampled according to response (n = 12 responders, and 14 nonresponders based on changes
in both pain and physical function at 3 and 9 months after baseline) to an exercise and physical activity intervention.
Semistructured individual interviews were conducted. Inductive thematic analysis was undertaken within each
subgroup using grounded theory principles. A deductive approach compared themes and subthemes across sub-
groups. Findings were triangulated with quantitative data.
Results. (Sub)themes common to responders and nonresponders included the intervention components that
facilitated engagement, personal attitudes and expectations, beliefs about osteoarthritis and exercise role, importance
of adherence, and perceived strength gains with exercise. In contrast to responders who felt empowered to
self-manage, nonresponders accepted responsibility for lack of improvement in pain and function with exercise,
acknowledging that their adherence to the intervention was suboptimal (confirmed by quantitative adherence data).
Nonresponders believed that their excess body weight (supported by quantitative data) contributed to their outcomes,
encountered exercise barriers (comorbidities, stressors, and life events), and perceived that the trial measurement
tools did not adequately capture their response to exercise.
Conclusion. Responders and nonresponders shared some similar perceptions of exercise. However, along with
perceived limitations in trial outcome measurements, nonresponders encountered challenges with excess weight,
comorbidities, stressors, and life events that led to suboptimal adherence and collectively were perceived to contribute
to nonresponse.
INTRODUCTION
Over 260 million people globally have knee osteoarthritis
(OA) (1), a condition that accounts for a considerable proportion
of global disability. Joint pain and physical dysfunction are com-
mon features of knee OA and the main reasons that drive people
to seek care from health professionals (2,3). There is no cure for
knee OA, and arthroplasty is typically reserved for patients with
end-stage disease whose joint pain has not been adequately
relieved by appropriate nonsurgical approaches.
Clinical guidelines advocate nondrug nonsurgical strategies
(4–6) focused on self-management. Exercise and physical activity
are recommended as standard care for all patients with OA
throughout the course of the disease (7). Muscle weakness is
The views expressed herein are those of the authors and not necessarily
those of the NHS, the NIHR, or the Department of Health and Social Care.
Supported by the National Health and Medical Research Council
(grant 1157977). Dr. Hinman’s work was supported by the National Health
and Medical Research Council (Senior Research fellowship grant 1154217).
Dr. Hall’s work was supported by the National Health and Medical Research
Council (Investigator grant 1172928). Dr. Foster’s work was supported by the
NIHR (research professorship grant NIHRRP-011-015). Dr. Bennell’s work
was supported by the National Health and Medical Research Council
(Investigator grant 1174431).
1
Rana S. Hinman, BPhysio (Hons), PhD, Sarah E. Jones, BSc (Hons), PhD,
Rachel K. Nelligan, BPhysio, PGCertPhysio, PhD, Penelope K. Campbell,BAppSci
(FoodSci&Nutr), Michelle Hall, BSc (Hons), MSc, PhD, Kim L. Bennell, BAppSci
(Physio), PhD: The University of Melbourne, Melbourne, Victoria, Australia;
2
Nadine E. Foster, BSc (Hons), DPhil: The University of Queensland and Metro
North Health, Brisbane, Queensland, Australia;
3
Trevor Russell, BPhysio, PhD:
The University of Queensland, Brisbane, Queensland, Australia.
Author disclosures are available at https://onlinelibrary.wiley.com/action/
downloadSupplement?doi=10.1002%2Facr.25085&file=acr25085-sup-0001-
Disclosureform.pdf.
Address correspondence via email to Rana S. Hinman, BPhysio (Hons),
PhD, at ranash@unimelb.edu.au.
Submitted for publication September 27, 2022; accepted in revised form
December 29, 2022.
1925
Arthritis Care & Research
Vol. 75, No. 9, September 2023, pp 1925–1938
DOI 10.1002/acr.25085
© 2023 American College of Rheumatology.
... Since osteoarthritis is a complex disease with many overlapping features, the assumption that all exercises are equal in impact as well as beneficial or safe in all forms and stages of this disease must be questioned given most researchers failed to confirm the presence or absence of any accompanying joint loading improvements or non improvements or worsening of joint structural stability plus inflammation, and disease biomarker status. The associated relevance of extraneous variables such as obesity, muscle metabolic and structural post exercise alterations [57][58][59], plus the probable mediating role of comorbidities, stress [59] and possible age related intrinsic capacity declines [1] are also hard to discern at present. Adherence as well as to what degree home exercises performed in some studies replicated the desired recommendations with high fidelity is also not duly reported or evident in many cases or negated as a factor of note [57]. ...
... Since osteoarthritis is a complex disease with many overlapping features, the assumption that all exercises are equal in impact as well as beneficial or safe in all forms and stages of this disease must be questioned given most researchers failed to confirm the presence or absence of any accompanying joint loading improvements or non improvements or worsening of joint structural stability plus inflammation, and disease biomarker status. The associated relevance of extraneous variables such as obesity, muscle metabolic and structural post exercise alterations [57][58][59], plus the probable mediating role of comorbidities, stress [59] and possible age related intrinsic capacity declines [1] are also hard to discern at present. Adherence as well as to what degree home exercises performed in some studies replicated the desired recommendations with high fidelity is also not duly reported or evident in many cases or negated as a factor of note [57]. ...
... At the same time, even if deemed high quality as far as research design goes [56] not all published exercise regimen data may apply to all older osteoarthritis cases especially those with some form of heart disease for example who may not be studied, or where no adaptations to the studied regimen are evident or alluded to, as well as those with one or more co morbid health conditions. Moreover, in accepting that more cases performing exercise will have less osteoarthritis pain than not, no matter how this is approached [26,57], the data fail to clearly support this premise for large samples, or for example for hip osteoarthritis [30] or as mentioned by Hinman et al [59] where the role of extraneous variables, competing interventions, and reasons why some exercise participants do not respond favorably in all cases is often unreported, while blinding and instrument subjectivity, and reliability and fidelity of these are not always assured or discussed and where exercises may be unsupervised, applied on a limited basis, and based on complex exercise combinations [30,60] or possible practitioner as well as patient personal preferences. Safety issues due to poorly directed and enacted exercise impacts in the face of joint damage and derangement, in particular, for example in the frail older adult with sarcopenia or bone fragility are unfortunately rarely alluded to. ...
Exercises, Older Adults, Osteoarthritis 1970-2024
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  • Sep 2024
Persons with osteoarthritis often have signs of reduced muscle strength. Some studies suggest that this strength could be improved with exercise. However, does this form of therapy improve the disease status as assessed by improvements in cartilage viability, a hallmark of the disease? This brief describes the possible usage of exercises in general, plus those known to improve strength and function, and reduce pain and whether structural impacts that favor or impede disease regression have been observed in this context among the older osteoarthritis adult population. Since exercise may also do harm, rather than good in osteoarthritis management if excessive, contra indicated, or suboptimal, what is the consensus in this regard in 2024?
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... The limited available evidence detracts from the clinical interpretation of the findings. of patients may not respond positively to exercise [13] aiming to reduce pain [14,15] or improve function [14]. Exercise therapy is not a "one-size-fit-all" solution, and many clinical, contextual, and psychosocial factors can modulate its effects. ...
... The impact of mHealth on improving pain and function in those with chronic pain may vary based on the particular condition, the specific mHealth modality, and the individuals' characteristics [35,36]. A better understanding of the factors associated with the outcome following exercise therapy in patients with chronic pain is warranted to identify potential responders [13]. Exploratory analyses suggest that psychological [39], racial, and ethnic factors [40] can influence the effect of digitally delivered exercise interventions in adults with musculoskeletal pain. ...
Exploring Factors Associated with Changes in Pain and Function Following mHealth-Based Exercise Therapy for Chronic Musculoskeletal Pain: A Systematic Review with Meta-Analysis and Meta-Regression
Article
Full-text available
  • Jul 2024
Exercise therapy is the first-line intervention recommended for those with chronic musculoskeletal pain (CMP). Smartphone technologies (mHealth) represent a feasible means for exercise prescription and individualization. This systematic review with meta-analysis aimed to identify factors associated with changes in pain and function following mHealth-based exercise therapy in patients with CMP. CINAHL (via EBSCOhost), Embase, PubMed, Scopus, and SPORTdiscus were searched from inception to February 2023. Observational and controlled clinical trials with correlation or regression analysis of factors associated with the effect of mHealth exercise interventions on pain and function were included. The risk of bias, completeness of interventions, spin of information, and certainty in the evidence were evaluated. Eight studies with 51,755 participants were included. Reduced pain intensity after intervention was associated with higher physical function: r (95% CI) = −0.55 (−0.67 to −0.41); I2 = 86%, Tau2 = 0.02; p < 0.01. Meta-regression identified the Body Mass Index (BMI), exercise dose, and completion rate as potential moderators between changes in pain and physical function following mHealth exercise therapy. No association was found between pain and anxiety: r (95% CI) = 0.15 (−0.08 to 0.37); I2 = 87%, Tau2 = 0.02; p = 0.19. Very low certainty in the evidence was observed due to serious concerns regarding the risk of bias, inconsistency, and indirectness. The limited available evidence detracts from the clinical interpretation of the findings.
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... For example, cases exhibiting and evoking excess dismay at their changing body or social image and function and their possible influence that may extend to feelings of depression and pessimism, excess stress, weight issues, and unwanted comorbid health issues [16] may increase their distress as well as their degrees of anxiety. In addition, although amenable to change if suboptimal, diet that is not always considered relevant by the mainstream osteoarthritis provider and of which the sufferer is unaware may greatly add to the disease burden. ...
Osteoarthritis Self-Management and Awareness: Potential Relevance and Consequences
Article
Full-text available
  • Nov 2024
Brief explores whether: a degree of thoughtful attention to one's disabling health situation can be harnessed and actively directed towards the initiation and pursuit of some degree of desirable self-management practices with a high degree of consistency versus a more passive or fatalistic disease perspective of inaction, that can evoke reactive cognitions that are disease provoking, such as possible anxiety. Based on peer reviewed data drawn from the PUBMED, APA PsycNet, and Google Scholar data bases results show that while this issue is very sparsely addressed to date it may be one worthy of future study.
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... Despite the impact of osteoarthritis on patients, society and the National Health Service (NHS), there are few therapeutic options for osteoarthritis [5][6][7]. Some non-pharmacological treatments such as physiotherapy and exercise show beneficial effects on pain and function [8,9] but many non-pharmacologic treatments suffer from poor adherence [10][11][12][13]. Pharmacologic treatments such as non-steroidal anti-inflammatory drugs (NSAIDs) are associated with serious side-effects [14] or lack strong evidence of benefit [5,7]. ...
Intra-articular corticosteroid injections for osteoarthritis: A qualitative study of patients’ and clinicians’ experiences
Article
Full-text available
Background Osteoarthritis is a leading cause of joint pain and disability. Intra-articular corticosteroid injections (IACs) are often used in primary care once other recommended treatments have failed. Evidence shows that IACs provide short-term relief of osteoarthritis symptoms, yet little is known about patients’ and primary care clinicians’ experiences and beliefs about their use. We explored patients’ and primary care clinicians’ views about IACs, including the benefits, disadvantages, perceived risks of treatment, when they are used, and factors that affect decision-making. Methods We conducted individual interviews with patients and primary care clinicians and used inductive thematic analysis to investigate their views and experiences of intra-articular corticosteroid injections for osteoarthritis (IACs). Findings We interviewed 38 patients and 19 primary care clinicians. We identified 6 patient themes: variation in access; awareness of IACs; views of risk and trust; effectiveness of IACs; variation in onset and effect duration; and an alternative to undesirable treatments. In the interviews with clinicians, we identified an overarching theme of caution and competence, which included eight subthemes: confidence and (dis)comfort with practical procedures; risk of adverse outcomes; training; uncertainty about evidence and guidelines; technical uncertainties; IACs use on the osteoarthritis pathway; perceived benefits and impacts of IACs; and the possibility of placebo. Conclusion Patients and clinicians valued IACs’ potential to relieve symptoms and improve quality of life. Variability in patients’ access to treatment appears related to clinicians’ confidence in delivering injections and their concerns about the evidence base. Variation in dose frequency and timing reflect clinicians’ uncertainty about current guidance. Despite variation in effectiveness patients preferred IACs to other forms of pain medication and to delay or avoid surgery. IACs were mostly used as an adjunct treatment before surgery was offered. These findings can inform further research into the effectiveness of IACs and improvements in information and guidance.
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... As adherence and responding to exercise is a challenge and potential causes are considered multifactorial in osteoarthritis, a movement coach aims to motivate the patient to reach goals and to support adhering to a healthy lifestyle. 93,94 After a total knee arthroplasty for osteoarthritis, a multidisciplinary approach entails that a physiotherapist among other healthcare professionals (such as dieticians, occupational therapists, psychologist) are involved in the rehabilitation of the patient. The experts agreed on consulting a physiotherapist, as early as possible after the surgical intervention, and within 24h (but preferably a few hours after surgery) to enhance (active) mobilisation of the patient. ...
A quality standard and quality indicators for Symptomatic knee osteoarthritis care
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  • Apr 2024
This KCE project aimed to develop quality statements and quality indicators for the management of symptomatic knee osteoarthritis in the Belgian setting and aimed to add to the quality of care offered to patients with symptomatic knee osteoarthritis.
View
... Barriers that have been associated with lower participation in exercise in recent cross-sectional and cohort studies [12][13][14] are lower physical fitness and lower exercise self-efficacy levels, while also younger and women patients have a higher risk to drop out. 13 Qualitative research [15][16][17][18][19] has identified that the most frequently cited barriers toward participation in exercise for adults with knee or hip osteoarthritis include physical co-morbidities, kinesiophobia, depression, daily life stressors, and the time-consuming commitment. Given exercise (including aerobic training, exercise, yoga, Tai Chi, Qigong, mindful body stretching, Pilates, aquatic exercises, and exergaming) improves mental and physical health outcomes in adults with knee or hip osteoarthritis, [20][21][22][23] understanding the prevalence and moderators of dropouts in exercise RCTs for adults with knee or hip osteoarthritis is an important research question. ...
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Processing of real-time surface electromyography signals during knee movements of rehabilitation participants
Article
Full-text available
  • Dec 2024
  • IJECE
In this work, we present a knee rehabilitation system focusing on the processing of surface electromyography (sEMG) signals measured from the vastus lateralis (VL) and vastus medialis (VM) muscles of rehabilitation participants. A two-channel electromyography (EMG) device and the NI-myRIO embedded device are used to collect real-time sEMG signals in accordance with pre-designed rehabilitation programs. The novelty and contribution of this work is that we develop an sEMG processing function where real-time sEMG data are automatically processed and sEMG results of both VL and VM in terms of root mean square value (RMS), different RMS levels of VL and VM, and maximum RMS for each round of knee movements are provided. The results here indicate how well the rehabilitation users can move their knees during rehabilitation, referring to knee and muscle performances. Experimental results from healthy participants show that we can automatically and efficiently collect and monitor rehabilitation results, allowing rehabilitation participants to know how their knees performed during testing and medical experts to evaluate and design treatment.
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Telehealth Mindful Exercise for People with Knee Osteoarthritis: A Decentralized Feasibility Randomized Controlled Trial
Article
  • Jun 2024
Objective Negative psychological beliefs like fear avoidance and catastrophizing can interfere with exercise engagement in people with knee osteoarthritis (OA). Mindfulness, when integrated with exercise, could potentially address both psychological and physical impairments. Our objectives were to optimize and assess the feasibility of a novel telehealth, group-based mindful exercise intervention for people with knee OA. Methods We conducted a decentralized randomized controlled trial where participants (n = 40) with symptomatic knee OA were randomized into mindful exercise (n = 21) or exercise-only (n = 19) groups. Both groups received supervised group-based interventions weekly for 8-weeks via Zoom. Primary outcomes were safety, fidelity, and feasibility of the mindful exercise intervention. Participants completed patient-reported outcomes (PRO) for pain, function, and psychological measures at baseline, week-8, and week-14. Results Participants were from 21 US states; >90% identified as having White race, 16% were from rural areas, and approximately 40% had an annual income < $50,000. At 8-weeks, mindful exercise and exercise groups had retention rates of 86% (18/21) and 100% (19/19), and attendance was 54% (11.4/21) and 68% (13/19) respectively. There were no adverse events in the mindful exercise group and four in the exercise group related to exacerbation of knee pain. Preliminary findings showed numerically larger improvements in several PROs for the mindful exercise group. Conclusion An 8-week telehealth, group-based, mindful exercise intervention was safe for people with knee OA. Our decentralized approach was feasible in terms of recruitment and retention. Further refinement is needed to improve intervention attendance and participant diversity.
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A Wearable Accelerometer-Based System for Knee Angle Monitoring During Physiotherapy
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Wearable inertial sensors can revolutionize the field of physiotherapy by enabling continuous remote assessment, early detection of mobility issues, and monitoring of recovery from injury or surgery. This can be achieved by integrating these sensors with onboard processors and a communication technology. In this work, we propose a wearable system that uses accelerometer data to obtain a clinical knee angle. The system comprises sensors on the thigh and shank along with embedded firmware. A simple accelerometer-inclination method was used to compute the thigh and shank angles, and the knee angle was calculated from these leg segment angles. The experimental results demonstrate that the proposed approach is sufficient for measuring the knee angle, obviating the need for additional sensors. This reduction in computational complexity was achieved without compromising the accuracy of knee angle computation. Measurements were performed in clinically relevant positions (supine, sitting, standing, and during level walking) to validate the system, and the results were compared with a video-based reference system. The measurements were closely aligned with the reference system, as indicated by the average RMSE of 1.71° for the exercises and 2.51° for the leveled walk. This is an acceptable accuracy because the minimal clinically important differences for the knee angle is 6°. However, it was demonstrated that sensor placement can affect the accuracy. This portable, cost-effective, non-invasive, and embedded system, capable of continuous assessment in free-living environments, would be advantageous for acquiring quantitative patient data.
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How Do Nonsurgical Interventions Improve Pain and Physical Function in People With Osteoarthritis? A Scoping Review of Mediation Analysis Studies
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Objective Nonsurgical interventions are recommended for osteoarthritis (OA). However, how interventions change pain and physical function is unclear. Therefore, the objectives of this scoping review were to 1) identify what potential mediators of nonsurgical interventions on pain and physical function have been evaluated and 2) summarize the findings according to intervention, joint, and outcome. Methods We searched Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Scopus databases. Studies were included if they conducted a mediation analysis on a randomized controlled trial evaluating a nonsurgical intervention on OA of any joint. Outcomes were pain and physical function. Results Nine knee OA studies, evaluating diet plus exercise, exercise, unloading shoes, high‐expectation communication during acupuncture, and telephone‐based weight loss plus exercise were identified. Except for weight loss and self‐efficacy, putative mediators (knee muscle perfusion/extensor strength/adduction moment, systemic inflammatory biomarkers, physical activity, dietary intake, and pain beliefs) were evaluated by single studies. Ten mediators partially mediated intervention (diet plus exercise, exercise, high‐expectation communication) effects on pain and physical function. Eight mediators were common to pain and function (reduced weight, increased knee extensor strength, and increased self‐efficacy). Constant knee flexor muscle perfusion partially mediated exercise effects on pain, and knee pain relief partially mediated exercise effects on function. Conclusion In knee OA, some evidence suggests that the benefits of 1) diet and exercise are mediated through changes in body weight, systemic inflammation, and self‐efficacy; 2) exercise is mediated through changes in knee muscle strength and self‐efficacy; and 3) high‐expectation communication style is mediated through changes in self‐efficacy.
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Patient experiences with physiotherapy for knee osteoarthritis in Australia—a qualitative study
Article
Full-text available
  • Mar 2021
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.
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Association between therapeutic alliance and outcomes following telephone-delivered exercise by a physical therapist for people with knee osteoarthritis: secondary analyses from a randomised controlled trial (Preprint)
Article
Full-text available
  • Aug 2020
Background The therapeutic alliance between patients and physical therapists has been shown to influence clinical outcomes in patients with chronic low back pain when consulting in-person. However, no studies have examined whether the therapeutic alliance developed between patients with knee osteoarthritis and physical therapists during telephonic consultations influences clinical outcomes. Objective This study aims to investigate whether the therapeutic alliance between patients with knee osteoarthritis and physical therapists measured after the second consultation is associated with outcomes following telephone-delivered exercise and advice. Methods Secondary analysis of 87 patients in the intervention arm of a randomized controlled trial allocated to receive 5 to 10 telephone consultations with one of 8 physical therapists over a period of 6 months, involving education and prescription of a strengthening and physical activity program. Separate regression models investigated the association between patient and therapist ratings of therapeutic alliance (measured after the second consultation using the Working Alliance Inventory Short Form) and outcomes (pain, function, self-efficacy, quality of life, global change, adherence to prescribed exercise, physical activity) at 6 and 12 months, with relevant covariates included. Results There was some evidence of a weak association between patient ratings of the alliance and some outcomes at 6 months (improvements in average knee pain: regression coefficient −0.10, 95% CI −0.16 to −0.03; self-efficacy: 0.16, 0.04-0.28; global improvement in function: odds ratio 1.26, 95% CI 1.04-1.39, and overall improvement: odds ratio 1.26, 95% CI 1.06-1.51; but also with worsening in fear of movement: regression coefficient −0.13, 95% CI −0.23 to −0.04). In addition, there was some evidence of a weak association between patient ratings of the alliance and some outcomes at 12 months (improvements in self-efficacy: regression coefficient 0.15, 95% CI 0.03-0.27; global improvement in both function, odds ratio 1.19, 95% CI 0.03-1.37; and pain, odds ratio 1.14, 95% CI 1.01-1.30; and overall improvement: odds ratio 1.21, 95% CI 1.02-1.42). The data suggest that associations between therapist ratings of therapeutic alliance and outcomes were not strong, except for improved quality of life at 12 months (regression coefficient 0.01, 95% CI 0.0003-0.01). Conclusions Higher patient ratings, but not higher therapist ratings, of the therapeutic alliance were weakly associated with improvements in some clinical outcomes and with worsening in one outcome. Although the findings suggest that patients who perceive a stronger alliance with their therapist may achieve better clinical outcomes, the observed relationships were generally weak and unlikely to be clinically significant. The limitations include the fact that measures of therapeutic alliance have not been validated for use in musculoskeletal physical therapy settings. There was a risk of type 1 error; however, findings were interpreted on the basis of clinical significance rather than statistical significance alone. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12616000054415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369204
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Moderators of the effects of therapeutic exercise for people with knee and hip osteoarthritis: A systematic review of sub-group analyses from randomised controlled trials
Article
Full-text available
  • Nov 2020
Objective 1) To identify potential moderators of the effect of therapeutic exercise explored in randomised controlled trials (RCTs) of knee and hip osteoarthritis (OA); 2) summarise the extent, strength and quality of evidence reported for moderators. Design Systematic review (PROSPERO CRD42019148074). Inclusion criteria: a) RCTs with sub-group analyses investigating potential moderator variables; b) participants with knee and/or hip OA; c) therapeutic exercise interventions compared to either no exercise control or alternative exercise intervention(s), and; d) measuring pain or physical function outcomes. Included RCTs’ risk of bias and sub-group analysis quality were assessed. Data were extracted on sub-group analyses (methods and potential moderators), outcomes (pain and function) and sub-group findings (associated statistics of potential moderator∗intervention effects). Findings were analysed using narrative synthesis. Results 14 RCTs were included; 13 knee OA RCTs (n = 2743 participants) explored 23 potential moderators and 1 hip OA RCT (n = 203) explored 6 potential moderators. Sub-group analysis quality was mixed. Knee varus malalignment was the only moderator of therapeutic exercise compared to non-exercise control in 1 RCT (WOMAC-pain adjusted difference 12.7 in the neutral alignment sub-group and 1.8 in the malaligned sub-group, interaction term: p = 0.02). Varus thrust, knee laxity/instability, obesity and cardiac problems all moderated the effect of therapeutic exercise on pain or function compared to different comparison exercise. Conclusions Therapeutic exercise may be effective for reducing pain in people with knee OA and neutral alignment but not for those with varus malalignment. The exercise moderator literature is limited. More robust evidence is required to inform sub-group exercise selection.
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Challenges With Strengthening Exercises for Individuals With Knee Osteoarthritis and Comorbid Obesity: A Qualitative Study With Patients and Physical Therapists
Article
Full-text available
  • Dec 2021
Objective To explore challenges associated with implementing a home‐based strengthening exercise program for individuals with knee osteoarthritis and comorbid obesity. Methods This is a qualitative study embedded within a randomized controlled trial comparing 2 home‐based strengthening programs (weight‐bearing functional exercise versus non–weight‐bearing quadriceps strengthening exercise) for individuals with knee osteoarthritis and comorbid obesity. Patients in both exercise programs attended 5 consultations with a physical therapist and undertook a home‐based exercise program for 12 weeks. After trial completion, semistructured individual telephone interviews were conducted with 22 patients and all 7 physical therapists who delivered trial interventions. Interviews were recorded, transcribed verbatim, and thematically analyzed using an inductive approach. Results Three themes arose: 1) psychological challenges (false assumptions about exercise; fear of pain; disliking exercise; mental effort of the weight‐bearing functional program; underestimating capability); 2) physical challenges (complexity of the weight‐bearing functional program; cuff weights and straight leg raise being problematic in non–weight‐bearing quadriceps program; other health conditions); and 3) overcoming challenges (incentives to exercise; accountability; education and reassurance; tailoring the exercise program). Conclusion Patients and physical therapists experienced numerous psychological and physical challenges to exercise, including a fear of pain, having false assumptions about exercise, difficulties with exercise performance, application of cuff weights, and adverse impacts of other health conditions.
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Guidance for Implementing Best Practice Therapeutic Exercise for Patients With Knee and Hip Osteoarthritis: What Does the Current Evidence Base Tell Us?
Article
Full-text available
  • Dec 2021
Therapeutic exercise is a recommended first‐line treatment for patients with knee and hip osteoarthritis (OA); however, there is little specific advice or practical resources to guide clinicians in its implementation. As the first in a series of projects by the Osteoarthritis Research Society International Rehabilitation Discussion Group to address this gap, we aim in this narrative review to synthesize current literature informing the implementation of therapeutic exercise for patients with knee and hip OA, focusing on evidence from systematic reviews and randomized controlled trials. Therapeutic exercise is safe for patients with knee and hip OA. Numerous types of therapeutic exercise (including aerobic, strengthening, neuromuscular, mind‐body exercise) may be utilized at varying doses and in different settings to improve pain and function. Benefits from therapeutic exercise appear greater when dosage recommendations from general exercise guidelines for healthy adults are met. However, interim therapeutic exercise goals may also be useful, given that many barriers to achieving these dosages exist among this patient group. Theoretically‐informed strategies to improve adherence to therapeutic exercise, such as patient education, goal‐setting, monitoring, and feedback, may help maintain participation and optimize clinical benefits over the longer term. Sedentary behavior is also a risk factor for disability and lower quality of life in patients with knee and hip OA, although limited evidence exists regarding how best to reduce this behavior. Current evidence can be used to inform how to implement best practice therapeutic exercise at a sufficient and appropriate dose for patients with knee and hip OA.
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Behaviour change text messages for home exercise adherence in knee osteoarthritis: A randomised trial (Preprint)
Article
Full-text available
  • Jun 2020
  • J MED INTERNET RES
Background: Exercise is a core recommended treatment for knee osteoarthritis (OA), yet adherence declines, particularly following cessation of clinician supervision. Objective: This study aims to evaluate whether a 24-week SMS intervention improves adherence to unsupervised home exercise in people with knee OA and obesity compared with no SMS. Methods: A two-group superiority randomized controlled trial was performed in a community setting. Participants were people aged 50 years with knee OA and BMI ≥30 kg/m2 who had undertaken a 12-week physiotherapist-supervised exercise program as part of a preceding clinical trial. Both groups were asked to continue their home exercise program unsupervised three times per week for 24 weeks and were randomly allocated to a behavior change theory-informed, automated, semi-interactive SMS intervention addressing exercise barriers and facilitators or to control (no SMS). Primary outcomes were self-reported home exercise adherence at 24 weeks measured by the Exercise Adherence Rating Scale (EARS) Section B (0-24, higher number indicating greater adherence) and the number of days exercised in the past week (0-3). Secondary outcomes included self-rated adherence (numeric rating scale), knee pain, physical function, quality of life, global change, physical activity, self-efficacy, pain catastrophizing, and kinesiophobia. Results: A total of 110 participants (56 SMS group and 54 no SMS) were enrolled and 99 (90.0%) completed both primary outcomes (48/56, 86% SMS group and 51/54, 94% no SMS). At 24 weeks, the SMS group reported higher EARS scores (mean 16.5, SD 6.5 vs mean 13.3, SD 7.0; mean difference 3.1, 95% CI 0.8-5.5; P=.01) and more days exercised in the past week (mean 1.8, SD 1.2 vs mean 1.3, SD 1.2; mean difference 0.6, 95% CI 0.2-1.0; P=.01) than the control group. There was no evidence of between-group differences in secondary outcomes. Conclusions: An SMS program increased self-reported adherence to unsupervised home exercise in people with knee OA and obesity, although this did not translate into improved clinical outcomes. Trial registration: Australian New Zealand Clinical Trials Registry 12617001243303; https://tinyurl.com/y2ud7on5. International registered report identifier (irrid): RR2-10.1186/s12891-019-2801-z.
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Technology versus tradition: A non-inferiority trial comparing video to face-to-face consultations with a physiotherapist for people with knee osteoarthritis. Protocol for the PEAK randomised controlled trial
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Background: Knee osteoarthritis (OA) is a global problem that causes significant pain and physical dysfunction, substantially impacting on quality of life and imposing enormous cost to the healthcare system. Exercise is pivotal to OA management, yet uptake by people with knee OA is inadequate. Limited access to appropriately skilled health professionals, such as physiotherapists, for prescription of an exercise program and support with exercise is a major barrier to optimal care. Internet-enabled video consultations permit widespread reach. However, services offering video consultations with physiotherapists for musculoskeletal conditions are scant in Australia where there is typically no Government or private health insurer funding for such services. The paucity of robust evidence demonstrating video consultations with physiotherapists are clinically effective, safe and cost-effective for knee OA is hampering implementation of, and willingness of healthcare policymakers to pay for, these services. Methods: This is an assessor- and participant-blinded, two-arm, pragmatic, comparative effectiveness non-inferiority randomised controlled trial (RCT) conducted in Australia. We are recruiting 394 people from the community with chronic knee pain consistent with a clinical diagnosis of knee OA. Participants are randomly allocated to receive physiotherapy care via i) video-conferencing or; ii) face-to-face consultations. Participants are provided five consultations (30-45 min each) with a physiotherapist over 3 months for prescription of a home-based strengthening exercise program (to be conducted independently at home) and physical activity plan, as well as OA education. Participants in both groups are provided with educational booklets and simple exercise equipment via post. The co-primary outcomes are change in self-reported i) knee pain on walking; and ii) physical function, with a primary end-point of 3 months and a secondary end-point of 9 months. Secondary outcomes include changes in other clinical outcomes (health-related quality of life; therapeutic relationship; global ratings of change; satisfaction with care; self-efficacy; physical activity levels), time and financial costs of attending consultations, healthcare usage and convenience. Non-inferiority will be assessed using the per-protocol dataset. Discussion: Findings will determine if video consultations with physiotherapists are non-inferior to traditional face-to-face consultations for management of people with knee OA. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12619001240134. http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377672&isReview=true.
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Comparative effect of two educational videos on self-efficacy and kinesiophobia in people with knee osteoarthritis: An online randomised controlled trial
Article
  • Jun 2022
  • OSTEOARTHR CARTILAGE
Objective: To compare change in self-efficacy for managing knee osteoarthritis (OA) pain and kinesiophobia after watching an educational video based on an empowerment and participatory discourse with a video based on a disease and impairment discourse. Design: Two-arm randomised controlled trial with participants aged ≥45 years with knee pain (n=589). Participants completed both baseline and follow-up outcomes and watched one randomly-allocated video (12-minute duration) during one 30-45-minute session within a single online survey. The experimental video presented evidence-based knee OA information using design and language that aimed to empower people and focus on activity participation to manage OA, while the control video presented similar information but with a disease and impairment focus. Primary outcome measures were Arthritis Self-Efficacy Scale pain subscale (range 0-10) and Brief Fear of Movement Scale for OA (range 6-24). Secondary outcomes were expectations about prognosis and physical activity benefits, perceived importance and motivation to be physically active, knee OA knowledge, hopefulness for the future, level of concern and perceived need for surgery. Results: Compared to control (n=293), the experimental group (n=296) showed improved self-efficacy for managing OA pain (mean difference 0.4 [95%CI 0.2, 0.6] units) and reduced kinesiophobia (1.6 [1.1, 2.0] units). The experimental group also demonstrated greater improvements in all secondary outcomes apart from hopefulness, which was high in both groups. Conclusion: An educational video based on an empowerment and participatory discourse improved pain self-efficacy and reduced kinesiophobia in people with knee OA more than a video based on a disease and impairment discourse. Clinicaltrials: gov registration NCT05156216, Universal trial number U1111-1269-6143.
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Experiences of responsiveness to exercise in people with chronic whiplash: A qualitative study
Article
  • Apr 2021
Exercise is recommended in clinical guidelines for the treatment of chronic whiplash associated disorders (WAD). However, randomised controlled trials have shown similar effects for comprehensive exercise programs and advice. To date, there is no clear understanding of why some individuals with WAD appear to respond to exercise whilst others do not. The aim of this study was to explore the experiences and self-reported characteristics of people with chronic whiplash identifying as ‘responders’ and ‘non-responders’ to exercise. Semi-structured interviews were conducted with 13 people with chronic whiplash (patients) and seven treating physiotherapists. Patients were asked whether they responded to the exercise program, and what contributed to this. Physiotherapists were asked to share their experiences about the characteristics of people that appear to respond to exercise, and those that do not. An interpretive descriptive approach was selected to facilitate the generation of discipline-specific knowledge. Four themes were generated from patient and physiotherapist interviews, including: (1) the therapeutic relationship, (2) exercise experiences and beliefs, (3) self-efficacy and acceptance, (4) physical and psychological determinants of responsiveness. Responsiveness to exercise is complex and multifaceted. Clinicians may seek to identify the presence of discrete physical impairment(s) (e.g., range of motion restriction), and where present, determine whether targeted exercise results in an immediate and positive response. Clinicians may also focus their efforts on developing aspects of the therapeutic relationship identified as important to patients, such as hope, partnership and rapport.
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