Abstract
Background Integrated models of care are recommended for people with knee osteoarthritis (OA). Exercise is integral to management, yet exercise adherence is problematic. Telephone-based health coaching is an attractive adjunct to physical therapist–prescribed exercise that may improve adherence. Little is known about the perceptions and interpretations of physical therapists, telephone coaches, and patients engaged in this model of care.
Objectives The purpose of this study was to explore how stakeholders (physical therapists, telephone coaches, and patients) experienced, and made sense of, being involved in an integrated program of physical therapist–supervised exercise and telephone coaching for people with knee OA.
Design A cross-sectional qualitative design drawing from symbolic interactionism was used.
Methods Semistructured interviews with 10 physical therapists, 4 telephone coaches, and 6 patients with painful knee OA. Interviews were audiorecorded, transcribed, and analyzed using thematic analysis informed by grounded theory.
Results Four themes emerged: (1) genuine interest and collaboration, (2) information and accountability, (3) program structure, and (4) roles and communication in teamwork. Patients reported they appreciated personalized, genuine interest from therapists and coaches and were aware of their complementary roles. A collaborative approach, with defined roles and communication strategies, was identified as important for effectiveness. All participants highlighted the importance of sharing information, monitoring, and being accountable to others. Coaches found the lack of face-to-face contact with patients hampered relationship building. Therapists and coaches referred to the importance of teamwork in delivering the intervention.
Limitations The small number of physical therapists and telephone coaches who delivered the intervention may have been biased toward favorable experiences with the intervention and may not be representative of their respective professions.
Conclusions Integrated physical therapy and telephone coaching was perceived as beneficial by most stakeholders. Programs should be structured but have some flexibility to give therapists and coaches some freedom to adjust treatment to individual patient needs as required. Opportunities for visual communication between telephone coaches and patients could facilitate relationship building.
Knee osteoarthritis (OA) is a common chronic disease, affecting around 24% of the adult population.1 It is a significant cause of knee pain in older people, often results in physical disability, and has considerable impact on quality of life. Knee OA has no cure, thus clinical guidelines advocate a combination of pharmacological and nonpharmacological treatment strategies.2 Due to disease chronicity, guidelines recommend a focus on self-help and patient-driven treatments rather than on passive therapies delivered by clinicians. Experts agree that management of OA should be personalized and involve shared decision making,3 taking into account the patient's wishes and preferences. An integrated package of care, rather than single treatments delivered in isolation or succession, also is recommended.3
Exercise is recognized as a core component of conservative management of people with OA because of its beneficial effects on pain and physical function.4 Additionally, exercise and physical activity may confer broader systemic health benefits. Physical therapists are a common provider of tailored exercise prescription for patients with knee OA in the clinical setting. However, external funding and service constraints often influence physical therapist consultations. Thus, consultations are typically limited to a small number of visits, usually over a relatively short time frame and with little long-term follow-up.5 In addition, use of motivational strategies and behavior change techniques that are tailored to meet individual preferences and that facilitate different people to adhere to prescribed exercise can be challenging in a time-limited physical therapy consultation and difficult for physical therapists to administer in the absence of specific training in these techniques. Research has shown that benefits of exercise for people with knee OA disappear over time once exercise participation is stopped.6 Reduced exercise participation is particularly likely to occur once patient contact with the clinician supervising the exercise program has ceased. Both patients with OA and health professionals have identified the need for better support for self-management to help people with OA manage their condition more effectively and appropriately.7 Thus, strategies and models of care that promote patient-centered support and long-term exercise adherence are essential components for OA chronic disease management.8
Adherence to exercise programs often requires substantial behavior change in order to accommodate regular exercise participation into daily life, particularly for people with chronic musculoskeletal pain. Telephone contact and reinforcement by another individual (other than the clinician prescribing exercise) can facilitate exercise adherence and maintenance.8 Health coaching is increasingly used for chronic disease prevention and self-management in the public and private health care sectors to improve adherence to treatment recommendations and to facilitate health behavior change. Health coaching involves a person, usually a health professional, actively assisting an individual with a chronic disease to change his or her health behaviors in a collaborative and individualized manner.9 Health coaching interventions typically integrate a range of complementary health behavior change theories and principles. A systematic review concluded that there is a solid evidence base supporting the efficacy of telephone coaching for improving physical activity levels.10 Thus, the use of telephone coaching to complement physical therapy for the treatment of people with knee OA is an attractive possibility for improving long-term adherence to exercise. However there has been limited research evaluating telephone coaching for people with knee OA,11–13 including the integration of telephone coaching with physical therapy as a model of care.
In addition, little is known about how people involved in delivering or receiving exercise or telephone coaching interventions for knee OA experience and make sense of these interventions. Qualitative research examining the views of patients with chronic heart disease about health coaching highlights the importance of the interpersonal relationship between the health coach and patient.14 Patients with chronic obstructive pulmonary disease found telephone coaching acceptable and reported that coaching increased their motivation and assisted with strategies for making and sustaining beneficial health changes.15 However, there are no qualitative studies of the perspectives of people with knee OA about telephone coaching. Thus, it is unclear whether such an intervention may be a useful adjunct to physical therapy in this patient group. A central premise of personalized and integrated care is that each health professional understands how other disciplines within the team interact with each other and complement their contribution to individual patient management.16 Despite calls for integrated and multidisciplinary care of people with OA,17 there are no qualitative studies examining stakeholders' perspectives, understanding, and beliefs about the efficacy of combining telephone coaching with physical therapy for treating patients with knee OA. Such information will assist in the development and modification of novel models of care for delivering exercise to people with knee OA.
We conducted a qualitative study alongside a randomized controlled trial (RCT) evaluating the efficacy of adding telephone coaching to a physical therapy program of exercise and physical activity for people with knee OA.18 The aim of the qualitative study was to explore how key stakeholders (physical therapists, telephone coaches, and patients) experienced, and made sense of, being involved in delivering or receiving an integrated physical therapy and telephone coaching intervention.
Method
Design
We conducted a cross-sectional qualitative study drawing from symbolic interactionism. As this research was aimed at exploring how participants perceived and made sense of their involvement in an integrated physical therapy and telephone coaching intervention, a qualitative research design was used, drawing from the social theory of symbolic interactionism.19,20 Symbolic interactionism emphasizes the importance of symbols and the interpretive processes that are inherent within human interactions. It provides a theoretical framework for interpretive understanding, with special attention paid to context and purpose of interactions.21 The essence of symbolic interactionism is “subjective meaning” and interpretation,22 and the approach is based on the premise that people construct perceptions and meanings from their interactions with others.
Sampling Methods
Three groups of participants were recruited as key informants from our large RCT18: (1) patients with knee OA, (2) physical therapists, and (3) telephone coaches. Sequential purposive sampling was used to recruit people with knee OA who had been allocated to receive both physical therapy and telephone coaching in the RCT and had completed the 6-month intervention. We approached 8 patients representing both sexes, a range of ages, and varying levels of symptomatic severity and exercise adherence. All physical therapists (n=13) and most telephone coaches (n=4/5) who delivered interventions in the RCT were invited to participate (one telephone coach resigned due to health reasons). Physical therapists and telephone coaches were approached to participate after the intervention phase of the RCT was finished for all 168 trial participants.
Participants
All participants provided written informed consent to participate in the qualitative study. Selection criteria for entry into the larger RCT for participants with knee OA have previously been described.18 Briefly, these criteria included: (1) average knee pain ≥4 on an 11-point numeric rating scale (0=“no pain,” 10=“worst pain possible”); (2) American College of Rheumatology clinical classification criteria for knee OA23 (any 3 of the following criteria: 50 years or older, stiffness lasting less than 30 minutes, crepitus felt on passive or active movement of the knee, bony tenderness, bony enlargement, or no warmth to touch); and (3) classification of “sedentary” or “insufficient physical activity time” according to the Active Australia Survey.24 Physical therapists with at least 2 years of postgraduate musculoskeletal practice experience and working in private practice in a range of geographical locations around Melbourne, Australia, were recruited to deliver physical therapy. Telephone coaches were recruited from health professionals willing to undertake, or who had completed, a training program by HealthChange Australia to develop skills in behavior change support and be involved in the trial.
Interventions
The protocol for the physical therapy program and the telephone coaching intervention has been previously published.18 Briefly, physical therapists were trained in the delivery of a structured exercise and physical activity program. The program was delivered over five 30-minute consultations in weeks 1, 3, 7, 12, and 20 of a 6-month period. Structured exercise comprised 4 to 6 individualized lower limb exercises (performed 3 times per week) from a standardized set, including at least 3 knee extensor strengthening exercises and at least 1 hip abductor strengthening exercise. The remaining optional 1 or 2 exercises could be chosen from other exercises in the set or could be any exercise of the physical therapist's choice to address an impairment or functional deficit related to the participant's knee problem. The therapist prescribed exercises and dosages based on assessment findings. Therapists also advised participants to increase their general physical activity levels.
People with knee OA were provided with an information booklet explaining the benefits of exercise and physical activity for OA, as well as information about behavior change support processes. Telephone coaching calls were provided 6 to 12 times over the 6-month period, with calls occurring in weeks 2, 4, 8, 13, 21, and 25, and the remainder at the discretion of the coach, physical therapist, and patient. The duration of telephone calls averaged 28 minutes (SD=13). The behavior change model underpinning the telephone coaching intervention was HealthChange Methodology (HealthChange Australia). HealthChange Methodology operationalizes and integrates theories and principles that are commonly used as the basis for complex behavioral interventions and that have an impact on health literacy, readiness, motivation, and self-efficacy to follow treatment advice.25–27 It is a decision framework for integrating patient-centered information exchange and behavior change principles and processes into clinical practice and programs to improve patient adherence to clinical recommendations. The model addresses 3 crucial components of facilitating behavior change9: (1) effective information exchange, (2) assistance to form behavioral goal intention, and (3) helping to convert intention into action and maintenance. The approach draws on principles and techniques used in motivational interviewing, solution-focused counseling, and cognitive-behavioral therapy.
All health coaches undertook 3 days of training by HealthChange Australia and mentored skills practice prior to trial commencement. An additional day of training by project research staff familiarized the health coaches with trial procedures and provided basic education on OA pathology and the role of exercise. The coaches also were provided a copy of the same information booklet given to the patients. Written information exchange between the telephone coaches and physical therapists occurred to facilitate an integrated model of care. Following each physical therapy and telephone coaching session, therapists and coaches were asked to complete an online form outlining topics discussed and problems experienced by the participant (if any), plus other relevant information, such as goals identified, adherence to the exercise program, and other general physical activity plans. Completed forms were made accessible via the Internet using a secure site for sharing information. Coaches and therapists were asked to read each other's entries prior to their session with the patient.
Data Collection and Management
Data was collected via semistructured individual interviews. This method was chosen to allow each participant to provide rich information from his or her own perspective and experience.28 Interview questions were designed to examine how participants understood specific aspects of the intervention, as well as to enable them to describe, in their own words, their perceptions, interpretations, and experiences of being involved (through open questions).
The same investigator (P.K.C.) conducted (mostly over the telephone) and transcribed all interviews. Interview topics (Appendix) were developed with reference to the integrated program goals and included beliefs about the role of the telephone coaching component of the program, perceptions about the interaction of the coaching protocol with the physical therapy protocol, reflections about the communication strategies used between the physical therapist and telephone coach, and perspectives on barriers to implementation of an integrated physical therapy and telephone coaching intervention. Interviews were audiotaped.
Drawing from the overarching theory of symbolic interactionism, participants were encouraged to provide, in their own words, their experience, perceptions, and beliefs about the integration of physical therapist–delivered exercise, physical activity advice, and telephone coaching. The deliberate link between the research design and interview method is an example of theoretical rigor.29 Clear descriptions of data management and processes of analysis demonstrate procedural and interpretive rigor. Pseudonyms were assigned to the participants for confidentiality purposes. All data were de-identified and stored in digital format on a password-protected university server.
Data Analysis
In accordance with the theoretical stance of symbolic interactionism, the data were thematically analyzed drawing from 2 key tenets of grounded theory.30,31 The first involved the systematic and structured way of engaging with the data. The second involved an emphasis on the interplay and constant comparison between the data and the analytic process.32 In analysis guided by grounded theory, the first step involves the process of open coding, consisting of line-by-line analysis of all of the facets that appear as important or interesting to the research question.30 The same experienced qualitative researcher (C.M.D.) initially read and re-read transcripts to identify content within the data that appeared important or interesting to the research question.30 The next step in the analytic process involved segmenting data into descriptive categories, where a category represented a unit of information composed of ideas and instances.30 For example, many patients mentioned the importance of the coach or the therapist understanding their specific and individual needs. Based on the theoretical stance that people construct meaning from their experience,33 the analytic process at this stage involved asking questions of the data, including: “Why do patients focus on a need for the coach and the therapist to understand them?” and “Under what conditions does this seem important to them?” The category of genuine interest was developed to discuss these findings. A second researcher (P.K.C.) read the transcripts and confirmed these categories.
From this initial data categorization, the next analytic step, known as axial or theoretical coding, encouraged connections to be made between a category and its subcategories and involved building analytic categories that reconceptualized the initial codes.34 Each of these steps of analysis also was influenced by an overall approach of constant comparison where information from the data is compared with emerging categories35 and coded concepts are cross-referenced with the data as a whole to both expand and refine the conceptual explanations.36 Discussion between 2 researchers (C.M.D. and P.K.C.) generated a complete list of categories and themes, which were subsequently reviewed and discussed with all members of the research team to reach consensus about the coding framework and final themes. All analytic steps were done using standard word processing rather than qualitative analysis software. Data saturation was reached in the physical therapist and patient transcript analysis, as the coding categories remained stable and no new categories or themes emerged in the final transcripts.29 There were fewer telephone coaches interviewed, and data saturation was not as clearly defined in these transcripts.
Role of the Funding Source
This study was supported by funding from the National Health & Medical Research Council (Program Grant #631717). Dr Hinman is supported by Australian Research Council Future Fellowship (FT130100175). Dr Bennell is supported by a National Health & Medical Research Council Fellowship (#1058440).
Results
Participant Descriptive Data
We approached 8 patients with knee OA, and 6 (75%) participated. Reasons for declining participation included being too busy (n=1) and family illness (n=1). Two physical therapists declined to participate due to time commitments, and 1 physical therapist failed to respond to the invitation, leaving 10 physical therapists (77%). All 4 telephone coaches (100%) agreed to participate. Characteristics of the patients with knee OA, physical therapists, and telephone coaches are provided in Tables 1, 2, and 3, respectively. The mean age of the patients with knee OA was 62 years, and 50% (n=3) were female. Average knee pain and physical function at entry into the RCT (based on the Western Ontario and McMaster Universities Osteoarthritis Index37) indicated mild to moderate OA symptoms. The physical therapists had an average of 19 years of clinical experience, and half were female. The telephone coaches, representing 3 distinct health care disciplines, were relatively inexperienced in telephone coaching, with only 2 telephone coaches (50%) reporting prior coaching experience.
Characteristics of Patients With Knee Osteoarthritis (n=6)
Characteristics of Physical Therapists (n=10)
Characteristics of Telephone Coaches (n=4)
Summary of Themes
Four main themes emerged from the thematic analysis of interview transcripts across all 3 participant groups. These themes represent “repeated patterns of meaning”38 derived from each of the participants' descriptions of their understanding and experience of participation in the integrated intervention. They were: (1) genuine interest and collaboration, (2) information and accountability, (3) program structure, and (4) roles and communication in teamwork (Tab. 4). Each of these themes is discussed below according to how they emerged from each of the 3 participating groups.
Key Themes and Illustrative Quotes
Theme 1: genuine interest and collaboration.
Patients with knee OA appreciated the personalized and genuine interest from the physical therapist or health coach and were aware of the benefits of their complementary roles. This sense and appreciation of personalized attention was further clarified by some patients' negative comments when the coach or therapist did not seem to understand or connect with their personal circumstances (Tab. 4). Both physical therapists and coaches appreciated how their participation afforded them opportunities to collaborate. Physical therapists noticed the positive impact on patients of personalized attention from the telephone coach and from the advice and education they provided in their clinical role (Tab. 4).
Theme 2: information and accountability.
All 3 groups of participants referred to the importance of giving and receiving information and of being monitored and, therefore, accountable to someone else. The impact of this feeling of accountability was to increase their motivation to exercise. Patients with knee OA described feeling accountable to their physical therapist and not wanting to let down the therapist. They felt a sense of responsibility to meet the set goals. Similarly, some patients described a sense of accountability to the telephone coach because the coach seemed to genuinely care about their progress. This sense of accountability was strongly influenced by whether they perceived the attention from either the coach or therapist to be genuine and tailored to their situation, as described in the first theme. Coaches recognized the value of monitoring and encouraging patients to develop their own understanding of the links between exercise and decreased pain. Physical therapists commented on the positive impact of information, education, and structured monitoring on patients' adherence to exercise. Physical therapists reported a renewed appreciation of the positive therapeutic impact of giving clear information and monitoring progress as a result of the protocol requirement to provide explicit and specific monitoring of patients' progress and specific educational advice. For many therapists, their participation in the trial represented a form of professional development. Taking direction from a specific treatment protocol freed the therapists to notice and reflect on the impact of the interventions. They discussed how the combination of exercises and education about OA worked to empower patients and improve their motivation and adherence.
Theme 3: program structure.
Participant groups expressed both positive and negative perceptions of the defined structure and program of exercises. The structured program enabled patients with knee OA to incorporate the prescribed exercises into their daily schedules. They found the exercises simple to do and were aware that the physical therapist would follow up on their progress. However, simplicity and repetition were expressed as sources of frustration, and some patients found the exercises either boring or irrelevant to their lifestyle (Tab. 4).
Similarly, some physical therapists thought the structure and specified timing of the exercise program restricted their capacity to modify exercises and provide adequate follow-up. However, most comments by physical therapists about the exercise regimen were positive. Being obliged to follow a structured protocol allowed them to experience a different OA treatment regimen than what they typically used in clinical practice and to observe and learn from the impact of the defined exercise protocol on patient progress. Although many physical therapists commented on the benefits of an externally imposed treatment structure, the protocol was also a source of conflict between the therapists' perception of their usual clinical role to independently decide appropriate treatment and their role in the research study to adhere to the standardized treatment protocol (Tab. 4).
Telephone coaches appreciated the structure provided by the intervention protocol. Their comments about the structure of the exercises, and how patients included them into their daily routine, resonated closely with patients' descriptions. However, telephone coaches found the set protocol of using only telephone-based communication and lack of face-to-face contact with their patients difficult and felt that this protocol hampered their ability to establish their normal rapport and build effective relationships with their patients (Tab. 4).
Theme 4: roles and communication in teamwork.
Both the physical therapists and the telephone coaches referred to the importance of teamwork in delivering the integrated intervention (Tab. 4). They discussed ideals of teamwork as “sharing a similar philosophy” (Rachel), “working as a tandem” (Patricia), “having a mutual understanding,” (Rachel) and “emphasising the same treatment” (Julie) with “the client as the central character” (Patricia). Patients did not explicitly identify the importance of teamwork, but they did notice and comment if physical therapists and coaches were markedly different in their therapeutic approaches or goals.
Some therapists expressed ambivalence as to the role of the telephone coach and queried whether a second professional was necessary to fulfill the health coach role (Tab. 4). Some therapists felt that health coaching was part of their professional role as physical therapists and, therefore, part of their usual clinical practice. However, even where physical therapists were uncertain about the need for the health coach, they recognized that reinforcement of health messages from another clinician could be valuable. Coaches also commented on the complementary, yet overlapping, roles of the physical therapist and the coach with respect to goal setting. Some experienced the overlap as a source of conflict or friction if the clinicians were not working from the same set of goals. Others noticed reluctance from the patients to talk about physical activity, as the patients felt that was the physical therapist's role, not the coach's role.
Some therapists thought that they could perform the coach role, whereas others thought having a separate coach freed them up to focus on other treatment aspects (Tab. 4). Almost all coaches and therapists commented that the necessary teamwork was less likely to succeed if communication processes were not clearly prescribed or if the coach or physical therapist did not recognize or support each other's goals or use the communication structure in place. All coaches and therapists recognized that for integrated care to be effective, communication needed to be collaborative, patient-centered, and consistent, even though different views were expressed about the preferred medium of communication (including face-to-face, email, and via the Web-based protocol).
Discussion
Although treatment of people with knee OA should be delivered as an integrated package of care,3 physical therapy for people with knee OA usually occurs in isolation and with little interaction with other health care providers. In light of this fact, and the poor long-term adherence of patients to exercise,39 we proposed a novel model of care that integrates telephone health coaching with physical therapist–supervised exercise. This qualitative study explored how participants perceived and made sense of their involvement in delivering or receiving this package of care.
Genuine interest was highly valued by patients and by therapists and coaches who recognized positive effects of close interest and attention to a patient's needs. Patients noticed if care delivered by clinicians did not appear genuine or individually centered. Although telephone coaches were specifically trained in patient-centered behavior change support principles and techniques, the participating physical therapists were not. This lack of specific training may explain the “business-type” approach of a physical therapist noted by one patient. Physical therapists may benefit from specific training in behavior change support in order to maximize their treatment effectiveness, which is likely to benefit all of their patients and not just those with knee OA.
Our study showed how giving information to patients to increases their understanding of knee OA increases their motivation to be accountable and adherent to exercise, consistent with previous research.7 This finding highlights the crucial role that both physical therapists and telephone coaches play in educating patients about OA and the benefits of exercise and physical therapy. All health care professionals involved in exercise prescription for people with knee OA should dedicate consultation time toward educating patients according to their level of knowledge, understanding, and individual needs in order to maximize exercise adherence. Participants also recognized the importance of program structure in assisting them to exercise, consistent with previous research.40 Program structure assisted patients to develop behaviors that could be absorbed into their daily routines. However, some program flexibility is important to ensure a tailored approach, to prevent boredom with exercise, and to allow therapists and coaches to monitor their patients as often as needed to promote individual adherence.
For patients and coaches, lack of face-to-face communication sometimes hampered relationship development. Health coaching was delivered by telephone, and additional efforts to personalize the coach-patient relationship may be needed. These findings may be relevant to any telephone-delivered health service. Potential strategies may include use of video chat software or more simple approaches (eg, an introductory letter about, and photograph of, each stakeholder). Our coaches were relatively inexperienced. More experienced health coaches may be more comfortable with the telephone as a communication medium. Thus, future programs may want to recruit only experienced telephone coaches to deliver health coaching interventions.
Teamwork was a predominant theme that emerged as important for our integrated intervention. Physical therapists and health coaches must be willing to merge their professional roles. Communication between health professionals is integral in this complex multidisciplinary model of care. It is likely that these findings would be equally applicable to other integrated multidisciplinary models of care. Clear and agreed-upon strategies for communication are required, and these strategies must be valued and utilized by both parties. Clinicians may need to negotiate individual communication strategies to maximize effectiveness.
Participant experiences were consistent with the team development stages proposed by Tuckman.41 The first stage is forming, where individuals orient themselves to the task and test boundaries for interpersonal and task behaviors. Physical therapists identified constraint (protocol rigidity) in this stage, and coaches reflected forming by focusing on goals and role boundaries. The second stage is storming, represented by intergroup conflict. Patient experiences resonated most strongly with this stage. Patients expressed both negative and positive responses about being monitored by clinicians. Norming (stage 3) involves an acceptance of team member roles and increased understanding of how to effectively work together. Some physical therapists described the positive impact of the integrated program on patient progress. Coaches reported subtle shifts in patients' attention, such as noting an increased interest by patients in positive lifestyle changes. Patients recognized the impact of exercises on functional capacity. Performing is the fourth and most functional stage. Health coaches and physical therapists' views were most strongly aligned in this stage. All clinicians emphasized the need for collaboration and teamwork to ensure the best patient outcomes.
Our study has a number of limitations. It was nested within an RCT that involved only a small number of physical therapists and telephone coaches to deliver the intervention, who may not be representative of their respective professions and may have been biased toward favorable experiences with the intervention. Data saturation was not achieved with health coaches, and further relevant information about the experiences of the telephone coaches may be gained in larger samples. Our participants with knee OA all volunteered for the RCT and may have held inherent beliefs about exercise, physical therapy, and health coaching. They may not be representative of the wider population of people with knee OA. In a qualitative project such as this, researchers necessarily shape and interpret the data, and the small number of participants limits the generalizability.42 Our intervention cannot be generalized beyond the protocol in the RCT, and application in “real-world” settings may result in different stakeholder perceptions and experiences. However, inclusion of all 3 groups of stakeholders in our study is a strength, and the detailed published protocol for our intervention18 allows for replication in clinical practice.
Our study was conducted within the Australian health system. While the broad themes are likely to be applicable to similar health systems, it is unclear if our findings are generalizable to other countries. The limitations in terms of generalizability are offset by the recognized functions of qualitative research to provide insights into practice and not just a description or measurement of practice.43 These insights provide opportunities to make sense of behaviors that are hard to measure and a conceptual framework to guide further research.
Future research should investigate how best to integrate physical therapist–supervised exercise management with psychologically informed health coaching. This research may require face-to-face visits with health coaches to maximize program effectiveness and acceptability. Research also is needed to determine how to best develop and support the necessary teamwork for effective delivery of integrated care. Physical therapy and health coaching services that are physically co-located may allow more successful implementation of such a model of care. Although it is possible that training physical therapists to fulfill the role of health coach may warrant investigation, our data suggest that the contribution by a separate health coach to the “team” maximizes effectiveness.
In conclusion, integrated physical therapist–supervised exercise and telephone-delivered health coaching were perceived as beneficial for management of knee OA by most stakeholders. A collaborative approach, with clearly defined roles and effective communication practices, was integral for program effectiveness. Future programs should be structured but also allow some flexibility to ensure treatment is tailored to individual patient needs and to allow therapists and coaches some freedom to adjust treatment as needed. Opportunities for visual communication (eg, video conferencing) between telephone coaches and patients could be explored to facilitate further relationship building.
Appendix.
Semistructured Interview Topics
Footnotes
Dr Hinman, Dr Delany, and Dr Bennell provided concept/idea/research design. Dr Hinman, Dr Delany, and Ms Campbell provided writing. Ms Campbell provided data collection. Dr Hinman, Dr Delany, and Ms Campbell provided data analysis. Dr Hinman, Ms Campbell, and Dr Bennell provided project management. Dr Bennell provided fund procurement. Ms Gale and Dr Bennell provided consultation (including review of manuscript before submission).
This study was approved by the Human Research Ethics Committee of The University of Melbourne.
This study was supported by funding from the National Health & Medical Research Council (Program Grant 631717). Dr Hinman is supported by Australian Research Council Future Fellowship (FT130100175). Dr Bennell is supported by a National Health & Medical Research Council Fellowship (1058440).
- Received May 6, 2015.
- Accepted August 18, 2015.
- © 2016 American Physical Therapy Association
References
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