Therapeutic alliance facilitates adherence to physiotherapy-led exercise and physical activity for older adults with knee pain: a longitudinal qualitative study.

Abstract

What are people's experiences and perceived impact of physiotherapist-led exercise interventions for knee pain attributable to osteoarthritis? What barriers and facilitators to change in exercise and physical activity behaviour exist over time? A longitudinal qualitative study was undertaken; it involved face-to-face, semi-structured and longitudinal interviews. Interviews were undertaken with older adults with knee pain and who had been randomised to one of three physiotherapist-led exercise intervention arms in the Benefits of Effective Exercise for knee Pain (BEEP) trial. Thirty participants were enrolled in this qualitative study, with interviews scheduled at the end of the trial intervention period and 12 months later. A 'layered approach' to thematic analysis was used, including open coding (using constant comparison), deductive coding and within-case and cross-case longitudinal analysis of change. Different levels of exercise supervision, progression and individualisation emerged, matching the content of the intervention protocols. Barriers to exercise and general physical activity were similar across intervention arms (lack of motivation, time, physical environment, lack of supervision and/or monitoring). Despite individualising exercise programs and specifically targeting exercise, some barriers to adherence remained at 12 months. Factors facilitating longer-term exercise adherence included change in or retained knowledge about the role of exercise for knee pain and the presence and quality of a therapeutic alliance, which was also reflective of the participants' experience of the intervention, regardless of the trial arm. Despite a focus on individualisation and exercise adherence, barriers remained in the longer term. Strong therapeutic alliance during treatment appeared to facilitate adherence to exercise and general physical activity. The findings highlight ongoing physiotherapy support and therapeutic alliance as targets for future adherence-enhancing interventions for exercise in older adults with knee pain.