To our knowledge, this is the first study that surveys the conservative non-pharmacological management of patients with knee OA in Switzerland. The main finding was that the international clinical guidelines for the management of knee OA were not systematically applied in Switzerland. The (non-) adherence to the guidelines was related to the diagnosis as well as the referral to exercise as recommended in the guidelines of knee OA. Some important barriers to and facilitators for the use of the guidelines have been detected and evaluated. As most important barriers were rated patients who were either disinterested or already physically active, whilst as most important facilitators were rated the importance of the topic exercise and patients who were insufficiently physically active.
The surveyed GPs, rheumatologists and orthopaedic surgeons reported that they most used X-ray and MRI in addition to their clinical assessment. Guideline recommendations suggest that a careful clinical examination is sufficient, unless there is any additional benefit to imaging patients as part of the diagnostic pathway or to confirm a differential diagnosis (11,25,26). The fact that orthopaedic surgeons showed a substantially higher use of MRI could be due to referrals from other specialists, thus of possibly more severe cases with knee OA to evaluate the surgical option.
There is a gap between the specialists’ ratings for the treatment options, especially regarding ‘referral to physiotherapy’, and their estimated rate of referrals to exercise. More than 80% of the specialists chose ‘referral to physiotherapy’ as a treatment option, whereas the estimated rate of referrals to exercise across the subgroups was around 54%. In all subgroups, the patients’ expectations or level of suffering as well as their own experience and the clinical picture, drove the decision-making for referral to exercise. Interestingly, even though the orthopaedic surgeons are the last specialists when a surgery is indicated, they did not show a lower rate of referral to exercise. They also prioritized “degree of OA” as reason for referral to exercise higher than GPs or rheumatologists. It can be assumed that orthopaedic surgeons may refer patients with lower degrees of OA to exercise and patients with higher degree of OA to surgery.
There seemed to be no systematic use of the guidelines among all specialists and therefore no systematic suggestion or referral to exercise as first line intervention. Interestingly knowledge and adherence to guidelines was comparable between the GPs and the specialists for the musculoskeletal system, i.e. rheumatologists and orthopaedic surgeons, even though GPs are more often challenged with multimorbid patients where guideline recommendations are often not systematically applicable. The only significant difference between the GPs and the specialists for the musculoskeletal system was in the referral pattern. GPs are usually primarily consulted and may refer the patients to rheumatologists and orthopaedic surgeons, who in turn see more referred patients than by direct access.
The evidence for the effectiveness of exercise in people with knee OA to reduce pain, improve physical function and quality of life in short- and long-term has been confirmed over and over in meta-analysis (5,9,19,27). Already in 2015, the Cochrane Collaboration stated that the evidence for the effects of exercise were so convincing that further studies were unlikely to change this strong and high-quality evidence (9). Previous studies showed that suboptimal use of exercise could be due to patients’ preferences or lack of information about conservative treatment options (28,29). The surveyed specialists have an important impact by their own attitude and how they communicate possible treatment options. They should therefore be aware that they enhance the patients’ motivation towards exercise by explaining them the positive outcomes of exercise, and support the shared decision-making towards exercise (9, 28, 29).
Overall, we conclude that there is a substantial gap between the guideline recommendations and clinical practice in the management of knee OA in Switzerland. To facilitate the guideline application and referral to exercise, it is important to translate the recommendations into a best-practice exercise programme that is of high quality and applicable in clinical practice and provide easy guidance for patients and health care providers alike. There are structured exercise and education programmes for knee OA that have been successfully established across the world, i.e. “Osteoarthritis Chronic Care Program (OACCP) Australia”, “Better management of patients with osteoarthritis (BOA) Sweden”, “Good Life with osteoarthritis in Denmark (GLA:D)”, “Osteoarthritis Healthy Weight For Life (OA HWFL) Australia”, “Amsterdam osteoarthritis cohort (AMSOA) The Netherlands” or “Joint Implementation of Osteoarthritis guidelines in the West Midlands (JIGSAW) UK” (12). All those programmes translate the guideline recommendation into practice with the goal to enhance self-management and are endorsed by OARSI. The programmes deliver the first line treatment exercise and education with different degrees of intensity and standardization. Some programmes include weight management support. The programmes have many similar contents, but differences in targeted groups of patients and health care professionals. Most programmes assess pain, function and quality of life. Such a structured exercise and education programme could be a way to overcome the evidence-performance gap in Switzerland. Further, it may support the national strategy 2017–2024 for NCDs, including musculoskeletal diseases, that emphasizes systematic disease management and patients’ self-management (13). Knee OA is no longer seen as a “bone to bone” disease caused by “wear and tear” that requires quick (surgical) action, but as a long-term illness, that affects the whole person and needs effective management of the symptoms. Understanding the disease, its causes and consequences may enhance the patients’ motivation towards exercise and therefore self-management (30).
For the successful implementation of a best-practice exercise and education programme, the perceived barriers and facilitators of the surveyed specialists, i.e. patients’ interest in exercise or physical activity, need to be considered when developing the implementation strategy (31).
This study has some limitations. The survey focused on the conservative non-pharmacological management of knee OA, specifically the use of exercise. This was due to the perception of exercise as an underused treatment option. The specialists participating in the survey may however be genuinely more interested in exercise as therapeutic option, and therefore, selection bias may have occurred (32). Although the response rate seems quite low, it can be considered acceptable for a study that addressed participants about a topic that presumably was not their main focus (29, 34), additionally the participants were representative for their peers, i.e. the members of their respective society (35). A further limitation may be that choosing an answer through multiple-choice questions and the technically imposed need for choosing an answer option to progress with the survey may have led to choice bias or position bias (30).