Knee osteoarthritis and comorbidity

<b>Purpose</b>: 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.<br/><b>Methods</b>: 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).<br/><b>Results</b>: 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 OA<br/>and 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.<br/><b>Conclusions</b>: 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.