Purpose: A structured, tailored exercise therapy strategy was found to significantly improve physical functioning, reduce pain and was safe for patients with knee osteoarthritis (OA) and severe comorbidity. The intervention was performed in a specialized, secondary care center. Before the intervention can be implemented in primary care, appropriate education as well as insight into barriers and facilitators is needed. This study aimed to 1) evaluate the feasibility and effect of an interactive course on the exercise therapy strategy for patients with OA and comorbidity for physiotherapists (PTs) working in primary care; and 2) map barriers for a larger scale implementation of the protocol in primary care.Methods: A pre-posttest study was performed among PTs who were member of a network for rheumatic diseases and PTs from regional subdivisions of the Royal Dutch Society for Physical Therapy (KNGF) in the Netherlands (North-Holland and Mid-Holland) all working in primary care. PTs were offered a postgraduate blended educational course consisting of an e-learning lecture (7 hours study load) and two interactive workshops (each 3 hours study load). Measures of its feasibility and effectiveness included a questionnaire on knowledge (50 multiple choice questions, score ranging from 1 to 50) before (T0) and two weeks after the course (T1)) and a patient vignette to measure clinical reasoning (nine open questions, score ranging from 0 to 5) before the course (T0) and six months after the course (T2). Course satisfaction was administered on a 0-10 point scale (higher score means more satisfaction), directly after the course. Barriers for using the protocol were measured at T2 by means of a 27 item questionnaire, comprising five different dimensions: (i) Design, Content and Feasibility; (ii) Change in working method; (iii) Knowledge and Skills; (iv) Applicability; and (v) Social environment (each item was scored on a 5-point Likert scale, ranging from 0 totally agree to 4 totally disagree).Results: In total, 34 physiotherapists were included. Statistically significant (P < 0.05) improvement was found in knowledge about knee OA and comorbidity between baseline and two- weeks post education, with an average increase of 4.4 points above the baseline score. Also, a statistically significant improvement (P < 0.05) was found for clinical reasoning on adapting knee OA exercise therapy to the comorbid disease between baseline and six- months post education. Overall, the PTs were satisfied with the educational course (7.9 points (SD 0.9) (n ¼ 33)). The majority of PTs found the protocol to be supportive regarding clinical reasoning and clinical decision making. In a period of six months, 15 out of 34 PTs had treated at least one patient with knee OAand comorbidity according to the protocol. Perceived barriers for implementation included the small number of patients with OA and severe comorbidity being referred or referring themselves, treatment time needed to provide care according the protocol, and the limited number of treatments reimbursement by the insurance companies.Conclusions: An interactive educational course on exercise therapy for knee OA patients with comorbidity proved to be effective in improving knowledge and clinical reasoning skills of primary care PTs. Main barriers for larger scale implementation include limited referrals of patients with knee OA and severe comorbidity to PTs and limited number of treatments reimbursement by the insurance companies. Specialists and patients should be encouraged to consider exercise therapy as a treatment option for patients with knee OA and comorbidity.
BackgroundCardiac rehabilitation (CR) can reduce mortality and improve physical functioning in older patients, but current programs do not support the needs of older patients with comorbidities or frailty, for example due to transport problems and physical limitations. Home-exercise-based cardiac rehabilitation (HEBCR) programs may better meet these needs, but physiotherapy guidelines for personalising HEBCR for older, frail patients with cardiovascular disease are lacking.PurposeTo provide expert recommendations for physiotherapists on how to administer HEBCR to older adults with comorbidities or frailty.MethodsThis Delphi study involved a panel of Dutch experts in physiotherapy, exercise physiology, and cardiology. Three Delphi rounds were conducted between December 2020 and February 2022. In the first round panellists provided expertise on applicability and adaptability of existing CR-guidelines. In the second round panellists ranked the importance of statements about HEBCR for older adults. In the third round panellists re-ranked statements when individual scores were outside the semi-interquartile range. Consensus was defined as a semi-interquartile range of ≤ 1.0.ResultsOf 20 invited panellists, 11 (55%) participated. Panellists were clinical experts with a median (interquartile range) work experience of 20 (10.5) years. The panel reached a consensus on 89% of statements, identifying key topics such as implementing the patient perspective, assessing comorbidity and frailty barriers to exercise, and focusing on personal goals and preferences.ConclusionThis Delphi study provides recommendations for personalised HEBCR for older, frail patients with cardiovascular disease, which can improve the effectiveness of CR-programs and address the needs of this patient population. Prioritising interventions aimed at enhancing balance, lower extremity strength, and daily activities over interventions targeting exercise capacity may contribute to a more holistic and effective approach, particularly for older adults.
OBJECTIVE: The objectives of the present study were to: (1) evaluate the effect of an educational course on competence (knowledge and clinical reasoning) of primary care physical therapists (PTs) in treating patients with knee osteoarthritis (KOA) and comorbidity according to the developed strategy; and (2) identify facilitators and barriers for usage.METHOD: The present research was an observational study with a pretest-posttest design using mixed methods. PTs were offered a postgraduate course consisting of e-learning and two workshops (blended education) on the application of a strategy for exercise prescription in patients with KOA and comorbidity. Competences were measured by questionnaire on knowledge (administered before and 2 weeks after the course), and a patient vignette to measure clinical reasoning (administered before the course and after a 6 month period of treating patients). Facilitators and barriers for using the strategy were assessed by a questionnaire and semi-structured interviews.RESULTS: Thirty-four PTs were included. Competence (knowledge and clinical reasoning) improved significantly (p < 0.01). Fourteen out of 34 PTs had actually treated patients with KOA and comorbidity, during a 6-month period. The strategy was found to be feasible in daily practice. The main barriers included the limited number of (self-) referrals of patients, limited number of reimbursed treatment sessions by insurance companies and a suboptimal collaboration with (referring) physicians.CONCLUSION: A blended course on exercise therapy for patients with KOA and comorbidity seems to improve PTs' competence through increasing knowledge and clinical reasoning skills. Identified barriers should be solved before large-scale implementation of exercise therapy can take place in these complex patients.
