Objective Physiotherapists commonly provide non-surgical care for people with knee osteoarthritis (OA). It is unknown if patients are receiving high-quality physiotherapy care for their knee OA. This study aimed to explore the experiences of people who had recently received physiotherapy care for their knee OA in Australia and how these experiences aligned with the national Clinical Care Standard for knee OA.
Design Qualitative study using semistructured individual telephone interviews and thematic analysis, where themes/subthemes were inductively derived. Questions were informed by seven quality statements of the OA of the Knee Clinical Care Standard. Interview data were also deductively analysed according to the Standard.
Setting Participants were recruited from around Australia via Facebook and our research volunteer database.
Participants Interviews were conducted with 24 people with recent experience receiving physiotherapy care for their knee OA. They were required to be aged 45 years or above, had activity-related knee pain and any knee-related morning stiffness lasted no longer than 30 min. Participants were excluded if they had self-reported inflammatory arthritis and/or had undergone knee replacement surgery for the affected knee.
Results Six themes emerged: (1) presented with a pre-existing OA diagnosis (prior OA care from other health professionals; perception of adequate OA knowledge); (2) wide variation in access and provision of physiotherapy care (referral pathways; funding models; individual vs group sessions); (3) seeking physiotherapy care for pain and functional limitations (knee symptoms; functional problems); (4) physiotherapy management focused on function and exercise (assessment of function; various types of exercises prescribed; surgery, medications and injections are for doctors; adjunctive treatments); (5) professional and personalised care (trust and/or confidence; personalised care) and (6) physiotherapy to postpone or prepare for surgery.
Conclusion Patients’ experiences with receiving physiotherapy care for their knee OA were partly aligned with the standard, particularly regarding comprehensive assessment, self-management, and exercise.
- adult orthopaedics
- musculoskeletal disorders
- qualitative research
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Strengths and limitations of this study
A strength of this study was using a qualitative design to explore how the experiences of people receiving physiotherapy care for knee osteoarthritis (OA) in Australia aligned with the national Clinical Care Standard.
A range of participants was interviewed, including males and females of differing age, occupational status and geographical location across Australia.
Participants responded to advertisements and/or Email invitations to participate and thus our sample may be biased towards those who had favourable experiences with physiotherapy and/or were successful at accessing physiotherapy.
Our sample was constrained to participants who could speak English so may not represent the experiences of people from culturally and linguistically diverse backgrounds.
Physiotherapists are a primary contact health profession in Australia so patient experiences with physiotherapy care for knee OA may be different in other countries where people can only access a physiotherapist on referral.
Knee osteoarthritis (OA) is highly prevalent and a leading cause of pain and disability worldwide.1 Clinical guidelines advocate non-surgical interventions such as exercise, weight loss (for people who are overweight or obese) and education regarding self-management as first-line treatments for knee OA,1–3 Physiotherapists are important providers of non-surgical care for people with knee OA and receive more OA referrals from general practitioners than other allied health providers.4 In addition, patients generally perceive physiotherapists to be important to assist them in managing their OA and prescribing exercises.5 6
To date, there are indications that physiotherapy care provided to people with knee OA may not necessarily align with evidence-based care standards. We recently conducted a qualitative study to explore the experiences of Australian physiotherapists delivering care for people with knee OA and how their experiences aligned with the national Clinical Care Standard.7 The Clinical Care Standard for knee OA defines seven key aspects of care that people with knee OA should expect to receive in Australia.8 We found physiotherapists tended to rely on biomedically oriented assessment and would often provide treatment (such as manual therapy) and self-management strategies that aimed to address the ‘mechanical’ aspects of knee OA. The primary focus for physiotherapists was to provide goal-orientated personalised exercise. Surgery was perceived as a last resort, and patient comorbidity, adherence and desire for a ‘quick fix’ were the main clinical challenges experienced. Physiotherapists also described a mismatch between what they knew and what they did when it came to imaging, weight management and manual therapy. Weight loss, medication and surgical advice were perceived to be outside of their scope of practice. Nevertheless, physiotherapists’ reported experiences were mostly consistent with the quality care standard.7 Findings from this study provide useful information about physiotherapy management of people with knee OA but it can be argued that a patient’s perspective of their physiotherapy care experiences may not necessarily be similar to that of the therapist.
Several qualitative studies have explored patient experiences of receiving care for their knee OA from either a multidisciplinary team which included physiotherapists9–14 or solely from physiotherapists.15–19 However, none of these studies have specifically explored patient experiences receiving physiotherapy assessment, diagnosis, treatment options and follow-up appointments for their knee OA. This study is complementary to our previous similar qualitative study with physiotherapists as participants.7 In the present study, we aim to explore the experiences of Australians who had recently received physiotherapy care for their knee OA and how these experiences aligned with the national Clinical Care Standard for knee OA. Such information will help enhance our understanding of patient experiences with physiotherapy care for their condition and may help inform strategies to improve future care and service delivery.
This qualitative study used semistructured interviews and was based on a constructivist paradigm, where knowledge is built through active experience and interpretation.20 Qualitative methods allow for in-depth examination of the attitudes, experiences and behaviours of individuals in their natural context and can contribute to a broader understanding of medical research.21–23 The Standards for Reporting Qualitative Research checklist was used to ensure explicit and comprehensive reporting of this study.24
Patient and public involvement
Patients or the public were not actively involved in the design, conduct, reporting or dissemination plans of our research.
A convenience sample of adults who had sought physiotherapy care to manage their knee OA were recruited from around Australia via Facebook and our research volunteer database. Inclusion criteria for participants were: (1) met the National Institute for Health and Care Excellence OA clinical criteria1 (aged 45 years or above, had activity-related knee pain and any knee-related morning stiffness lasted no longer than 30 min) and (2) consulted a physiotherapist about their knee OA in the prior 6 months. Participants were excluded if they had self-reported inflammatory arthritis and/or had undergone knee replacement surgery for the affected knee. The final sample size was determined by the principles of data saturation, this being when no new themes emerged from the data.25 Participants provided written informed consent and ethical approval was granted by the School of Health Sciences Human Ethics Advisory Group, University of Melbourne. Interviews were conducted between December 2019 and January 2020.
Semistructured interview guides (table 1) were developed, informed by the quality statements of the Australian Government’s OA of the Knee Clinical Care Standard.8 It defines seven domains of care that people with knee OA should expect to receive, regardless of where they are treated in Australia, spanning comprehensive assessment, diagnosis, education and self-management, weight loss and exercise, medications, regular review and surgical options for people with knee OA. Participants were reimbursed for their time with a $50 gift card.
Individual interviews were conducted via telephone by PLT, a female graduate research student and physiotherapist trained in qualitative methodologies. Telephone interviews were conducted to facilitate participation of people with knee OA from Australia (irrespective of geographical location) and to promote a perception of anonymity in interviewees.26 Interview questions were refined following the first three phone interviews to improve clarity for participants based on experience from the initial interviews. The refinement also helped to enhance/expand the prompts to ensure rich information were collected from the participants. Interviews were audio recorded and transcribed verbatim by an external provider.
An inductive thematic approach was used initially.27 In order to minimise over-representation, two researchers conducted the data analysis simultaneously. Following Morse et al’s approach to inductive thematic analysis (which advocates for four steps: (1) read and reread interview transcripts; (2) step back and reflect on interviews as a whole; (3) identify ideas of similar nature; (4) group ideas into themes),27 first, the student researcher (PLT) and another postdoctoral researcher (BL) with expertise in qualitative methodologies (and who is not a physiotherapist) individually read each transcript. Next, they reread and inductively coded each transcript to identify topics and initial patterns of emerging ideas. They then compared codes and grouped similar topics/ideas into categories before organising them into broader themes and subthemes. The interview data were also deductively analysed according to the national Clinical Care
Standard for knee OA. These were further reviewed and discussed with the broader research team (RSH, KLB, TE). The senior researcher (RSH) read all transcripts prior to discussion to ensure data credibility and confirmability. Analysis was performed using standard word processing software.17
Seventy-six participants responded to the interview invitation but only 31 fulfilled the eligibility criteria for this study. Of the 31 eligible participants, 24 completed the interview while the remaining either declined participation or were not contactable. Table 2 describes the 24 participants interviewed. Three-quarters were female, and the mean (SD) age was 64 (10) years (range: 49–81). Participants resided in all of Australia’s six states and two territories. Most lived in major cities (79%), with some from outer regional (13%) or inner regional areas (8%). Most (67%) people reported less than 5 sessions of physiotherapy for their knee OA in the prior 6 months, some (25%) between 5 and 9 and 2 (8%) reported 10 or more sessions.
Six themes emerged following the inductive thematic analysis.27 An audit trail of evidence showing examples of each stage of the data analysis is presented in online supplemental file 1. The six themes identified are outlined in table 3 and described below.
Theme 1: Presented with a pre-existing OA diagnosis
Participants tended to have a diagnosis of knee OA already made by a doctor prior to their physiotherapy consultation and did not seek physiotherapists to take on a diagnostic role. They often brought knee imaging results with them to the physiotherapy consultation. Some expected physiotherapists to access imaging results from their general practitioners. Participants described a range of other health professionals they had consulted for their knee problems before consulting a physiotherapist, such as a general practitioner, rheumatologist, orthopaedic surgeon and/or sports medicine physician.
Participants generally perceived their pre-existing knowledge and understanding about OA to be adequate. They had typically acquired their knowledge from personal experience and/or from conversations with healthcare professionals prior to them seeking physiotherapy care. Often, knowledge about OA was constructed from imaging (eg, X-ray) results. Participants often described their OA with phrases such as ‘wear and tear’, ‘bone on bone’, ‘degenerative’ and/or ‘cartilage wear’.
Theme 2: Wide variation in access and provision of physiotherapy care
Participants accessed physiotherapy through a variety of care models, including consultations at private physiotherapy practices, participation in programmes specifically developed for OA management delivered in the public (eg, Osteoarthritis Chronic Care Programme (OACCP)28) and private (Good Life with Osteoarthritis Denmark (GLA:D29) healthcare settings, participation in more generic strengthening-based programmes (eg, Kieser Australia30), hydrotherapy and/or generic exercise classes (eg, Pilates/gym). Most were referred by their general practitioners or other medical specialists but some ‘self-referred’ to a local physiotherapist. Participants chose their physiotherapist by convenience (eg, physiotherapist located in the same medical practice as their general practitioner or located close to home), by following a recommendation from their friend or doctor, or based on prior experience (eg, previously consulted the physiotherapist for other musculoskeletal conditions and/or their knee problem).
Participant attendance at physiotherapy services often relied on funding being available to subsidise cost of care. Some participants described accessing physiotherapy in public hospital settings (eg, OACCP28), some received Medicare rebates for physiotherapy services in the private sector (eg, via Chronic Disease Management Plans31), while others were subsidised through their private health insurance or other regulatory body (such as worker compensation schemes). A few participants paid out-of-pocket to cover their physiotherapy costs. Participants often ceased their physiotherapy visits because funding ran out.
Participants received physiotherapy care via individual consultations and/or via group sessions. Some participants attended one-on-one consultations several times before transitioning to a group setting. Most described undergoing an individual assessment with the physiotherapist, including those who ultimately participated in group classes. People referred to physiotherapy under the Chronic Disease Management Plan typically attended individual physiotherapy sessions up to five times.
Theme 3: Seeking physiotherapy care for pain and functional limitations
Participants spoke about their knee symptoms as a major driver of seeking care, including ongoing knee pain, swelling, clicking and muscle weakness. They expressed frustration with the pain they experienced, particularly when it made them unable to move the knee or walk properly. Words such as ‘click’, ‘crunch’ or ‘crack’ were commonly used to describe other symptoms. Participants spoke about feeling weak around their knees, which caused their knee to ‘give way’ or ‘collapse’. Participants also sought care because of difficulties with functional activities such as walking, driving, getting in/out of the bed/chair/toilet/shower, negotiating steps and squatting. Some participants avoided doing sports/recreational activities (eg, cycling, surfing, running, swimming) for fear of exacerbating pain. Many people expected physiotherapists to provide treatments to relieve the pain and assist with building knee strength, as well as helping them to return to activities they previously enjoyed or were now unable to do.
Theme 4: Physiotherapy management focused on function and exercise
The physiotherapist typically assessed functional ability, including walking, squatting, getting in/out of a chair and negotiating stairs. Some participants were timed when performing functional tests, and others were asked to repeat the tests as they progressed through their treatment sessions. Participants consistently described exercise as a key component of their physiotherapy consultations. They received advice about different types of exercises for their OA, including strengthening, cardiovascular, stretching, balance and functional movement programmes. Some participants were instructed to use exercise equipment such as elastic resistance bands and/or weights to progress the intensity of the exercises. For those who were given home exercise programmes, exercise handouts or online instructions were provided. Some participants also attended supervised group exercise classes such as gym or fitness-based programme, Pilates, hydrotherapy, balance and/or strengthening classes.
Participants tended not to expect information about surgery, medications and knee injections from their physiotherapist, instead considering these domains of care as a doctor’s responsibility. Many did not see the need for physiotherapists to cover these options further and some participants felt that physiotherapists should refrain from providing any medication advice because they do not have prescription rights.
Some participants received adjunctive treatments from physiotherapists such as massage, dry needling/acupuncture and manual knee mobilisation techniques to relieve muscle tightness and joint stiffness. Transcutaneous electrical nerve stimulation and electronic muscle stimulator machines were sometimes provided to relieve knee pain and stimulate muscles, respectively. Other common adjunctive treatments offered by physiotherapists included ultrasound, heat/cold pack, taping and using a knee brace. These were typically delivered during individual physiotherapy consultations.
Theme 5: Professional and personalised care
Generally, most participants were happy and satisfied with the physiotherapy care they received. Some described having trust in their physiotherapists, both in their clinical skills and professional knowledge when managing knee OA. Most felt that their physiotherapist understood and appreciated the problems they were experiencing, and some were impressed that the physiotherapist was able to identify what was ‘going on’ with their knees. Participants were also confident that their physiotherapists could help them by providing practical advice and/or strategies to overcome their specific problems.
Participants valued the highly personalised care they received and felt that physiotherapists generally provided care that was tailored to their needs. They spoke about their physiotherapist as being empathetic and understanding towards their condition/circumstances. Some felt that their physiotherapist ‘knew them well’, which enabled the physiotherapist to provide the care and support they desired/needed. Others highlighted the value of working collaboratively with their physiotherapist and appreciated having a ‘two-way discussion’, where the participant was asked for their input in devising a treatment plan for their OA. When care was not personalised, participants expressed a sense of disappointment, describing the treatment received as a ‘sausage factory’, ‘supermarket shelf’ or being a ‘one size fits all programme’
Theme 6: Physiotherapy to postpone or prepare for surgery
Participants perceived that joint replacement surgery was inevitable for their knee problems. Many were informed of this by their doctor and some were already on hospital waiting lists for surgery. However, participants were also advised by their doctors/surgeons to delay surgery for as long as possible and some attended the physiotherapist in an effort to achieve this. Participants generally believed that physiotherapists were not able to ‘cure’ OA but could help in reducing its impact. Some described the role of physiotherapy as providing them with strategies to strengthen the knees and alleviate their OA symptoms in order to delay surgery. While some participants ‘prepared’ their knee for surgery by seeing a physiotherapist, others were keen to have surgery as soon as possible.
Alignment with Clinical Care Standard for knee OA
Deductive analysis was used to generate table 4, which summarises how participant experiences of physiotherapy care for knee OA aligned with the Clinical Care Standard.
This qualitative study explored experiences of people who had received physiotherapy care for their knee OA in Australia and how they aligned with the national Clinical Care Standard for knee OA.8 Participants within this study valued physiotherapists’ ability to provide professional and personalised care and described having a strong sense of trust and/or confidence in their physiotherapist. They also felt that physiotherapists understood their problems. These findings are consistent with previous research, which showed that patient satisfaction with physiotherapy care for a range of musculoskeletal conditions was generally high in Australia and other countries such as those in Northern Europe, North America, the UK and Ireland.32 Physiotherapists’ interpersonal and communication skills are important attributes to high patient satisfaction.32 Our findings suggest that, generally, patients within this study perceived Australian physiotherapists to work in a patient-centred way to ensure that patients’ treatment expectations, needs and preferences are respected. Such care aligned with the Clinical Care Standard relating to self-management, where patients received management plan that suited their needs and preferences. These findings were also similar to our previous study with physiotherapists,7 who described offering an individualised self-management plan based on knee symptoms and signs, functional ability and goals.
Participants utilised various referral pathways and a range of different funding models to access physiotherapy care through a diverse array of service delivery options. This suggests that there is not a single ‘one size fits all’ model of physiotherapy care that will suit the needs and individual circumstances of all Australians living with knee OA. Our findings highlight how important it is for healthcare systems to offer different models of physiotherapy care, in both the public and private sectors, for example, spanning individual consultations through to group exercise classes. This helps to reduce inequity of access to physiotherapy care for people with knee OA, which may arise from geographical location or socioeconomic status.33 Indeed, a community-based survey of 1000 people with arthritis in Australia found that over two-thirds of respondents felt that they did not cope well with their condition because of the healthcare they experienced, and felt that they had poor access to medical doctors, specialists and allied health professionals.34 Allowing patients the flexibility to choose which type of physiotherapy service best suits their needs, preferences and financial situation also aligns with a philosophy of patient-centred care,35 36 and permits the patient to have some control over their own healthcare.
Our findings highlight how reliant people with knee OA are on government-funded healthcare and/or third-party payers (such as private health insurers) to fund their physiotherapy care. Participants predominantly accessed and received care from physiotherapists in private practice settings and typically ceased physiotherapy when funding ran out and they were required to pay out-of-pocket for services. These findings are consistent with key Australian policy documents, including the National Osteoarthritis Strategy,37 that have called for expansion of funding to support OA care delivery, including care delivered by physiotherapists.38 Given the chronicity of knee OA, regular reviews and follow-up are advocated to allow for monitoring of symptoms, permit timely changes to management and to support effective self-management.1 However, similar to a previous study in Australia,39 the costs associated with physiotherapy treatments were identified by our participants as an important barrier to continuing to access physiotherapy care for OA. Our findings highlight the importance of funding mechanisms for physiotherapy services to relieve the financial burden that people experience when accessing necessary care for knee OA. Therefore, it remains unclear if patients were offered regular reviews by their physiotherapist, as recommended by the Clinical Care Standard, due to lack of funding being a potential barrier to regular reviews.
Although pain was one of the important drivers of care-seeking in our participants, many also desired help from the physiotherapist to maintain or improve muscle strength and physical function. These findings highlight the need for physiotherapists to codevelop (with the patient) a multifaceted management plan that does not only focus on pain relief strategies but also incorporates interventions that target strength and assist patients to engage in activities that are meaningful to them. It is thus not surprising that participants in our study described the important role that physiotherapists played in prescribing personalised exercise and addressing functional deficits. A systematic review of patients’ perceived health service needs for OA also showed that one of the key reasons patients typically consulted physiotherapists was for exercise advice/prescription.5 Our patient perspectives about the important role that physiotherapists play in prescribing exercise align with the perspectives of general practitioners,40 41 who often refer patients with chronic knee pain to physiotherapists for exercise. General practitioners describe lack of time as the most common barrier for them to initiate exercise with their patients, preferring instead to refer their patient to a physiotherapist.40 42 Similarly, physiotherapists themselves also perceived exercise and physical activity to be their main role in the management of people with knee OA7 43 and are confident to prescribe exercises to improve knee strength and range of movement.44 However, inconsistent with the Clinical Care Standard, it appeared that patients were predominantly assessed by their physiotherapist for their knee symptoms and functional limitations, with little consideration of psychosocial factors. In addition, the management plan provided by the physiotherapist tended to overlook strategies specifically related to weight loss/maintenance. Our patient findings are also similar to our previous study with physiotherapists,7 who tended to focus on biomedical assessment and management of knee OA. Regarding weight loss advice, they generally provided education about the importance of weight loss rather than advice about strategies to lose weight.
Interestingly, participants tended to have an OA diagnosis already made prior to their physiotherapy consultation. They also believed that they already had adequate knowledge and understanding about their knee OA. This was despite the fact that participants appeared to have different perceptions about knee OA (describing it as ‘wear and tear’, ‘bone on bone’, ‘degenerative’ and/or ‘cartilage wear’) and their belief that surgery is an inevitable consequence. These perceptions and beliefs about OA are similar to findings from another study exploring reasons why patients resorted to surgical interventions for knee OA.45 Once the participants in that study had been ‘diagnosed’ with ‘bone-on-bone’ changes, many disregarded exercise-based interventions (which they believed would damage their joint) in favour of alternative and experimental treatments (which they believed would help regenerate lost cartilage). Such perceptions and beliefs about OA are detrimental considering there is often a mismatch between imaging findings and OA symptoms46 47 and that conservative management such as exercise can reduce pain irrespective of radiographic severity.48 49 In addition, as some primary care specialists are hesitant to refer patients with OA to physiotherapy because they either perceive exercise to be ineffective or lack trust in physiotherapists to provide evidence-based care,50 patients may not necessarily have been well-informed about the benefits of exercises during their specialist consultation.51 In order to maximise success with exercise interventions, these findings suggest that physiotherapists could consider reframing their conversations to actively invite the patient to share their pre-existing knowledge about OA so that any perceptions may be subtly corrected, and evidence-based educational resources shared. Physiotherapists should consider the language they use when discussing OA (ie, avoid biomedical terms such as ‘wear and tear’ or ‘degenerative’) so that they are not contributing to patient misinformation (ie, joint surgery is inevitable; OA symptoms will worsen over time), and instead provide a sense of hope and optimism for prognosis with conservative care.
Participants also did not expect physiotherapists to provide them with information regarding medications, knee injections and surgery even though these topics are advocated as important responsibilities of all health professionals when managing OA.1 52 Instead, participants generally approached their medical doctors for advice in these domains of care. This is likely because, in Australia, physiotherapists can only provide advice about over-the-counter medications and do not have prescribing rights. Regarding knee surgery, patients mainly sought physiotherapy care to postpone or prepare for knee surgery. Our patient findings are similar to our previous study with physiotherapists,7 who had also felt that surgical advice was outside the scope of practice of physiotherapy care. However, some physiotherapists described their role as preparing patients for knee surgery when they were referred for physiotherapy.
Some participants received adjunctive treatments from their physiotherapist, such as massage, acupuncture and electrotherapy interventions despite limited evidence to support their use.1 3 53 We do not know if participants specifically requested these treatments and/or if their physiotherapist helped the participant to make an informed treatment decision by discussing their limited treatment efficacy for knee OA. Patients with other musculoskeletal conditions, such as low back pain, often present to physiotherapists with preconceived ideas about physiotherapy treatment,54 and may desire ‘hands-on’ treatment or any intervention that has previously eased their back symptoms. Physiotherapists may feel obliged to provide treatments with limited efficacy in order to meet the patient’s treatment expectation.
A strength of our study was its qualitative design, which allowed us to explore the experiences of people receiving physiotherapy care for knee OA in Australia. In order to explore diversity in experiences, we interviewed a range of participants, including males and females of differing age, occupational status and geographical location across Australia. Our study also has limitations. There was no patient and public involvement in the design of this research. Participants responded to advertisements (social media) and/or Email invitations (research volunteer database) to participate and thus our sample may be biased towards those who had favourable experiences with physiotherapy and/or were successful at accessing physiotherapy. There were many more females than males in the sample which may reflect the social media approach to recruitment. Participants were reimbursed for their time with a US$50 gift card so they might have responded to interview questions in a socially desirable manner. Efforts were made to reduce this effect by informing participants at the beginning of the interview that there were no right or wrong answers to the questions asked. Our sample was constrained to participants who could speak English and given that 21% of Australians speak a language other than English at home,55 we do not know if our findings reflect the experiences of people from culturally and linguistically diverse backgrounds. Furthermore, physiotherapists are a primary contact health profession in Australia, so patient experiences with physiotherapy care for knee OA may be different in other countries where people can only access a physiotherapist on referral. Future research is particularly warranted in low-to-middle income countries, given that social factors such as education level and income influence patient access to allied health services such as physiotherapy.56 Our findings may also not be applicable in countries where cultural beliefs differ considerably from the Australian context. The perception of pain, health beliefs and concept of disability and its management often vary from one culture to another57 and thus may influence patients’ experiences managing their conditions.
In conclusion, our findings provide evidence from the patient’s perspective about the important role physiotherapists play in the care of Australians with knee OA, reinforcing the need for equitable access to physiotherapy services that are supported by a range of funding models. Findings highlight the importance of different pathways for accessing care to meet the needs of individuals and ensure that all people with knee OA are adequately supported in managing their condition. Overall, patients’ experiences with receiving physiotherapy care for their knee OA were partly aligned with the Clinical Care Standard, particularly regarding comprehensive assessment, self-management, and exercise.
Contributors PLT, KLB, KD and RSH contributed to the study conception and design. PLT completed data collection. PLT, KLB, BL, TE, KD and RSH contributed to the data analysis and interpretation of data. PLT wrote the first draft of the manuscript. PLT, KLB, BL, TE, KD and RSH revised the paper and provided scientific input. PLT, KLB, BL, TE, KD and RSH approved the final version of the manuscript.
Funding This work was supported by funding from the National Health and Medical Research Council (Centre of Research Excellence; number 1079078). Ms Teo is supported by a PhD stipend from the Australian Government Research Training Programme Scholarship. Professor Hinman is supported by a National Health and Medical Research Council Fellowship (#1154217). Professor Bennell is supported by a National Health and Medical Research Council Investigator Grant (# 1174431). Professor Dziedzic was part-funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands and a Knowledge Mobilisation Research Fellowship (KMRF- 2014-03-002) from the NIHR and is an NIHR Senior Investigator. The funders had no role in the development of the study method, interpretation of the results or reporting.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.
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