Patients' and Practitioners' Views of Knee Osteoarthritis and Its Management: A Qualitative Interview Study

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DOI: 10.1371/journal.pone.0019634 · Source: PubMed
To identify the views of patients and care providers regarding the management of knee osteoarthritis (OA) and to reveal potential obstacles to improving health care strategies. We performed a qualitative study based on semi-structured interviews of a stratified sample of 81 patients (59 women) and 29 practitioners (8 women, 11 general practitioners [GPs], 6 rheumatologists, 4 orthopedic surgeons, and 8 [4 GPs] delivering alternative medicine). Two main domains of patient views were identified: one about the patient-physician relationship and the other about treatments. Patients feel that their complaints are not taken seriously. They also feel that practitioners act as technicians, paying more attention to the knee than to the individual, and they consider that not enough time is spent on information and counseling. They have negative perceptions of drugs and a feeling of medical uncertainty about OA, which leads to less compliance with treatment and a switch to alternative medicine. Patients believe that knee OA is an inevitable illness associated with age, that not much can be done to modify its evolution, that treatments are of little help, and that practitioners have not much to propose. They express unrealistic fears about the impact of knee OA on daily and social life. Practitioners' views differ from those of patients. Physicians emphasize the difficulty in elaborating treatment strategies and the need for a tool to help in treatment choice. This qualitative study suggests several ways to improve the patient-practitioner relationship and the efficacy of treatment strategies, by increasing their acceptability and compliance. Providing adapted and formalized information to patients, adopting more global assessment and therapeutic approaches, and dealing more accurately with patients' paradoxal representation of drug therapy are main factors of improvement that should be addressed.
Patients’ and Practitioners’ Views of Knee Osteoarthritis
and Its Management: A Qualitative Interview Study
Sophie Alami
, Isabelle Boutron
, Dominique Desjeux
, Monique Hirschhorn
, Gwendoline Meric
Franc¸ois Rannou
, Serge Poiraudeau
1 Interlis, Universite
Paris Descartes, Paris, France, 2 AP-HP, Centre d’Epide
miologie Clinique, Universite
Paris Descartes, Paris, France, 3 Universite
Paris Descartes, Paris,
France, 4 Pfizer, Paris, France, 5 AP-HP, Service de Re
ducation et Re
adaptation de l’Appareil Locomoteur et des Pathologies du Rachis, Universite
Paris Descartes, INSERM
IFR 25 Handicap, Paris, France
To identify the views of patients and care providers regarding the management of knee osteoarthritis (OA) and to
reveal potential obstacles to improving health care strategies.
We performed a qualitative study based on semi-structured interviews of a stratified sample of 81 patients (59
women) and 29 practitioners (8 women, 11 general practitioners [GPs], 6 rheumatologists, 4 orthopedic surgeons, and 8
[4 GPs] delivering alternative medicine).
Two main domains of patient views were identified: one about the patient–physician relationship and the other
about treatments. Patients feel that their complaints are not taken seriously. They also feel that practitioners act as
technicians, paying more attention to the knee than to the individual, and they consider that not enough time is spent on
information and counseling. They have negative perceptions of drugs and a feeling of medical uncertainty about OA, which
leads to less compliance with treatment and a switch to alternative medicine. Patients believe that knee OA is an inevitable
illness associated with age, that not much can be done to modify its evolution, that treatments are of little help, and that
practitioners have not much to propose. They express unrealistic fears about the impact of knee OA on daily and social life.
Practitioners’ views differ from those of patients. Physicians emphasize the difficulty in elaborating treatment strategies and
the need for a tool to help in treatment choice.
This qualitative study suggests several ways to improve the patient–practitioner relationship and the efficacy
of treatment strategies, by increasing their acceptability and compliance. Providing adapted and formalized information to
patients, adopting more global assessment and therapeutic approaches, and dealing more accurately with patients’
paradoxal representation of drug therapy are main factors of improvement that should be addressed.
Citation: Alami S, Boutron I, Desjeux D, Hirschhorn M, Meric G, et al. (2011) Patients’ and Practitioners’ Views of Knee Osteoarthritis and Its Management: A
Qualitative Interview Study. PLoS ONE 6(5): e19634. doi:10.1371/journal.pone.0019634
Editor: Ulrich Thiem, Marienhospital Herne - University of Bochum, Germany
Received November 29, 2010; Accepted April 8, 2011; Published May 5, 2011
Copyright: ß 2011 Alami et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was funded by Pfizer. The funders had no role in study design, data collection, data analysis, decision to publish, writing the manuscript.
Competing Interests: Sophie Alami, Isabelle Boutron, Dominique Desjeux, and Serge Poiraudeau received honoria from Pfizer and Gwendoline Meric is
employed by Pfizer.
* E-mail:
Society must prepare itself for an aging world. Arthritis (mainly
osteoarthritis [OA]) is the most common cause of reported
disabilities [1,2]. Hence, disability and participation restriction is
becoming an important component to assess in defining public
health strategies.
The patient point of view regarding health status has gained
importance in decision-making procedures and has been consid-
ered a possible criterion standard to assess treatment efficacy [3].
Results of a recent French survey suggest that the burden of knee
OA in primary care is substantial [4], and a substantial decrease in
health-related quality of life (HRQoL) was also reported in a
family practice setting [5,6]. However, disability and HRQoL are
usually measured by fixed-item questionnaires that do not take
into account patient priorities. A survey conducted in primary care
suggested that patients perceived knee OA to be more disabling
than hypertension, diabetes mellitus and heart diseases, whereas
physicians considered these 3 latter conditions the most important
chronic conditions [7]. Patients with knee and hip OA or
rheumatoid arthritis (RA), healthy professionals, and healthy
controls do not agree on the importance of disabilities [8,9]. These
discrepancies between patients and physicians in defining the
importance of an illness associated with substantial decreases in
HRQoL should lead to a paradigmal shift toward a more patient-
centred approach. Taking into account patient priorities may lead
to a better understanding of what is important to them [10].
Although patients with OA and their physicians may differ in
their assessment of what is important in health and symptom status
[11], views of patients and practitioners concerning knee OA
management have been seldom studied. A qualitative study
involving semi-structured interviews of German patients with OA,
nurses, and general practitioners (GPs) suggested that GPs should
focus more on disability and pain and on giving information about
PLoS ONE | 1 May 2011 | Volume 6 | Issue 5 | e19634
treatment [12]. Qualitative research is probably the best way to
understand patients’ needs and contexts and could improve
therapeutic strategies and their assessment [13]. The US Food and
Drug Administration has recently proposed guidelines for patient-
reported outcomes that emphasize the need for semi-structured
interviews of patients to ensure content validity of these
instruments [14]. We aimed to qualitatively assess patients’ and
physicians’ views concerning knee OA and its management by
using semi-structured interviews.
Ethics statement
All patients gave their written informed consent to participate in
the study. The study protocol was approved by the ethics
committee of Cochin Hospital, Paris. Investigations were con-
ducted according to the principles of the Declaration of Helsinki.
Qualitative interview study
This was a qualitative interview study of patients and care
providers conducted according to guidelines for inductive
qualitative research [15,16].
Semi-structured interviews were conducted with both patients
and care providers to explore patients’ and care providers’ views
about knee OA management. Individual behaviours (attitudes and
practices), personal feelings and interpretations, social interactions
and material backgrounds were specifically examined throughout
the patients’ therapeutic journey, to allow for a deep understand-
ing of patients’ expectations and fears and beliefs and practition-
ers’ expectations.
A heterogeneous sample of 81 patients and 29 care providers
was selected. The sample selection was based on non-probability
judgment sampling, assuring both relevance to the subject and
diversity of the members selected [17]. The diversity of the care
providers’ sample was ensured for age (,45 years, n = 11), gender
(8 women), specialty (11 GPs, 6 rheumatologists, 4 orthopedic
surgeons, 8 [4 GPs] delivering alternative medicine), and place of
practice (23 urban/6 rural). The diversity of the patient sample
was ensured for age (45–60 years, n = 29; 61–80 years, n = 38;
.80 years, n = 14), gender (59 women), professional activities (yes,
n = 34; retired, n = 57), and place of living (55 urban/6 rural). This
quite large sample size for a qualitative study is explained by the
limited data available on the subject, the diversity of the
population concerned by knee OA and the exploratory nature of
the research. The patients were selected from files of care
providers not involved in the interview process.
After a study of the literature on evidence-based procedures and
guidelines for knee OA, interviews of experts in the field and
patients’ perspectives of chronic diseases, we compiled semi-
structured interview guides with open-ended questions. Interview
guides for both groups were as similar as possible to allow
comparison across groups.
The interview guides were structured by combining a ‘‘funnel-
shaped’’ structure and the ‘‘itinerary method’’ [18–22]. The
funnel-shaped structure was adopted to ensure that the interviews
allowed for an inductive comprehension of the social reality at
stake beneath the knee OA situation. The itinerary method of data
collection was derived from anthropological data collection
techniques and focused on objects, practices and the decision-
making process. Applied to a therapeutic situation, the method
allows the researcher to follow the course of the situation for the
patient, from the appearance of the abnormality to the time of the
interview, thus placing knee OA in a broader context than the
medical one. The postulate underneath this framework is that
patients’ views on knee OA management cannot be limited to the
collection of explicit expectations that the patients can possibly
express: they have to be identified throughout an analysis of the
global social situation in which knee OA occurred and was (or was
not) managed, identifying contradictions, ambivalence, implicit
expectations or unanswered needs.
The interview guides thus combined a thematic structure (views
of OA, its effects and the following adjustments, description and
evaluation of the patients’ therapeutic journey, expectations, and
fears and beliefs) with chronological sequences to detail the
therapeutic journey and the course of consultation: diagnostic
routines, information giving, prescribing, advice for lifestyle, and
referrals. For physicians, the interview guide covered practitioners’
views of arthritis and knee OA (specificity, causes, limitations and
social impacts, evolution); the description of the management of
knee OA to analyze decision-making processes (different sequences
were detailed, such as the diagnosis process[es] and routine[s])
[interrogatory, physical examination, announcement of the
diagnosis, counseling, etc.]; and therapeutic decision-making
processes [including renewal, adjustment and modification of
prescriptions, referral to another physician, uncertainties encoun-
tered], the description of the patient–practitioner interactions at all
steps of the therapeutic journey (identifying questions asked,
information delivered, subjects discussed, patients’ resistance or
specific demands, and social strategies adopted), and practitioners’
The mean time for these interviews was 1.5 hr for patients and
1 hr for physicians Interviews for 8 patients were structured as
‘‘life history interviews’’ focusing on knee OA and lasted 2 hr. We
used the life history technique to question the social construction
of the views of knee OA and its management. Classically, we
proceeded chronologically, asking the interviewees to describe
their childhood right up to the present day. Nevertheless, we
adapted this technique by focusing on the life story with arthritis
and its management to look at family stories and identify opinions,
behaviour or attitudes related to arthritis that might have been
passed down through generations. In the case of arthritis, family
stories are used to interpret personal experiences, for self-
diagnosis, and to evaluate the gravity of the illness and ‘‘heredity’’.
The stories appeared to work as a reinforcement of medical
diagnosis. In the specific case of arthritis, life history interviews
revealed confusion between ‘‘rheumatism’’ and ‘‘arthritis’’ in the
patients’ minds.
All patients but 14 who preferred public places were interviewed
at home by trained interviewers. Care provider interviews took
place at practice locations. During the interview, the interviewer
ensured that every aspect was explained sufficiently and in detail.
The conversations were recorded digitally, transcribed literally
and analyzed by 4 researchers (all sociologists). An initial
categorizing system was established on the basis of the interview
guides. This first thematic index was modified, categories and
subcategories being added as they emerged from the analysis of the
data and researchers continually checking that they had a
common understanding of the categories generated. Numerous
free categories were developed, discussed, adjusted and grouped in
Views Concerning Knee Osteoarthritis Management
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an iterative and inductive process. All data were coded according
to the final thematic index generated.
Patient views
Two main domains were identified: one about the patient–
physician relationship and the other about treatment.
Patient–physician relationship
Sources of satisfaction. Confidence with the practitioner
seemed to determine the relationship and depend on a
combination of factors. One factor was the feeling of being in a
specific and individualized relationship with the care provider that
gives the feeling that the physician is ‘‘their’’ doctor. This feeling
was related to the interpersonal and communication skills of
physicians and their ability to adopt a holistic approach to the
‘‘This doctor, he doesn’t know my case. When he comes home, he
doesn’t chat, he doesn’t ask questions. Whereas the other doctor (the one
I prefer), asks questions about my family, about my home. He is lovely.
Sometimes, he waves at me while driving. The other one goes by as if he
doesn’t know me.’’ (Patient)
‘‘Sometimes, there are patients that make mistakes but my doctor, he
sorts out everything! He is really competent. He is kind and he has a real
sense of humor. I do appreciate him a lot, because he is really human.’’
This feeling also stemmed from specific behavior that conveyed
the accessibility of the physician and ethical qualities such as
devotion, conviction, prioritizing therapeutic over financial
considerations, and resoluteness in disease management.
‘‘One day, for instance, I was in holiday with my husband. My knee
was painful but I was out of anti-inflammatory. They didn’t want to
give me my treatment at the drug store as I had no prescription. I called
my GP: he made me one, and faxed it to the drugstore. I am really
pleased with him.’’ (Patient)
‘‘I also have a GP I see very often. I can have an appointment in two
days with him if I need one.’’ (Patient)
‘‘Young doctors don’t really care nowadays. Money is more important
that humanity sometimes.’’ (Patient)
Medical competence was also reported and estimated by the
physician’s estimated reputation, age and training. All these factors
conveyed a sense of security to the patients, which is, to a certain
extent, a way to deal with the uncertainty of their medical
situation: uncertainty about the origin of the illness, the efficiency
of treatment, and the evolution of the disease and its impact on
their daily life. Moreover, this trusting relationship appeared to
allow for patient cooperation and participation and for patients to
be part of the medical decision-making process:
‘‘The doctor talks decently to you. He respects your identity, your
wishes. He told me: I can operate now but if you want, I can also delay
the surgery. It pleased me that he considered what I wanted.’’ (Patient)
Sources of dissatisfaction. Sources of dissatisfaction were
not totally compatible with sources of satisfaction. A main source
of dissatisfaction was the physician accentuating the patient’s
feeling of uncertainty about OA by the patient feeling that they
received unclear explanations or insufficient knowledge:
‘‘You know, doctors don’t talk a lot. And I don’t follow their jargon; I
don’t really understand what they say. They don’t try (to be understood);
they don’t lose their time.’’ (Patient)
‘‘I’ve never had answers to my expectations and to my questions before (I
met this new doctor). I am interested in whatever information I can have
because we (patients) are sorely in need of information.’’ (Patient)
Practitioners trivializing OA and having fatalistic attitudes gave
patients the feeling that their complaints were not recognized:
‘‘Anyway, I’ve always been skeptical about the knowledge and the
interest of the care providers for osteoarthritis. They always gave me
vague information, they are not able to precise the evolution of
osteoarthritis. They are fatalists: they say that osteoarthritis is normal
and that there is nothing to do. It shows clearly that physicians have a
fatalistic attitude towards osteoarthritis that they are not concerned, not
informed.’’ (Patient)
Physicians imparting the feeling that therapeutic options are
only palliative led patients to question the efficacy of what they call
‘‘modern medicine’’ for OA:
‘‘Classical medicine acts on symptoms. In other words, it decreases pain
but it does not cure the cause.’’ (Patient)
‘‘- It’s the same when I have a headache, I take a painkiller my
headache calms down, but this does not solve the real problem… That’s
how I see it now (Patient)
The systematic rejection by some physicians of alternative
medicine options was also a source of dissatisfaction:
‘‘What I don’t like is that doctors, whatever their speciality, do not
recognize that there are alternatives to traditional medicine. They don’t
want to admit alternative medicine can also be efficient.’’ (Patient)
Evolution of satisfaction. Satisfaction and dissatisfaction are
not stable but are contingent and dynamic processes. Satisfaction
with a practitioner results from complex processes mobilizing
social, material, symbolic, and psychological factors, as well as
priorities, which vary among individuals. These variations depend
on OA evolution, the effect of health status on patients’ lives, and
patients’ psychological status, and they evolve over time.
Dissatisfaction does not seem to result from one cause but rather
occurs with the progressive accumulation of factors leading to
discontentment and finally to the rejection of treatments and
sometimes practitioners. This process can lead to the disruption of
the therapeutic relationship. Punctual dissatisfaction in a confident
global relationship does not call into question this relationship and
does not lead to disruption of this relationship. Finally, a long
relationship does not necessarily mean satisfaction with the
‘‘- I have my current GP for 2 years now, and I had a family GP
before. He was my GP for a very long time. But the thing is he took
things lightly, so I stopped seeing him.
- (Can you tell me more about that?)
- He entered into the room; he took my pulse, listened, and nothing else.
Views Concerning Knee Osteoarthritis Management
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- (What was he light about?)
- Well, he never changed his views: he was not really active. He did not
make me do any blood tests, X-rays… If I wanted one, I had to ask:
‘‘Can we do an X-ray?’’ ‘‘Oh yes if you wish so’’ and so we did it. To
me it is not a doctor…
- (How long did you see him?)
- 10 years at least.
- (Why did you wait so long to switch?)
- Well, I am not keen on changes… Not keen at all… I don’t like to
change my GP for another one, I can’t deal with it I am loathed of
- (Why?)
- I don’t know! I don’t know, but… one day I had an operation. I was
sent to hospital and he never asked about me, nothing…At that time I
felt offended (and then I switched for another GP).
Treatments. Patients’ views of treatments are various and
ambivalent, which sheds light on an overall reserved appreciation
of biomedical treatments for knee OA. Pharmacological
treatments are considered useful for symptoms (immediate relief
of pain) but unsuccessful for disease evolution. Patients’ views of
treatments differ depending on whether knee OA is considered an
occasional or a chronic problem. Expectations of those considering
knee OA an occasional problem are mainly symptom relief,
whereas expectations of those considering knee OA a chronic
problem are to dispose of a treatment being able to modify or stop
OA evolution.
Patients’ views of drug therapies for knee OA are paradoxical,
the drugs being considered both therapeutic and noxious. This
view generates fear and avoidance about drug therapies and a
general attitude that could be designated ‘‘the less drug therapy
‘‘When I’m in the middle of big crisis, when I actually can’t move, I
take anti-inflammatory drugs but I am trying to avoid taking them as
long as possible. I really have to be stuck for several days to take it.’’
Patients’ categorization of treatments for knee OA does not fully
correspond to those of care providers. Complementary exams,
especially imaging, are considered part of the treatments and are
appreciated and awaited.
Oral medications: Analgesics are considered periodic symptomatic
helpers. Their use is considered occasional, to anticipate a painful
situation or to attenuate an existing symptom. Fear of side effects
and dependency are reservations formulated by patients especially
for opioids:
‘‘I became addictive to morphine, and I find this medicine really
dangerous because… you don’t feel the pain anymore. It’s the ideal
treatment for the pain, but it’s a fake. To me it’s a fake. Because when
you meet professors, you deny you’re suffering in a way, and when the
professor asked me: ‘‘do you feel the pain madam?’’ How could I give a
logical answer? You can only answer ‘‘no’’ because you don’t feel
anything anymore. And the more you take these pills, the more relieved
you are, but it still is drugs…’’ (Patient)
This view leads to dosage restriction for long-duration
Non-steroidal anti-inflammatory drugs (NSAIDs) are perceived
as having an important risk of significant side effects:
‘‘I am against it, they are rubbish. All of them have side effects. The
liver has to eliminate everything. That’s why I was not keen on anti-
inflammatory drugs.’’ (Patient)
Their use is considered a periodic solution without regular
renewal. Patients taking NSAIDs commonly reported their limited
efficacy and the absence of long-term effects and expressed fears
about tolerance with regard to limited treatment options.
‘‘It’s also for this reason I don’t want to take too much medicine. I am
scared it will not do anything otherwise, especially when I will need it, later.
(…)I do not to take too much because I know it can create addiction issues.
I don’t take many of them. 2 or 4, that’s all. I can control myself. (…) I
know this osteoarthritis of the knee will get worse. If I start taking medicine
already, I think they won’t work when I’ll need them.’’ (Patient)
The accommodations patients used to limit drug use were
enduring pain, taking drugs during acute crisis or to prevent pain
for special events that should not be spoiled by crisis, and reducing
the dosage:
‘‘I am the one who knows when it hurts too much. If it is unbearable, I
take painkillers. But (…) the painkiller I take gives me stomach
problems although it really works on the pain. If I do feel pain but it’s
not too serious I take paracetamol. (…) I deal with it according to the
pain. He (my doctor) gave me Diclofenac but it has never really
worked’’ (Patient)
Although the distinction between whether slow-acting symp-
tomatic drugs for OA (SYSADOA) are drugs or dietary
supplements is not absolutely clear in patients’ minds, opinions
were positive. Patients emphasize the positive effects on pain, the
absence of significant side effects as compared with NSAIDs, and
the importance of having these therapeutic agents when treatment
options are limited. However, patients feel confident in abandon-
ing these treatments without medical counseling when they
consider their effects questionable. Dietary supplements are taken
when prescribed by physicians or recommended by relatives:
‘‘A friend told me: ‘‘this year the doctor gave me cod-liver oil’’. It’s very
important for the cartilage. We can also take shark cartilage as a dietary
supplement. It’s my GP who told me first that Harpagophytum was
relevant for arthritis. And as they are all natural products, I thought
‘‘why not’’?’’ (Patient)
Dietary supplements are considered natural alternatives to
pharmacological drugs. The image of ‘‘giving food’’ to joints is
‘‘I read cautiously all the things written on these products. And actually,
when you have knee problems, it’s as if the joint was not well-oiled.
Dietary supplements feed the cartilage, and make the joints suppler. So
it’s getting better. We do have less pain (…) May be by getting older,
the renewal of the cells works not so well. By taking these products, it
does help my cells to renew.’’ (Patient)
The absence of side effects or counter-indications is emphasized.
To take dietary complements appears to be a compensative
strategy in a context of few treatment options, which therefore
corresponds to dissatisfaction with conventional drug therapy and
constitutes auto-medication.
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Local treatments: Local topical treatment is associated with the
idea of pain relief and has a positive image. Local treatments are
considered positively for different reasons: self-administration
combined with massage is important for the mental construction
of the image of pain relief;
‘‘Diclofenac cream helps me psychologically. It makes me feel better but
it’s psychological, I do know it doesn’t really work. The cream is made
especially for muscle pain, and in this case it is not that at all. The real
thing is my cartilage is ruined, and the bones scrape together.’’ (Patient)
Because local topical treatments are applied to the area below
the administration site, local treatments match the strategy of ‘‘less
drug therapy possible’’ sought by patients; patients’ expectations
seem to be lower for local treatments than for oral drugs, which
might also decrease the risk of ‘‘being disappointed’’.
Corticoid injection in the knee invokes ambivalent apprecia-
tions. Efficacy and rapidity of action are emphasized, but patients
worry about the infiltration itself and the component injected,
perceived as potentially weakening the cartilage. Hyaluronic acid
injection in the knee is considered an alternative to surgery and
drug therapy and has a positive image because it is thought to be a
less aggressive procedure. Nevertheless, this treatment invokes
extremely different appreciations, from totally ineffective to
miraculously effective, concerning its efficacy.
Non-pharmacological treatments: Exercise therapy is considered
essential after knee surgery to recover mobility and is important
during the disease to increase muscle strength and relieve pain.
Some patients regret the short-term effect of symptom relief,
whereas others emphasize the lack of professionalism of physical
therapists. Appreciations concerning spa therapy differ, some
patients considering that it has substantial benefit and others
considering it as a simple distraction. Knee orthosis is appreciated
because of the reassurance given by the increased feeling of
stability and because of pain relief attributed to heat. However,
patients express aesthetic concerns and emphasize the burden of
wearing an orthosis. Soles are considered complementary options
to decrease weight bearing on the affected leg during gait. Assistive
devices such as canes or wheelchairs are accepted as transitory
options but are much less well accepted because they imply old age
and loss of autonomy and because of the image reflected, if
considered as permanent options.
‘‘This (wheeling chair) is awful! I don’t accept it. I had to take it
because I could not walk in my house (…) However, I don’t want to go
out with that. Maybe it is misplaced pride but it downgrades you.
People stare at you and that annoys me. (…) because when we go for a
walk or when we go shopping, and I no longer do that, people
immediately look at you. I no longer do the food shopping. My husband
does it.’’ (Patient)
‘‘I don’t want to meet people we know. For instance, I never go
downtown with the cane. My husband does the food shopping. Neither I
would go window shopping in Toulouse though I love that. First I get
tired faster and I don’t like people see me with the cane.’’ (Patient)
Interventions on the knee: Joint lavage and arthroscopy are described
as inducing only transient pain relief. Total knee arthroplasty is
considered ‘‘the last-chance’’ medical procedure and is desired to
occur as late as possible. Such therapy catalyzes general worries
about surgical procedures fears of anesthesia, nosocomial
infections, failure concerning results which can lead to increased
disability. Patients express concerns about the lack of clarity
concerning indications for surgery. The post-surgery period is also
a cause for fear because it is perceived as long and painful. Patients
who already experienced knee surgery have divergent assessments:
some emphasize the recovery of functional performance and
others express some deception about results.
‘‘I was a little disappointed by the first (knee surgery). The pain
remained. I expected a better result. I’ve never been able to walk like I
did before. I met people in physical therapy who were so happy with the
surgery that they ran for the second knee. I have to say that I expected
more than that…’’ (Patient)
Alternative therapies: Patients cite several alternative therapies
acupuncture, osteopathy, homeopathy, naturopathy, phytothera-
py, and Shiatsu but express various opinions about the efficacy of
these treatments. Reasons for choosing these therapies are to avoid
long-term drug intake, delay the time for surgery, and their greater
emphasis on prevention than biomedicine approaches. The use of
dietary supplements gives the patients the feeling of being active,
especially when confronted with fatalistic attitudes and trivializa-
tion of OA. Moreover, dietary supplements are not seen as a
symptomatic or palliative answer but as a more satisfying option,
an attempt to ‘‘cure the cause’’ of the illness. Reasons advanced for
choosing or switching to alternative therapies are to have a
physician directly administer the therapy and that physicians who
deliver or prescribe alternative therapies be more accessible and
open to discussion, have more empathy, spend more time with
their patients, and consider patients more globally in their
environment as compared with physicians prescribing biomedicine
‘‘At first, the acupuncturist asks me how I feel, and we talk too. I felt
depressed occasionally, so it is another thing we can talk about. He can
do something. He considers the patient as a whole, which is a real
difference with physicians like the rheumatologist who examines you,
asks you three questions and has finished with you. I do think the
relationship with the doctor in alternative medicine is longer, deeper and
makes more sense. I could tell you the same for the homeopath. With
him it is at least 45 minutes; he asks many questions to have a global
view.’’ (Patient)
Patients’ self-implication in the treatment: Patients develop additional
strategies to decrease the effects of knee OA on pain and
functional limitations such as the use of heat or cold. Some
patients declare having modified their diet or doing exercise more
frequently to better resist the effects of knee OA. These strategies
are suggested by physicians or are the result of self-adaptation.
Practitioner views
About the disease. Practitioners do not share homogenous
perceptions of knee OA. These perceptions waver between a
fatalist view of the disease with a trend to trivialization and a more
voluntarist opinion emphasizing the consequences of knee OA on
functional performance of patients and the need to modify the OA
status in practitioners’ representations. Practitioners’ talks reveal a
relative trivialization of OA in general and knee OA, which is
perceived as the natural degradation of the body with age, a
frequent and universal disease, and an ineluctable phenomenon (a
‘‘(Knee osteoarthritis) is part of getting older, it’s normal really, not
normal, but it makes sense as it is part of the natural evolution.’’ (GP)
Views Concerning Knee Osteoarthritis Management
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‘‘I will go further, I do not think it is a disease, it is a normal
degeneration. It is inevitable. It is a more or less severe ageing depending
on human beings. To me, it’s more linked to ageing than to a disease,
it’s somehow inevitable. Everyone has osteoarthritis with ageing whereas
not everybody has diabetes or hypertension… Or even cancer.’’ (GP)
Representations of the seriousness of knee OA are ambivalent.
Knee OA is considered potentially disabling:
‘‘It is a bloody nuisance, a thing which makes your life a misery and
restricts your activities.’’ (GP)
‘‘Knee osteoarthritis is a real barrier to a normal and nice life: they
(patients) become dependent.’’ (GP)
At the same time, its seriousness is weighed in terms of other
diseases considered more serious:
«And there are some more severe pathologies! With knee osteoarthritis,
we don’t have to provide the psychological support we have to do for
cancer or diseases like that!’’ (Surgeon)
Practitioners delivering alternative medicine have heteroge-
neous perceptions of knee OA largely depending on the type of
care delivered. Knee OA causes are deducted from interpretation
models of each alternative therapy (energetic disequilibrium for
those delivering acupuncture, physiologic disequilibrium for
osteopath, emotional disequilibrium for those delivering herbs):
‘‘I have a general answer one could say: it is an energetic deterioration; it
is true that when you take the pulse, we almost find the same thing in
everyone. That means that, at one stage, there is an energy that does no
longer go through the energetic circuit, that damage the cartilage; then, it
causes arthritis and we can feel it through the pulse. That’s why I said
it is a general answer.’’ (Acupuncture therapist)
‘‘The interesting point is to know why this knee osteoarthritis appeared.
It represents emotional worries that joy, rest and happy moments have
not succeed to evacuate. Too much bad news, tough life experiences have
for consequence that one day, you cannot deal with them anymore and
keep them inside yourself. As a result, the body has to react and does it
through out diseases and accidents. People have to investigate and be
introspective. It may have several origins on a physiological aspect. But
on the behavioural aspect, Bach Flowers are the one who will work.
This may be due to overwork.’’ (Flower counselor and naturopathic
About the diagnosis. Practitioners (mainly GPs) consider
that the aim of the first visit for knee symptoms is to distinguish
between mechanical and inflammatory pain, which is sufficient to
establish an appropriate prescription. The precise diagnosis of
knee OA during this first visit is not considered crucial because it is
not necessary for prescribing. Knee radiographs are considered
essential for diagnosis confirmation and are prescribed after the
first visit by practitioners who consider it important to have an
early diagnosis or after the first line of treatment failed by those
considering that early diagnosis is not crucial, generally before
referring to a specialist:
‘‘At the beginning, we don’t need to know for sure that it is knee
osteoarthritis. If the pain calms down naturally, it means we have time
to deal with it. If it is osteoarthritis, even if it is a rheumatic disease, it
will become chronic and therefore come back from time to time.’’ (GP)
As compared with practitioners delivering biomedicine, those
delivering alternative medicine consider knee OA easy to diagnose
and understand. Care providers who are not medical doctors tend
to perform a more global (whole body) examination than those
who are medical doctors, mainly to define causes of the disease
and elaborate the therapeutic program.
About treatments and prescription strategies. Practitioners’
representations of management steps are schematic and built
according to flare-up treatments. The first step consists mainly of
symptomatic pharmacological treatments and management by GPs;
the second step consists in joint injections (mainly corticoids) and is
managed by a knee specialist (rheumatologist in France); and the third
step is joint replacement by the orthopedic surgeon.
‘‘First are anti-inflammatory drugs and then, depending on the
evolution, if it develops slowly or not, we will go to injections. And the
prosthetic knee is really the last option considered.’’ (GP)
Prescription steps being limited, practitioners tend to optimize
prescriptions by several strategies, varying the drugs within a same
family, going back to the simplest prescriptions when they have not
been previously prescribed, and associating complementary
therapy (mainly between flare-ups with a prevention goal).
‘‘If (the patient) tells you ‘‘your last treatment did not work’’, then you
change. In the same therapeutic class, we try to select a more powerful
drug, a little more effective.’’ (Surgeon)
‘‘We realize that people with arthritis immediately take anti-
inflammatory treatment. They do not even have DolipraneH where as,
sometimes, just a half dose of it is enough. We have to explain that it is
better for them to take DolipraneH, that it is less toxic than other
treatments (Rheumatologist)
Practitioners mentioned various treatments for knee OA and
classified them in 3 general categories: flare-up treatments
(NSAIDs, opioids, coticoids injections, joint lavage, alternative
medicine), between–flare-up treatments (SYSADOAs, hyaluronic
acid injections, physical therapy, knee braces, soles), and surgical
treatments (osteotomy, total knee replacement).
Practitioners’ opinions of the efficacy of drugs differ by the drug
superfamily: analgesics are considered symptomatic treatments
with limited effects, NSAIDs symptomatic treatments with
frequent and serious side effects and numerous counter-indica-
tions, and SYSADOAs treatments without scientific proof of
efficacy but with few and minor side effects that could help reduce
other symptomatic treatments. GPs and rheumatologists consider
total knee replacement the ultimate and only really efficient
treatment, whereas orthopedic surgeons consider it one of the
treatment options for knee OA. Care providers delivering
alternative therapy have enthusiastic perceptions of the efficacy
of the type of care they deliver. They are more critical of
pharmacological treatment defined as chemica because they have
side effects, inhibit cartilage regeneration and may be dangerous
by hiding the symptom (pain), which is a useful yellow flag to know
when knee should be put at rest:
‘‘(Practitioners) use chemicals and it compromises all our treatments: it
pollutes them. They cure people with chemicals that get them crazy and
dependent when natural products are available. They offer patients
inefficient chemicals that might poison them and cause them diseases.’’
(Acupuncture therapist)
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‘‘Painkillers may also have another side effect: as the pain is being
stopped, the patient will keep on his activities. He will play rugby and
so worsen osteoarthritis. Pain is an alarm that has to be listened to.
Killing the pain is not enough for the disease to disappear.’’
(Homeopath, acupuncture therapist and GP)
The logics underlying the elaboration of prescriptions.
The decision and elaboration of prescriptions for knee OA is a
complex procedure (designated as ‘‘therapeutic do-it yourself’’)
combining several modalities of adaptation mobilizing medical and
‘‘common’’ knowledge. Prescription is fashioned by 3 logics:
medical knowledge of the practitioner, the practitioner’s
representation of the treatments and the role they assign to each
of these treatments, and the perception that the practitioner has of
the patient and his/her expectations.
When practitioners elaborate a prescription, their objectives are
not restricted to solving knee OA symptoms but are also to provide
a response to patients’ demands and expectations, optimize
compliance to treatments, and minimize risks, including their
own risks (mainly liability). According to their perceptions of
treatments, practitioners can be differentiated by 4 attitudes
determining therapeutic choices:
those with a positive perception of existing treatments and
consider that they can treat knee OA;
‘‘Now we get to put grafts such as for hair. There are hair grafts and we
now manage to have cartilage grafts. We put small pads of cartilage
that eventually over time spread like grass.’’ (Surgeon)
those with a pragmatic analysis of treatment and use available
those who consider existing treatments insufficiently efficient
and try to compensate in other ways, including organizing
social activities for their patients to prevent against isolation
and depression, regularly calling their patients, or developing a
partnership with domestic help; and
those who do not know how to deal with treatment options.
‘‘We, patients and physicians, are in the dark! (…) We are not
comfortable with this pathology. (…) We really ought to know what are
the impacts and the procedures according to the patients’ profiles and
risks.’’ (GP)
Practitioners also take into account their patients’ profile to
adapt their prescription. Patients are classified according to 4 main
variables: social characteristics, medical presentation, psycholog-
ical profile, and activities. These variables lead to a very complex
categorization of patient profiles; the tendency is to simplify to 2
main profiles determining therapeutic priorities: active (including
sports), young patients, to whom surgery (conservative or not)
should be proposed quickly, along with psychological support; and
older, inactive patients with co-morbidities, to whom total knee
replacement should be proposed as late as possible, for whom pain
levels should be controlled and acceptable, and co-morbidities not
worsened by pharmacological treatments. Implicitly, practitioners
also classify patients in 2 categories: the ‘‘easy’’ patients, defined as
living in the country, ‘‘not too old’’ with mild knee OA or very old
resigned and fatalist; and the ‘‘complex’’ patients, defined as living
in town, involved in sports, and those with obesity, co-morbidities,
psychological distress, or professional claims. Medical doctors
delivering alternative medicine tend to deliver biomedicine first
and then alternative therapy when they define themselves mainly
as a practitioners; those defining themselves as mainly care
providers usually begin with alternative therapy. Those delivering
alternative medicine more often emphasize diets and may forbid
certain types of food.
Practitioners’ expectations. Spontaneously, practitioners
express few expectations concerning knee OA management.
Nevertheless, analysis of interviews led to the identification of
expectations concerning pharmacological treatments, outcome
measures, prevention, medical education, and research.
Concerning pharmacological treatments, practitioners expect
treatment with structural efficacy that could slow or stop knee
OA evolution:
‘‘We are all dreaming of a product which would rebuild the cartilage
just by injecting it into the joints.’’ (GP)
They also emphasize the need for medications with fewer side
effects and counter-indications in order to increase therapeutic
options. They also expect tools (decision trees) to help in
therapeutic decision-making by defining treatments according to
patient profiles:
‘‘We should have a decision checklist based on assessment of risks that
would help us to identify how to proceed in 3 or 4 steps with knee
osteoarthritis patients. We mainly need medical information. (…) We
really need to know what are impacts on patients, the process to follow
and the risks according to patients’ typology.’’ (GP)
Practitioners have reserved opinions about existing assessment
tools mainly because they question their applicability in routine
practice. However, some express expectations concerning tools
better assessing certain dimensions such as psychological impact,
personal life, and aesthetic burden. Practitioners emphasize that
prevention could lead to earlier management of the disease at an
earlier stage with probably more effective treatment strategies
delivered to patients easier to treat because of fewer co-
morbidities. They also express the need to focus prevention on
the population at risk (the risk cited being professional status and
overweight). Practitioners also express expectations about specific
education and information focusing on the disease and its
treatments, the stake again being help in therapeutic decision-
‘‘We should have more information, as practitioners, to know what to
do. (…) I feel it is vague for us, and also for the patients! Practitioners
of my age are not so confident with surgery… it (knee OA) is a
pathology that makes us feel uncomfortable. There is no problem with
hips surgery but when the knee is concerned, it is a frightening surgery.’’
Some practitioners deplore the lack of research interest in knee
OA and others think it is not a priority:
‘‘There are very little studies done (…) there might be small teams of
researchers working on osteoarthritis in various countries but there are no
significant funds allocated to osteoarthritis. I recognize that if we want
people to work till they are 70, we will need to do something against
osteoarthritis!’’ (Rheumatologist)
Patients’ expectations seen by practitioners. Practitioners
tend to differentiate 2 patients profiles: young, active patients with
Views Concerning Knee Osteoarthritis Management
PLoS ONE | 7 May 2011 | Volume 6 | Issue 5 | e19634
many expectations and old (or very old), resigned patients who
consider knee OA a normal aging process, have few expectations and
no longer believe in the efficacy of medicine. Practitioners consider
that patients have expectations concerning symptoms (mainly pain
and disability), visits to the practitioner (to be examined with special
focus on auscultation and arterial tension recording and receive
information on the diagnosis, prognosis and counseling), and
prescriptions (demand fo r X-rays, propose drugs that are not over-
the-counter, topics, recommendations concerning aesthetic burden
for women). Practitioners identify specific but various patients’
expectations concerning surgery (patients wishing to undergo surgery
as soon as possible and others wishing to avoid this treatment option).
They also have concerns about patients’ unrealistic expectations
about surgery such as returning to the functional performance lost a
long time ago:
‘‘There are the objectively unsatisfied patients: when there is a problem with
the prosthesis, when it is loosening or when there is an infection, but that
scarcely happens. And there are the subjectively unsatisfied: the ones who
always have pain; who no longer can walk three hours hunting; who are
never happy with anything and who have thought that it (surgery) would
bring them back 10 years before. The typical example is the 70 years old
grand-mother with osteoarthritis everywhere and a rotten spine sorry for
the word but that’s how we talk between us –who does not understand why
she has not recovered and be as before.’’ (Surgeon)
To our knowledge, this is the largest qualitative study of
patients’ and care providers’ views of knee OA management in
terms of number of patients and care providers interviewed and
broadness of topics tackled.
Patient views
Patient–physician relationship. The ideal patient–
physician relationship is characterized by its flexibility, and
satisfaction cannot be considered a simple accumulation of
factors. The principle of physicians adjusting their behavior and
practice to the patient seems to constitute the pivotal stake in
satisfaction. Practitioners giving satisfaction should be both in the
fields of consumerism and technical, social and moral
competencies and are finally ‘‘summoned’’ to accept a perpetual
adaptation process to changing states and profiles of their patients.
Differences may exist between patients’ declared and real
expectations. Patient often express expectations about information,
for instance. Nevertheless, this expectation is variable, not
uniformly shared between patients or during the therapeutic
course. Moreover, this expectation can be less a need for more
information than a need for re-assurance. The existence,
formalization, accessibility and possibility of multiple returns for
information probably matters more than a simple systematization
and standardization of information.
Treatments. The patients’ relationship with treatments,
particularly drug therapies, is modulated by their own and
others’ experience with these treatments and by living with knee
OA. It evolves over time with self-medication and self-modulation
of dosages and variable degrees of compliance with prescribed
therapies, sometimes leading to their being abandoned. Patients
modulate prescribed medications according to 2 main criteria:
relief of pain and physical or functional limitations and
experienced or perceived risks or side effects. Patients with a
long duration of knee OA seem to have these modulations.
Facilitators of and barriers to improving knee OA
management concerning treatments.
Patients’ expectations
regarding treatments vary according to the consideration of knee
OA as an occasional or permanent problem. However, we
identified a common attitude of resistance to change induced by
this clinical situation, which suggests coping strategies similar to
those observed for other chronic pain conditions such as low back
pain [23].
All patients share the need for efficient symptomatic treatment
strategies, but those considering knee OA as chronic emphasize
the curative dimension of treatments and focus on more attention
paid to causes and repercussions of knee OA.
Patients expect a shift in the management of knee OA from a
technical viewpoint, centred on physical symptoms, to a more
global viewpoint centred on the patient in all his/her dimensions.
The stake is to promote knee OA management strategies that will
not be limited to physical symptoms but will take into
consideration the impact of knee OA on symbolic, temporal,
relational, psychological, emotional, material, and physical
dimensions. Patients emphasize the strategic importance of the
patient–physician relationship in their satisfaction with knee OA
management, the necessary flexibility of this relationship, and the
risk of the ‘‘routinization’’ of management in chronic clinical
situations being an obstacle to the adaptation of this management
to the specificities of the patient’s profile.
Dealing more accurately with patients’ paradoxal representa-
tion of drug therapy is also a way to improve knee OA
management. This issue raises the question of the conditions of
optimizing drug therapy prescriptions. The equation to resolve
combines 4 main dimensions: patients’ representation of drugs
(chemical, aggressive, harmful), their representation of the efficacy
of drugs (material and symbolic), the more or less acceptable
impact of the disease combined with the immediate demand of
patients, and the possible contradiction between patients’ way of
life (routines) and the specificities (side effects) of prescribed
Practitioner views. Practitioners’ views differ largely from
patients’ views, and the perception of patients’ expectations by
practitioners differs from those directly expressed by patients. This
finding has already suggested in previous works in the field of
osteoarticular chronic diseases [7–9].
Recent medical and social evolutions have led practitioners to
manage patients in a context of relative uncertainty. These
uncertainties influence how the medical visit is conducted, how
professional time is managed and the level of practitioners’
remuneration. In this context, specific to knee OA, the practitioner
must be confident in the patient talk about symptoms, assessment
of treatment efficacy, and compliance with treatment and
counselling. Pain and disability are subjective symptoms difficult
to assess, the difficulty being increased by the unwillingness of
practitioners to use specific assessment tools for these symptoms.
Practitioners must elaborate their prescriptions on this uncertain
basis. We identified practitioners with 2 opposite attitudes: those
who adapt their prescriptions to patient complaints, and those who
prescribe the same treatment whatever the intensity of the
complaint. When prescribing, practitioners must deal with 3
constraints: the feeling, mainly for GPs, of having imperfect
information on therapeutic options (a limitation of their medical
knowledge); having to deal with patients who have access to
information and who want to take an active part in therapeutic
decisions; and, to increase the acceptability of their prescriptions
and therefore increase compliance, the necessity to explain and
justify their therapeutic choices, which is time-consuming when
they have professional time constraints. The main facilitators for
Views Concerning Knee Osteoarthritis Management
PLoS ONE | 8 May 2011 | Volume 6 | Issue 5 | e19634
increasing the quality of knee OA management seem to partly
contradict constraints related to professional practice conditions.
In conclusion, this qualitative study exploring the views of
patients and care providers of knee OA management suggest
several ways to improve the patient–practitioner relationship and
the efficacy of treatment strategies, probably by increasing their
acceptability and compliance. The main factors of improvement
we identified are providing adapted, formalized information to
patients, adopting more global assessement and therapeutic
approaches, and dealing more accurately with patients’ paradoxal
representation of drug therapy. Finally, we confirm that patients’
and practitioners’ views of OA largely differ, and more attention
should be paid to patients’ views to increase treatment adherence.
Author Contributions
Conceived and designed the experiments: SA DD IB MH GM SP.
Performed the experiments: SA DD MH. Analyzed the data: SA DD IB
MH FR SP. Contributed reagents/materials/analysis tools: SA DD MH.
Wrote the paper: SA IB FR SP. Critical review of the manuscript: DD MH
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    • "The participants expressed ambivalence about using analgesics. Fears of side effects and dependency have been discussed frequently in previous research (Alami et al., 2011; Pouli et al., 2014; Sale, Gignac, & Hawker, 2006). However, the participants in our study did not report a fear of dependency, but, instead, fear of long-term side effects. "
    [Show abstract] [Hide abstract] ABSTRACT: Aim: Knee arthroplasties are an increasingly common treatment for osteoarthritis (OA) and the main indication is pain. Previous research states, however, that 15-20% of the operated patients are dissatisfied and 20-30% have persistent pain after surgery. This study is aimed at describing patients' experiences of living with knee OA when scheduled for surgery and further their expectations for future life after surgery. Methods: We interviewed 12 patients with knee OA scheduled for arthroplasty, using semi-structured qualitative interviews. The interviews were recorded and transcribed verbatim and analyzed using qualitative thematic analysis. Findings: Three categories were formulated with an overriding theme: "It's not just a knee, but a whole life." The three categories were "Change from their earlier lives," "Coping with knee problems," and "Ultimate decision to undergo surgery." The main finding was that knee OA affects the whole body and self, ultimately affecting the patients' lives on many levels. Further findings were that knee OA was considered to be the central focus in the participants' lives, which limited their level of activity, their ability to function as desired, their quality of life, and their mental well-being. Although surgery was considered to be the only solution, the expectations regarding the outcome differed. Conclusions: The participants were forced to change how they previously had lived their lives resulting in a feeling of loss. Thus, the experienced loss and expectations for future life must be put into the context of the individual's own personality and be taken into account when treating individuals with knee OA. The experience of living with knee OA largely varies between individuals. This mandates that patients' assessment should be considered on individual basis with regard to each patient.
    Full-text · Article · Mar 2016
    • "Sanders et al. [41] identified barriers related to three stages: first, some were reluctant to present themselves for treatment because of their perceptions that arthritis was part of normal ageing and that there was little that could be offered to them; second, while many had consulted GPs, their experiences were mostly negative, with GPs appearing to confirm the lack of effective treatment and rarely offering referral to secondary care; and third, waiting lists and rationing were perceived to be a barrier to getting treatment in secondary care and sometimes surgery appeared to be denied because they were considered 'too young' or not sufficiently disabled. These barriers may partly be explained by a gap in essential knowledge about OA and available treatment alternatives [16, 42, 43] . Dissemination of key information about OA is one approach that could increase patients' knowledge and abilities to make informed decisions . "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Osteoarthritis (OA) is the most common form of arthritis worldwide, affecting a growing number of people in the ageing populations. Currently, it affects about 50 % of all people over 65 years of age. There are no disease-modifying treatments for OA; hence preference-sensitive treatment options include symptom reduction, self-management and surgical joint replacement for suitable individuals. People have both ethical and legal rights to be informed about treatment choices and to actively participate in decision-making. Individuals have different needs; they differ in their ability to understand and make use of the provided information and to sustain behaviour change-dependent treatments over time. Methods: As a part of a larger research project that aims to develop and test a web-based support tool for patients with hip OA, this paper is a qualitative in-depth study to investigate patients' need for information and their personal emotional needs. We invited 13 patients to participate in individual interviews, which were audiotaped. The audio-tapes were transcribed verbatim and analysed using an inductive thematic analysis approach. Results: The thematic analysis revealed a pattern of patients' information and emotional needs, captured in several key questions relevant to the different stages of the disease experience. Based on these results and research literature, we developed a model illustrating the patients' disease experience and treatment continuum. Six phases with accompanying key questions were identified, displaying how patients information and emotional needs arise and change in line with the progression of the disease experience, the clinical encounters and the decision-making process. We also identified and included in the model an alternative route that bypasses the surgical treatment option. Conclusion: Patients with hip OA are in great need of information both at the time of diagnosis and further throughout the disease development and care continuum. Lack of information may result in unnecessary and dysfunctional misconceptions, underuse of potentially helpful treatment options and uninformed decisions. Patients need continuous support from health professionals and their families in order to find and consider effective treatment strategies.
    Full-text · Article · Mar 2016
    • "Osteoarthritis, a common painful disabling disease, frequently affecting the knee joint, often thought to be untreatable, can be favourably impacted by a variety of conservative management approaches applied alone, or in combination, including, but not limited to, patient education, weight reduction, the appropriate application of assistive devices and orthotics, exercises to maximize muscle strength and endurance, joint range of motion and aerobic capacity, among others. That is, carefully tailored and personalized uni-or multicomponent approaches recommended in light of the extent of prevailing joint destruction, and the patient's age, health status, beliefs, fears, anxieties, and general capabilities for self-management can potentially yield quite favorable rather than unfavourable disease outcomes [75, 98]. However, because pain relief that leads to excessive joint use could have adverse effects on damaged cartilage [80], a structure very sensitive to mechanical signals [81] , enabling the patient's understanding of all potential contributing factors to the prevailing structural damage and dysfunction, such as loading magnitude and frequency [81], is desirable in efforts to reduce their pain and prevent excess disability, while promoting independence, as well as life quality [82, 83] as outlined inFigure 1. "
    Full-text · Article · Nov 2015 · BMC Health Services Research
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