Understanding the management of osteoarthritis in Tasmania and a novel approach to change

Background
Osteoarthritis (OA) is a serious, painful, and disabling disease which affects over 2.2 million Australians. This thesis focuses on knee OA, as this is the most commonly affected weight bearing joint. Current guidelines for the management of knee OA recommend conservative (non-surgical) management using a combination of non-pharmacological and pharmacological treatments. Non-pharmacological treatments of patient education and self-management, exercise and weight management are considered first line, core treatments recommended at all stages of disease. Pharmacological treatments, including paracetamol and non-steroidal anti-inflammatory medications, are focused on pain relief but are only modestly effective. Joint replacement surgery is recommended when these treatments fail to provide adequate pain relief or maintenance of function. Despite these recommendations, current management of OA falls short of best practice. There is underuse of guideline recommended first line care and overuse of medications and surgery to treat OA. Exercise uptake by patients is also low and only 13% of people with OA meet physical activity guidelines. To address these issues, we must understand both the clinician and patient perspective in managing OA. Additionally, identifying effective, low-cost, accessible, scalable, and sustainable strategies to promote physical activity in people with knee OA is crucial to improve their physical activity levels, maintain function, and manage symptoms.
Aims:
The overall aim of this thesis was to understand the management of OA in Tasmania, Australia and investigate a novel method for improving physical activity among people with knee OA. The specific aims were:

1. To understand the management of OA by GPs and surgeons in Tasmania.
2. To understand the experience of patients with OA in Tasmania.
3. To determine the feasibility of using an existing community based physical activity initiative (parkrun) for people with knee OA

Methods
These aims were addressed through the following three studies:
Study one: Understanding the management of osteoarthritis: A qualitative study of GPs and orthopaedic surgeons in Tasmania, Australia. Purposive sampling was used to recruit 17 GPs and 10 surgeons from Tasmania. Semi-structured interviews were audio-recorded, transcribed, coded, and thematically analysed to document understanding of OA, management and treatment decision making.
Study two: Navigating the maze of osteoarthritis (OA) treatment: A qualitative study exploring the experience of individuals with OA in Tasmania, Australia. Purposive sampling was used to recruit 26 participants with knee OA, aged 45 years and over, from Tasmania. Semi-structured interviews were audio-recorded, transcribed, coded, and thematically analysed to document the experience of people with OA, gain an understanding of their management of the health system and explore their opinions on exercise and joint replacement surgery.
Study three: Feasibility of ‘parkrun’ for people with knee osteoarthritis: A mixed-methods pilot study. A mixed methods pilot study was used to enrol people with knee OA who were not meeting physical activity guidelines. Participants were asked to walk in four consecutive parkrun events supervised by an exercise physiologist or physiotherapist. Feasibility was assessed by recruitment data (numbers screened and time to enrol 15 participants), adherence to the protocol, acceptability (measured by confidence, enjoyment, and difficulty ratings and assessed through qualitative interviews), and safety (adverse events). Secondary measures were changes in knee pain measured by visual analogue scale (VAS), function and stiffness measured by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and physical activity levels assessed using a self-reported International Physical Activity Questionnaire (IPAQ).
Key findings:
GPs and surgeons in Tasmania had a shared understanding of the cause and management of OA which aligned well with evidence-based best practice. Conservative management was highly supported by GPs and surgeons, with a focus on exercise and/or physiotherapy. Key treatment barriers for GPs and surgeons included managing poor patient understanding of OA, unrealistic expectations for treatment, lack of patient motivation and scepticism towards exercise, and cost and accessibility of conservative treatment options. Surgery was considered a suitable option when conservative management options had been exhausted.
From the patient perspective, individuals with knee OA in Tasmania were navigating a maze of OA treatments. They perceived that their GP did not have an ongoing role in the management of their disease. Participants were self-directing their management and sampling from a range of treatment options, some of which would be considered low-value care, including treatments which are neither recommended for or against in guidelines (topical capsaicin, platelet rich plasma injections) or strongly recommended against (stem cell therapy). However, they believed that exercise was beneficial for OA and perceived surgery as a last resort.
For the parkrun pilot study, seventeen participants (n=17) were enrolled over eleven months and recruitment was slower than anticipated. Fourteen participants completed all four parkruns, three of whom shortened the 5km course to ~3 km. Across all four parkruns, 75% of participants reported high confidence that they could complete the upcoming parkrun and the majority (87%) enjoyed participating. Most participants rated parkrun either “slightly difficult” (38.5%) or “moderately difficult” (35%) and two mild adverse events were reported. Participants had a significant improvement in Visual Analogue Scale (VAS) (0- 100mm) knee pain from baseline to post intervention, a change of -17.7mm (95% CI -29.4 to -5.9). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for pain, function and stiffness also showed significant improvements: pain score change -60.8 (95% CI -107.2 to -14.4), function score change -209.8 (-367.0 to -52.5) and stiffness score change -38.3 (-61.1 to -15.5)). While not significant, physical activity levels also improved.
Conclusion
This thesis explored the understanding and management of OA in a regional state in Australia, from the perspective of both clinicians and patients. Studies identified key barriers to treatment that can be addressed to improve the management of OA by clinicians and potential ways to improve access to treatment for patients. This work is informing health system redesign in Tasmania to improve OA care, including working with the Tasmanian Health Service to introduce evidence-based programs and models of care for OA management. These changes are supported by the recently released State-wide Elective Surgery Four Year Plan which aims to ensure no patients are waiting longer than is clinically recommended for their surgery. The thesis also explored a new initiative to potentially improve symptoms and increase physical activity in people with knee OA. The parkrun pilot study is the first to explore parkrun as an intervention in people with a chronic disease. The scalability, accessibility, and wide appeal of parkrun, together with the promising feasibility data supports the development of larger programs of research to evaluate the use of parkrun to improve physical activity in people with knee OA.