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“Sounds a bit crazy, but it was almost more personal:” a qualitative study of patient and clinician experiences of physical therapist-prescribed exercise for knee osteoarthritis via Skype
- The findings of this study demonstrate that both patients and physical therapists had mostly positive experiences using Skype as a service delivery model for physical therapist-supervised exercise management of moderate knee osteoarthritis (OA).
- Patients and therapists found skype consultations for knee OA to be efficient, effective, empowering, and surprisingly personal.
BACKGROUND & OBJECTIVE
Knee pain related to knee osteoarthritis (OA) is a worldwide problem affecting one-quarter of adults (1). As knee OA has no known “cure”, management aims to minimize pain and optimize function and quality of life, while delaying or preventing arthroplasty. Exercise is often advocated as a fundamental component of nonsurgical management of knee OA, as it has been shown across a wide range of studies to have beneficial effects on pain, physical function, and quality of life (2,3).
Physical therapists commonly prescribe exercise for patients with knee OA, yet access to physical therapy services is limited for many (e.g. physical proximity, inability to pay, and/or availability of therapists), which demonstrates the need for new models of service delivery to aid in addressing the gradual rise of chronic health problems. Telerehabilitation via video conferencing is a potentially effective and cost-effective strategy for this patient group that remains relatively unexplored to date.
The aim of this study was to explore the experiences of patients and physical therapists using Skype for exercise management of knee pain related to knee OA.
The findings from this study indicate that virtual rehab is not only feasible and acceptable, but that it has the potential to increase access to supervised exercise for people with knee OA.
A qualitative research approach was used for this study which consisted of semi-structured individual interviews for data collection, allowing participants to provide rich information.
Participants in this study were patients with persistent knee pain associated with OA, as well as physical therapists. Participants were provided with 7 internet-based Skype-delivered physical therapy sessions for 3 months; the main purpose being to prescribe an individualized home-based strengthening program to be undertaken 3 times per week. The therapist selected 5-6 suitable exercises from the study protocol based on patient goals, clinical history, and observation of walking, sit-to-stand, and squat tasks. Exercises were demonstrated by the therapist, and the participant performed the exercise while the physical therapist watched. At subsequent sessions, exercises were reviewed and progressed.
Upon semi-structured interviews of the patients and the therapists, both parties were impressed by the technology despite occasional difficulties such as poor internet connection leading to pixilation and reduced clarity of audio. Both patients and therapists also considered Skype-delivered care to be convenient for patients, because of the time efficiency, flexibility, and the access it afforded. Patients appreciated not having to travel to a clinic, find parking, wait in the waiting room, or walk long distances when in pain. Patients also reported that they enjoyed the flexibility to participate in sessions anywhere they could connect to the internet, including at work, on day trips to the beach, or on holidays.
Additionally, the theme of patient empowerment to self-manage emerged from both patients and physical therapists, as the home environment was important in achieving this empowerment. Patients emphasized being comfortable and relaxed, enabling them to focus on performance of and adherence to prescribed exercises.
Positive therapeutic relationships were also a theme that emerged. Patients appreciated the personal and undivided attention they received from their physical therapist, as well as the supportive and friendly relationships they felt were developed.
For the therapist, adjusting routine treatment emerged as an important theme. Therapists were forced to modify usual habits and rely more on information shared by patients, rather than information derived from routine physical assessment tasks. Despite this limitation, all therapists felt patients responded favorably to the exercises prescribed.
One limitation to the ability to apply this information directly to other patient populations is that in this study, the patients and therapists all volunteered for the trial and may have been highly motivated and/or biased toward positive experiences and outcomes from the intervention. Additionally, all patients who did not speak English were excluded from the study, which means we are unable to draw conclusions about the effect of skype sessions in which there might be a minor language barrier. The findings of this study are also only generalizable to patients with moderate levels of pain and dysfunction and cannot be applied to more severe symptom presentation or other diagnoses. Finally, the recruitment of patients for interviews was conducted 3-6 months after completing treatment sessions which may have influenced recall accuracy.
The findings of this study demonstrate that both patients and physical therapists had mostly positive experiences using Skype as a service delivery model for physical therapist-supervised exercise management of moderate knee OA. Additionally, the findings indicate that virtual medicine/rehab is not only feasible and acceptable, but that it has the potential to increase access to supervised exercise for people with knee OA who may have limited capacity to attend regular in-clinic visits.
Furthermore, this study suggests that hands-on manual therapies are not considered essential in the treatment of those with moderate knee pain related to OA, and that education and supervised exercise when prescribed both in-person and virtually are sufficient for acceptable patient outcomes.
Virtual consultations should be considered in the management of people with moderate knee OA as a sole form of interaction for some patients, or more likely in combination with traditional in-clinic visits. Reasons for choosing virtual management may include, but shouldn’t be limited to, patient preference, patient schedule, financial concerns, transportation limitations, geographical location, time effectiveness, cost effectiveness, and encouraging improved patient self-management strategies.
Hinman R, Nelligan R, Bennell K, Delany C (2017) "Sounds a Bit Crazy, But It Was Almost More Personal:" A Qualitative Study of Patient and Clinician Experiences of Physical Therapist-Prescribed Exercise For Knee Osteoarthritis Via Skype. Arthritis Care Res (Hoboken), 69(12), 1834-1844.
- Pereira D, Peleteiro B, Araujo J, Branco J, Santos RA, Ramos E. The effect of osteoarthritis definition on prevalence and incidence estimates: a systematic review. Osteoarthritis Cartilage 2011;19:1270–85.
- Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Semin Arthritis Rheum 2014;43:701–12.
- Hinman R, Nicolson P, Dobson F, Bennell K. Use of nondrug, nonoperative interventions by community-dwelling people with hip and knee osteoarthritis. Arthritis Care Res. 2015;67:305-309