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Barriers and facilitators of loaded self-managed exercises and physical activity in people with patellofemoral pain: understanding the feasibility of delivering a multicentred randomised controlled trial, a UK qualitative study
  1. Benjamin E Smith1,2,
  2. Fiona Moffatt3,
  3. Paul Hendrick3,
  4. Marcus Bateman1,
  5. James Selfe4,
  6. Michael Skovdal Rathleff5,6,
  7. Toby O Smith7,
  8. Phillipa Logan2
  1. 1 University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
  2. 2 Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
  3. 3 Division of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK
  4. 4 Department of Health Professions, Manchester Metropolitan University, Manchester, UK
  5. 5 Research Unit for General Practice in Aalborg, Department of Clinical Medicine at Aalborg University, Aalborg, Denmark
  6. 6 Department of Occupational Therapy and Physiotherapy, Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
  7. 7 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  1. Correspondence to Benjamin E Smith; benjamin.smith3{at}


Objectives There is an emergent body of evidence supporting exercise therapy and physical activity in the management of musculoskeletal pain. The purpose of this study was to explore potential barriers and facilitators with patients and physiotherapists with patellofemoral pain involved in a feasibility randomised controlled trial (RCT) study. The trial investigated a loaded self-managed exercise intervention, which included education and advice on physical activity versus usual physiotherapy as the control.

Design Qualitative study, embedded within a mixed-methods design, using semi-structured interviews.

Setting A UK National Health Service physiotherapy clinic in a large teaching hospital.

Participants Purposively sampled 20 participants within a feasibility RCT study; 10 patients with a diagnosis of patellofemoral pain, aged between 18 and 40 years, and 10 physiotherapists delivering the interventions.

Results In respect to barriers and facilitators, the five overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants’ engagement with the loaded self-managed exercises and (5) physiotherapists’ clinical development. Locus of control was one overarching theme that was evident throughout. Contrary to popular concerns relating to painful exercises, all participants in the intervention group reported positive engagement. Both physiotherapists and patients, in the intervention group, viewed the single exercise approach in a positive manner. Participants within the intervention group described narratives demonstrating self-efficacy, with greater internal locus of control compared with those who received usual physiotherapy, particularly in relation to physical activity.

Conclusions Implementation, delivery and evaluation of the intervention in clinical settings may be challenging, but feasible with the appropriate training for physiotherapists. Participants’ improvements in pain and function may have been mediated, in some part, by greater self-efficacy and locus of control.

Trial registration number ISRCTN35272486; Pre-results.

  • patellofemoral pain
  • pfp
  • qualitative research
  • rehabilitation medicine

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  • Contributors BES was responsible for conception and design, compiling the interview schedule, interviewing, transcribing, coding, analysis and interpretation, drafting and revising the manuscript. FM was responsible for conception and design, compiling the interview schedule, coding, analysis and interpretation, drafting and revising the manuscript. PH, MB, JS, MSR, TOS and PL were involved in conception and design, interpretation and reviewing revisions to the manuscript. All authors have read and approved of the final manuscript.

  • Funding This report is independent research arising from a Clinical Doctoral Research Fellowship, Benjamin Smith, ICA-CDRF-2015-01-002 supported by the National Institute for Health Research (NIHR) and Health Education England. TOS is supported by funding from NIHR Oxford Health Biomedical Research Centre.

  • Disclaimer The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR, HEE or the Department of Health.

  • Competing interests None declared.

  • Ethics approval This study was approved by the West Midlands—Black Country Research Ethics Committee (16/WM/0414) and Sponsored by University Hospitals of Derby and Burton NHS Foundation Trust. IRAS reference 211417.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Further quotations are available from BES at No additional data are available.

  • Patient consent for publication Not required.

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