Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients with severe knee osteoarthritis: A qualitative interview study nested in the QUADX-1 trial

Aim Clinical guidelines recommend non-surgical treatment before surgery is considered in patients eligible for knee replacement (KR). Surgical treatment is provided by orthopedic surgeons and exercise therapy is provided by physical therapists. This study aimed to investigate key stakeholder perspectives on pre-operative, home-based exercise therapy with one exercise-only in patients eligible for KR. Methods 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 KR. 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 KR. Interviews were analyzed using content analysis. Results From the content analysis three main themes emerged: 1) Physical therapists and orthopedic surgeons ambivalence in their professional roles, 2) Orthopedic surgeons view on exercise, and 3) Coordinated non-surgical and surgical care. Conclusion 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 KR. 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. Trial registration: ClinicalTrials.gov, ID: NCT02931058.


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. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The aim of this study was to identify perceived facilitators and barriersamong  This qualitative study is an embedded part of a "parent" randomized trial (the 115 QUADX-1 trial) investigating the dose-response relationship of pre-operative exercise 116 therapy prior to potential KR in patients with severe knee OA (24). The trial employs a model 117 of coordinated non-surgical and surgical treatment where orthopedic surgeons re-evaluate 118 patients' need for surgery following exercise in the municipality. In the Danish health care 119 system, non-surgical treatment is performed in the municipalities and surgical treatment is 120 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
(which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.01.22.20018416 doi: medRxiv preprint 7 performed at the hospitals. To ensure coherent care pathways with high quality for patients, 121 cross-sector coordination of treatment is essential. In the QUADX-1 trial, the patients exercise 122 unsupervised at home for twelve weeks after an initial exercise instruction by a physical 123 therapist. At four and eight weeks, the patients have follow-up consultations with the physical 124 therapist. The project is designed as an intervention trial with concurrent gathering of 125 information for clinical applicability and implementation (the present qualitative study), also 126 referred to as a hybrid design I (25). The exercise intervention consists of one muscle 127 strengthening exerciseseated knee-extensions using an elastic exercise band as resistance. 128 This one specific exercise was chosen based on the concept of "less is more", as it was 129 considered pragmatic and simple. That is, it is easy to set up at home, easy to remember how 130 to perform, requires little intellectual effort and is easy to master. Further, an exercise 131 intervention comprising one exercise was chosen as compliance to home-based exercise is 132 reported to be poor (26-29) and an intervention of one exercise could increase adherence.  CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
(which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020. 01 The study was carried out in Denmark, where the health care system is publicly 150 funded from taxes, enabling the Danish welfare state to provide free treatment for all citizens. 151 The orthopedic department where this study was performed is an integrated part of the 152 hospital and has more than 45,000 ambulatory visits and around 7,000 operations are 153 performed every year. All municipalities have rehabilitation centers where patients are 154 referred to outpatient rehabilitation subsequent to treatment at the hospital, for example KR. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. We aimed to use focus group interviews for all participants as the purpose of the 176 interviews was to explore the perceived facilitators and barriers and associated feelings, 177 experiences and attitudes of the health care professionals on the coordinated non-surgical and 178 surgical treatment investigated in the QUADX-1 trial. Focus group methodology is 179 considered an appropriate method for this purpose because participants can freely express and 180 discuss their experiences as well as listen to the experiences of the other participants. It is 181 therefore particularly suitable to collect data on social groups, interactions, interpretations and 182 norms (30,31,33). We completed the focus group interview with the physical therapists as 183 planned, but it proved practically impossible with the orthopedic surgeons due to very tight 184 work schedules. As a compromise, we conducted single interviews instead because this 185 method is suitable for producing in-depth data on a particular phenomenon or topic (34). Both  CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  199 Before the interviews, the two interview guides were piloted by RSH and JK in two single 200 interviews with health care professionals to revise poorly formulated questions after which 201 they were re-piloted. The focus group interview lasted two hours (including two breaks) and 202 the single interviews lasted between 30 and 40 minutes. At the focus group interview, the 203 moderator (RSH) facilitated the dialogue while JK observed the interview and took notes of 204 topics important to pursue. RSH and JK went through these notes in the two breaks in the 205 focus group interview and adjusted the interview to ensure that these topics were included 206 (e.g. topics not pursued by RSH due to preconception as a physical therapist). The single 207 interviews were conducted by RSH and at the first single interview, JK observed and took 208 notes of important topics, which were used to qualify the following interviews. Following  CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
(which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.01.22.20018416 doi: medRxiv preprint Fully transcribed interviews were brought together into one text constituting the 216 unit of analysis. Before analyzing the interviews, RSH read the data material through several 217 times to obtain a sense of the whole. The transcribed interviews were analyzed by RSH and 218 JK using inductive thematic analysis to group the data into sub-themes and themes (35). The 219 analytical process involved 1) dividing the text into meaning units, 2) condensing meaning  (Table 1). Through this process, it was possible for RSH to put his preconception in   . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
(which was not peer-reviewed) The copyright holder for this preprint  The study was performed according to the Helsinki Declaration (38). 239 Participants were informed that participation in the interviews was voluntary and that they  The thematic analysis showed three main themes: 1) Physical therapists' and orthopedic 251 surgeons' ambivalence in their professional roles, 2) Orthopedic surgeons view on exercise, 252 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.   . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.    One sub-theme that emerged from the focus group interview was that the 286 physical therapists are conscious about the importance of educating and providing patients 287 with tools to self-manage their condition. In patients with chronic conditions (e.g. knee OA) 288 self-management is especially important if the effect of treatment is to be sustained following 289 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.   As the physical therapists are aware of this, they embrace this skill and express 310 that it is important to give patients a sense of responsibility for their own treatment and to 311 teach them principles of self-management of their condition. In this way, even though they 312 distance themselves from the patients, they keep some control over the patient's treatment.

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. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  The limited face-to-face contact between patient and physical therapist where 327 they only see each other three times over the course of three months, gives rise to several 328 concerns among the physical therapists. They express concern about the quality (and thus 329 effectiveness) of the exercise (treatment) when it is primarily home-based as they are not 330 there to ensure high quality in the exercises and provide timely adjustments. Related to this is 331 a concern about the limited number of predefined consultations with the possibility of 332 supervising and adjusting the exercise. A physical therapist explained: CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint . https://doi.org/10.1101/2020.01.22.20018416 doi: medRxiv preprint thinking that I wanted to examine them more closely in general and in relation to their knee 338 OA. Yes, now it's only this one exercise they get." (Physical therapist 2, focus group 339 interview).

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The predefined and advisory role with a limited number of consultations 341 challenges and simplifies their professional role and, thus, becomes a potential barrier.   is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The physical therapists express concern regarding exercise treatment with one 361 exercise as they think it is a rigid treatment limiting usage of their professional skills. One    However, they also discuss two facilitators related to the one home-based 379 exercise approach. Providing patients with one exercise keeps the intellectual effort required 380 to a minimum while also taking less time to complete. The physical therapists describe the 381 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint In continuation of this, the physical therapists also mention that the one exercise   is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.   CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint . https://doi.org/10.1101/2020.01.22.20018416 doi: medRxiv preprint severe symptoms is referred to exercise treatment, the orthopedic surgeons are convinced that 428 the patient will come back without feeling better. One orthopedic surgeon gave an example:      is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The orthopedic surgeons also expressed concern for patients still active in the    CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.   exercise. An orthopedic surgeon can easily refer a patient to exercise if he/she deems this to 544 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  Another view on exercise is that it is a treatment where the patient "can be 585 parked" until surgery is needed. From this perspective, exercise is used in a less constructive 586 and inclusive way, and more as a practical solution that can be used until the patient is ready 587 for surgical treatment. One orthopedic surgeon explained: 588 "It (exercise) can be an advantage. If I don't think they are candidates for 589 surgery, then I "park" them out there (to exercise)." (Orthopedic surgeon 3, single interview).   is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not peer-reviewed)
The copyright holder for this preprint      The physical therapists are positive towards coordinated non-surgical and surgical 672 treatment as they believe the patients are provided with an altogether better care pathway 673 when exercise is tried before the decision for surgery is made. This was shown in statements 674 like the following:

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"I like the idea -that the patient isn't told at the first consultation that "you need a 676 knee replacement"that exercise is tried and then the need for surgery is re-evaluated. That 677 is, "this (exercise) worked for me", or "this did not work for me". I think this is a reasonable 678 care pathway." (Physical therapist 4, focus group interview).

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The physical therapists also believe that patients would appreciate such a coordinated 681 care pathway and would feel confident that all treatment options have been explored. Further,

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The copyright holder for this preprint . https://doi.org/10.1101/2020.01.22.20018416 doi: medRxiv preprint in such a coordinated care setting the patients would experience that the health care 683 professionals at the hospital and in the municipality are communicating and working together.

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A physical therapist explains: 685 "…I think that the individual patient will feel that they have been taken good care of… 686 That all treatment options have been tried out and that they have had a good care pathway... 687 Also, in relation to communication, that they (the patients) experience that we and they (the

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. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. i.e. "too simplistic" and "restricted intervention, wanted to add manual therapy as a treatment 773 option" and "the role of on-going support" (21).

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When an orthopedic surgeon considers surgery for knee OA for a patient who is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint . https://doi.org/10.1101/2020.01.22.20018416 doi: medRxiv preprint right treatment, for example due to a skepticism towards the long-term effectiveness of 781 exercise. The orthopedic surgeon could argue that surgery should be offered right away since 782 the indication for surgery is met regardless of whether the patient has tried non-surgical 783 treatment or not. In this situation, the preferences of the orthopedic surgeon become a barrier 784 for adherence to clinical guidelines (including referral to exercise therapy).

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Other challenges for the orthopedic surgeons are their role as agents for the  CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
(which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020. 01.22.20018416 doi: medRxiv preprint This study has both strengths and limitations which should be considered when 877 interpreting the findings. One of the main strengths is that all potential participants were 878 included for the interviews. That is, all physical therapists and eligible orthopedic surgeons 879 (supervisors and co-authors deemed not eligible due to conflict of interest) involved in the  approved by all co-authors (i.e. physical therapists, an orthopedic surgeon and a nurse).

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. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. We gratefully thank all participating physical therapists and orthopedic surgeons 920 for their contribution to the present study. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.