BMC Health Services Research
BioMed Central
Open Access
Research article
Measuring physiotherapy performance in patients with
osteoarthritis of the knee: A prospective study
Gro Jamtvedt*1,2, Kristin Thuve Dahm1, Inger Holm3,4 and Signe Flottorp1
Address: 1Norwegian Knowledge Centre for the Health Services, P.O. Box 7004, St. Olavs plass, 0103 Oslo, Norway, 2Centre for Evidence Based
Practice, Bergen University College, Bergen, Norway, 3Section of Health Science, Faculty of Medicine, University of Oslo, Norway and
4Rikshospitalet University Hospital, 0027 Oslo, Norway
Email: Gro Jamtvedt* - grj@kunnskapssenteret.no; Kristin Thuve Dahm - ktd@nokc.no; Inger Holm - inger.holm@rikshospitalet.no;
Signe Flottorp - sf@nokc.no
* Corresponding author
Published: 8 July 2008
BMC Health Services Research 2008, 8:145
doi:10.1186/1472-6963-8-145
Received: 3 December 2007
Accepted: 8 July 2008
This article is available from: http://www.biomedcentral.com/1472-6963/8/145
© 2008 Jamtvedt et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background: Patients with knee osteoarthritis [OA] are commonly treated by physiotherapists
in primary care. Measuring physiotherapy performance is important before developing strategies
to improve quality. The purpose of this study was to measure physiotherapy performance in
patients with knee OA by comparing clinical practice to evidence from systematic reviews.
Methods: We developed a data-collection form and invited all private practitioners in Norway [n
= 2798] to prospectively collect data on the management of one patient with knee OA through 12
treatment session. Actual practice was compared to findings from an overview of systematic
reviews summarising the effect of physiotherapy interventions for knee OA.
Results: A total of 297 physiotherapists reported their management for patients with knee OA.
Exercise was the most common treatment used, provided by 98% of the physiotherapists. There
is evidence of high quality that exercise reduces pain and improves function in patients with knee
OA. Thirty-five percent of physiotherapists used acupuncture, low-level laser therapy or
transcutaneous electrical nerve stimulation. There is evidence of moderate quality that these
treatments reduce pain in knee OA. Patient education, supported by moderate quality evidence for
improving psychological outcomes, was provided by 68%. Physiotherapists used a median of four
different treatment modalities for each patient. They offered many treatment modalities based on
evidence of low quality or without evidence from systematic reviews, e.g. traction and mobilisation,
massage and stretching.
Conclusion: Exercise was used in almost all treatment sessions in the management of knee OA.
This practice is desirable since it is supported by high quality evidence. Physiotherapists also
provide several other treatment modalities based on evidence of moderate or low quality, or no
evidence from systematic reviews. Ways to promote high quality evidence into physiotherapy
practice should be identified and evaluated.
Background
Osteoarthritis [OA] is the most common condition affect-
ing synovial joints [1]. The number of persons affected by
OA in the western world will increase because its prevaPage 1 of 7
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BMC Health Services Research 2008, 8:145
lence increases with age [1]. Patients with knee OA are
managed in primary care, and they represent a large group
seen by physiotherapists. An overview of systematic
reviews covering physiotherapy interventions for patients
with osteoarthritis of the knee demonstrates that exercise
can reduce pain and improve function in patients with
knee OA [2]. It also indicates that low-level laser, transcutaneous electrical nerve stimulation and acupuncture can
reduce pain, and that psychoeducation, including patient
education and self-management programmes, can
improve psychological outcomes. Thus, physiotherapy
can improve pain and function and play an important
role in the management of patients with knee OA.
Improving the quality of care is a major issue for all health
care systems, and measuring performance is essential for
the planning and evaluation of quality improvement
strategies [3-5]. Measuring performance means comparing actual clinical practice to desired clinical practice.
Patient perspectives of care and patient outcomes can also
be included in performance measurements [3]. Most performance studies in physiotherapy have described management of low back pain [6-9]. Although OA is a highly
prevalent disease, little is known about the performance,
including physiotherapy for patients with OA [10].
The aim of this study was to measure physiotherapy performance in patients with knee OA by comparing actual
clinical practice to evidence from systematic reviews.
Methods
The study was conducted among private physiotherapy
practitioners in Norway, who are integrated into primary
health care. The National Committees for Research Ethics
in Norway approved the protocol for the study.
Data collection form
For the purpose of this study, we developed a paper-based
data-collection form to register actual clinical practice for
patients with knee OA. We started the development by visiting several practices, observing physiotherapists treating
patients with knee OA. In two one-day meetings, ten clinicians invited through The Norwegian Physiotherapy
Association developed, piloted and revised the data-collection form in collaboration with the researchers. We
piloted the form among 10 physiotherapists and assessed
the reliability of the form using 15 independent observations of treatment sessions. We evaluated the relationship
between data entered independently by the observer, who
was an experienced physiotherapist, and data entered by
the treating physiotherapists and calculated kappa scores.
The final form was in three parts (see variables and the
original data-collection form in Additional files 1 &2).
Part one covered patient characteristics, the physiotherapy
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examination and the treatments goals, e.g. the patients
gender and age, time since diagnosis, type of pain classified in six categories (e.g., pain at night, rest, weight bearing, start of activity) and intensity of pain measured on a
ten point visual analog scale (VAS), co-morbidity and the
physiotherapist's judgement of physical activity level and
patient weight. The aims of treatment, e.g. reducing pain,
improving function, muscle strength, aerobic capacity or
increasing knowledge were assessed on a six point scale
from "Not important at all" to "Very important".
Part two was designed to report the treatment modalities
used in each session during 12 sessions. This part contained a list of 35 different treatments, e.g. types of exercise, massage, traction, hot packs, physical modalities,
information and patient education. We also collected
information about whether the patients were treated individually or in groups. We chose 12 treatment sessions
because this is the number most often used when general
practitioners refer patients to physiotherapy in Norway.
Part three collected information on characteristics of the
physiotherapists, e.g. gender, age, years since qualification, work setting and postgraduate education. A designer
contributed to the lay-out to create a user-friendly form.
Recruitment
We invited all private practitioners, identified by membership of The Norwegian Physiotherapy Association in February 2006, to participate in the study [n = 2798]. We
asked the physiotherapists to report the management of
the first patient with knee OA referred to their practice
[one case], and to complete the form at every treatment
session. The diagnosis should be confirmed by x-ray or
magnetic resonance imaging. Patient who had a knee
arthrosplasty or postoperative treatments were excluded.
In response to an invitation letter sent out in May 2006,
744 physiotherapists replied that they did not normally
treat patients with OA, or that they had other reasons for
not being eligible. In August 2006 we distributed the
anonymous data-collection form with a pre-paid return
envelope to the remaining physiotherapists [n = 2054]. To
increase the response rate, we sent two reminder letters to
all, and one e-mail postcard to those with an e-mail
address, and we contacted practices with more than five
physiotherapists by telephone. The study was also
described in the Norwegian Physiotherapy Journal and in a
newsletter sent to all private practitioners. The data collection period was nine months, from August 2006 to May
2007.
Research evidence and performance
We have previously summarised the evidence from systematic reviews on physiotherapy interventions for
patients with knee OA in an overview, and assessed the
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quality of evidence for each intervention, comparison and
outcome [2]. The quality of evidence for the interventions
was categorised as high, moderate or low, or as no evidence from systematic reviews. The quality of the evidence
indicates the extent to which one can be confident that the
estimate of effect is correct. High quality evidence indicates that further research is very unlikely to change our
confidence in the estimate of effect.
We measured physiotherapy performance by comparing
practice reported in the data-collection forms to the findings from the overview. If the physiotherapist used interventions that were supported by evidence for improving
patient outcomes of high or moderate quality, we interpreted the practice as desirable. Even though there was a
lack of evidence for the effects of giving advice, we considered giving advice and information about physical activity
and weight reduction as desirable practice.
Analysis
We performed descriptive analysis, based on frequency
distribution and percentages, to assess characteristics of
the patients and the physiotherapists, and the treatments
used. Different types of exercise, e.g. exercises aimed to
increase muscle strength, aerobic capacity, coordination
or range of motion, were merged into one treatment
modality. We classified the use of each treatment modality into three categories, "not used", "used in up to 80% of
the sessions" and "used in more than 80% of the sessions". "Used in more than 80% of the sessions" was
interpreted as treatment used in almost all sessions. We
also calculated the total number of different treatment
modalities used by each physiotherapist through the sessions.
Results
We received a response from 527 therapists. Among these,
297 had treated one patient with knee OA and had completed the data-collection form. The responders that did
not complete the form (n = 230) reported various reasons
for not completing, e.g. no patient referred during the
study period (n = 109), not working in clinical practice (n
= 41) or specialist in other areas such as neurology, child
or mental health (n = 46).
When assessing the reliability of the data-collection form
we found that the different items had a kappa score that
varied from 0.8 to 1.0. For some types of exercise, e.g exercise aimed at increasing strength, coordination and stability, the score was lower.
The mean age of the physiotherapists was 47 years [SD =
11]. Almost half [47%] were women [Table 1]. Patients
had a mean age of 65 years [SD = 11], and 67% were
women. Pain intensity during the last week was 5.9 [SD =
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Table 1: Characteristics of physiotherapists (N = 297)
Variable
Age [mean [SD]]
Year since qualification [mean [SD]]
Women [%]
Practice setting [%]
Single practice
2–5 colleagues
More than 5 colleagues
Postgraduate education [%]
Specialist [%]
Masters degree [%]
47 [11]
21 [12]
47
15
58
27
26
11
3
2.1] on a 10-point visual analogue scale [VAS]. Almost
half of the patients [46%] suffered from pain during
night, or at rest. More than half had bilateral knee OA, and
32% were diagnosed more than five years ago. Thirty three
percent were considered overweight, and 31% had important co-morbidity, most frequently reported was cardiovascular diseases or low back pain. Fifty percent of the
patients were referred to physiotherapy for knee OA for
the first time.
The most important aim for the treatment, as reported by
the therapists, was to reduce pain [92%], followed by
increasing muscle strength [85%].
Exercise was used by all but six physiotherapists [2%], and
86% used exercise in almost all sessions; 11% of physiotherapists provided exercise as the only treatment at all 12
sessions. As described in Table 2, there is high quality evidence that exercise reduces pain and improves physical
function in patients with knee OA. Type of exercise, e.g.,
improving muscle strength, gait, range of motion and stability varied widely, both within and across sessions. Muscle strengthening exercises were most commonly used
(90%). Few physiotherapists (17%) treated their patients
in a group setting.
There is evidence of moderate quality that transcutaneous
electrical nerve stimulation [TENS], low-level laser therapy and acupuncture reduce pain. Each of these modalities were used by less than 25% of the therapists [Table 2].
Moderate quality evidence suggests that short-wave or
pulsed electromagnetic energy has no effect on outcomes
for knee OA. This modality was provided by only 10% of
physiotherapists.
The physiotherapists applied a median number of four
[range 1–10] different treatment modalities for each
patient throughout the sessions. Massage, traction/mobilisation and stretching were the next most common
modalities after exercise, and were applied in approximately half of patients [Table 2]. There is no evidence
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Table 2: Number [%] of treatment modalities used in the management of patients with knee osteoarthritis according to quality of
evidence from systematic reviews (SR)
Type of intervention
Not used at all Used in up to 80% of
the sessions
Used in more than 80%
of the sessions
Quality of evidence
Exercise
6 [2]
35 [12]
256 [86]
TENS (transcutaneous electrical
nerve stimulation)
Low level laser therapy
Acupuncture (manual, electrical
and trigger point)
Short wave therapy (and pulsed
electromagnetic energy)
260 [88]
16 [5]
21 [7]
High for pain reduction and
improved physical function
Moderate for no improvement in
psychological outcomes
Moderate for pain reduction
265 [89]
237 [80]
22 [7]
40 [14]
10 [4]
20 [7]
Moderate for pain reduction
Moderate for pain reduction
268 [90]
16 [5]
13 [4]
Patient education, self53 [18]
management and psychoeducation
214 [72]
29 [10]
Ultrasound
Thermotherapy (heat packs)
Thermotherapy (cold packs)
Braces and orthosis
Tape
Massage
Traction
Stretching
Advice about physical activity
Advice about weight reduction
among 102 patients considered
overweight
21 [7]
20 [7]
12 [4]
21 [7]
10 [3]
69 [24]
60 [20]
57 [19]
220 [74]
55 [54]
27 [9]
26 [8]
7 [2]
3 [1]
1 [0]
91 [30]
78 [26]
81 [27]
45 [15]
4 [4]
Moderate for no reduction in
pain or improvement in physical
function
Moderate for improving
psychological outcomes
Moderate for no difference in
pain or physical function
Low for all outcomes
Low for all outcomes
Low for all outcomes
Low for all outcomes
No evidence from SR
No evidence from SR
No evidence from SR
No evidence from SR
No evidence from SR
No evidence from SR
249 [84]
251 [85]
278 [94]
273 [92]
286 [96]
137 [46]
158 [53]
158 [53]
32 [11]
43 [42]
from systematic reviews about the effect of these treatments.
There is evidence of moderate quality that psychoeducation, including patient education and self-management
programmes improve psychological outcomes, e.g., scales
of psychological disability, mental functioning, self-efficacy or depressive symptoms. Sixty eight percent used
interventions that were classified as psychoeducation,
such as education about OA and coping with the disease.
Almost all physiotherapists [90%] provided information
and guidance about physical activity, and 76% prescribed
a home exercise programme.
The physiotherapists provided advice and information
about weight reduction to 59 [58%] of the 102 patients
that they considered overweight. On the other hand,
almost all patients that the physiotherapist assessed to
need more physical activity [n = 101] received advice and
support for increasing activity level [n = 92].
Discussion
To our knowledge, this is the first study of physiotherapy
performance for patients with knee OA. The study
describes clinical practice in terms of individual patients,
as recorded prospectively by therapists during every treatment session. We compared the treatment to findings
from an overview of systematic reviews. Quality of care
includes many elements. We have studied one important
factor that contributes to quality, – the factor of clinical
effectiveness.
Almost all therapists in this study used exercise in all treatment sessions. This current practice is desirable, since it is
supported by evidence of high quality. Less than 35% of
physiotherapists used acupuncture, low-level laser therapy or TENS which have moderate-quality evidence for
reducing pain. In addition, physiotherapists used many
treatment modalities with low-quality evidence or no evidence from systematic reviews, e.g., traction, massage and
stretching.
The physiotherapists provided different types of exercises.
Because there is no evidence from systematic reviews to
support one specific type or dose [11], we merged different types of exercise into one treatment modality. Clearly,
we lost some information about practice by this procedure, but as long as no type of exercise is shown to be
more beneficial than another we think this was reasonable. We also categorised different information modalities,
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but separated simple information about exercise and
weight reduction from pscychoeducation and self-management programmes. There is clearly an overlap between
these interventions that might introduce information bias
or misclassification in this study. The effects of advice and
information about exercise and weight reduction provided by physiotherapists to patients with knee OA is
unclear, although systematic reviews have demonstrated
that exercise and weight reduction improve outcomes in
knee OA [2]. However, professional advice and guidance
with continued support can encourage people from the
general population to be more physically active [12].
Long-term adherence to exercise is required to maintain
the benefits of exercise in knee OA, and because long-term
adherence requires regular motivation, supervision and
monitoring [12], physiotherapists should include such
guidance in all treatment sessions. Although many gave
advice about physical activity, few physiotherapists [15%]
reported having provided this in more than 80% of the
sessions.
Only 58% of the patients that the physiotherapists categorized as overweight were given information and advice
about weight reduction. The therapists rated subjectively
if the patient was overweight. This method might be
prone to bias because we do not know how this measure
compares with body mass index, which is commonly used
to identify overweight. However, clinical judgement and
experience might be as important as body mass index for
offering patients advice about weight reduction. There are
many plausible explanations why many physiotherapists
did not focus on weight reduction, e.g., they do not have
enough knowledge and/or skills on how to address the
problem, the topic is too intimate or they provide advice
on physical activity instead. Still we think that physiotherapists might contribute to the positive outcomes of weight
reduction by supervision and guidance, perhaps in cooperation with a dietician.
Our findings are comparable to studies of physiotherapy
performance for low back pain which demonstrate that
adherence to guidelines varies across different treatment
modalities [6,9,13]. Treatments for which evidence is limited or absent are also frequently used [6,9]. Interestingly,
our study shows that electrotherapy modalities that can
reduce pain supported by moderate quality evidence were
used by less than 35% of the physiotherapists. In studies
of low back pain [6,14], electrotherapy was more frequently used even though there was no evidence of effect.
However, interventions should always be specified to
meet the need from individual patients, and the physiotherapists might choose not to use these modalities if the
patient had mild pain. If providing electrotherapy, the
physiotherapist should choose modalities supported by
moderate quality evidence instead of modalities with no
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evidence, or with evidence of no effect. Still, almost all
therapists used exercise, and exercise can also reduce pain.
Though, we can not argue that the therapists were providing inadequate care by not using low level laser, TENS or
acupuncture.
There are some limitations to this study. The response rate
was low, and this might be a threat to the validity of the
data of physiotherapy performance because the therapists
that responded might have different practice pattern than
the study population. We feared that a low response rate
might be a problem, and we tried to develop a strategy to
get a large and unbiased sample of responses from Norwegian physiotherapists. We invited all private practitioners
in Norway to the study. We used finding from a systematic
review on how to increase response rate [15]. We contacted the physiotherapists before the study started, the
data-collection form was user-friendly with pre-paid
return and we had several follow-up contacts. In addition,
we enclosed a bar of dark chocolate with a sticker saying
"Thank you for contributing to physiotherapy documentation" randomly to half of the physiotherapists.
The physiotherapists who participated were comparable
to private practitioners in Norway regarding age [mean
age reported by the Norwegian Physiotherapists Association is 48], although a higher proportion of men
responded to our study. We have no additional information about the non-responding physiotherapists. Surprisingly many physiotherapists reported that they did not
treat a patient with knee OA during the study period. This
might also be the case for many of the non-responders.
Other studies of physiotherapy performance in primary
care that have used a prospective design have experienced
the same lack of participation [6,16]. When Swinkels et al
established a network to collect practice data on a continuous basis in The Netherlands they only collected data
from 90 physiotherapists [9].
Another potential source of bias is the self-selection of
patients, because the therapists might choose patients that
are not representative to patients normally treated in private practice. We asked the physiotherapists to report the
management of the first patient with knee OA. The characteristics of the patients in the study are comparable to
patients included in 36 trials in a systematic review on
physical interventions for patients with OA [17]. The
mean age was 65.1 years and the mean baseline pain score
was 62.9 on a 100-mm VAS.
We collected data by self-report from the therapist. Selfreport of practice might represent a threat to validity
because some therapists might report treatments that they
do not perform. Some might also adopt new practice pat-
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BMC Health Services Research 2008, 8:145
tern because they think it is expected. This might mean
that self-reported adherence rates to guidelines could
exceed the rate measured by medical records or observation [18]. There might be variation in how the therapists
interpret and respond to the data collection from.
We measured performance by comparing practice to findings from systematic reviews. For some interventions we
lack evidence because we did not identify any systematic
reviews. Evidence of high quality from primary studies
not included in systematic reviews might be available for
such interventions. This is clearly a limitation to our
approach. Secondly, some reviews needed updating.
Inclusion of new primary studies might change the estimates of effect and the quality of evidence. Finally, it is
crucial to remember that "no evidence from systematic
reviews" does not imply "evidence of no effect".
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Conclusion
This study provides information about physiotherapy performance in patients with knee OA. Exercise is the most
common treatment and this is supported by high quality
evidence. Physiotherapists also provide several treatment
modalities based on moderate and low quality evidence
of benefit, or without evidence from systematic reviews.
We need more research to develop and identify the best
methods to measure physiotherapy performance in primary care.
Abbreviations
OA: osteoarthritis; SD: standard deviation: TENS: transcutaneous electrical nerve stimulation; VAS: visual analogue
scale.
Competing interests
The authors declare that they have no competing interests.
It is difficult to measure physiotherapy performance
because physiotherapy practice is complex. Treatment can
differ both within and across sessions. Type, dose and frequency vary and the interaction and communication
between patient and therapist are important parts of the
therapy. In the present study we assessed performance for
one measurable part of physiotherapy practice, but we
excluded interpersonal communication, structural aspects
of care, organisational culture, teamwork and access.
These are other important parts of high quality physiotherapy care. Multiple data collection methods might be
used to get a more comprehensive picture of actual physiotherapy practice.
Despite clear limitations in our methods, this study contributes to the knowledge about physiotherapy performance in patients with knee OA. We need research to
develop valid and reliable methods to measure physiotherapy performance in primary care, as well as research
on how to bridge research and clinical practice. Specifically, we should identify effective ways to promote interventions supported by high quality evidence. Finally, in
order to be able to measure performance in physiotherapy, we need more research and more systematic reviews
on the effects of physiotherapy interventions for patients
with knee OA. Because physiotherapists use exercise regularly for patients with knee OA, and there are different
opinions about optimal exercise regimen, studies should
compare different types, settings, intensities and volumes
of exercise. Interventions that are frequently used by physiotherapists without evidence from systematic reviews,
e.g., traction, massage and stretching for patients with
knee OA, should be tested in rigorous trials and summarised in reviews.
Authors' contributions
GJ wrote the protocol and designed the study, developed
the data-collecting instrument, performed the analysis
and drafted the first version of the manuscript. KTD contributed to designing the study, piloted the instrument,
entered data into SPSS and revised drafts of the manuscript. IH and SF contributed to the idea of the project and
to design and analysis and revised drafts of the manuscript. All authors approved the final manuscript
Additional material
Additional file 1
Variable list.
Click here for file
[http://www.biomedcentral.com/content/supplementary/14726963-8-145-S1.doc]
Additional file 2
Data collection form.
Click here for file
[http://www.biomedcentral.com/content/supplementary/14726963-8-145-S2.pdf]
Acknowledgements
We thank Saga Høgheim for assistance with data entering, Julia Tavridou for
lay-out and the Norwegian physiotherapists for completing the data collection. The study was funded by The Norwegian Fund for Post-Graduate
Training in Physiotherapy.
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