This survey asked people from primary care with mild to moderate chronic knee pain about the treatment they had received and their treatment preferences, and matched these against the recommendations of evidence-based management guidelines. While most people had received some form of treatment, the treatment they received frequently did not reflect guideline recommendations or treatment preferences, though nearly a half of people expressed no treatment preference.
Clinical guidelines for the management of knee pain recommend initially employing non-pharmacological interventions (verbal and written information about the condition, self-management, physiotherapy, etc), supplemented with simple analgesia (paracetamol, topical agents), if necessary progressing to stronger second line oral analgesia (opioids and NSAIDs), reserving surgery for people unresponsive to conservative management [3, 13, 14]. In general, the clinical guidelines reflect lay people's treatment preferences for physiotherapy, not medication or surgery, and confirms the findings of previous studies [8, 16]. However, in spite of management guidelines, the popularity and proven efficacy of physiotherapy [17, 18], the unpopularity of medication, people's willingness to put up with pain to avoid taking medication [10] and serious concerns regarding the safety [19–21], efficacy [22] and costs [5] of medication, the majority of people had been prescribed analgesia or NSAIDs to alleviate their knee pain, while less than half had been referred to physiotherapy. Poor adherence to these clinical guidelines and the suboptimal management of osteoarthritis is not uncommon [23, 24].
We did not specifically enquire what information, education or advice people had received, but most people will probably have received some information and advice about their condition informally during clinical consultations, rather than through a formal structured self-management programme. That no participant spontaneously mentioned information/advice as an intervention received suggests that they didn't receive any information, but if information was given people do not perceive it to be an intervention per se or it was ineffectual and people do not value its usefulness [16].
Lack of information about chronic joint pain, its causes, effects, prognosis and effective treatment options can have a major influence on people's preference for, acceptance of and adherence to treatment. Nearly half of the participants did not express any treatment preference. While some people will be happy to devolve decisions about their treatment to healthcare professionals [19], others will want to be involved in deciding their management. Coming to an informed decision about management requires that all available options are known. If the lack of treatment preference reflects limited awareness of effective treatment options, the ability of people to make informed decisions will be impeded. Tallon et al reported that although few people valued patient education/information many thought this should be a research priority, and the authors suggested it may be a way of people asking to take control of their condition [16]. If correct, not giving people information is denying them control over their condition. Our study suggests that despite the prioritisation of education/information recommended in clinical guidelines, if delivered at all, it is delivered ineffectually so people do not appreciate, utilise and implement the information. Ensuring people have sufficient information to make informed realistic decisions about treatment and eliciting treatment preferences may facilitate the decision-making process.
A sizable number of people (10%) had received surgery (arthroscopy, lavage, menisectomy) though there is little evidence these procedures are effective and they carry inherent risks. Although a few people had been referred for orthopaedic assessment they were undecided about accepting when given a date as they did not perceive it to be necessary [25]. This ambivalence highlights the unpopularity of surgery [26]; without prompting 10% of people stated they did not want surgery because of the nature of the intervention or the negative experiences of people they knew. It also highlights the disparity between lay people's perceptions about the need for medical/surgical intervention and a healthcare professional's assessment of need [25, 27], emphasising the necessity of informed shared decision-making when deciding important management strategies. A small minority of people (<4%) nominated knee surgery as their preferred treatment.
This study has limitations that need to be considered. Firstly, it was not a "purpose-designed" in-depth survey of patient preferences, and it had to be carried out within the time and resource limitations of the RCT. We wanted to identify important issues that might be explored in greater detail, for example the nature of patient preferences, using in-depth interviews. Secondly, an RCT of a physiotherapy-based intervention might recruit people who prefer physiotherapy and are biased against medication, surgery and other interventions, while people with strong preferences against physiotherapy and exercise may have decided not to participate, giving a biased sample. However, the high proportion of people who had no treatment preference suggests selection bias did not influence the results greatly. Finally, information given during consent may have increased people's awareness of physiotherapy and other treatment options causing them to respond differently in the light of this knowledge. Again, if correct, more participants would have been expected to express treatment preferences.
In summary, we found a mismatch between people's treatment preferences, the treatment they had received and treatment that evidence-based guidelines recommend they should receive for chronic knee pain. Pressures on time and resources may be encouraging routine prescription of palliative medication [28], which is not recommended by current guidelines as an effective, efficient or safe way to manage chronic joint pain, instead of providing more and better information enabling people to make informed management choices. People in this study told us they wanted what the guidelines say they should get – initially non-pharmacological interventions with minimal medical/surgical intervention, with increasing medical/surgical intervention if these are ineffective. People's preferences and judgement of need for an intervention, their positive experience and concerns about outcome and side-effects influence acceptance of and adherence to treatment [29]. Enabling people to make informed choices, and delivering people's preferred healthcare interventions is likely to promote better adherence to optimal, effective management, especially when their preferences closely reflect the recommendations of the best available evidence.
