Point-by-point revision of
PONE-D-20-02454
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
Enclosed, please find a revised version of the above manuscript. We have carefully
addressed all comments and questions from the reviewer and editor, which we believe
has significantly improved the quality of the manuscript. We have submitted a detailed
point-by-point list of our replies to the comments and questions made and associated
changes made in the manuscript. This has been submitted together with the submission
of the revised manuscript. All parts in the text that have been modified are described
in the below point-by-point response.
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Author response
Thanks for notifying us on these omissions. We have now updated the style requirements
accordingly.
Journal requirement #2
In your Methods section, please provide additional information about the participant
recruitment method and the demographic details of your participants. Please ensure
you have provided sufficient details to replicate the analyses such as: a) the recruitment
date range (month and year), b) a description of any inclusion/exclusion criteria
that were applied to participant recruitment, c) a table of relevant demographic details,
and d) descriptions of where participants were recruited (the specific locations and
names of the municipalities and hospitals) and where the research took place.
Author response
We thank the reviewer for this clarifying comment. We agree with the comment and have
added the below information to the manuscript. We refrain from naming the individual
municipalities and the hospital to keep the identity of the participants anonymous.
We believe that by doing this we also adherence to the General Guidelines for Human
Research Participant Data as stated on the PLOS ONE website (https://journals.plos.org/plosone/s/data-availability). The below is an excerpt from the website: Data that are not directly identifying
may also be inappropriate to share, as in combination they can become identifying.
For example, data collected from a small group of participants, vulnerable populations,
or private groups should not be shared if they involve indirect identifiers (such
as sex, ethnicity, location, etc.) that may risk the identification of study participants.
Action taken
The highlighted text has been added to the “recruitment and study participants” and
“procedures” paragraphs. Demographic details are provided in Table 1.
We recruited six physical therapists from three municipalities in the capital region
of Denmark and four orthopedic surgeons from one university hospital in the capital
region of Denmark involved in the QUADX-1 trial [1] (Table 1). Inclusion criteria:
participants had to be involved in the QUADX-1 trial, as the intervention under study
was not implemented in routine clinical practice. No exclusion criteria were applied.
Thus, the six physical therapists and four orthopedic surgeons represents all possible
participants as we sought situational representativeness rather than demographic [2].
We recognize that a sample size of ten participants could be a limitation and inadequate
to attain data saturation. However, we consider this necessary as this was the only
possibility to investigate facilitators and barriers among the orthopedic surgeons
and physical therapists involved in the QUADX-1 trial. When interpreting the results
this should be kept in mind. Participants were contacted by the primary investigator
and interview moderator (RSH) by e-mail with an invitation to participate in the interviews
between November 2016 and June 2017. RSH sent the invitations because he would be
conducting the interviews. All invited participants accepted. All eligible physical
therapists had daily clinical work with patients diagnosed with knee OA and rehabilitation
following KR. All eligible orthopedic surgeons had daily clinical work with patients
potentially eligible for KR due to knee OA symptoms. A random sample of patients participating
in the QUADX-1 trial were also interviewed about their perceptions of facilitators
and barriers towards coordinated non-surgical and surgical treatment using pre-operative
home-based exercise therapy with one exercise. This work is as yet unpublished.
Changes made at page 8-9, lines 168-188
And
The interviews took place in meeting rooms at a university hospital in the capital
region of Denmark.
Changes made at page 11, lines 221-222.
Journal requirement #3
Thank you for clarifying that oral consent was obtained from the participants for
the interviews conducted in this study. In your Methods section, please also state:
- Why written consent could not be obtained
- Whether consent was informed
- Whether the Institutional Review Board (IRB) approved use of oral consent
- How oral consent was documented
For more information, please see our guidelines for human subjects research: https://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research
Author response
We thank the reviewer for this comment. We agree that this is important to make clearer
in the manuscript.
Consent was informed. We have added information to the manuscript to make this clearer.
The IRB approved the study with no specification on the type of informed consent for
qualitative interviews. We choose oral informed consent, why written informed consent
was not originally obtained. Written informed consent was not originally obtained
for the following reasons: 1) the head of departments approved the health care professional’s
participation in the study, 2) we did not expect the interviews to include personally
identifiable topics (which they did not) and 3) as the head of departments approved
the health care professionals participation and that the participants gave oral consent,
informed consent was essentially given twice. However, to make any uncertainties and
misunderstandings clear we have gathered written informed consent from the interview
participants subsequently. Please see Supplementary Information 6 for an example of
the written informed consent formula.
Action taken
The highlighted text has been added to the “Ethics” paragraph.
The study was performed according to the Helsinki Declaration [3]. Before undertaking
the interviews, all participants were provided oral and written information about
the aim of the study, procedures to be undertaken, potential risks and benefits of
participation, expected duration of the study and extent of confidentiality of personal
identification, assured that participation was voluntary and that they could withdraw
consent at any time during the interview. All invited participants were allowed a
minimum of 24 hours to consider participation. All participants were informed about
anonymity and confidentiality and gave written informed consent to participate in
the interviews. All participants are pseudo-anonymized and reported data are de-identified
(no mentioning of names or date of birth). Data were stored on a file drive secured
by log-in. The study has been approved by The National Committee on Health Research
Ethics (Protocol no.: H-16025136).
Changes made at page 13-14, lines 269-279.
Journal requirement #4
We note you have included a table to which you do not refer in the text of your manuscript.
Please ensure that you refer to Table 2 in your text; if accepted, production will
need this reference to link the reader to the Table.
Author response
Thanks for spotting this error, which we have now corrected. Table 2 is now table
3, as a new table (Table 1: Participant demographics) has been introduced earlier
in the manuscript.
Action taken
A reference for table 3 is now provided in the first paragraph of the results section.
…and 9) Responsibilities in coordinated care and engagement in the care pathway (Table
3). The themes and sub-themes represent different facilitators and barriers among
orthopedic surgeons and physical therapists towards home-based pre-operative exercise
in patients eligible for KR.
Changes made at page 14, line 292.
Journal requirement #5
Thank you for stating the following in the Competing Interests section:
"The authors have declared that no competing interests exist.
Dr. Troelsen reports personal fees from Zimmer Biomet, grants from Zimmer Biomet,
personal fees from European Knee Society, outside the submitted work."
Please confirm that this does not alter your adherence to all PLOS ONE policies on
sharing data and materials, by including the following statement: "This does not alter
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Author response
Thanks for notifying us on this. We have added the required sentence to the declaration
of competing interests. Please see the cover letter.
Additional Editor Comments (if provided)
Editor comment #1
Design: Please give a reference for the design and identify the ontology and epistemology
of this design. This will impact comments for the results in the next version.
Author response
We thank the editor for this comment. We believe we have given a reference for the
design in the paragraph named Context: The QUADX-1 trial (Page 6, lines 119-136).
To make this clearer we have added a sentence and a reference in the Design paragraph
(Page 8, lines 152-153).
Ontologically, clinical practice regarding patients with knee osteoarthritis is understood
as dynamic, complex and in constant change and that there is no definitive truth to
this context. Knowledge is relational and is created among people. For this reason,
it is relevant to investigate and understand facilitators and barriers among physical
therapists and orthopedic surgeons towards a model of coordinated non-surgical and
surgical care with an exercise intervention designed as home-based with only one exercise.
To understand this context better a hybrid I design is applied [4]. A hybrid I design
emphasises the effectiveness of an intervention but at the same time recognizes that
clinical practice is complex, and that implementation is not a linear process. This
is taken into consideration by also investigating the context and the associated facilitators
and barriers.
Epistemologically the study applies single- and focus group interviews as these are
acknowledged methods to investigate topics which cannot be quantified or measured.
Qualitative methods are interpretive and appropriate to get a deeper understanding
of attitudes, behaviour, opinions and feelings and potential discrepancies among these.
This is also relevant when it comes to understanding facilitators and barriers among
physical therapists and orthopedic surgeons towards a model of coordinated non-surgical
and surgical care.
Action taken
We performed interviews to understand the perceived barriers and facilitators among
the orthopedic surgeons and physical therapists regarding this novel coordination
of surgical and non-surgical treatment prior to the beginning of the parent trial.
By using interviews RSH was able to interpret words as well as body language to obtain
a better understanding. Further, it provided an opportunity to create trust between
RSH and the participants which is important when talking about facilitators and barriers
related to work, habits and potential associated feelings. This is an acknowledged
design when investigating facilitators and barriers in an implementation context [4].
Changes made at page 7-8, lines 146-153.
Editor comment #2
Make sure you adhere to the methods section of a framework like COREQ (Tong) or SRSQ
(Obrien) – from these consider the following: Sample size.
Author response
We thank the editor for this comment. We agree that this is important to highlight
in the manuscript. We recognize the limitation of the sample size and the consequences
it could have regarding data saturation. The participants were selected for their
ability to provide information about the topic under investigation. We sought situational
representativeness rather than demographic, andparticipants were selected based on
their ability to provide information about the area under investigation [2]. As stated
below, we found this limitation necessary to investigate facilitators and barriers
among the health care professionals involved in the clinical trial, as these were
the only possible participants to the interviews. We have made this potential limitation
clearer in the manuscript. We have reported the manuscript using the SRSQ checklist,
please see appendix 1.
Action taken
The highlighted text has been added to the “recruitment and study participants” paragraph.
Thus, the six physical therapists and four orthopedic surgeons represents all possible
participants as we sought situational representativeness rather than demographic representativeness
(37). We recognize that a sample size of ten participants could be a limitation and
inadequate to certify data saturation. However, we consider this necessary as this
was the only possibility to investigate facilitators and barriers among the orthopedic
surgeons and physical therapists involved in the QUADX-1 trial. When interpreting
the results this should be kept in mind.
Changes made at page 8-9, lines 172-178.
Editor comment #3
Use a supplementary file to show changes in interview schedule – was this also a cognitive
interview?
Author response
We thank the editor for this comment. We agree and believe that the supplementary
file adds to the transparency of the methods used. This was not a cognitive interview.
Action taken
We have added a supplementary file with adjustments and additions to the semi-structured
interview guides. Please see supplementary file S4.
Following every interview, RSH and JK listened to the audio file and adjusted the
interview guide based on new important topics (S4 File).
Changes made at page 11, lines 234-236.
Editor comment #4
Identify what literature was used to develop the interview schedule.
Author response
We thank the editor for this comment. We agree that highlighting the literature used
to develop the interview guides provides transparency to the foundation and design
of the study.
The interview guides were based on literature related to the organization and recommended
order of non-surgical and surgical treatment in patients eligible for knee replacement
[5–9], effectiveness of exercise therapy in patients with knee OA [10–13], traditional
organization of exercise therapy [14–16], knee replacement surgery [8,9,17], previous
identified barriers and facilitators towards exercise therapy and surgery [18–20]
and shared decision-making [21] in patients eligible for knee replacement.
Action taken
The above information has been added to the paragraph “Interviews: Focus group and
single interviews” in the manuscript. The paragraph has been changed from:
Both the focus group interview and the single interviews were guided by semi-structured
interview guides with open-ended questions (S2 File and S3 File). A “funnel approach”
was used at all interviews starting with broad open-ended questions followed by probing
and sensitizing questions aiming to elicit deeper and more detailed information [22].
To:
Both the focus group interview and the single interviews were guided by semi-structured
interview guides with open-ended questions (S2 File and S3 File). The interview guides
were based on literature related to the organization and recommended order of non-surgical
and surgical treatment in patients eligible for knee replacement [5–9], effectiveness
of exercise therapy in patients with knee OA [10–13], traditional organization of
exercise therapy [14–16], knee replacement surgery [8,9,17], previous identified barriers
and facilitators towards exercise therapy and surgery [18–20] and shared decision-making
[21] in patients eligible for knee replacement. A “funnel approach” was used at all
interviews starting with broad open-ended questions followed by probing and sensitizing
questions aiming to elicit deeper and more detailed information [22].
Changes made at page 10-11, lines 205-215.
Editor comment #5
An audit trail must be given for your thematic analysis (examples of each stages of
the analysis you say has been done so it can be checked – have this in a supplementary
file – move table 1 to show the development of this).
Have a section at the end on trustworthiness and how this was identified. Make sure
this links to your paradigmatic position and doesn’t contradict it.
Author response
We thank the editor for this comment. We agree with the comment and believe that providing
an audit trail will strengthen the transparency of the steps taken in the thematic
analysis. We have added an audit trail and a section on trustworthiness as supporting
information.
Action taken
The following reference to the supporting information has been added to the manuscript.
An audit trail of the thematic analysis and a section on trustworthiness is provided
as supporting information (S5 file).
Changes made at page 12, lines 260-261.
Editor comment #6
Could the analysis have been driven by a priori analysis? Explain your answer.
Author response
Yes, the analysis could have been driven by an a priori analysis. If we had had a
hypothesis which we wanted to test or had applied a deductive analysis based on a
framework or theory the analysis could have been driven by an a priori assumption
[23,24]. As we applied inductive analysis with an exploratory aim the analysis was
not driven by an a priori assumption [25].
Reviewer comments
Reviewer #1:
Dear authors, I have read through your article with great interest. I acknowledge
the value of exercise in the management of knee osteoarthritis, as well as the need
for in-depth understanding of the role healthcare professionals and contextual factors
in implementing innovations in clinical practice. After reading your manuscript though,
its aims and significance were still unclear to me. I hope my comments below will
help showcase the study.
Reviewer comment #1
Title
Not in line with aims as stated in abstract. Also, make sure the title reflects the
manuscript content.
Author response
We thank the reviewer for this comment. We agree that the title and aims stated in
the abstract and manuscript were not aligned. We have adjusted the title and aligned
the aims stated in the abstract and manuscript. We have left the information on “coordinated
non-surgical and surgical treatment” out of the title to make it shorter and more
reader friendly.
Action taken
The title has been changed from:
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.
To:
Perceived facilitators and barriers among physical therapists and orthopedic surgeons
to pre-operative home-based exercise with one exercise-only in patients eligible for
knee replacement: A qualitative interview study nested in the QUADX-1 trial
Changes made at page 1, lines 2-4.
The aim in the abstract has been changed from:
This study aimed to investigate key stakeholder perspectives on pre-operative, home-based
exercise therapy with one exercise-only in patients eligible for KR.
To:
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.
Changes made at page 2, lines 28-31.
The aim in the manuscript has been changed from:
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 with severe knee osteoarthritis using pre-operative
home-based exercise therapy with one exercise.
To:
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.
Changes made at page 6, lines 110-113.
Introduction
Overall, a better case needs to be made as to why this study is needed. At present
the study aims do not logically follow from the arguments made in the introduction.
There are important gaps. Specifically:
Reviewer comment #2
Why is exercise treatment appropriate for patients eligible for knee replacement?
This is a specific subgroup of people living with knee OA (kOA), typically those who
have severe radiographic and/or clinical characteristics. Two guidelines are cited
as main supporting literature. The one in English (McAlindon et al 2014), which I
could access, firstly is based on systematic reviews of studies from patients with
kOA of any severity/ progression; secondly, small short term benefits are reported
for land based exercise (including aerobic and range of movement exercises), and similar
effect sizes are reported for strengthening exercises. It cannot be concluded that
exercise therapy should be offered to pre-surgical kOA patient. More population-specific
and up-to-date literature is needed.
The authors could also expand on who is/ is not eligible for KR.
Author response
We thank the reviewer for this clarifying comment. We agree with the comment and have
added the following to the manuscript, to make the argument for pre-operative exercise
therapy for patients eligible for knee replacement clearer in the manuscript. We have
also added a paragraph on who is eligible for knee replacement.
Action taken
The highlighted text has been added to the introduction paragraph.
Both international and national guidelines recommend non-surgical treatment (i.e.
exercise therapy, weight loss, self-management and education) before surgery is considered
in patients eligible for KR [5–7,26–28] – and recent studies show that exercise therapy
can provide clinically relevant improvements in knee OA symptoms in patients eligible
for KR [10–13,29,30]. Despite this, it is estimated that up to 25% of patients could
be inappropriately receiving KR prior to the recommended non-surgical treatment [17].
Changes made at page 4, lines 66-71.
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 [5,6,26] and x-rays [21,31]. Knee OA is roughly categorized as mild-to-moderate
or severe and the main difference between the two categories is the level of symptomatology
(e.g. knee pain levels) [32]. Patients with severe knee OA are more likely to be deemed
eligible for KR and undergo surgery [33–35]. 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 [36].
Changes made at page 4, lines 69-77.
Reviewer comment #3
What is the context of clinical practice and healthcare policies in Denmark? What
patients’/ healthcare professionals’ needs does the proposed trial meet/ what innovation(s)
does it introduce?
These points need to be linked to the components of the proposed intervention components
(e.g., advantages of home based exercise, shortcomings of exercise therapy that includes
variety of exercises).
Author response
We thank the reviewer for this comment. We agree that the context of the study is
important. The main challenges in Danish Healthcare is coordination of non-surgical
and surgical care as many patients consult an orthopedic surgeon without having tried
non-surgical care. This is not in line with national recommendations and a waste of
resources. This trial investigates a potential solution for this challenge. The purpose
of the investigated coordinated care pathway of non-surgical and surgical treatment
is to improve care provided to patients eligible for knee replacement. The context
of clinical practice is that currently there is no coordinated evaluation of the effect
of non-surgical treatment. That is, when an orthopedic surgeon refers a patient to
non-surgical treatment before surgery (complying with national guidelines and recommendation)
no coordinated evaluation exists where a healthcare professional evaluates whether
this treatment has been sufficient or whether a new treatment should be commenced,
e.g. surgery. We believe we have described this on page 5, lines 78-82 – first with
an example of an existing coordinated care pathway and then with an example of a lacking
coordinated care pathway. On page 6, lines 121-123 the coordinated treatment is described
in short again. The purpose of offering one home-based exercise is to provide patients
with a simple and cheap alternative to group-based exercise (often with self-payment).
The components and content of the exercise intervention (one home-based knee-extensor
exercise) are independent or the coordination of care. That is, in relation to the
coordinated care pathway of non-surgical and surgical treatment the exercise intervention
could also have been supervised with several exercises. The purpose of the coordinated
care pathway with re-evaluation of the non-surgical treatment by an orthopedic surgeon
would be the same.
Reviewer comment #4
Regarding physical therapy, aren’t patients offered this treatment option at an earlier
point in disease progression, prior to being eligible for KR? Or the suggested pre-surgical
one-exercise treatment is additional to that.
Author response
We thank the reviewer for this comment. Yes, according to guidelines and recommendations
patients should be referred to exercise therapy at an earlier stage in the disease
progression – which most patients are. Despite this, some patients still consult an
orthopedic surgeon without have tried out exercise [37]. This is a big challenge in
the Danish healthcare system. At this point the pre-operative home-based exercise
intervention with one exercise is introduced as a simple and cheap alternative to
supervised exercise at fixed time point at a rehabilitation centre (often with self-payment).
Reviewer comment #5
It would also be helpful to further explain what constitutes “coordination”. It is
described as “novel” (line 144), but it is not clear how it differs from simple referral
to exercise therapy by the orthopaedic surgeon (which is the case in UK).
Author response
The context of clinical practice is that currently there is no coordinated evaluation
of the effect of non-surgical treatment. That is, when an orthopedic surgeon refers
a patient to non-surgical treatment before surgery (complying with national guidelines
and recommendation) no coordinated evaluation exists where a healthcare professional
evaluates whether this treatment has been sufficient or whether a new treatment should
be commenced, e.g. surgery. We believe we have described this on page 5, lines 78-82
– first with an example of an existing coordinated care pathway and then with an example
of a lacking coordinated care pathway. On page 6, lines 121-123 the coordinated treatment
is described in short again.
Reviewer comment #6
What are the potential advantages/ hypothesized benefits of using one-only exercise
therapy specifically?
Author response
We thank the reviewer for this comment. We agree that it’s important to argue why
only one exercise was used. The advantages of using a one exercise-only approach is
that it’s simple and pragmatic. That is, it is easy to set up at home, easy to remember
how to perform, requires little intellectual effort and is easy to master [38]. Many
physical rehabilitation interventions comprise several exercises each with its own
specific instruction, resulting in accumulation of time and intellectual effort needed
to be able to complete the intervention effectively. Pertaining to this notion, Henry
and colleagues found that older adults prescribed two exercises performed the exercises
more accurately according to the exercise instruction than subjects prescribed eight
exercises [39]. In line with this, it is expected that simple exercise prescriptions
will facilitate a mastery of the exercise [38]. Furthermore, questioning the approach
of multi-exercise interventions is whether there is an added muscular strength benefit
of having several exercises that stresses the same muscle tissue as this is unknown
and could be unnecessary [40]. Several exercises require more time dedicated to exercising
and thus calls for a larger motivation. Furthermore, several exercises require a certain
amount of surplus mental energy, which often is low in patients as their condition
is demanding. Also, exercise can inflict pain also counteracting adherence. Thus,
the rational for investigating a single knee-extension strength home-based exercise
is that it could improve adherence as it is simple (minimal intellectual effort),
does not take a long time (requires less surplus energy) and is likely to inflict
less pain (less stress imposed on the knee joint). The knee-extensor exercise is chosen
as the knee-extensor muscles are the single most important muscles related to knee
pain and physical function in patients with knee OA [6,41–43].
We believe we have addressed this in the manuscript under the paragraph named “Context:
The QUADX-1 Trial” on pages 6-7, lines 119-139. The arguments provided in the manuscript
are less comprehensive than in the above paragraph as we refer to the protocol paper
of the QUADX-1 Trial for further information on the single knee-extensor exercise
[1].
Further, being physical therapists ourselves (some of the authors), it is our experience
that the profession sometimes is too optimistic on behalf of the patients they treat.
Afraid of not addressing a deficit that may or may not be linked to symptoms, we prescribe
more exercises than justified by the scientific evidence - a better safe than sorry
approach. Unfortunately, this approach may do no good for exercise adherence [39].
So, with the one-exercise approach, we wanted to challenge this, well aware that if
the parent trial (QUADX-1) came out “negative” with regards to dosage-differences
- but more importantly - without any effect on surgical status, the patients would
say: You used one exercise only. What were you thinking? The QUADX-1 trial results
are not published yet, but in confidence we can say that it works surprisingly well.
Reviewer comment #7
Other:
Para 2, makes the argument of strong physical therapist-patient relationship in contrast
to surgeon-patient relationship before moving on (par 3) to the need for coordination
between the two. It is unclear what the purpose of such an argument is, since the
intervention under scope is characterized by limited physical therapist- patient interaction.
Author response
We thank the reviewer for this comment. We agree that the purpose of this argument
is unclear in the introduction of the manuscript. The argument related to the therapist-patient
relationship is brought up again in the discussion – where we believe the purpose
is clearer (Page 35-36, lines 766-785).
Action taken
We have deleted the paragraph in the introduction (Page 5, lines 81-89).
Exercise therapy is generally provided by physical therapists and most often consists
of different exercises (an exercise program) which can be supplemented with other
treatment modalities, such as e.g. manual therapy [14,15,44]. This supervised and
group-based organization of treatment enables physical therapists to interact and
to engage themselves to a great extent in the treatment of their patients, creating
a strong physical therapist-patient relationship [16]. This high level of engagement
is possible because physical therapists spend a relatively long time with the patients
during an exercise session [16]. This is in contrast to orthopedic surgeons who only
have limited time with patients in their out-patient clinic to assess the need for
surgical treatment [16,45].
Reviewer comment #8
The aim stated in line 106 (“identify perceived facilitators and barriers”) is different
from aim stated in abstract (“investigate key stakeholder perspectives”). In the methods
section this qualitative study is presented as aiming at “clinical applicability and
implementation” (line 126). Please be clear and consistent about the study aims, which
should also be reflected in the interview schedules, results and discussion.
Author response
We thank the reviewer for this comment. We agree that this is unclear. Please see
our response to reviewer comment #1 for our corrections and alignment related to the
aim stated in the abstract and manuscript. We also agree with the discrepancy related
to the study aim in the method section. We have aligned this with the above corrections
to the aim of the study.
Action taken
The paragraph “Context: The QUADX-1 trial” in the methods section was changed from:
The project is designed as an intervention trial with concurrent gathering of information
for clinical applicability and implementation (the present qualitative study), also
referred to as a hybrid I design [4].
To:
The project is designed as an intervention trial with concurrent identification of
perceived facilitators and barriers (the present qualitative study), also referred
to as a hybrid I design [4].
Changes made at page 7, lines 129-131.
Methods
As the aims of the study remain to be clarified, further revisions might be needed
in the process of analysis. For example, if the study focuses on identifying barriers
and facilitators to implementation the unit(s) of analysis might change, or a deductive
approach could be adopted at some point in the process.
Author response
Based on comment from the associate editor and reviewer we have made major revision
to the introduction and methods paragraphs and clarified the why we used an inductive
approach.
As the aim of the analysis was exploratory, we applied an inductive approach [25].
If we had had a hypothesis which we wanted to test or had a framework or theory to
base the analysis on we could have applied a deductive analysis [23,24].
Reviewer comment #9
That aside, the main issue here is the limited study sample, which raises questions
about credibility of the findings, especially since data saturation is not discussed/
was not achieved. How was variability in participants’ experiences ensured? Some information
on relevant participants’ characteristics (e.g. level of experience in their profession)
and on hospital and rehabilitation centres (e.g., how were they selected? Considered
typical?) could help in this direction. Further, the authors could consider (A) repeating
the interviews with the participants post-intervention or (B) interview a wider sample
of healthcare professionals outside the QUADX-1 trial, until saturation is achieved.
The latter would be particularly useful in planning implementation of the proposed
therapy in standard healthcare practice.
Author response
We thank the reviewer for this comment. We agree that this is important to highlight
in the manuscript. We recognize the limitation in the sample size and the consequences
it could have regarding data saturation. The participants were selected based on their
ability to provide information about the topic under investigation. We sought situational
representativeness rather than demographic representativeness meaning that participants
were selected for their ability to provide information about the area under investigation
[2]. As stated below we found this limitation necessary to investigate facilitators
and barriers among the health care professionals involved in the clinical trial as
these were the only possible participants to interview. We have made this potential
limitation clearer in the manuscript.
Information on the included municipalities and hospital as well as the timeframe have
been added to the manuscript. Demographic details on the participants are now provided
in Table 1. We have reported the manuscript using the SRSQ checklist, please see appendix
1.
Action taken
The highlighted text has been added to the “recruitment and study participants” paragraph.
Thus, the six physical therapists and four orthopedic surgeons represents all possible
participants as we sought situational representativeness rather than demographic representativeness
(37). We recognize that a sample size of ten participants could be a limitation and
inadequate to attain data saturation. However, we consider this necessary as this
was the only possibility to investigate facilitators and barriers among the orthopedic
surgeons and physical therapists involved in the QUADX-1 trial. When interpreting
the results this should be kept in mind.
Changes made at page 8-9, lines 172-178.
The highlighted text has been added to the “recruitment and study participants” and
“procedures” paragraphs.
We recruited six physical therapists from three municipalities in the capital region
of Denmark and four orthopedic surgeons from one university hospital in the capital
region of Denmark involved in the QUADX-1 trial [1] (Table 1). Inclusion criteria:
participants had to be involved in the QUADX-1 trial, as the intervention under study
was not implemented in routine clinical practice. No exclusion criteria were applied.
Thus, the six physical therapists and four orthopedic surgeons represents all possible
participants as we sought situational representativeness rather than demographic [2].
We recognize that a sample size of ten participants could be a limitation and inadequate
to attain data saturation. However, we consider this necessary as this was the only
possibility to investigate facilitators and barriers among the orthopedic surgeons
and physical therapists involved in the QUADX-1 trial. When interpreting the results
this should be kept in mind. Participants were contacted by the primary investigator
and interview moderator (RSH) by e-mail with an invitation to participate in the interviews
between November 2016 and June 2017. RSH sent the invitations because he would be
conducting the interviews. All invited participants accepted. All eligible physical
therapists had daily clinical work with patients diagnosed with knee OA and rehabilitation
following KR. All eligible orthopedic surgeons had daily clinical work with patients
potentially eligible for KR due to knee OA symptoms. A random sample of patients participating
in the QUADX-1 trial were also interviewed about their perceptions of facilitators
and barriers towards coordinated non-surgical and surgical treatment using pre-operative
home-based exercise therapy with one exercise. This work is as yet unpublished.
Changes made at page 8-9, lines 168-188
And
The interviews took place in meeting rooms at a university hospital in the capital
region of Denmark.
Changes made at page 11, lines 221-222.
Reviewer comment #10
Also, a couple of discrepancies: the chosen method of data analysis is described at
places as thematic analysis (e.g. lines 219, 234, 253, 264, 710), elsewhere as content
analysis (abstract, citation 35).
Author response
We thank the reviewer for this comment. We agree with the discrepancies and have changed
the wording “content analysis” to “thematic analysis” in the abstract/manuscript.
The reference related to the type of analysis has been changed from Graneheim et al.
(content analysis) [46] to Nowell et al. (thematic analysis) [47].
Action taken
In the abstract the following changes have been made.
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 thematic analysis.
Changes made at page 2, line 39.
Results
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.
Changes made at page 2, line 41.
Reviewer comment #11
In the surgeons’ interview schedule (S3, Q4) self-management, including education,
are mentioned. These are further reported in results and discussion. However, they
are not described in the introduction and methods. Please ensure consistency and transparency
in reporting.
Author response
We thank the reviewer for this clarifying comment. We agree with the comment and have
added the below information to the manuscript to improve the consistency between the
introduction and results/discussion sections.
Action taken
The highlighted text has been added to the introduction paragraph.
Both international and national guidelines recommend non-surgical treatment (i.e.
exercise therapy, weight loss, self-management and education) before surgery is considered
in patients eligible for KR [5–7,26–28] – and recent studies show that exercise therapy
has been found to provide clinically relevant improvements in knee OA symptoms in
patients eligible for KR [10–13,29,30].
Changes made at page 4, lines 63-67.
Other, minor comments:
Reviewer comment #12
Some details of the Context could fit better in the introduction, especially where
literature review is involved (e.g., lines 131-133).
Author response
We thank the reviewer for this comment. We understand the point of moving the literature
review part to the introduction. Despite this we suggest keeping the structure as
it is. We believe it improves the reader friendliness to separate the more general
introduction from information specifically related to the intervention under study
(the QUADX-1 trial, the context).
Reviewer comment #13
Line 220- was all text divided into meaning units?
Author response
We thank the reviewer for this comment. Parts of the text without coherent information
or meaning were not divided into meaning units. This could be text parts with small
talk and/or drift away from the topic under investigation. These were coded as “not
for us”. As an example, during the focus group interview with the physical therapists
this could be topical drift towards organization of treatment for patients with other
diagnoses and complaining’s about general political decisions affecting their work
(unrelated to the QUADX-1 trial).
Reviewer comment #14
How many municipalities are served by/linked to this orthopaedic department (line
152)?
Author response
We thank the reviewer for this comment. The Copenhagen University Hospital Hvidovre
receives patients from ten municipalities. The three collaborative municipalities
in the QUADX-1 trial (Copenhagen, Hvidovre and Brøndby) were chosen as the demography
in these three municipalities are representative for the population that the hospital
service (e.g. socioeconomic status).
Reviewer comment #15
Line 178 “experiences…on the coordinated… treatment”. Consider removing the term “experience”,
since this is about preconceptions, not actual experiences with the trial (line 196).
Author response
We thank the reviewer for this comment. We agree that “experiences” is misleading
since the purpose is about preconceptions (as the reviewer point out). We have removed
the phrasing “experiences” from the sentence.
Action taken
The paragraph “Interviews: Focus group and single interviews” was changed from:
We aimed to use focus group interviews for all participants as the purpose of the
interviews was to explore the perceived facilitators and barriers and associated feelings,
experiences and attitudes of the health care professionals on the coordinated non-surgical
and surgical treatment investigated in the QUADX-1 trial.
To:
We aimed to use focus group interviews for all participants as the purpose of the
interviews was to explore the perceived facilitators and barriers, associated feelings,
opinions and attitudes of the health care professionals on the coordinated non-surgical
and surgical treatment investigated in the QUADX-1 trial.
Changes made at line page 10, lines 195-198.
Reviewer comment #16
Lines 229-232. More details on how these preconceptions changed, would be useful.
Author response
We thank the reviewer for this comment. We agree that more details on how the preconceptions
changes increase the credibility of the process and findings. We have added an example
of a change in preconceptions.
Action taken
The highlighted text has been added to the paragraph “Data analysis”.
Through this process, it was possible for RSH to put his preconception in dialogue
with the text (fusion of horizons). Thus, the understanding of physical therapists
and orthopedic surgeons perceived facilitators and barriers towards coordination of
surgical and non-surgical treatment gradually changed [48]. As an example, one preconception
was related to orthopedic surgeons’ view on exercise as not being useful in patients
with severe knee OA. This preconception changed when the effect of exercise or lack
hereof was mentioned as useful in the decision on surgery or not.
Changes made at page 12, lines 254-260.
Results
I acknowledge that data analysis was reviewed and agreed upon by more than one researcher.
However, the reported results do not appear to clearly reflect (patterns found in)
the data and the subthemes and themes appear to be poorly supported. Specifically:
Reviewer comment #17
Quotes do not represent all participants. There are no quotes from physical therapists
4 and 5. Instead quotes from selected participants appear repeatedly. For example,
subthemes relevant to surgeons are supported by more than one quote from the same
participant but not more than two participants are referenced (subthemes 3, 5, 6,
8, 9).
Author response
We thank the reviewer for this comment. We acknowledge that the representation of
the quotes in the manuscript can be distinctive. The quotes showed in the manuscript
are chosen as they are exemplary and thus representative for more participants than
the one quoted. The quotes are chosen because they support central points in the analysis
and therefore back a specific point. The participants in the focus group interview
adopted different roles where participants 1, 2, 3 and 6 contributed more actively
with answers to questions while participant 4 and 5 were more reticent. Participant
4 and 5 were more reticent with their answers despite numerous invitations from the
moderator to contribute with their opinions. Participant 4 and 5 contributed more
with statements acknowledging and supporting answers from the other participants.
See below example:
Physical therapist 1: “I think it will be interesting to see when we can do with just
one exercise”.
Physical therapist 4: “Well, I feel the same way”.
Reviewer comment #18
The subtheme title and content (i.e., authors description, original quotes) are often
not in line and there doesn’t seem to be a connecting thread within each subtheme.
In addition, there is overlap between suggested subthemes. Two examples: under the
theme “professional role simplified” a substantial amount of text (lines 344-357)
discusses physical therapists’ expressed preference towards more than one treatment
options; the supporting quote is on therapists’ views regarding good candidates for
the proposed treatment. The context of the next subtheme, “skepticism towards one
home-based exercise”, includes again a discussion on physical therapists’ suggestions
for more treatment options (lines 367-374), positive views of one exercise (376-94)
and reference to “professional self-image” (376-78).
Author response
We thank the reviewer for this comment. We agree that the tread within some of the
sub-themes was unclear. We have reviewed and revised the results section. We have
renamed and re-arranged theme 1 and 2 and moved the associated sub-themes accordingly.
We have changed the name of theme 1 from “Physical therapists’ and orthopedic surgeons’
ambivalence in their professional roles” to “Physical therapists’ dilemma with one
home-based exercise”. The associated sub-themes are 1) Supporting patient self-management
is a physical therapy core skill, 2) Professional role as a physical therapist is
simplified, 3) Skepticism towards one home-based exercise and 4) Patient preferences.
The name of theme 2 is changed from “Orthopedic surgeons view on exercise” to “Orthopedic
surgeons’ dilemma with exercise”. The associated sub-themes are 1) Skepticism towards
(long-term) effect of exercise in patients with severe knee OA, 2) Patient preferences
and 3) Different purposes of referring a patient to exercise.
Theme 3 and associated sub-themes are unchanged.
Action taken
The revision and re-arrangement of the result section is comprehensive and thus we
have refrained from copying the changes into this document. We refer to the uploaded
file labelled “Revised Manuscript with Track Changes” where we believe the changes
are easier to assess.
Reviewer comment #19
Parts of the results sections read more like discussion of the findings/ authors’
interpretations or review of the literature. Some examples: lines 277-280; 288-292;
452 (citation). On a similar note, the choice of wording in authors’ descriptions
at points reads more like their own perspectives rather than participants’ perspectives.
Some examples: 586-587 “exercise is used in a less constructive and inclusive way
(by the surgeons)”; “professional dilemma” (612)- unclear what the dilemma is on,
since surgeons’ quotes overall give their reasoning and clear-cut perspectives for
using or not using a treatment (eg quotes on 549, 569, 579); “preferences” (line 605)
rather than “clinical judgment”.
Author response
We thank the reviewer for this comment. We agree that parts of the result section
read more like interpretation. We have removed the suggested sentences from the manuscript.
Regarding the comment related to the “professional dilemma” presented in the summary:
The dilemma emerges when the orthopedic surgeons follow guideline recommendations
and this conflicts with their clinical expertise and patient preferences. We believe
we have explained this at page 35, lines 766-769.
Action taken
The following excerpts has been removed from the manuscript.
Exercise therapy is a central treatment modality in the physical therapy profession,
not least in the treatment of patients with knee OA. Most exercise therapy is organized
in group sessions where physical therapists monitor and adjust treatment closely,
allowing a high degree of engagement in the treatment. However, in the interviews
it turned out that the physical therapists recognize the importance of supporting
patient self-management to complement supervised exercise therapy.
Changes made at page 16.
One sub-theme that emerged from the focus group interview was that the physical therapists
are conscious about the importance of educating and providing patients with tools
to self-manage their condition. In patients with chronic conditions (e.g. knee OA)
self-management is especially important if the effect of treatment is to be sustained
following supervised exercise. Exercise is likely a life-long treatment in patients
with knee OA making provision of supervised exercise unrealistic, again underlining
the importance of patient self-management.
Changes made at page 16, lines 312-314.
Another view on exercise is that it is a treatment where the patient “can be parked”
until surgery is needed. From this perspective, exercise is used in a less constructive
and inclusive way, and more as a practical solution that can be used until the patient
is ready for surgical treatment.
Changes made at page 28, lines 604-605.
Reviewer comment #20
Original data provided is not in English, therefore not accessible to the majority
of the readers.
Author response
We thank the reviewer for this comment. We acknowledge the limitation that the original
data is not in English and thus not accessible to the majority of readers. The original
data for all the interviews comprise >100 closely written pages and >48.000 words.
The original data is made available without restrictions together with the manuscript
providing readers with the possibility of translation.
Reviewer comment #21
“Barriers” and “facilitators” are not reported in a consistent way in the results
and the relevant research question is not answered comprehensively.
Author response
We thank the reviewer for this comment. We agree that in parts of the results section
it was not clearly reported whether the results (sub-themes) were perceived as facilitators
or barriers. We have made this clear and it is now reported consistently throughout
the results section. That is, each sub-theme ends with sentence explaining whether
it is a facilitator or a barrier. See below for changes made to the manuscript.
Related to the comment that the research question is not answered comprehensively
we have made the link between the study aim (perceived facilitators and barriers)
and the results clearer. The first paragraph in the results section end with the following
sentence: “The themes and sub-themes represent different perceived facilitators and
barriers among orthopedic surgeons and physical therapists towards home-based pre-operative
exercise in patients eligible for KR” (page 14, lines 292-294). Further, each paragraph
related to theme 1-3 ends with a summary of the findings highlighting the perceived
facilitators and barriers. Please see the summary paragraphs below.
Action taken
Sub-theme 1 (page 17, lines 333-337)
As the physical therapists are aware of this, they embrace this skill and express
that it is important to give patients a sense of responsibility for their own treatment
and to teach them principles of self-management of their condition. In this way, even
though they distance themselves from the patients, they keep some control over the
patient’s treatment, and it becomes a potential facilitator.
Sub-theme 2 (page 18, lines 366-367)
The predefined and advisory role with a limited number of consultations challenges
and simplifies their professional role and, thus, becomes a potential barrier.
Sub-theme 3 (page 19, lines 387-389)
A home-based single exercise intervention without the option of exercise adjustment
or the addition of other exercises becomes a potential barrier to physical therapists.
Sub-theme 4 (page 20, lines 419-423)
This underlines that according to the physical therapists not all patients are candidates
for home-based exercise, which also supports the option of a stratified treatment
approach (two treatment options). The possibility of two treatment options and thus
a better chance of providing treatment suiting individual patient preferences becomes
a potential facilitator.
Sub-theme 5 (page 24, lines 512-515)
Lack of belief in the effectiveness of exercise for patients with severe knee OA,
doubt about the long-term effects of exercise and knowledge about the effectiveness
of surgery create skepticism in the orthopedic surgeons, and these become potential
barriers to referring patients with severe knee OA to exercise.
Sub-theme 6 (page 28, lines 587-590)
Thus, motivation is an important patient characteristic for the orthopedic surgeons,
as they do not want to refer patients to a treatment that they are not going to adhere
to due to lack of motivation. This would be a waste of everyone’s time and resources
and becomes a potential barrier for referring patients to exercise.
Sub-theme 7 (page 29, lines 616-618)
Assessing the effect of exercise on knee-related symptoms, evaluating patient resources,
and providing patients with a “breathing space” to consider the treatment option of
surgery all become potential facilitators for referring a patient to exercise.
Sub-theme 8 (page 31, lines 671-673)
Referring to exercise without knowing the content of the treatment provided and the
time associated with referral to exercise becomes potential barriers for the orthopedic
surgeons to refer patients to exercise.
Sub-theme 9 (page 34, lines 723-725)
Clear allocation of responsibility in relation to exercise referral and providing
patients an optimized and transparent care pathway becomes potential facilitators
for the coordinated non-surgical and surgical care pathway.
Summary theme 1 (page 21, lines 425-434)
In summary, a single exercise home-based intervention creates a dilemma among the
physical therapists. On the one hand the physical therapists perceive the importance
of providing patients with tools for self-management, the advantage of having two
treatment options to meet patient preferences and the potential advantages of providing
patients with only one exercise as facilitators for implementing the one exercise.
These factors support the simplified treatment approach among the physical therapists
and their view on their professional role. On the other hand, the physical therapists
believe that the simplified treatment approach simplifies their professional role,
limits contact time with patients and providing only one exercise limits use of professional
skills. These barriers challenge the physical therapists creating ambivalence in their
professional role.
Summary theme 2 (page 29-30, lines 627-639)
In summary, results from our single interviews with the orthopedic surgeons show that
adhering to clinical guideline recommendations - and at the same time using clinical
expertise and considering patient preferences - creates a professional dilemma among
the orthopedic surgeons. On the one hand, facilitators such as using exercise as a
means to examine patient’s motivation for rehabilitation, providing patients with
a low-risk-of-complications treatment while considering the option of surgery and
knowledge of the effect of exercise can help guide the decision of surgery support
the use of exercise as a treatment modality among orthopedic surgeons for patients
with severe knee OA. On the other hand, barriers among the orthopedic surgeons towards
referring patients with severe knee OA to exercise were skepticism towards the effect
of exercise and especially the long-term effect in patients with severe knee OA and
the dilemma of referring patients to exercise who are not motivated for this treatment
modality. These barriers challenge the orthopedic surgeons creating ambivalence in
their professional role.
Summary theme 3 (page 34, lines 727-732)
In summary, the orthopedic surgeons express frustration with variation in the treatment
provided for the patients when they refer them to exercise in the municipality which
becomes a barrier to referring patients to exercise. The physical therapists are positive
in respect of the coordinated care pathway as they believe this will mean that patients
are provided with quality care. This becomes a facilitator for coordinated non-surgical
and surgical treatment.
I would recommend that the authors:
Reviewer
Review the analytical process aiming to create more homogenous and comprehensive subthemes/
themes. Finding should reflect patters found across participants. This might not be
that important if the aim is to identify trial implementation strategies, but this
need to be clearer and methods modified accordingly
Author response
We believe we have addressed this in the responses to reviewer comment #18 and #19
and that the associated changes to the results section makes this more homogenous
and consistent.
Reviewer
Provide a supplementary table where under each subtheme there is one quote from each
participant that supports the subtheme
Author response
We believe we have addressed this in response to reviewer comment #17.
Reviewer
Provide a translation in English of a single interview and part of the focus group.
Author response
We believe we have addressed this in response to reviewer comment #20.
Reviewer
Be succinct when reporting the findings. Indicate which text represents views/ perspectives
etc. expressed by the participants (e.g. participants described, agreed, emphasized/...).
Also provide more indications of frequency/ homogeneity of the statements made (eg
all/ most/ few physical therapists expressed…). Be more reflective and refrain from
making interpretations in this section.
Author response
We believe we have addressed this in response to reviewer comment #18 and #19 along
with the associated changes made in the manuscript.
Reviewer
Also, please keep a consistent and easy to follow structure. Examples of issues in
the structure that are confusing for the reader: “physical therapists” section (line
276 onwards) and orthopedic surgeons (line 407 onwards) appear as subthemes, with
their own introductory paragraph, although these are not previously mentioned- unclear
what they represent; Subtheme numbering: in lines 254-260 the subthemes are numbered
1 to 9, Table 2 has no numbering, whereas in the remaining results sections subthemes
are re-numbered from 1.
Author response
We believe we have addressed this in response to reviewer comment #18 and #19 along
with the associated changes made in the manuscript.
Discussion
Reviewer
I believe this section will be revisited following revisions on the previous sections,
therefore it won’t be of use commenting on the content as it is. Overall, a number
of good points are discussed. Areas for refinement could be: clear take-home messages
(3-4) that bring the discussion back to the points raised in the introduction (study
aims, study population, existing gaps, concepts, trial implementation etc.).
Author response
We thank the reviewer for this comment. We agree that take-home messages are important
for the readability of the manuscript. We believe we have addressed this in the summary
at the end of the discussion paragraph (page 40-41, lines 883-899).
References
1. Husted RS, Troelsen A, Thorborg K, Rathleff MS, Husted H, Bandholm T. Efficacy
of pre-operative quadriceps strength training on knee-extensor strength before and
shortly following total knee arthroplasty: protocol for a randomized, dose-response
trial (The QUADX-1 trial). Trials. 2018;19: 47. doi:10.1186/s13063-017-2366-9
2. Horsburgh D. Evaluation of qualitative research: Evaluation of qualitative research.
Journal of Clinical Nursing. 2003;12: 307–312. doi:10.1046/j.1365-2702.2003.00683.x
3. WMA. World Medical Association. WMA Declaration of Helsinki - Ethical Principles
for Medical Research Involving Human Subjects. 2017. Available: Available at: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/. Accessed November 15, 2017
4. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation
Hybrid Designs: Combining Elements of Clinical Effectiveness and Implementation Research
to Enhance Public Health Impact. Medical Care. 2012;50: 217–226. doi:10.1097/MLR.0b013e3182408812
5. Sundhedsstyrelsen - Knæartrose. Nationale kliniske retningslinjer og faglige visitationsretningslinjer.
1st ed. Kbh.; 2012.
6. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra
SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis.
Osteoarthr Cartil. 2014;22: 363–388. doi:10.1016/j.joca.2014.01.003
7. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee.
The Cochrane Database of Systematic Reviews. 2015;9: CD004376. doi:10.1002/14651858.CD004376.pub3
8. Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, et al. Knee replacement.
The Lancet. 2012;379: 1331–1340.
9. Hawker G, Wright J, Coyte P, Paul J, Dittus R, Croxford R, et al. Health-Related
Quality of Life after Knee Replacement: Results of the Knee Replacement Patient Outcomes
Research Team Study*. The Journal of Bone and Joint Surgery (American Volume). 1998;80:
163–173. doi:10.2106/00004623-199802000-00003
10. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, et al.
A Randomized, Controlled Trial of Total Knee Replacement. New England Journal of Medicine.
2015;373: 1597–1606. doi:10.1056/NEJMoa1505467
11. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Rasmussen S, et
al. Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year
outcome from two parallel randomized controlled trials. Osteoarthritis and Cartilage.
2018;26: 1170–1180. doi:10.1016/j.joca.2018.04.014
12. Dabare C, Le Marshall K, Leung A, Page CJ, Choong PF, Lim KK. Differences in
presentation, progression and rates of arthroplasty between hip and knee osteoarthritis:
Observations from an osteoarthritis cohort study-a clear role for conservative management.
International Journal of Rheumatic Diseases. 2017;20: 1350–1360. doi:10.1111/1756-185X.13083
13. Gwynne-Jones JH, Wilson RA, Wong JMY, Abbott JH, Gwynne-Jones DP. The Outcomes
of Nonoperative Management of Patients With Hip and Knee Osteoarthritis Triaged to
a Physiotherapy-Led Clinic at Minimum 5-Year Follow-Up and Factors Associated With
Progression to Surgery. The Journal of Arthroplasty. 2020 [cited 10 Mar 2020]. doi:10.1016/j.arth.2020.01.086
14. World Confederation for Physical Therapy W. Policy statement. Description of
physical therapy. World Confederation for Physical Therapy; 2015.
15. Higgs J, Refshauge, K, Ellis E. Portrait of the physiotherapy profession. Journal
of Interprofessional Care. 2001;15: 79–89. doi:10.1080/13561820020022891
16. Miciak M, Mayan M, Brown C, Joyce AS, Gross DP. The necessary conditions of engagement
for the therapeutic relationship in physiotherapy: an interpretive description study.
Archives of Physiotherapy. 2018;8. doi:10.1186/s40945-018-0044-1
17. Cobos R, Latorre A, Aizpuru F, Guenaga JI, Sarasqueta C, Escobar A, et al. Variability
of indication criteria in knee and hip replacement: an observational study. BMC Musculoskeletal
Disorders. 2010;11. doi:10.1186/1471-2474-11-249
18. Hofstede SN, Marang-van de Mheen PJ, Vliet Vlieland TPM, van den Ende CHM, Nelissen
RGHH, van Bodegom-Vos L. Barriers and Facilitators Associated with Non-Surgical Treatment
Use for Osteoarthritis Patients in Orthopaedic Practice. Coles JA, editor. PLOS ONE.
2016;11: e0147406. doi:10.1371/journal.pone.0147406
19. Bunzli S, Nelson E, Scott A, French S, Choong P, Dowsey M. Barriers and facilitators
to orthopaedic surgeons’ uptake of decision aids for total knee arthroplasty: a qualitative
study. BMJ open. 2017;7: e018614.
20. Littlewood C, Mawson S, May S, Walters S. Understanding the barriers and enablers
to implementation of a self-managed exercise intervention: a qualitative study. Physiotherapy.
2015;101: 279–285. doi:10.1016/j.physio.2015.01.001
21. Slover J, Shue J, Koenig K. Shared Decision-making in Orthopaedic Surgery. Clinical
Orthopaedics and Related Research®. 2012;470: 1046–1053. doi:10.1007/s11999-011-2156-8
22. Kitzinger J. Chapter 3. Focus groups. 3rd edition. Qualitative Research in Health
Care. 3rd edition. Blackwell Publishing Ltd; 2006.
23. Potter WJ. An Analysis of Thinking and Research About Qualitative Methods. Mahwah:
Lawrence Erlbaum; 1996.
24. Bryman A, Burgess RG. Analyzing Qualitative Data. London: Routledge; 1994.
25. Gadamer H. Sandhed og metode, grundtræk af en filosofisk hermeneutik (Originaltitel:
Wahrheit und Methode). Århus: Systime; 2004.
26. Conaghan PG, Dickson J, Grant RL. Care and management of osteoarthritis in adults:
summary of NICE guidance. BMJ. 2008;336: 502–503. doi:10.1136/bmj.39490.608009.AD
27. Ravaud P. Management of osteoarthritis (OA) with an unsupervised home based exercise
programme and/or patient administered assessment tools. A cluster randomised controlled
trial with a 2x2 factorial design. Annals of the Rheumatic Diseases. 2004;63: 703–708.
doi:10.1136/ard.2003.009803
28. Hurley MV, Walsh NE, Mitchell H, Nicholas J, Patel A. Long-term outcomes and
costs of an integrated rehabilitation program for chronic knee pain: A pragmatic,
cluster randomized, controlled trial. Arthritis Care & Research. 2012;64: 238–247.
doi:10.1002/acr.20642
29. Calatayud J, Casaña J, Ezzatvar Y, Jakobsen MD, Sundstrup E, Andersen LL. High-intensity
preoperative training improves physical and functional recovery in the early post-operative
periods after total knee arthroplasty: a randomized controlled trial. Knee Surgery,
Sports Traumatology, Arthroscopy. 2016;25: 2864–2872. doi:10.1007/s00167-016-3985-5
30. Skoffer B, Maribo T, Mechlenburg I, Hansen PM, Søballe K, Dalgas U. Efficacy
of Preoperative Progressive Resistance Training on Postoperative Outcomes in Patients
Undergoing Total Knee Arthroplasty: Progressive Resistance Training Before TKA. Arthritis
Care & Research. 2016;68: 1239–51. doi:10.1002/acr.22825
31. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development
of criteria for the classification and reporting of osteoarthritis: classification
of osteoarthritis of the knee. Arthritis & Rheumatology. 1986;29: 1039–1049. doi:10.1002/art.1780290816
32. Dell’Isola A, Steultjens M. Classification of patients with knee osteoarthritis
in clinical phenotypes: Data from the osteoarthritis initiative. Lammi MJ, editor.
PLoS ONE. 2018;13: e0191045. doi:10.1371/journal.pone.0191045
33. Mandl LA. Determining who should be referred for total hip and knee replacements.
Nature Reviews Rheumatology. 2013;9: 351–357. doi:10.1038/nrrheum.2013.27
34. Dieppe P. Who should have a joint replacement? A plea for more ‘phronesis.’ Osteoarthritis
and Cartilage. 2011;19: 145–146. doi:10.1016/j.joca.2010.08.018
35. Gossec L, Paternotte S, Maillefert JF, Combescure C, Conaghan PG, Davis AM, et
al. The role of pain and functional impairment in the decision to recommend total
joint replacement in hip and knee osteoarthritis: an international cross-sectional
study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement.
Osteoarthritis and Cartilage. 2011;19: 147–154. doi:10.1016/j.joca.2010.10.025
36. Mancuso CA, Ranawat CS, Esdaile JM, Johanson NA, Charlson ME. Indications for
total hip and total knee arthroplasties. The Journal of Arthroplasty. 1996;11: 34–46.
doi:10.1016/S0883-5403(96)80159-8
37. Ingelsrud LH, Roos EM, Gromov K, Jensen SS, Troelsen A. Patients report inferior
quality of care for knee osteoarthritis prior to assessment for knee replacement surgery
– a cross-sectional study of 517 patients in Denmark. Acta Orthopaedica. 2019; 1–6.
doi:10.1080/17453674.2019.1680180
38. Newman S, Steed L, Mulligan K. Chronic physical illness: self- management and
behavioural interventions. NewmanS,SteedL,MulliganK.Chronicphysicalillness:self- maMaidenhead:
Open University Press; 2009.
39. Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance
and performance in adults over 65 years of age. Physical Therapy. 1999;79: 270–277.
40. Rhea MR, Alvar BA, Burkett LN, Ball SD. A Meta-analysis to Determine the Dose
Response for Strength Development. Medicine & Science in Sports & Exercise. 2003;35:
456–464. doi:10.1249/01.MSS.0000053727.63505.D4
41. Culvenor AG, Ruhdorfer A, Juhl C, Eckstein F, Øiestad BE. Knee Extensor Strength
and Risk of Structural, Symptomatic, and Functional Decline in Knee Osteoarthritis:
A Systematic Review and Meta-Analysis: Risk of Deterioration in Knee OA and Knee Extensor
Strength. Arthritis Care & Research. 2017;69: 649–658. doi:10.1002/acr.23005
42. Øiestad BE, Juhl CB, Eitzen I, Thorlund JB. Knee extensor muscle weakness is
a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis.
Osteoarthritis and Cartilage. 2015;23: 171–177. doi:10.1016/j.joca.2014.10.008
43. Juhl C, Christensen R, Roos EM, Zhang W, Lund H. Impact of Exercise Type and
Dose on Pain and Disability in Knee Osteoarthritis: A Systematic Review and Meta-Regression
Analysis of Randomized Controlled Trials: Impact of Exercise Type and Dose in Knee
Osteoarthritis. Arthritis & Rheumatology. 2014;66: 622–636. doi:10.1002/art.38290
44. PubMed.com Medical Subject Heading. Exercise Therapy (MeSH-term). 2019 [cited
29 May 2019]. Available: https://www.ncbi.nlm.nih.gov/mesh/?term=exercise+therapy
45. Klaber Moffett JA, Richardson PH. The influence of the physiotherapist-patient
relationship on pain and disability. Physiotherapy Theory and Practice. 1997;13: 89–96.
doi:10.3109/09593989709036451
46. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts,
procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24:
105–112. doi:10.1016/j.nedt.2003.10.001
47. Nowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis: Striving to Meet
the Trustworthiness Criteria. International Journal of Qualitative Methods. 2017;16:
160940691773384. doi:10.1177/1609406917733847
48. Dahlager L, Fredslund F. Hermeneutisk analyse – og forståelse og for-forståelse.
4th ed. Forskningsmetoder i folkesundhedsvidenskab. 4th ed. Kbh.: Munksgaard Danmark;
2011.
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