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Therapeutic alliance facilitates adherence to physiotherapy-led exercise and physical activity for older adults with knee pain: a longitudinal qualitative study

Moore, Andrew J; Holden, Melanie A; Foster, Nadine E; Jinks, Clare


Andrew J Moore

Nadine E Foster


Objectives: To investigate patients’ experiences and impact of physiotherapist (physical therapist) led exercise interventions for knee pain attributable to osteoarthritis, and to explore barriers and facilitators to change in exercise and physical activity behaviour over time.

Methods: Face-to-face, semi-structured, longitudinal interviews were undertaken with older adults with knee pain randomised to one of three physiotherapist-led exercise intervention arms in the BEEP trial (Benefits of Effective Exercise for knee Pain); n=30 on intervention completion, n=22 12 months later. A ‘layered approach’ to thematic analysis included open coding (using constant comparison), deductive coding and within-case and cross-case longitudinal analysis of change.

Results: Different levels of exercise supervision, progression and individualisation emerged, matching the content of the intervention protocols. Barriers to exercise and general physical activity were similar across intervention arms (lack of motivation, time, physical environment, lack of supervision and/or monitoring). Despite individualising exercise programmes and specifically targeting exercise, some barriers to adherence remained at 12 months. Factors facilitating longer-term exercise adherence included change in or retained knowledge about the role of exercise for knee pain and the presence and quality of a therapeutic alliance which was also reflective of participants’ experience of the intervention regardless of trial arm.

Conclusions: Despite a focus on individualisation and exercise adherence, barriers remained in the longer-term. Strong therapeutic alliance during treatment appears to facilitate adherence to exercise and general physical activity. The findings highlight on-going physiotherapy support and therapeutic alliance as targets for future adherence enhancing interventions for exercise in older adults with knee pain.

Journal Article Type Article
Acceptance Date Nov 14, 2019
Online Publication Date Dec 13, 2019
Publication Date 2020-01
Publicly Available Date May 26, 2023
Journal Journal of Physiotherapy
Print ISSN 1836-9553
Publisher Elsevier
Peer Reviewed Peer Reviewed
Volume 66
Issue 1
Pages 45-53
Keywords Physiotherapy, Therapeutic alliance, Osteoarthritis, Knee, Exercise, Physical activity
Publisher URL
PMID 31843425