Does telephone-delivered exercise advice and support by physiotherapists improve pain and/or function in people with knee osteoarthritis? Telecare randomised controlled trial.

OBJECTIVE: Evaluate a physiotherapist-led telephone-delivered exercise advice and support intervention for people with knee osteoarthritis. METHODS: Participant-blinded, assessor-blinded randomised controlled trial. 175 people were randomly allocated to (1) existing telephone service (≥1 nurse consultation for self-management advice) or (2) exercise advice and support (5-10 consultations with a physiotherapist trained in behaviour change for a personalised strengthening and physical activity programme) plus the existing service. Primary outcomes were overall knee pain (Numerical Rating Scale, range 0-10) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, range 0-68) at 6 months. Secondary outcomes, cost-effectiveness and 12-month follow-up were included. RESULTS: 165 (94%) and 158 (90%) participants were retained at 6 and 12 months, respectively. At 6 months, exercise advice and support resulted in greater improvement in function (mean difference 4.7 (95% CI 1.0 to 8.4)), but not overall pain (0.7, 0.0 to 1.4). Eight of 14 secondary outcomes favoured exercise advice and support at 6 months, including pain on daily activities, walking pain, pain self-efficacy, global improvements across multiple domains (overall improvement, improved pain, improved function and improved physical activity) and satisfaction. By 12 months, most outcomes were similar between groups. Exercise advice and support cost $A514/participant and did not save other health service resources. CONCLUSION: Telephone-delivered physiotherapist-led exercise advice and support modestly improved physical function but not the co-primary outcome of knee pain at 6 months. Functional benefits were not sustained at 12 months. The clinical significance of this effect is uncertain. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (#12616000054415).

Addition of telephone coaching to a physiotherapist-delivered physical activity program in people with knee osteoarthritis: a randomised controlled trial protocol.

BACKGROUND: Knee osteoarthritis (OA) is one of the most common and costly chronic musculoskeletal conditions world-wide and is associated with substantial pain and disability. Many people with knee OA also experience co-morbidities that further add to the OA burden. Uptake of and adherence to physical activity recommendations is suboptimal in this patient population, leading to poorer OA outcomes and greater impact of associated co-morbidities. This pragmatic randomised controlled trial will investigate the clinical- and cost-effectiveness of adding telephone coaching to a physiotherapist-delivered physical activity intervention for people with knee OA. METHODS/DESIGN: 168 people with clinically diagnosed knee OA will be recruited from the community in metropolitan and regional areas and randomly allocated to physiotherapy only, or physiotherapy plus nurse-delivered telephone coaching. Physiotherapy involves five treatment sessions over 6 months, incorporating a home exercise program of 4-6 exercises (targeting knee extensor and hip abductor strength) and advice to increase daily physical activity. Telephone coaching comprises 6-12 telephone calls over 6 months by health practitioners trained in applying the Health Change Australia (HCA) Model of Health Change to provide behaviour change support. The telephone coaching intervention aims to maximise adherence to the physiotherapy program, as well as facilitate increased levels of participation in general physical activity. The primary outcomes are pain measured by an 11-point numeric rating scale and self-reported physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale after 6 months. Secondary outcomes include physical activity levels, quality-of-life, and potential moderators and mediators of outcomes including self-efficacy, pain coping and depression. Relative cost-effectiveness will be determined from health service usage and outcome data. Follow-up assessments will also occur at 12 and 18 months. DISCUSSION: The findings will help determine whether the addition of telephone coaching sessions can improve sustainability of outcomes from a physiotherapist-delivered physical activity intervention in people with knee OA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12612000308897.

Implementation of person-centred practice principles and behaviour change techniques after a 2-day training workshop: A nested case study involving physiotherapists.

OBJECTIVES: The aims of the present study were to determine how well physiotherapists implemented person-centred practice principles and behaviour change techniques after a workshop, and to evaluate whether self-audit of performance differed from audits of an experienced training facilitator. METHODS: Eight physiotherapists each completed a 2-day workshop followed by two telephone consultations with four patients with knee osteoarthritis. The training facilitator audited audio-recordings of all consultations, and therapists self-audited 50% of consultations using a tool comprising: (a) 10 person-centred practice principles rated on a numerical rating scale of 0 (need to work on this) to 10 (doing really well); and (b) seven behaviour change techniques rated with an ordinal scale (using this technique effectively; need to improve skill level; or need to learn how to apply this technique). RESULTS: Physiotherapists showed "moderate" fidelity to person-centred principles, with mean scores between 5 and 7 out of 10. For behaviour change techniques, the training facilitator believed that physiotherapists were using three of seven techniques "effectively" during most consultations and "needed to improve skill levels" with most other techniques. Physiotherapists scored themselves significantly lower than the training facilitator for two of 10 person-centred principles, and tended to rate their skills using behaviour change techniques less favourably. CONCLUSIONS: Physiotherapists performed moderately well when implementing person-centred practice principles and behaviour change techniques immediately after training, but had room for improvement, particularly for skills relating to providing management options and changing thinking habits. Physiotherapists' self-ratings of performance generally did not differ from expert ratings; however, they underestimated their ability to implement some principles and techniques.

Training Physical Therapists in Person-Centered Practice for People With Osteoarthritis: A Qualitative Case Study.

OBJECTIVE: To explore physical therapists' experiences with, and the impacts of, a training program in person-centered practice to support exercise adherence in people with knee osteoarthritis. METHODS: This was a qualitative case study using semi-structured interviews, nested within a clinical trial. Eight Australian physical therapists were interviewed before, and after, training in person-centered practice for people with knee osteoarthritis. Training involved a 2-day workshop, skills practice, and audit of 8 consultations with 4 patients (per therapist), and a final single-day workshop for audit feedback and consolidation. Semi-structured interviews were audio-recorded and transcribed verbatim. Data were thematically analyzed. RESULTS: Three pretraining themes arose regarding usual communication style, definitions of person-centered care, and sharing exercise adherence responsibility. Three themes related to the training experience emerged: learning a new language, challenging conceptions of practice, and putting it into practice. Post-training, 3 themes arose regarding new knowledge deepening understanding of person-centered care, changing beliefs about sharing responsibilities, and changed conceptions of role. CONCLUSION: Although physical therapists found training overwhelming initially as they realized the limitations of their current knowledge and clinical practice, they felt more confident and able to provide person-centered care to people with knee osteoarthritis by the end of training. Training in structured person-centered methodology that provides opportunity for skills practice with patients using a restructured consultation framework can change physical therapists' beliefs about their roles when managing patients with osteoarthritis and positively impact their clinical practice.

Telephone Coaching to Enhance a Home-Based Physical Activity Program for Knee Osteoarthritis: A Randomized Clinical Trial.

OBJECTIVE: To investigate whether simultaneous telephone coaching improves the clinical effectiveness of a physiotherapist-prescribed home-based physical activity program for knee osteoarthritis (OA). METHODS: A total of 168 inactive adults ages ≥50 years with knee pain on a numeric rating scale ≥4 (NRS; range 0-10) and knee OA were recruited from the community and randomly assigned to a physiotherapy (PT) and coaching group (n = 84) or PT-only (n = 84) group. All participants received five 30-minute consultations with a physiotherapist over 6 months for education, home exercise, and physical activity advice. PT+coaching participants also received 6-12 telephone coaching sessions by clinicians trained in behavioral-change support for exercise and physical activity. Primary outcomes were pain (NRS) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC; score range 0-68]) at 6 months. Secondary outcomes were these same measures at 12 and 18 months, as well as physical activity, exercise adherence, other pain and function measures, and quality of life. Analyses were intent-to-treat with multiple imputation for missing data. RESULTS: A total of 142 (85%), 136 (81%), and 128 (76%) participants completed 6-, 12-, and 18-month measurements, respectively. The change in NRS pain (mean difference 0.4 unit [95% confidence interval (95% CI) -0.4, 1.3]) and in WOMAC function (1.8 [95% CI -1.9, 5.5]) did not differ between groups at 6 months, with both groups showing clinically relevant improvements. Some secondary outcomes related to physical activity and exercise behavior favored PT+coaching at 6 months but generally not at 12 or 18 months. There were no between-group differences in most other outcomes. CONCLUSION: The addition of simultaneous telephone coaching did not augment the pain and function benefits of a physiotherapist-prescribed home-based physical activity program.

Telephone-Delivered Exercise Advice and Behavior Change Support by Physical Therapists for People with Knee Osteoarthritis: Protocol for the Telecare Randomized Controlled Trial.

BACKGROUND: Exercise and physical activity are a core component of knee osteoarthritis (OA) care, yet access to physical therapists is limited for many people. Telephone service delivery models may increase access. OBJECTIVE: Determine the effectiveness of incorporating exercise advice and behavior change support by physical therapists into an existing Australian nurse-led musculoskeletal telephone service for adults with knee OA. DESIGN: Randomized controlled trial with nested qualitative studies. SETTING: Community, Australia-wide. PARTICIPANTS: One hundred seventy-five people ≥45 years of age with knee symptoms consistent with a clinical diagnosis of knee OA. Eight musculoskeletal physical therapists will provide exercise advice and support. INTERVENTION: Random allocation to receive existing care or exercise advice in addition to existing care. Existing care is a minimum of one phone call from a nurse for advice on OA self-management. Exercise advice involves 5-10 calls over 6 months from a physical therapist trained in behavior change support to prescribe, monitor, and progress a strengthening exercise program and physical activity plan. MEASUREMENTS: Outcomes will be measured at baseline and at 6 and 12 months. Primary outcomes are knee pain and physical function. Secondary outcomes include other measures of knee pain, self-efficacy, physical activity and its mediators, kinesiophobia, health service usage, work productivity, participant-perceived change, and satisfaction. Additional measures include adherence, adverse events, therapeutic alliance, satisfaction with telephone-delivered therapy, and expectation of outcome. Semi-structured interviews with participants with knee OA and therapists will be conducted. LIMITATIONS: Physical therapists cannot be blinded. CONCLUSIONS: This study will determine if incorporating exercise advice and behavior change support by physical therapists into a nurse-led musculoskeletal telephone service improves outcomes for people with knee OA. Findings will inform development and implementation of telerehabilitation services.