What Influences Patient Satisfaction after TKA? A Qualitative Investigation.

BACKGROUND: Patient satisfaction is a common measure of the success of an orthopaedic intervention. However, there is poor understanding of what satisfaction means to patients or what influences it. QUESTIONS/PURPOSES: Using qualitative study methodology in patients undergoing TKA, we asked: (1) What does it mean to be satisfied after TKA? (2) What factors influence satisfaction levels after TKA? METHODS: People in a hospital registry who had completed 12-month follow-up questionnaires and were not more than 18 months post-TKA at the time of sampling were eligible (n = 121). To recruit a sample that provided insight into a range of TKA experiences, we divided eligible candidates on the registry into quadrants based on their responder status and satisfaction level. A responder was an individual who experienced a clinically meaningful change in pain and/or function on the WOMAC according to the Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria. Individuals were considered satisfied unless they indicated somewhat dissatisfied or very dissatisfied for one or more of the four items on the Self-Administered Patient Satisfaction Scale. From the resulting quadrants: responder satisfied, nonresponder satisfied, nonresponder dissatisfied, responder dissatisfied, we identified men and women with a range of ages and invited them to participate (n = 85). The final sample (n = 40), consisted of 10 responder satisfied, nine nonresponder satisfied, eight nonresponder dissatisfied, and 13 responder dissatisfied; 71% were women, with a mean age of 71 ± 7 years and a mean time since TKA surgery of 17 ± 2 months (range 13 to 25 months). Interview transcripts were analyzed by looking for factors in the participants' narrative that appeared to underscore their level of satisfaction and attaching inductive (data-derived, rather than a priori derived) codes to relevant sections of text. Coded data from participants who reported high and low levels of satisfaction were compared/contrasted and emerging patterns were mapped into a conceptual model. Recruitment continued until no new information was uncovered in data analysis of subsequent interviews, signalling to the researchers that further interviews would not change the key themes identified and data collection could cease. RESULTS: In those with high satisfaction levels, satisfaction was conceptualized as an improvement in pain and function. In those with low satisfaction levels, rather than an improvement, satisfaction was conceptualized as completely resolving all symptoms and functional limitations. In addition, we identified three pathways through which participants reached different levels of low and high satisfaction: (1) The full-glass pathway, characterized by no or minimal ongoing symptoms and functional deficits, which consistently led to high levels of satisfaction; (2) the glass-half-full pathway, characterized by ongoing symptoms and functional limitations, which led to high satisfaction; and (3) the glass-half-empty pathway, also characterized by ongoing symptoms and functional limitations, which led to low satisfaction levels. The latter two pathways were mediated by three core mechanisms (recalibration, reframing valued activities, and reconceptualization) influenced either positively or negatively by (1) a persons' thoughts and feelings such as optimism, self-efficacy, pain catastrophizing, external locus of control; and (2) social and contextual factors such as fulfilment of social roles, therapeutic alliance, lack of family/social support. CONCLUSIONS: This qualitative study suggests that for preoperative patients in whom unrealistically high hopes for complete symptom resolution and restoration of functional capacity persists, it may be appropriate to direct them away from TKA due to the risk of low satisfaction. For postoperative patients troubled by ongoing symptoms or functional limitations, clinicians may improve levels of satisfaction by targeting the three core mechanisms (recalibration, reframing valued activities, and reconceptualization) through addressing modifiable negative thoughts and feelings in interventions such as psychology or psychotherapy; and negative social and contextual factors by promoting a strong therapeutic alliance and engagement in community activities. Given that these factors may be identifiable preoperatively, future research is needed to explore if and how addressing them preoperatively may improve satisfaction post-TKA. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Australian physiotherapists attitudes, perceptions, and behaviours towards psychosocial screening tools: a qualitative interpretive description study.

PURPOSE: Psychosocial factors are a barrier to recovery for people with musculoskeletal pain and psychosocial screening tools are consistently recommended by best practice guidelines to assist in identification. However, many physiotherapists do not use these tools. Presently, the perspectives on psychosocial screening tools of Australian physiotherapists are unknown. Exploration of these factors may create targets for increased uptake. The purpose of this paper is to qualitatively explore Australian physiotherapists' attitudes, perceptions, and behaviours towards psychosocial screening tools for musculoskeletal pain conditions. MATERIALS AND METHODS: An Interpretive description qualitative study design was employed. Seventeen Australian physiotherapists were interviewed about their attitudes, perceptions, and behaviours towards psychosocial screening tools. Interviews were transcribed verbatim and analysed according to interpretive description. RESULTS: Analysis highlighted three major themes: (1) understanding the patient through psychosocial screening, (2) confidence and competence with psychosocial factors, and (3) factors outside of my control influence screening. CONCLUSIONS: This study presents a deeper understanding of Australian physiotherapists' diverse attitudes and practices regarding psychosocial screening tools. The research highlights not only the variability in perspectives towards the relevance of psychosocial factors in patient assessments, but also the influence of external elements such as patient demographics and clinic culture on the utilization of these screening methods.

Australian physiotherapists' varying attitudes and limited understanding of the impact of psychosocial factors may hinder the use of recommended psychosocial screening.Concerns about scope of practice, tool appropriateness for different patients, and clinic culture further challenge the integration of psychosocial assessments.The findings from this study indicate the need to provide more education to Australian physiotherapists on the importance and use of psychosocial risk factor screening, as part of clinical care standards and best practice guidelines in the management of patients, with musculoskeletal pain conditions.The findings from this study can support the creation of targeted training/innovations to improve the uptake of screening tools in Australian musculoskeletal clinical practice, to improve the care of patients with musculoskeletal pain conditions.

Process of change for people with knee osteoarthritis undergoing cognitive functional therapy: a replicated single-case experimental design study.

PURPOSE: To examine the applicability and process of change of Cognitive Functional Therapy (CFT) in the management of pain and disability in people with knee osteoarthritis who were offered knee replacement surgery and had risk factors for poor response to surgery. METHODS: Single-case experimental design with a mixed-methods, repeated measures approach was used to investigate the process of change through CFT in four participants. Qualitative interviews investigated beliefs, behaviours and coping responses, and self-reported measures assessed pain, disability, psychological factors, and function at 25 timepoints. Study registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12619001491156). RESULTS: Qualitative data indicate that CFT promoted helpful changes in all participants, with two responses observed. One reflected a clear shift to a biopsychosocial conceptualisation of osteoarthritis, behavioural re-engagement and the view that a knee replacement was no longer necessary. The other response reflected a mixed conceptualisation with dissonant beliefs about osteoarthritis and its management. Psychological and social factors were identified as potential treatment barriers. Overall, quantitative measures supported the qualitative findings. CONCLUSION: The process of change varies between and within individuals over time. Psychological and social barriers to treatment have implications for future intervention studies for the management of knee osteoarthritis.IMPLICATIONS FOR REHABILITATIONCognitive Functional Therapy is applicable in the management of knee osteoarthritis.Reconceptualisation of osteoarthritis reflected a helpful change.Psychological and social factors emerged as barriers to recovery.

Demystifying Qualitative Research for Musculoskeletal Practitioners Part 4: A Qualitative Researcher's Toolkit-Sampling, Data Collection Methods, and Data Analysis.

SYNOPSIS: In this editorial, we discuss common methods used in musculoskeletal qualitative research, including approaches to sampling, data collection, and data analysis. We take a particular focus in this editorial on methods that involve "speaking to people." We highlight the back-and-forth or cyclic nature of qualitative research, and introduce readers to the use of natural language processing to analyze qualitative data. J Orthop Sports Phys Ther 2022;52(1):8-10. doi:10.2519/jospt.2022.10486.

Demystifying Qualitative Research for Musculoskeletal Practitioners Part 3: Phenomeno-what? Understanding What the Qualitative Researchers Have Done.

SYNOPSIS: In part 3 of "Demystifying Qualitative Research for Musculoskeletal Practitioners," we introduce the concept of "methodological approach" to encompass the plan of action that underpins the use of methods and desired outcomes, as well as the use of theory. Understanding the methodological approach in a qualitative study gives the reader a sense of what the qualitative researchers have "done," while theory has varying uses and meanings depending on type of qualitative study. In this installment, we cover some of the common methodological approaches used in the musculoskeletal field and provide a discussion about the different ways in which theory can be considered and used in a qualitative study. J Orthop Sports Phys Ther 2022;52(1):3-7. doi:10.2519/jospt.2022.10485.

Demystifying Qualitative Research for Musculoskeletal Practitioners Part 5: Rigor in Qualitative Research.

SYNOPSIS: In part 5 of this series, we turn our attention to concepts of rigor in qualitative research. In doing so, the use of quality appraisal tools and reporting checklists for qualitative studies is explored. Issues regarding a one-size-fits-all approach to these tools and checklists are discussed. Trustworthiness criteria are also described and applied to different qualitative paradigms and methodological approaches. J Orthop Sports Phys Ther 2022;52(2):60-62. doi:10.2519/jospt.2022.10487.

Demystifying Qualitative Research for Musculoskeletal Practitioners Part 1: What Is Qualitative Research and How Can It Help Practitioners Deliver Best-Practice Musculoskeletal Care?

SYNOPSIS: A progressive understanding of pain, disability, and health requires consideration of factors that may not easily be captured quantitatively. Qualitative research is a valuable tool to explore these "uncountable" phenomena and inform high-quality patient-centered care. Despite the utility of qualitative research in a musculoskeletal context, many practitioners are not familiar with qualitative terms and therefore may not reap the benefits of qualitative approaches. This editorial discusses what qualitative research is and how it can inform musculoskeletal clinical practice. J Orthop Sports Phys Ther 2021;51(11):531-532. doi:10.2519/jospt.2021.0110.

Demystifying Qualitative Research for Musculoskeletal Practitioners Part 2: Understanding the Foundations of Qualitative Research.

SYNOPSIS: In this second editorial about qualitative research for musculoskeletal practitioners, we turn our attention to the foundational assumptions that underpin all qualitative research. Specifically, we discuss research paradigms, which consist of ontological and epistemological assumptions, as well as the "lens" of the researcher. Understanding these foundational assumptions will help readers interpret the findings of qualitative studies relevant to a musculoskeletal context. J Orthop Sports Phys Ther 2021;51(12):559-561. doi:10.2519/jospt.2021.0113.

What influences patient satisfaction after total knee replacement? A qualitative long-term follow-up study.

OBJECTIVES: To explore whether a conceptual model of patient satisfaction previously developed 1-2 years post-total knee replacement (TKR) is still relevant 3-4 years post-TKR. Specifically, (i) what is the stability in satisfaction levels 3-4 years post-TKR? and (ii) does the existing conceptual model of patient satisfaction after TKR apply at this later follow-up? DESIGN: A constructivist grounded theory qualitative follow-up study. The present study was theoretically governed by the findings of the initial qualitative inquiry. One-on-one semi-structured interviews were used to test the assumptions of the model developed from the findings of the previous study. SETTING: An urban Australian public hospital PARTICIPANTS: From 40 people who participated in the original study, 11 participants were purposively sampled based on their level of satisfaction and factors driving satisfaction as reported in their first interview. There were six women and five men, the average time since TKR was 3 years and 5 months, and the average age at time of interview was 77 years. RESULTS: Satisfaction levels were mostly stable with the exception of three participants; two transitioned in a positive direction; one in a negative direction. The meaning of satisfaction and the factors that influenced satisfaction were consistent with the original findings. However, beliefs relating to the influence of ageing on persistent knee symptoms and functional limitations were more dominant in the present study. CONCLUSIONS: The findings provide support for patient satisfaction being a multifactorial construct that is potentially modifiable over time. Clinicians may apply the conceptual model we have described to optimise satisfaction in patients up to 3-4 years post-TKR.

Satisfaction after total knee replacement for osteoarthritis is usually high, but what are we measuring? A systematic review.

Objective: Patient satisfaction is considered an important outcome measure after total knee replacement, but the construct is complex. There is large variation both in how satisfaction is measured and estimates of the proportion of people who are satisfied after surgery. The aim of this systematic review was to i) evaluate the proportion of people reported to be satisfied after total knee replacement for osteoarthritis; and ii) assess the content validity of the utilised satisfaction measures. Methods: We searched four literature databases with search phrases 'Total Knee Arthroplasty' OR 'Total Knee Replacement' AND 'Patient satisfaction' for studies that measured satisfaction at least 6 month post-unilateral primary total knee replacement for knee osteoarthritis. Identified studies were assessed for risk of bias, and studies at high risk of bias were excluded (PROSPERO: CRD42017058936). Meta-analysis was not appropriate due to the heterogeneity in satisfaction instruments, thus satisfaction scores were described. The content validity of satisfaction questionnaires was assessed using the COnsensus-based Standards for the selection of health status Measurement Instruments criteria. Results: The present review found heterogeneity in the satisfaction questions used, as well as the satisfaction estimates from the various studies. Only two satisfaction instruments were relevant for a Total Knee Replacement population and both failed assessment for content validity due to lack of patient involvement during development and testing in accordance with the COnsensus-based Standards for the selection of health status Measurement Instruments criteria. Conclusion: Future research should focus on qualitative methods to elicit patients' perspectives of satisfaction to build theoretical understanding.

Effect of External Ankle Support on Ankle and Knee Biomechanics During the Cutting Maneuver in Basketball Players.

BACKGROUND: Despite the high prevalence of lower extremity injuries in female basketball players as well as a high proportion of athletes who wear ankle braces, there is a paucity of research pertaining to the effects of ankle bracing on ankle and knee biomechanics during basketball-specific tasks. PURPOSE: To compare the effects of a lace-up brace (ASO), a hinged brace (Active T2), and no ankle bracing (control) on ankle and knee joint kinematics and joint reaction forces in female basketball athletes during a cutting maneuver. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty healthy, semi-elite female basketball players performed a cutting task under both ankle brace conditions (lace-up ankle brace and hinged ankle brace) and a no-brace condition. The 3-dimensional kinematics of the ankle and knee during the cutting maneuver were measured with an 18-camera motion analysis system (250 Hz), and ground-reaction force data were collected by use of a multichannel force plate (2000 Hz) to quantify ankle and knee joint reaction forces. Conditions were randomized using a block randomization method. RESULTS: Compared with the control condition, the hinged ankle brace significantly restricted peak ankle inversion (mean difference, 1.7°; P = .023). No significant difference was found between the lace-up brace and the control condition ( P = .865). Compared with the lace-up brace, the hinged brace significantly reduced ankle and knee joint compressive forces at the time of peak ankle dorsiflexion (mean difference, 1.5 N/kg [ P = .018] and 1.4 N/kg [ P = .013], respectively). Additionally, the hinged ankle brace significantly reduced knee anterior shear forces compared with the lace-up brace both during the deceleration phase and at peak ankle dorsiflexion (mean difference, 0.8 N/kg [ P = .018] and 0.9 N/kg [ P = .011], respectively). CONCLUSION: The hinged ankle brace significantly reduced ankle inversion compared with the no-brace condition and reduced ankle and knee joint forces compared with the lace-up brace in a female basketball population during a cutting task. Compared with the lace-up brace, the hinged brace may be a better choice of prophylactic ankle support for female basketball players from a biomechanical perspective. However, both braces increased knee internal rotation and knee abduction angles, which may be problematic for a population that already has a high prevalence of knee injuries.