Abstract
Clinical guidelines recommend non-surgical treatment before surgery is considered in patients eligible for knee replacement. Surgical treatment is provided by orthopedic surgeons and exercise therapy is provided by physical therapists. The aim of this study was to identify perceived facilitators and barriers-among orthopedic surgeons and physical therapists-towards coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise. This qualitative study is embedded within the QUADX-1 randomized trial that investigates a model of coordinated non-surgical and surgical treatment for patients eligible for knee replacement. Physical therapists and orthopedic surgeons working with patients with knee osteoarthritis in their daily clinical work were interviewed (one focus group and four single interviews) to explore their perceived facilitators and barriers related to pre-operative home-based exercise therapy with one exercise-only in patients eligible for knee replacement. Interviews were analyzed using thematic analysis. From the thematic analysis three main themes emerged: 1) Physical therapists' dilemma with one home-based exercise, 2) Orthopedic surgeons' dilemma with exercise, and 3) Coordinated non-surgical and surgical care. We found that the pre-operative exercise intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons. The physical therapists were skeptical towards over-simplified exercise therapy. The orthopedic surgeons were skeptical towards the potential lack of (long-term) effect of exercise therapy in patients eligible for knee replacement. The consequence of these barriers and ambivalence in the professional role is important to consider when planning implementation of the model of coordinated non-surgical and surgical treatment. ClinicalTrials.gov, ID: NCT02931058.
Highlights
Physical therapists and orthopedic surgeons working with patients with knee osteoarthritis in their daily clinical work were interviewed to explore their perceived facilitators and barriers related to pre-operative homebased exercise therapy with one exercise-only in patients eligible for knee replacement
We found that the pre-operative exercise intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons
The physical therapists were skeptical towards over-simplified exercise therapy
Summary
Knee osteoarthritis (OA) is a growing challenge for the health care system and more knee replacements (KR) are performed each year to treat the condition with an estimated increase of 69% from 2012 to 2050 in the United States [1,2]. A key feature of knee OA is knee pain which is often associated with decreased quality of life, physical activity and muscle strength. Patients eligible for KR are provided highly specialized surgical treatment to help overcome their knee OA-related pain and concomitant symptoms [5,6]. Not eligible for KR, can be referred to non-surgical treatments such as exercise therapy and weight loss [7]. Eligibility for KR is based on several factors including; the patient’s medical history (i.a. knee pain, quality of life, limitations in daily living), physical examination (i.a. active and passive range of motion, palpation), effect of previous non-surgical treatment [7,8,10] and x-rays [20,21]. Most patients referred to KR present with severe radiographic knee OA (i.e. clear joint space narrowing, osteophytes, sclerosis and joint deformity) as this is believed to be a good indication as to whether KR will be an effective treatment [26]
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