Table 3

Themes, subthemes and exemplary quotes from the patient interviews

Theme 1: Presented with a pre-existing OA diagnosis
Prior OA care from other health professionalsMale, 76 years: ‘I got my MRI scan and I took it back to the doctor and it showed that I had osteoarthritis, that it was very inflamed, that my cruciate ligament resembled a celery stick and he got me to go to see the physio.’
Male, 75 years: ‘My knees got really bad about last July and I went to see a surgeon with the possible view of having replacements done. The diagnosis for both knees were bone on bone. He didn’t feel that I was severe enough to warrant surgery at that time, so on further discussion, he suggested that I go to physiotherapy to strengthen my legs. So, I went to a local physiotherapist.’
Female, 76 years: ‘I’ve had the experience with the osteoarthritis for about eight or nine years and first of all, I went to a knee specialist and then I went to a sports medicine specialist and orthopaedic surgeon. I did that for about eight or nine years and recently, I’ve been to a physiotherapist for the Good Life with osteoarthritis: Denmark (GLA:D) program*.’
Perception of adequate OA knowledgeFemale, 49 years: ‘I think I have a fairly good understanding of what osteoarthritis is. I understand that I have damage to the articular cartilage of my kneecap and medial femoral condyle. I have very little cartilage at all and that’s rubbing. To be honest, I didn’t need him (the physiotherapist) to explain all of that.’
Male, 70 years: ‘The physiotherapist saw the x-rays and they have training in interpreting x-rays like that for degenerative bone disease such as osteoarthritis, cartilage wear and things like that. I was well aware that I had osteoarthritis, so I don’t think he did anything to explain the osteoarthritis because I was fairly well aware of what it was on about.’
Male, 60 years: ‘It’s just basically wear and tear, and it’s really bone on bone. The surgeon explained it to me, too. He sat me down with him at his computer looking at the MRI. It’s little fragments of bone and stuff that are rubbing against each other and disintegration of your bone in your patella plus around your knee. Because there’s no blood flow in that area, it doesn't heal.’
Theme 2: Wide variation in access and provision of physiotherapy care
Referral pathwaysMale, 56 years: ‘Initially I went to the orthopaedic surgeon and it was deemed that surgery is inappropriate at the moment because of age and probably not severe enough to warrant a replacement. I [was referred by the surgeon to] the osteoarthritis [chronic care program). The [osteoarthritis] chronic care program† was really an intermediary or, hopefully, a step to prevent requiring a knee replacement as such.’
Female, 49 years: ‘I mentioned to my doctor I’m getting these sore knees, she said, you should try Kieser‡. I knew it was up the road, my friend went there, and my doctor said it could be a good idea.’
Female, 55 years: ‘I just chose them [the physiotherapy centre] because I knew they did Pilates and exercise rehab, so that’s why I went there. And they were close to home.’
Male, 72 years: ‘My doctor recommendation. I got on this Enhanced Primary Care Plan§ where they recommend a physiotherapist.’
Funding modelsFemale, 60 years: ‘I had an accident at work a few years ago. I suffered quite a bit of pain and I was referred to a specialist, and he did an arthroscopy. Then I was doing follow-up physiotherapy after the arthroscopy. The surgeon did another arthroscopy and I followed up with more physiotherapy - and started doing hydrotherapy under a physiotherapist. I was doing those sessions on a regular basis. WorkCover then ceased to cover me, and so I was doing them myself out-of-pocket.’
Female, 69 years: ‘I went to my general practitioner and got the five treatments that you can get from the government for chronic illness. [With] the care plan you only get five treatments, but then I’ve got private health insurance, so I saw him under that as well.’
Female, 69 years: ‘I had ancillary benefits at that stage and I only got about five treatments covered by that ancillary benefits with Medibank Private. I couldn’t afford the ancillary benefits anymore so, no, I won’t go to a physio now.’
Individual vs group sessionsFemale, 69 years: ‘The most recent physio visit was with a new physio because I was having a bicycle fit, and as part of the bike fit the physio did a full-on assessment so he talked more about osteoarthritis as well. I’ve only seen him once.’
Female, 55 years: ‘I didn’t see an individual physio for individual sessions in the last 6 months. I was always in group sessions. It’s a general fitness class but it’s mainly for menopausal age group. So, everyone has their own set of problems. It’s not tailored just for one problem; it’s tailored for everyone.’
Male, 75 years: ‘I went to a local physiotherapist and they did sort of two sessions of assessment. And then I started going to regular weekly classes.’
Female, 79 years: ‘Recently this year, I’ve been to a physiotherapist for the GLA:D* program. As part of the GLA:D* program, we had to do an education program and so she [the physiotherapist] showed us a diagram of the knee and explained how different things get worn out and rough. There were six different exercises in the GLA:D* program.’
Theme 3: Seeking physiotherapy care for pain and functional limitations
Knee symptomsFemale, 49 years: ‘My knees were becoming sorer and clicking as I walked, particularly up sets of stairs. And I have a lot of stairs at work. So, I thought I need to go and talk to a physio about it.’
Female, 51 years: ‘I had an ongoing knee problem and the pain was just killing me. I would be in tears with the pain. I went to the doctor; they were giving me anti-inflammatory tablets, they were not working. So, I said is there anything I can do, will physio help, and the doctor sent a referral to the physio.’
Female, 55 years: ‘Well, it was for knee pain that I wanted to go and build-up the strength in my legs to try and avoid surgery. I’ve lost capacity to squat and things like that; I’ve lost a lot of strength in my right leg and my legs have become quite bowed.’
Functional problemsFemale, 69 years: ‘I think she understood what my concerns were that I couldn’t get upstairs. I couldn’t drive the car because of the clutch and the knee pain. She looked at all those things and helped me with them.’
Female, 81 years: ‘I told her [the physiotherapist] that my foot turns in. I also told her that my knee crunches. I can manage the pain but going up and down stairs is one of the problems that I've got.’
Male, 72 years: ‘Well I told him [the physiotherapist], I said, look, I just want to get back surfing properly and snowboarding and skiing. I said I realise I’m 72 years old and it’s not going to be easy and they said, oh no, no problem we can do it.’
Theme 4: Physiotherapy management focused on function and exercise
Assessment of functionMale, 56 years: ‘Timing or just observing, getting in and out of a chair. Walking a set distance, I think it might have been like 100 metres and they time that. And then, there was going up and down stairs and they had some sort of a measurement with that. Then, over time would repeat that and see if there was any improvement.’
Female, 49 years: ‘He watched me from a seated position to standing. He looked at my movements. We went out the back and I did a lot of walking up and down, and they had a staircase of about three or four steps, and he watched where the pain happened there. He had me practicing, in particular, the way I walk up and down stairs to make sure that through my feet, I was balancing the weight and not throwing to one side.’
Male, 75 years: ‘They were measuring how far I could bend my legs laying down and standing up. Squats. Doing steps. They found that I was bending knees. I wasn’t walking correctly, but I was doing that to relieve the pain. They got me stepping up correctly with a straight leg. I think she made a record of all of her findings and then set these exercises to hopefully relieve some of the pain and strengthen my leg muscles.’
Various types of exercises prescribedFemale, 49 years: ‘He gave me an exercise program, just some gentle swinging of the knee initially, and then I built it up to other types of exercise. He had me practicing the way I walk up and down stairs, then we looked at me doing some kicking, gentle kicking with the board and gentle deep water running as opposed to doing the structured classes.’
Male, 75 years: ‘Other than exercise machines that they had in-house, there was elastic stretching band and she told me to do elliptical trainer at home and a cycle machine. I've got a list here. Its straight leg raise, bridging, clams, ball squeezes, sit to stand, lunges, calf raises ballet style, step-ups, go on the bike, and balance exercise.’
Female, 55 years: ‘I was doing Pilates, then I was doing Fit-Right classes. We did lots of clams with weights and off-weights. I did a lot of [reformer] where I sat on a spring-loaded box.’
Surgery, medications and injections are for doctorsMale, 56 years: ‘I think it’s the rheumatologist or my general practitioner who would be issuing the drugs so I didn’t think that would be physio. I don’t think meds ever really was their (the physiotherapists’) jurisdiction.’
Male, 72 years: ‘The physio doesn’t want to go into the drug side of it because of the risks. Why would he change it as regards something as serious as drugs? I’d had second thoughts and the fact that I thought they’d [a surgeon] done the wrong knee. He didn’t go into that because obviously that’s not part of his remit.’
Female, 69 years: ‘The surgeon will know better about how advanced it is and I’ve got a lot of faith in him. He can give me a better idea of where I should proceed after this. Because I’ve had it before, I have got a fairly good idea of what the process will be.’
Adjunctive treatmentsMale, 76 years: ‘I couldn’t bend the knee very well; I was in real pain and he gave me a couple of needle sessions both hot and dry needles. He massaged the knee; he did a lot to try and bend the knee.’
Male, 60 years: ‘It’s a little bit of ultrasound, but basically manipulation. I'm always tight in the hamstring. I play lawn bowls, and if it was niggly, I drop in the physio and say listen, could you tape my knee for me, please, and they do it for me straight away.’
Female, 69 years: ‘I did get a bit of massage and a trigger point treatment to help alleviate that. We also tried, I think it’s called EMS machine, an electronic stimulation machine, to try and build the muscle at one point because my kneecap was so aggravated.’
Theme 5: Professional and personalised care
Trust and/or confidenceMale, 76 years: ‘I thought he was excellent. He was one of the best physiotherapists I’ve ever seen in my life. His approach to everything, his care. Many of them can be in and out, I’m finished with you, I’ve only got so much time for you. None of that. He was extremely good, and I had complete trust in what he was doing. And when he did hurt me it wasn’t because he wanted to hurt me, he said, oh I’m sorry and tell me if that’s too hard.’
Female, 69 years: ‘I thought she was really good. I think she understood what my concerns were that I couldn’t get upstairs. I couldn’t drive the car because of the clutch and the knee pain. She looked at all those things and helped me with them.’
Female, 69 years: ‘When he gave them to me, they all seemed quite logical because I know nothing, I wouldn’t know what was good or bad for me. I trusted him because I had the condition before when my knee was bad. He also knew my background and what I’d been through, so that was good to have that kind of long-term relationship.’
Personalised careFemale, 51 years: ‘I had a good say in it because every time she suggested something she would ask. With appointment times, she would always check, ‘Is this a good time for you?’ Every time she suggested a treatment, she would ask me. She was always checking back with me.’
Female, 49 years: ‘I think he has a very good understanding of my knee problem and I think he understands that better than my doctors, because he’s worked side by side with me, he’s supported me, it’s more intimate. He’s been keen to help resolve the problems, rather than doing, what I call a supermarket shelf, one size fits all program. He’s really worked hard to try and work out what’s best in my circumstance.’
Female, 49 years: ‘I also went to a gym called Kieser which is – I call it the sausage factory of physiotherapy. The person who started the program for me was a physiotherapist and guided that program, but I guess I didn’t feel that really was addressing my issues. It was building my core strength, but it wasn’t really helping my knees.’
Female, 57 years: ‘My physiotherapist knows me well. I’ve been seeing him for some time, he seems to know where my problems lie. He spent the time to look at other areas which because of my osteoarthritis in my knee, I was having problems with. So at least he looked at all those areas, so I was happy with that. He came up with a few suggestions on how he would approach it, and then we went from there.’
Theme 6: Physiotherapy to postpone or prepare for surgery
Female, 60 years: ‘I was told by my surgeon a few years ago that it would be likely I would need a knee replacement. They don’t like to do it until it’s absolutely necessary. He kept telling me I was too young. They like to wait until you’re so old you might die under the knife or you don’t get long enough to enjoy the freedom of your new knee.’
Female, 69 years: ‘We were talking about the advantages of doing it [surgery] sooner than later, but then he’s [the physiotherapist] saying if I do it a bit later then we can strengthen the muscles in my knee and around my knee, that will make maybe recovery quicker.’’
Female, 60 years: ‘I’m on a waiting list to have a knee replacement. We know that the waiting list is fairly long, so I’ll keep myself as healthy and fit as I possibly can, so that I’m able to get through this okay.’
Male, 70 years: ‘Things like osteoarthritis and physiotherapy, there is only so much that physiotherapy can do. If it’s bone on bone that doesn't replace the cartilage. All that physiotherapy can do is prescribe activities and exercises to help ameliorate the impact of the osteoarthritis because osteoarthritis doesn't go away. I've had arthroscopies on my knees, so there’s no cartilage there. But I'm reluctant to have knee replacements.’
  • *GLA:D is an education and exercise programme developed in Denmark for people with hip/knee OA. The programme has been adapted and delivered by physiotherapists in Australia and comprises of an initial assessment, 12 supervised group exercise sessions, 2 group education sessions and a follow-up assessment.29

  • †The OACCP is a multidisciplinary model of care developed in New South Wales, Australia for people with hip/knee OA, specifically those awaiting elective joint replacement surgery. The programme is a public-health initiative in tertiary hospitals and offers conservative management, including programmes for exercise and weight loss, self-management advice, psychological and pharmacological reviews and disease management education.28

  • ‡Kieser is a strength training programme using specific equipment and was originally developed in Switzerland. The programme was adapted and delivered by physiotherapists in Australia in Kieser training centres.30

  • §The Enhanced Primary Care Plan is a former term for a programme now called a Chronic Disease Management Plan, which is a Medicare subsidised programme enabling general practitioners to refer patients with a chronic medical condition to a maximum of five allied health services (including physiotherapists) per calendar year.31

  • GLA:D, Good Life with Osteoarthritis: Denmark; OA, osteoarthritis; OACCP, Osteoarthritis Chronic Care Programme.