‘i would never have done it if it hadn’t been digital’: a qualitative study on patients’ experiences of a digital management programme for hip and knee osteoarthritis in sweden - interactive digital board

Abstract: objective to explore the experience of digital management of hip and knee osteoarthritis (OA)
Includes education and exercise, as well as options to chat with designated physical therapists for feedback, questions, and support.
The study was conducted at a regional hospital in southern Sweden.
Methods 19 patients (10 women)
Median age 66 (q1–q3, 57–71)
Over the years, after completing the first 6 weeks of the project, the confirmed hip or knee OA was interviewed using a semi-structured interview guide.
Interviews are recorded word for word and qualitative analysis is performed using systematic text enrichment.
Results three categories appeared in the interview process :(1)
Management plan to mitigate OA consequences; (2)
Experience in digital solutions and (3)
The obvious impact of digital schemes over time.
Most of the participants had positive experiences with the programme.
For these experiences, it is particularly important that there is no waiting list, the flexibility of participating in the program in terms of location and time, and the possibility of daily contact with a physical therapist.
These aspects are also highlighted as advantages compared to traditional care.
Conclusion digital management of OA, including education and exercise, is considered an effective alternative to traditional treatments for implementing OA guidelines in a wider community.
Easy access, easy exercise in your own, flexible choice, daily tracking
The support of physical therapists is considered to be the most important feature.
In addition, these results will help to further develop and improve the digital OA management programme.
Objective to explore the experience of digital management of hip and knee osteoarthritis (OA)
Includes education and exercise, as well as options to chat with designated physical therapists for feedback, questions, and support.
The study was conducted at a regional hospital in southern Sweden.
Methods 19 patients (10 women)
Median age 66 (q1–q3, 57–71)
Over the years, after completing the first 6 weeks of the project, the confirmed hip or knee OA was interviewed using a semi-structured interview guide.
Interviews are recorded word for word and qualitative analysis is performed using systematic text enrichment.
Results three categories appeared in the interview process :(1)
Management plan to mitigate OA consequences; (2)
Experience in digital solutions and (3)
The obvious impact of digital schemes over time.
Most of the participants had positive experiences with the programme.
For these experiences, it is particularly important that there is no waiting list, the flexibility of participating in the program in terms of location and time, and the possibility of daily contact with a physical therapist.
These aspects are also highlighted as advantages compared to traditional care.
Conclusion digital management of OA, including education and exercise, is considered an effective alternative to traditional treatments for implementing OA guidelines in a wider community.
Easy access, easy exercise in your own, flexible choice, daily tracking
The support of physical therapists is considered to be the most important feature.
In addition, these results will help to further develop and improve the digital OA management programme.
Background due to the reduction of medical resources, the long waiting list and the difficulty of meeting the needs of modern individuals who are often busy, using the web-
Over the past decade, there has been a significant increase in basic or digital management options in the healthcare sector.
1-3 accessibility and flexibility, social motivation, and the choice of anonymity and secrecy are common reasons for choosing digital options.
4-10 a recent comment also suggests that it may be easier to seek care and incorporate it into daily life when training is accompanied by the flexibility and anonymity offered by online delivery, some people even think they have a higher relationship with an online therapist than they have with a regular therapist. 6 However, web-
So far, there has been no significant research on the basis or digital management of skeletal diseases.
11 patients with osteoarthritis (OA)
A group of patients that constitute a potentially very beneficial set of digital management.
4 11 as mentioned earlier, guidelines for OA treatment (
Education, Sports and weight management)
12. it is not always implemented and few people with OA are properly managed.
Lack of medical resources, living in rural areas and low levels of education are all factors that may reduce the possibility of obtaining appropriate information on OA management options. 4 14 Web-
It was suggested that OA be intervened based or digitally as a way to provide guidance --
OA-based management can be used by a wider community.
4 11 15 Unlike patients with inflammatory arthritis whose digital management does not seem to increase physical activity or quality of life, 16 some studies show promising results of digital intervention in physical activity, pain and physical function in patients with hip or knee OA.
11 15 18-20 joint College 19 21 22 was developed in Sweden and is a digital version of the evidencebased face-to-face self-
Management plan to better manage patients with osteoarthritis (BOA).
13 23 as mentioned earlier, the programme includes OA education (
Teaching video on OA, physical activity and weight management)
, Personalized neural muscle exercises designed to improve lower limb strength and nerve muscle control are becoming more difficult, and there is an option to chat asynchronously with the designated physical therapist for feedback and questions.
Studies have shown that completing the 6-week introduction phase in this digital OA management plan can reduce pain and drug intake, increase physical function and walking ability, and reduce the willingness to operate.
However, the patient experience of OA digital management has not yet been evaluated.
This knowledge may help to further improve the digital management options for OA and facilitate the implementation of OA guidelines in a wider community.
Therefore, the purpose of this qualitative study was to investigate the patient's experience with the use of digital management protocols for hip and knee OA.
Method space and public participation statement the treatment plan of OA joint college is based on the following evidence
The concept of baby.
In addition to the interviews in this study, by analyzing the questionnaires and opinions of patients recruited through the Swedish Rheumatism Association, the digital platform has previously been further developed and improved.
These patients were able to test the joint College and conducted extensive interviews on their opinions.
All other aspects of the study were carried out without patient involvement.
Patients were not invited to comment on the design of the study and patients were not consulted
Related results or interpreting results.
Patients are not invited to participate in the writing or editing of this document for readability or accuracy.
The study was conducted at a regional hospital in southern Sweden.
Of the total sample of 2018 individuals who completed the digital OA management plan for 6 weeks from 2015 to 462, the first author emailed 73 invitations with written information about the study (AC).
Inclusion criteria are clinical hip or knee OA, previously confirmed or diagnosed by plastic surgeons involved in the program according to the American College of Radiology standard 25 26.
The exclusion criteria are as follows :(1)
Reporting that joints other than the hip or knee joint are the main joints of OA symptoms and (2)
Do not understand and/or speak Swedish.
Participants were intentionally selected to represent gender, different age groups, perceived pain, and physical function. 27 Twenty-
One participant was invited to participate in the study.
Since one does not speak Swedish, one does not return our call and the two are excluded.
10 female, 9 male, median age 66 (q1–q3, 57–71)
The study has been included for several years in a row.
Their main OA joint position is either on the knee (48%)or hip (52%)(
Participant features see Table 1).
All participants in the study completed the program through a fixed computer, laptop or mobile phone.
View this table: View the features of the inline View pop-up table 1 participant data collection two authors interviewed (
Physical therapy students and AC, physical therapists and doctors), as face-to-
Interview by Skype or telephone, depending on the location of the participants and the way to access Skype.
Semi-structured interview guidelines include areas of interest such (1)
The experience of living with OA ,(2)
Experience in OA management ,(3)
Experience in Digital Management Solutions (eg, set-
Up, education content, feedback, feedback-
Forwarding, availability and design)and (4)
Experiences that may increase the factors of their motivation, persistence, and emotional response.
In addition, participants were invited to make suggestions on possible improvements to the programme. Follow-
The Up question is used to encourage participants to elaborate on the subject and to explain or clarify the meaning and consequences of their experience.
Interview Guide and follow-up-
The Up problem was piloted in three elderly people with OA, not included in the study, and then minor edits were made.
The two interviewers completed the basic training of the interview techniques before collecting the data, and had nothing to do with the participants of the study.
Interviews lasting about 30-40 min were recorded and transcribed verbatim.
Data collection stops when no more information is added, that is, the interview does not add any new information to the results.
For an interview guide, please see Appendix 1 online.
Supplementary Appendix 1]bmjopen-2018-028388supp001. pdf]
System text enrichment for data analysis (STC)
According to malgi's image analysis, Malterud, 28, said.
The process of analysis includes the following steps :(1)
Form an overall impression and determine the theme; (2)
Distinction and sorting of meaning units to code; (3)
Formulate the meaning of each code meaning and (4)
Combine the meaning of concentration into descriptions and concepts (
See Appendix 2 online for examples).
STC was selected as a program to promote crossover
Case Synthesis of text and meaning.
28 Therefore, in the first step, read the interview transcript to obtain an overall impression of the whole and identify the main topics.
Then, the meaning unit is identified to form the code that represents the core of the statement.
At this stage, three authors (JE, AC and CSH)
Work alone to identify as many views and opinions as possible in the material.
Next, all authors work with coded data to produce a set of data that extract duplicate data and data that are not relevant to the purpose of the study.
Then organize the encoded data into sub-categories and re-organize the contents of the meaning units of each categoryexamined.
The meaning and representation of the data is expressed as an aspect of the content.
After that, sub-categories are divided into categories.
To validate the category and make sure that no important aspects are ignored, the author references the cluster back to the original data and reads it again.
Finally, recontextual data is represented as an explanation of the meaning of each category and representative quotes are selected for each category/subcategory.
Supplementary Appendix 2]bmjopen-2018-028388supp002. pdf]
Statement of patient and public participation OA joint college treatment program is based on the following evidence
The concept of baby.
In addition to the interviews in this study, by analyzing the questionnaires and opinions of patients recruited through the Swedish Rheumatism Association, the digital platform has previously been further developed and improved.
These patients were able to test the joint College and conducted extensive interviews on their opinions.
All other aspects of the study were carried out without patient involvement.
Patients were not invited to comment on the design of the study and patients were not consulted
Related results or interpreting results.
Patients are not invited to participate in the writing or editing of this document for readability or accuracy.
The study was conducted at a regional hospital in southern Sweden.
Of the total sample of 2018 individuals who completed the digital OA management plan for 6 weeks from 2015 to 462, the first author emailed 73 invitations with written information about the study (AC).
Inclusion criteria are clinical hip or knee OA, previously confirmed or diagnosed by plastic surgeons involved in the program according to the American College of Radiology standard 25 26.
The exclusion criteria are as follows :(1)
Reporting that joints other than the hip or knee joint are the main joints of OA symptoms and (2)
Do not understand and/or speak Swedish.
Participants were intentionally selected to represent gender, different age groups, perceived pain, and physical function. 27 Twenty-
One participant was invited to participate in the study.
Since one does not speak Swedish, one does not return our call and the two are excluded.
10 female, 9 male, median age 66 (q1–q3, 57–71)
The study has been included for several years in a row.
Their main OA joint position is either on the knee (48%)or hip (52%)(
Participant features see Table 1).
All participants in the study completed the program through a fixed computer, laptop or mobile phone.
View this table: View the features of the inline View pop-up table 1 participant data collection two authors interviewed (
Physical therapy students and AC, physical therapists and doctors), as face-to-
Interview by Skype or telephone, depending on the location of the participants and the way to access Skype.
Semi-structured interview guidelines include areas of interest such (1)
The experience of living with OA ,(2)
Experience in OA management ,(3)
Experience in Digital Management Solutions (eg, set-
Up, education content, feedback, feedback-
Forwarding, availability and design)and (4)
Experiences that may increase the factors of their motivation, persistence, and emotional response.
In addition, participants were invited to make suggestions on possible improvements to the programme. Follow-
The Up question is used to encourage participants to elaborate on the subject and to explain or clarify the meaning and consequences of their experience.
Interview Guide and follow-up-
The Up problem was piloted in three elderly people with OA, not included in the study, and then minor edits were made.
The two interviewers completed the basic training of the interview techniques before collecting the data, and had nothing to do with the participants of the study.
Interviews lasting about 30-40 min were recorded and transcribed verbatim.
Data collection stops when no more information is added, that is, the interview does not add any new information to the results.
For an interview guide, please see Appendix 1 online.
Supplementary Appendix 1]bmjopen-2018-028388supp001. pdf]
System text enrichment for data analysis (STC)
According to malgi's image analysis, Malterud, 28, said.
The process of analysis includes the following steps :(1)
Form an overall impression and determine the theme; (2)
Distinction and sorting of meaning units to code; (3)
Formulate the meaning of each code meaning and (4)
Combine the meaning of concentration into descriptions and concepts (
See Appendix 2 online for examples).
STC was selected as a program to promote crossover
Case Synthesis of text and meaning.
28 Therefore, in the first step, read the interview transcript to obtain an overall impression of the whole and identify the main topics.
Then, the meaning unit is identified to form the code that represents the core of the statement.
At this stage, three authors (JE, AC and CSH)
Work alone to identify as many views and opinions as possible in the material.
Next, all authors work with coded data to produce a set of data that extract duplicate data and data that are not relevant to the purpose of the study.
Then organize the encoded data into sub-categories and re-organize the contents of the meaning units of each categoryexamined.
The meaning and representation of the data is expressed as an aspect of the content.
After that, sub-categories are divided into categories.
To validate the category and make sure that no important aspects are ignored, the author references the cluster back to the original data and reads it again.
Finally, recontextual data is represented as an explanation of the meaning of each category and representative quotes are selected for each category/subcategory.
Supplementary Appendix 2]bmjopen-2018-028388supp002. pdf]
Results three main categories were identified during the analysis: management options to mitigate OA consequences.
The experience of digital solutions is divided into four categories :(1)
Easy to execute ,(2)
Flexible choice when and where ,(3)
Importance of interaction with healthcare professionals4)
Other incentives.
The perceived effects of digital schemes over time are divided into two categories :(1)
After the first 6 weeks, the perceived effect of the scheme and (2)
Reasons for continued participation in the programme (figure 1).
Participants also analyzed suggestions for improving the digital programme.
Download Figure 1 in the new tabDownload powerpoint to describe the category and subcategory overview of the participant's digital experience.
OA, osteoarthritis
Management options to mitigate the consequences of the OAThis category need to experience the perceived consequences of OA, resulting in patients eager to find a treatment that can mitigate the symptoms.
All participants described symptoms such as pain, interrupted sleep, decreased walking ability, immobility, and limited activity.
The main motivation for seeking professional management is pain.
Participants also found that their decreased functioning not only affected themselves, but also put a burden on their partner and family.
They are trying various ways to relieve pain and restore motor function.
They are eager to try any treatment that will ease their symptoms and improve their quality of life.
I feel that it is impossible to continue in this way in such a strong pain . . . . . . (I18)
. . . . . . You know . . . . . . When the worst, I can't go to the city center without thinking about how to get home.
I'm also thinking about surgery and other options but just to get better.
I feel really bad. I12)
You take every opportunity to improve yourself.
In the end, you know it will be beneficial. (I3)
This category includes four subcategories :(1)
Easy to execute ,(2)
Flexible choice when and where ,(3)
Importance of interaction with healthcare professionals4)
Other incentives.
Overall, the programme experience of the participants was positive.
They found the show easy to execute, flexible and motivating.
Interaction with a physical therapist is described as important for support and encouragement.
Participants who are easy to execute are satisfied with this set
The end of the show.
The programme is considered structured, educational and simple to implement.
Other factors that promote participation are teaching videos, email reminders, which are individually tailored and are becoming more difficult, but are also quickly completed.
This is a great set. up.
Not only is it practice, it's really educational and you understand the real meaning of arthritis. (I13)
I found it easy to understand.
It doesn't take a long time, it's really nice to receive these reminders via email (I18)
However, some participants felt that there were some difficulties in understanding how the programme worked.
They found that the progress of the exercise was not clearly described, or it was difficult to understand the specific words used in the video.
It was hard for me to understand at first, actually it took me some time to understand correctly.
It took me about a few weeks to actually get the system.
I think it's a pity. (I8)
Flexibility in choosing when and where all participants acknowledge the flexibility associated with this digital management programme.
Thank you very much for being able to practice without using any equipment at home or at any time, at any location.
Compared to traditional management, the ability to control when to practice and the point of time that does not have to make an appointment at a specific location is described as an advantage and further expressed as time
As participants do not have to ask for leave for OA management work, time is saved and stress is reduced.
One participant even said that she would never finish it if it was not a digital solution.
The flexibility I can decide for myself when to practice is very good.
When I have to dress, go out, and meet a physical therapist at this exact point in time, I don't have any scheduled point in time.
I can decide . . . . . . (I11)
I think it's not bad to do this on the Internet at all.
I would never do this if it weren't for numbers (I17)
Some participants described the long wait --
Therefore, the inventory and digital scheme of traditional OA management in primary care is a flexible option that they can start immediately.
Yes, it's also like there's such a long waiting list for primary care.
So I think I can start doing this right away. (I10)
Some participants felt that the importance of interacting with healthcare professionals receiving OA diagnostics without any physical meetings was a bit embarrassing.
There are concerns about missing the risk of serious illness if diagnosed by phone or internet.
It is difficult to give a diagnosis by phone.
You can do it, but it's more difficult and you may miss something . . . . . . There may be tumors there . . . . . . (I14)
Most participants have a very positive experience of interacting with their online physical therapist.
They described that they received a quick response to the question, as well as information and encouragement, and that they often received feedback within a few hours.
Some say their physical therapist's involvement is valuable for support and encouragement, especially if they experience pain during exercise.
Daily contact with physical therapists encourages them to exercise every day, which is also considered an advantage compared to traditional care management.
I think it's great to get in touch every day.
I think it stands out.
It put pressure on me to actually do these exercises and answer him [
Physical therapist
Give him a chance to provide feedback and information on other things . . . . . . You can't go to a physical therapist every day, every day.
That's not good.
They don't have time to take care of me and they have someone else to take care. (I12)
In contrast, some participants experienced unsatisfactory or even unsatisfactory contact with their online physical therapistexistent.
They describe that it may take a week for them to receive any responses, which are only partially answered or not at all.
Continuous tracking-
There was also a lack of feedback and encouragement on their performance in the programme.
At the beginning, they said someone would contact me on a regular basis, something like that.
But it didn't happen as I expected. I9)
Other motivational factors daily email reminders are often highlighted as motivational factors as they ensure that participants do not forget to practice and push them to do their activities on a daily basis.
The improvement of OA symptoms and the measurement feedback system provided by the program are other factors and are mentioned as motivation to assist participants in their exercise.
It's there and it's in my mailbox every day.
Well, I'm going to do this exercise today . . . . . . What pushed me.
I think this is good . . . . . . I need that. (I8)
The category of the perceived impact of digital programming on time includes two sub-categories :(1)
The perceived effect of the scheme after the first 6 weeks and (2)
Reasons for continued participation in the programme.
Most participants reported improved functioning and reduced pain.
However, some people feel that there is no improvement and their symptoms are the same as before entering the program.
After the first 6 weeks, many people continued to participate in the project to maintain positive improvement.
After the first 6 weeks, the perceived effects of the digital program several participants significantly reduced OA symptoms after completing the program.
Improvements commonly mentioned are pain relief, increased flexibility and improved walking ability.
In many cases, symptoms are still present, but are considered to be significantly improved, resulting in improved quality of life and less attention to the disease.
Many say they have recommended the program to friends and relatives with hip or knee OA as they are satisfied with the results and hope more people will be able to accept the same management program.
It helped me a lot.
If I hadn't done that, I don't think I could have gone like this today . . . . . . I don't think so . . . . . . I think this project has played an absolutely important role in the fact that I can manage my daily life as I do now, even though I have a big problem(I2)
Not all participants felt that they had symptoms relieved or improved after 6 weeks of project implementation.
Some have described that their symptoms are still the same, or initially improved, and then deteriorated as the physical function deteriorated and the pain worsened.
However, some of these participants still believe
Despite not experiencing the results they hoped.
The reason why positive results have not been achieved is because people think that they are too late to enter the program, that is, if exercise is started early in the disease, or exercise may slow the progress of the disease, these exercises may help.
Sadly, even if I do these exercises every day, every week, every month, every year . . . . . . Nothing happened . . . . . . I'm not getting better either. (I4)
It felt really good at first.
The reason it didn't help me was probably because I started too late. (I12)
Reason to continue to participate in the month after the program memany continues to do their exercises-Weekly evaluation.
Perceived functional improvement and pain relief as well as fear of worsening symptoms are highly motivating factors for continued exercise.
Another reason is that this may help them prepare for any surgery that is coming.
I believe in these exercises.
I think exercise is good for arthritis. I am convinced.
If I don't do it anymore, I think, then this terrible pain will start again. (I8)
On the other hand, some participants described pain relief and scheduled surgery as the reason for not continuing the programme.
Pain is usually reduced . . . . . . Then I didn't have the motivation as before, so I gave up my exercise . . . . . . Yes, I did.
In general, in physical therapy, it's hard to stay motivated if you don't have a lot of pain. (I19)
I have already met with my orthopaedic doctor and I plan to have an operation . . . . . . I think the problem is coming to an end.
That's why I don't do as much as I should. (I18)
Participants suggested some possible improvements to the digital programme.
For example, many people think that the practice is too little and the change is small, and after a period of time, the practice is considered a bit monotonous, especially if the participants are very active in the project, that is, a few days of exercise per week.
It has been suggested that changing and/or adding more exercises increases the motivation to do the exercises.
In the end, it gets a little boring because there are very few moves . . . . . . So I added some extra moves myself . . . . . . Doing the same thing every day is a bit boring. (I14)
Some participants who are not satisfied with the communication with the online physical therapist suggest using more feedback and encouragement to improve the patient's interaction with the physical therapist.
Another suggestion includes:
Enhance feedback on individual performance for specific exercises via video call or Skype.
You can send a video over the Internet, and then the physical therapist will check if you did the exercise and did the exercise correctly, and correct you if you did not do it correctly. (I19)
Management options to mitigate the consequences of the OAThis category need to experience the perceived consequences of OA, resulting in patients eager to find a treatment that can mitigate the symptoms.
All participants described symptoms such as pain, interrupted sleep, decreased walking ability, immobility, and limited activity.
The main motivation for seeking professional management is pain.
Participants also found that their decreased functioning not only affected themselves, but also put a burden on their partner and family.
They are trying various ways to relieve pain and restore motor function.
They are eager to try any treatment that will ease their symptoms and improve their quality of life.
I feel that it is impossible to continue in this way in such a strong pain . . . . . . (I18)
. . . . . . You know . . . . . . When the worst, I can't go to the city center without thinking about how to get home.
I'm also thinking about surgery and other options but just to get better.
I feel really bad. I12)
You take every opportunity to improve yourself.
In the end, you know it will be beneficial. (I3)
This category includes four subcategories :(1)
Easy to execute ,(2)
Flexible choice when and where ,(3)
Importance of interaction with healthcare professionals4)
Other incentives.
Overall, the programme experience of the participants was positive.
They found the show easy to execute, flexible and motivating.
Interaction with a physical therapist is described as important for support and encouragement.
Participants who are easy to execute are satisfied with this set
The end of the show.
The programme is considered structured, educational and simple to implement.
Other factors that promote participation are teaching videos, email reminders, which are individually tailored and are becoming more difficult, but are also quickly completed.
This is a great set. up.
Not only is it practice, it's really educational and you understand the real meaning of arthritis. (I13)
I found it easy to understand.
It doesn't take a long time, it's really nice to receive these reminders via email (I18)
However, some participants felt that there were some difficulties in understanding how the programme worked.
They found that the progress of the exercise was not clearly described, or it was difficult to understand the specific words used in the video.
It was hard for me to understand at first, actually it took me some time to understand correctly.
It took me about a few weeks to actually get the system.
I think it's a pity. (I8)
Flexibility in choosing when and where all participants acknowledge the flexibility associated with this digital management programme.
Thank you very much for being able to practice without using any equipment at home or at any time, at any location.
Compared to traditional management, the ability to control when to practice and the point of time that does not have to make an appointment at a specific location is described as an advantage and further expressed as time
As participants do not have to ask for leave for OA management work, time is saved and stress is reduced.
One participant even said that she would never finish it if it was not a digital solution.
The flexibility I can decide for myself when to practice is very good.
When I have to dress, go out, and meet a physical therapist at this exact point in time, I don't have any scheduled point in time.
I can decide . . . . . . (I11)
I think it's not bad to do this on the Internet at all.
I would never do this if it weren't for numbers (I17)
Some participants described the long wait --
Therefore, the inventory and digital scheme of traditional OA management in primary care is a flexible option that they can start immediately.
Yes, it's also like there's such a long waiting list for primary care.
So I think I can start doing this right away. (I10)
Some participants felt that the importance of interacting with healthcare professionals receiving OA diagnostics without any physical meetings was a bit embarrassing.
There are concerns about missing the risk of serious illness if diagnosed by phone or internet.
It is difficult to give a diagnosis by phone.
You can do it, but it's more difficult and you may miss something . . . . . . There may be tumors there . . . . . . (I14)
Most participants have a very positive experience of interacting with their online physical therapist.
They described that they received a quick response to the question, as well as information and encouragement, and that they often received feedback within a few hours.
Some say their physical therapist's involvement is valuable for support and encouragement, especially if they experience pain during exercise.
Daily contact with physical therapists encourages them to exercise every day, which is also considered an advantage compared to traditional care management.
I think it's great to get in touch every day.
I think it stands out.
It put pressure on me to actually do these exercises and answer him [
Physical therapist
Give him a chance to provide feedback and information on other things . . . . . . You can't go to a physical therapist every day, every day.
That's not good.
They don't have time to take care of me and they have someone else to take care. (I12)
In contrast, some participants experienced unsatisfactory or even unsatisfactory contact with their online physical therapistexistent.
They describe that it may take a week for them to receive any responses, which are only partially answered or not at all.
Continuous tracking-
There was also a lack of feedback and encouragement on their performance in the programme.
At the beginning, they said someone would contact me on a regular basis, something like that.
But it didn't happen as I expected. I9)
Other motivational factors daily email reminders are often highlighted as motivational factors as they ensure that participants do not forget to practice and push them to do their activities on a daily basis.
The improvement of OA symptoms and the measurement feedback system provided by the program are other factors and are mentioned as motivation to assist participants in their exercise.
It's there and it's in my mailbox every day.
Well, I'm going to do this exercise today . . . . . . What pushed me.
I think this is good . . . . . . I need that. (I8)
Participants who are easy to execute are satisfied with this set
The end of the show.
The programme is considered structured, educational and simple to implement.
Other factors that promote participation are teaching videos, email reminders, which are individually tailored and are becoming more difficult, but are also quickly completed.
This is a great set. up.
Not only is it practice, it's really educational and you understand the real meaning of arthritis. (I13)
I found it easy to understand.
It doesn't take a long time, it's really nice to receive these reminders via email (I18)
However, some participants felt that there were some difficulties in understanding how the programme worked.
They found that the progress of the exercise was not clearly described, or it was difficult to understand the specific words used in the video.
It was hard for me to understand at first, actually it took me some time to understand correctly.
It took me about a few weeks to actually get the system.
I think it's a pity. (I8)
Flexibility in choosing when and where all participants acknowledge the flexibility associated with this digital management programme.
Thank you very much for being able to practice without using any equipment at home or at any time, at any location.
Compared to traditional management, the ability to control when to practice and the point of time that does not have to make an appointment at a specific location is described as an advantage and further expressed as time
As participants do not have to ask for leave for OA management work, time is saved and stress is reduced.
One participant even said that she would never finish it if it was not a digital solution.
The flexibility I can decide for myself when to practice is very good.
When I have to dress, go out, and meet a physical therapist at this exact point in time, I don't have any scheduled point in time.
I can decide . . . . . . (I11)
I think it's not bad to do this on the Internet at all.
I would never do this if it weren't for numbers (I17)
Some participants described the long wait --
Therefore, the inventory and digital scheme of traditional OA management in primary care is a flexible option that they can start immediately.
Yes, it's also like there's such a long waiting list for primary care.
So I think I can start doing this right away. (I10)
Some participants felt that the importance of interacting with healthcare professionals receiving OA diagnostics without any physical meetings was a bit embarrassing.
There are concerns about missing the risk of serious illness if diagnosed by phone or internet.
It is difficult to give a diagnosis by phone.
You can do it, but it's more difficult and you may miss something . . . . . . There may be tumors there . . . . . . (I14)
Most participants have a very positive experience of interacting with their online physical therapist.
They described that they received a quick response to the question, as well as information and encouragement, and that they often received feedback within a few hours.
Some say their physical therapist's involvement is valuable for support and encouragement, especially if they experience pain during exercise.
Daily contact with physical therapists encourages them to exercise every day, which is also considered an advantage compared to traditional care management.
I think it's great to get in touch every day.
I think it stands out.
It put pressure on me to actually do these exercises and answer him [
Physical therapist
Give him a chance to provide feedback and information on other things . . . . . . You can't go to a physical therapist every day, every day.
That's not good.
They don't have time to take care of me and they have someone else to take care. (I12)
In contrast, some participants experienced unsatisfactory or even unsatisfactory contact with their online physical therapistexistent.
They describe that it may take a week for them to receive any responses, which are only partially answered or not at all.
Continuous tracking-
There was also a lack of feedback and encouragement on their performance in the programme.
At the beginning, they said someone would contact me on a regular basis, something like that.
But it didn't happen as I expected. I9)
Other motivational factors daily email reminders are often highlighted as motivational factors as they ensure that participants do not forget to practice and push them to do their activities on a daily basis.
The improvement of OA symptoms and the measurement feedback system provided by the program are other factors and are mentioned as motivation to assist participants in their exercise.
It's there and it's in my mailbox every day.
Well, I'm going to do this exercise today . . . . . . What pushed me.
I think this is good . . . . . . I need that. (I8)
The category of the perceived impact of digital programming on time includes two sub-categories :(1)
The perceived effect of the scheme after the first 6 weeks and (2)
Reasons for continued participation in the programme.
Most participants reported improved functioning and reduced pain.
However, some people feel that there is no improvement and their symptoms are the same as before entering the program.
After the first 6 weeks, many people continued to participate in the project to maintain positive improvement.
After the first 6 weeks, the perceived effects of the digital program several participants significantly reduced OA symptoms after completing the program.
Improvements commonly mentioned are pain relief, increased flexibility and improved walking ability.
In many cases, symptoms are still present, but are considered to be significantly improved, resulting in improved quality of life and less attention to the disease.
Many say they have recommended the program to friends and relatives with hip or knee OA as they are satisfied with the results and hope more people will be able to accept the same management program.
It helped me a lot.
If I hadn't done that, I don't think I could have gone like this today . . . . . . I don't think so . . . . . . I think this project has played an absolutely important role in the fact that I can manage my daily life as I do now, even though I have a big problem(I2)
Not all participants felt that they had symptoms relieved or improved after 6 weeks of project implementation.
Some have described that their symptoms are still the same, or initially improved, and then deteriorated as the physical function deteriorated and the pain worsened.
However, some of these participants still believe
Despite not experiencing the results they hoped.
The reason why positive results have not been achieved is because people think that they are too late to enter the program, that is, if exercise is started early in the disease, or exercise may slow the progress of the disease, these exercises may help.
Sadly, even if I do these exercises every day, every week, every month, every year . . . . . . Nothing happened . . . . . . I'm not getting better either. (I4)
It felt really good at first.
The reason it didn't help me was probably because I started too late. (I12)
Reason to continue to participate in the month after the program memany continues to do their exercises-Weekly evaluation.
Perceived functional improvement and pain relief as well as fear of worsening symptoms are highly motivating factors for continued exercise.
Another reason is that this may help them prepare for any surgery that is coming.
I believe in these exercises.
I think exercise is good for arthritis. I am convinced.
If I don't do it anymore, I think, then this terrible pain will start again. (I8)
On the other hand, some participants described pain relief and scheduled surgery as the reason for not continuing the programme.
Pain is usually reduced . . . . . . Then I didn't have the motivation as before, so I gave up my exercise . . . . . . Yes, I did.
In general, in physical therapy, it's hard to stay motivated if you don't have a lot of pain. (I19)
I have already met with my orthopaedic doctor and I plan to have an operation . . . . . . I think the problem is coming to an end.
That's why I don't do as much as I should. (I18)
After the first 6 weeks, the perceived effects of the digital program several participants significantly reduced OA symptoms after completing the program.
Improvements commonly mentioned are pain relief, increased flexibility and improved walking ability.
In many cases, symptoms are still present, but are considered to be significantly improved, resulting in improved quality of life and less attention to the disease.
Many say they have recommended the program to friends and relatives with hip or knee OA as they are satisfied with the results and hope more people will be able to accept the same management program.
It helped me a lot.
If I hadn't done that, I don't think I could have gone like this today . . . . . . I don't think so . . . . . . I think this project has played an absolutely important role in the fact that I can manage my daily life as I do now, even though I have a big problem(I2)
Not all participants felt that they had symptoms relieved or improved after 6 weeks of project implementation.
Some have described that their symptoms are still the same, or initially improved, and then deteriorated as the physical function deteriorated and the pain worsened.
However, some of these participants still believe
Despite not experiencing the results they hoped.
The reason why positive results have not been achieved is because people think that they are too late to enter the program, that is, if exercise is started early in the disease, or exercise may slow the progress of the disease, these exercises may help.
Sadly, even if I do these exercises every day, every week, every month, every year . . . . . . Nothing happened . . . . . . I'm not getting better either. (I4)
It felt really good at first.
The reason it didn't help me was probably because I started too late. (I12)
Reason to continue to participate in the month after the program memany continues to do their exercises-Weekly evaluation.
Perceived functional improvement and pain relief as well as fear of worsening symptoms are highly motivating factors for continued exercise.
Another reason is that this may help them prepare for any surgery that is coming.
I believe in these exercises.
I think exercise is good for arthritis. I am convinced.
If I don't do it anymore, I think, then this terrible pain will start again. (I8)
On the other hand, some participants described pain relief and scheduled surgery as the reason for not continuing the programme.
Pain is usually reduced . . . . . . Then I didn't have the motivation as before, so I gave up my exercise . . . . . . Yes, I did.
In general, in physical therapy, it's hard to stay motivated if you don't have a lot of pain. (I19)
I have already met with my orthopaedic doctor and I plan to have an operation . . . . . . I think the problem is coming to an end.
That's why I don't do as much as I should. (I18)
Participants suggested some possible improvements to the digital programme.
For example, many people think that the practice is too little and the change is small, and after a period of time, the practice is considered a bit monotonous, especially if the participants are very active in the project, that is, a few days of exercise per week.
It has been suggested that changing and/or adding more exercises increases the motivation to do the exercises.
In the end, it gets a little boring because there are very few moves . . . . . . So I added some extra moves myself . . . . . . Doing the same thing every day is a bit boring. (I14)
Some participants who are not satisfied with the communication with the online physical therapist suggest using more feedback and encouragement to improve the patient's interaction with the physical therapist.
Another suggestion includes:
Enhance feedback on individual performance for specific exercises via video call or Skype.
You can send a video over the Internet, and then the physical therapist will check if you did the exercise and did the exercise correctly, and correct you if you did not do it correctly. (I19)
Discussion we are trying to investigate the participant experience of the hip and knee OA digital management program.
Most participants reported improvements after the first 6 weeks, such as pain relief, increased mobility and improved quality of life.
Overall, the programme was considered easy to implement.
The flexibility to be able to practice anywhere and at any point in time is highly appreciated.
Compared to traditional care, daily contact with physical therapists is considered to be very important and an advantage, and participants believe that the support and encouragement they receive is important for continued exercise.
In addition, participants recommend adding more changes to exercises and follow-up activitiesup by video-calls.
Despite the international guidelines, many patients with hip and knee OA do not have the information about appropriate treatment and OA management options. 4 13 14 Web-
A management plan based on or digital is proposed as a way to promote the implementation of non-
Surgical treatment because it is possible for them to reach more people who need OA treatment.
4 Participants in this study were positive for most of the group-
The end of the show.
It is believed that it is valuable to be able to exercise anytime, anywhere without taking a vacation.
Some participants also mentioned that they could start doing digital programming right away instead of waiting --list.
They also went through the education of the program and they felt motivated by the daily email reminder and feedback system provided by the program.
This result is consistent with previous studies that investigated patients' perceptions of digital OA management, such as through the Internet or remote rehabilitation, and participants experienced such a convenient and time-consuming programsaving.
30 31 exercise is one of the cornerstones of OA management.
12 however, the results of the OA management programme depend largely on compliance with these activities.
People with OA are reported to be one of those who insist on this treatment particularly poorly, 32, although these patients seem to have a good hold on online treatment.
33 A recent systematic review of people with hip and knee OA identified factors such as increased awareness of the disease and the benefits of exercise, reduced symptoms, and easy access to training facilities, and be able to integrate exercise into daily life to facilitate the participation of exercise, while long travel and parking difficulties are considered obstacles.
34. current findings suggest that digital programmes may help to participate in OA management programmes and eliminate some of the barriers to participation in exercise, such as access to opportunities and time constraints, it also further emphasizes the importance of adequate information and education on the benefits of exercise and different treatment options in OA.
However, the digital program has some very different experiences, mainly related to perceived symptom improvement and contact with physical therapists.
Future quantitative surveys may reveal whether this discrepancy is related to compliance in the programme, that is, the level of activity.
Previous studies concluded that including behavior change techniques may increase adherence to the exercise35, and that digital delivery may allow patients to continue treatment week after week to further improve and maintain that they have
Previous studies have shown that the support and encouragement of medical staff is an important factor in promoting the participation of hip and knee OA patients in exercise.
This is also reflected in this study.
Interaction with a physical therapist is another important aspect highlighted by the participants.
Most participants have a positive experience with contact with designated physical therapists, who have a lot of motivation for daily contact and the support and encouragement provided.
This result further highlights previous findings that a strong healing alliance can be established without having to meet in person.
However, some participants were not satisfied with the contact, which in turn reduced their motivation to practice.
This may indicate that the support and encouragement of physical therapists is a prerequisite for a satisfactory experience with the digital OA management program.
According to the study of remote rehabilitation, we expressed some concerns about online diagnosis in the interview.
Some patients are worried that they may have more serious diseases, such as cancer, and it may be difficult to make differential diagnosis through the Internet.
It is therefore important to respond accordingly to these concerns and to provide information to patients explaining that OA is primarily diagnosed through symptoms and signs without the need to use radiography or laboratory equipment.
39. In addition, some participants wished to see the following:
Ups eliminates the risk of misperforming exercises through video calls.
This is consistent with previous research reports. Home of supervision
Basic exercises may raise concerns about the correct performance of the exercises.
Therefore, 5 31 40 video calls may be a way to further develop the show and optimize the digital programming experience without any physical meetings.
However, further research is needed on the impact of video sessions.
These results confirm the results of previous studies, as participants reported that the most important outcome of the programme was improvement, such as pain relief, increased flexibility and improved walking ability, this has brought about an improvement in the quality of life and reduced attention to diseases.
Interestingly, pain relief and scheduling of surgery are two factors that are described as facilitators and barriers to continued implementation of the programme.
Some participants continued to exercise as they experienced the program reducing their pain and they were worried that the pain would come back if they stopped exercising.
In contrast, some people think that reducing pain is the reason to stop exercising because when pain is no longer a problem, their motivation is lost.
Again, some participants continue to exercise because they want to be prepared for full joint replacement and be as healthy as possible (TJR)
, While others stopped exercising when they were scheduled to be in TJR because they thought the surgery would solve their problems anyway.
As we all know, preoperative exercise can improve the results after total knee replacement, such as length of stay, range of motion of the knee joint and physical function, so it is important to include in educational materials, to promote the rehabilitation of these patients after the future TJRs.
An advantage of this study was that participants were selected purposefully, including men and women with different ages, OA severity, physical function, and OA locations (hip or knee)
From different parts of Sweden.
However, since the participants are all over Sweden, most of the interviews are conducted by phone or Skype.
Due to the loss of visual input, this method may lead to a reduction in the depth of the interview.
In addition, two participants completed the programme more than 1 year before the interview, which may have affected their recollection of the programme and thus the experience expressed in the interview.
Another limitation may be the failure to record some demographic data of the participants, such as the level of education, the experience of using digital applications, and the year of OA diagnosis.
This information may increase the universality of the results.
In the whole process of data analysis, we have considered the reflexivity, that is, we have realized that
Understanding the author as a clinician and researcher may affect the data if you do not fully understand the previous experience.
42. all authors work individually in the process of data processing and continue to discuss during the analysis process, aiming to eliminate the possible impact of previous experience, which helps us to remain neutral about the data.
In addition, we have submitted a signature after each offer to show the representation of our participants and to add transparency and credibility to our discovery and interpretation of the data.
Conclusion The Digital management protocol of OA, including education and exercise, as well as the option to chat with designated physical therapists for feedback, questions and participation, may be an alternative to traditional treatment, and further promote the implementation of OA guidelines in a wider community.
Participants had positive experience with the programme, the flexibility of the programme in terms of location and timing.
Regular and regular contact with physical therapists is considered particularly important for a positive experience of the program, which is also highlighted as an advantage over traditional care.
In addition, the results of this study will contribute to the further development and improvement of OA digital management. References1.
Shopolthuisjv, WattMC, shopleyk, etc. Therapist-
Internet cognitive behavior therapy supporting anxiety disorder in adults.
The Cochrane Database Syst Rev2016; 3:Cd011565. doi:10. 1002/14651858. CD011565. pub2OpenUrl2.
Van Bergen, feldamm, Hoven, etc. Internet-
Meta-study of cognitive behavior therapy in patients with chronic physical diseases-Analyze comments.
J. Med Internet Res2014; 16:e88. doi:10. 2196/jmir.
2777openurlcrossrefubmed3.
Boogerdea, NoordamC, KremerJA, etc.
Cooperation: the feasibility of online treatment environment for adolescents with type 1 diabetes.
Children with Diabetes; 15:394–402. doi:10. 1111/pedi.
12103openurlcrossrefubmed4.
LiLC, CottC, JonesCA, etc.
Improving primary care for chronic skeletal diseases through digital media: People's Conference.
Prototype JMIR Res; 2:e13. doi:10. 2196/resprot. 2267OpenUrl5.
Biyorab, jostrom, John Senny, etc.
Female experience of the Internet
Treatment of stress urinary incontinence based on or by post.
Qualifying health Res2014; 24:484–93. doi:10.
1177/1049732314524486 openurlcrosspubmed6.
VerhoeksC, TeunissenD, van der Stelt-
SteenbergenA and others.
Expectations and experience of women in e-commerce
Health treatment: a systematic review.
Health Informatics j20177: 146045821772039. doi:10.
1177/14604582177203947.
Alimbidmons, TerlutterR.
Gender difference between Internet and virtual patient search for health information
Doctor's relationship in Germany: exploratory results on differences between men and women and why.
Internet Res2015; 17:e156. doi:10. 2196/jmir. 4127OpenUrl8.
Dompowellj, InglisN, RonnieJ, etc.
Features and motivations of online health information seekers: Crossover
Qualitative Interview Research.
The development of the Internet; 13:e20. doi:10. 2196/jmir.
1600openurlcrossrefpmed9. ↵Sánchez-
OrtizVC, house j, MunroC, etc.
"Computer will not judge you": a qualitative study of users' views on the Internet
Self-guided by cognitive behavior
Nursing and treatment package for neurological greed and related diseases.
Unqualified weight; 16:e93–e101. doi:10.
1007/BF03325314OpenUrlPubMed10.
Alimroettlj, BidmonS, TerlutterR.
What predicts the willingness of patients to receive online treatment and to pay for online treatment?
Results from the network
Survey based on survey of patient changes
Doctor relationship
Internet Res2016; 18:e32. doi:10. 2196/jmir. 5244OpenUrl11.
Coach PietrzakE, CoteaC, luxury train, etc. Self-
Management and Rehabilitation of osteoarthritis: Is there a place for the Internet
Based on intervention?
Telemed J. E. 19:800–5. doi:10. 1089/tmj. 2012. 0288OpenUrl12. ↵JevsevarDS.
Treatment of knee osteoarthritis: Evidence
Based on the guide, version 2nd.
J. Am Acad Orthop surg33; 21:571–6. doi:10. 5435/JAAOS-21-09-
571openurlcrossrefpmed13.
Thornthorstenssonca, GarellickG, RystedtH, etc.
Better management of patients with osteoarthritis: development of evidence and nationwide implementation
Osteoarthritis based on self-support
Management Plan.
Muscle and bone care13:67–75. doi:10. 1002/msc.
1085OpenUrlPubMed14.
LiLC, SayreEC, KopecJA, etc.
Non-drug quality of care in patients with knee and hip osteoarthritis in the community.
J Rheumatol2011; 38:2230–7. doi:10. 3899/jrheum.
110264 OpenUrlAbstract/free full text text15.
Shopbossend, VeenhofC, Van BeekKE, etc.
Effectiveness of the network
Physical activity-based interventions in patients with knee and/or hip osteoarthritis: a randomized controlled trial.
J. Med Internet res2015; 15:e257. doi:10. 2196/jmir. 2662OpenUrl16.
Griffith, whiteham, ThainPK, etc.
Effects of interactive digital intervention on physical activity in patients with inflammatory arthritis: a systematic review.
Rheumatol Int2018; 38:1623–34. doi:10. 1007/s00296-018-4010-8OpenUrl17.
BerryA, McCabeCS, MuirS, etc.
Digital behavioral change intervention to promote physical activity in osteoarthritis: a systematic review.
Summary of physiotherapy 2018; 23:197–206. doi:10. 1080/10833196. 2018.
1470747OpenUrl18.
Alimneroh, DahlbergJ, DahlbergLE. A 6-Week Web-
Treatment plan based on osteoarthritis: observation accuracy
Experimental study.
Res207 online medical journal; 19:e422. doi:10. 2196/jmir. 9255OpenUrl19.
Alimdahlbergle, GrahnD, DahlbergJE, etc. A Web-
Basic platform for patients with hip and knee osteoarthritis: a pilot study.
Res JMIR Protoc2016; 5:e115. doi:10. 2196/resprot. 5665OpenUrl20.
Alimsmittenaarp, Erhart-
HledikJC, KinsellaR, etc.
Transforming integrated conservative care for chronic knee pain into a digital care pathway: 12-Week and 6-
Monthly results of hinge health plan.
JMIR Rehabil is auxiliary to asil207; 4:e4. doi:10. 2196/rehab. 7258OpenUrl21. ↵. Joint Academy [
Dalberberger.
Dale Berg le: Union Collegea six-
Weekly online treatment plan for osteoarthritis.
International Society for the Study of osteoarthritisOARSI.
Liverpool, England: Osteoarthritis and Cartilage, 201823.
Ekjönssont, Ekvall HanssonE, ThorstenssonCA, etc.
Effects of education and supervision exercise on physical activity, pain, quality of life and selfefficacy -
Intervention Study with reference group.
BMC Musculoskelet Disord2018; 19:198. doi:10. 1186/s12891-018-2098-3OpenUrl24.
Nello, Dalberg.
Factors associated with the patient's willingness to consider joint surgery after completing the digital osteoarthritis treatment plan: a prospective cohort study.
Arthritis Care res2018doi:10. 1002/acr. 2377225.