Exercise for chronic knee pain: a national cross-sectional questionnaire survey of GPs in the UK

Abstract

Purpose: Older patients with chronic knee pain (CKP) attributable to osteoarthritis frequently present to general practitioners (GPs). As a core management approach for CKP, exercise reduces pain and improves function. This study aimed to investigate GPs’ use of exercise for CKP and to establish if current practice is in line with best available evidence. Methods: A cross-sectional questionnaire survey was posted to 5000 UK GPs. GPs’ reported behaviours regarding exercise use for CKP were determined using a multiple choice question relating to a vignette case which described a 58-year old female presenting for the first time with CKP. GPs who reported using exercise were asked to provide further details regarding the nature of the exercise and the actions they would take to implement this. Using an underpinning model (developed from behavioural theory), factors potentially associated with GPs’ exercise use were investigated. Descriptive statistics were used to describe exercise use and logistic regression was used to determine which factors were associated with exercise use. All analyses were undertaken with IBM SPSS Statistics (Version 20). Results: 835 GPs returned a completed questionnaire (adjusted response 17%) of which 729 (87%) stated they would use exercise for the patient with CKP. 538 (74%) reported using both local (lower limb) and general (aerobic) exercise. Of these, only 92 (17%) GPs employed local and general exercises in a way that was aligned to evidence-based recommendations, that is; they would advise, or refer for, local and general exercise and provide written information about both exercise types. Among the 347 GPs advising general exercise, swimming (49%), walking (41%) and cycling (34%) were most commonly suggested. Most GPs did not explicitly report that they would tailor exercise advice to the individual patient. Of the 729 GPs reporting to use exercise, 494 (68%) stated that they would follow-up to check adherence, using either opportunistic (61%) or planned (39%) follow-ups. Most (98%) GPs had experienced barriers to initiating exercise for CKP, the most frequently reported were insufficient time (51%) or expertise (41%) and the perception that patients prefer other management options (36%). Factors significantly associated with exercise use (OR (95% CI)) included GPs’ beliefs about consequences (agreement that knee problems are improved by local (3.23 (1.94,5.39) and general exercises (2.63 (1.38, 5.02))), moral norm (agreement that all patients should be prescribed local (3.08 (1.96, 4.83)) and general exercises (2.63 (1.45, 4.76))), beliefs about their role (belief that GPs should give information on type, duration and frequency of exercise (30.71 (5.02, 188.01)) and their skills (prior experience of having insufficient expertise to give detailed exercise information (0.50 (0.33, 0.76)). Perceived time limitations did not reduce overall exercise use but did affect initiation of exercises (71% disagreeing they had time constraints demonstrated local exercises compared with 53% who agreed). Some associations identified with exercise use were not well explained by the underpinning model, for example, similar exercise use among GPs who were positive and negative about the safety of local (90% vs. 88%) and general exercise (89% vs. 87%). Conclusions: Although most GPs reported using exercise for CKP, a minority used both local and general exercises in ways that align with evidence-based recommendations. The low response risks response bias and may have overestimated exercise use. Although the underpinning model identified attitudes and beliefs that were associated with exercise use by GPs, these associations were not always as expected. Better understanding of the key influences on GPs’ behaviour may require greater focus on factors influencing GPs’ decision-making. To maximise the benefit of exercise, GPs need to be supported to implement evidence-based exercise recommendations into patients’ management plans.