Impact of a Two-day Training Course on Knowledge and Confidence of German Physiotherapists in the Management of Hip and Knee Osteoarthritis

Abstract

Background

Clinical practice guidelines recommend a combination of exercise therapy and education for the management of hip and knee osteoarthritis. Initiated in 2013, the Good Life with osteoArthritis in Denmark (GLA:D) programme ensures standardised and evidence-based treatment. In a two-day training course, therapists are trained to provide the structured education and exercise program.

Aim

To evaluate the effect of the two-day training course on physiotherapists' subjectively perceived knowledge and confidence in treating hip and knee osteoarthritis.

Methods

Physiotherapists completed online surveys immediately before and two weeks after the GLA:D training course. They were asked to rate their confidence in providing guideline-adherent therapy for osteoarthritis, their beliefs about the evidence supporting different treatment options, and awareness of clinical practice guidelines. The effectiveness of the training course was evaluated using a pre- and post-training comparison.

Results

Of a total of 290 physiotherapists invited, 254 responded to the first survey (response rate: 87.6 %), including 114 women (44.9 %). The mean age of the respondents was 35 years (± 10.7). A total of 83 therapists (32.7 %) had obtained a higher academic degree. The follow-up questionnaire was completed by 85 respondents (response rate: 29.3 %). The two-day training course resulted in improvements in both subjectively perceived knowledge and confidence in providing guideline-adherent therapy. Over 98 % of respondents felt well-trained and able to provide exercise therapy and education according to guideline recommendations.

Conclusions

Participation in the two-day GLA:D training course led to positive changes in physiotherapists’ subjectively perceived knowledge and confidence in the management of hip and knee osteoarthritis. These findings underscore the need for targeted education to ensure the comprehensive implementation of evidence and guideline recommendations in clinical practice.

Trial registration

German Clinical Trials Register (DRKS00 032 853)

Keywords

physiotherapy - osteoarthritis - training program - guideline adherence

Introduction

Osteoarthritis of the hip and knee is a widespread disease worldwide, affecting around 20 percent of people over the age of 60 in Germany [1]. A combination of mechanical, inflammatory, and metabolic factors leads to structural changes throughout the joint. In addition to damage to the cartilage, other structures such as the muscles, ligaments and bones are also affected [2] [3]. There is a number of risk factors for the development of osteoarthritis, including advanced age, female gender, obesity, excessive strain and previous joint injuries [2] [4]. Patients suffer primarily from pain and functional limitations, which lead to a permanent impairment of their quality of life [5].

Regardless of the severity of the disease and the age of the patients, national [6] [7] and international [8] [9] [10] clinical practice guidelines recommend conservative, non-pharmacological therapy as the treatment of choice. Education, exercise therapy and weight management should therefore be made available to all patients with hip and knee osteoarthritis. In this context, physiotherapy plays a central role.

However, a systematic review summarizing the results of surveys of physiotherapists and patients from various countries suggests that, in the treatment of musculoskeletal disorders, interventions whose effectiveness has not been proven or has been insufficiently proven are often used instead of those that are explicitly recommended [11]. A survey of German physiotherapists also showed that even though many patients with hip and knee osteoarthritis are offered education and exercise therapy, therapeutic interventions with questionable or lacking evidence are often applied as well [12].

In 2013, the program Good Life with osteoArthritis in Denmark (GLA:D) was initiated with the aim of ensuring evidence-based care for all patients with hip and knee osteoarthritis [13]. GLA:D is based on 3 standardized core elements: 1) A two-day course to train physiotherapists in providing patient education and the exercise program, 2) participation in an eight-week education and training program for patients and 3) standardized collection of patient data at the start of the program, after 3 months and after 12 months to evaluate effectiveness [13].

The results of numerous studies prove the success of the program. For example, improvements in pain intensity and function as well as a reduction in the use of pain medication and days off work were demonstrated after 3 and 12 months [13] [14] [15] [16] [17]. However, since these studies did not include control groups, alternative factors influencing the observed effects of the program cannot be ruled out.

GLA:D has now been successfully introduced in many countries outside Denmark, including Canada, Australia, New Zealand and Ireland. In November 2022, the implementation of GLA:D began in Germany, initially as a pilot project in the federal state of North Rhine-Westphalia. While the effectiveness of the program for patients has been proven many times over, little research has been done to date on its possible effect on the therapists participating in the two-day training course. As part of a comprehensive program evaluation of GLA:D Australia using a mixed-methods approach, Barton et al. [17] reported that participation in the two-day training course had a large to moderate effect on the proportion of physiotherapists who felt confident in providing exercise therapy and education in accordance with clinical practice guidelines.

It is unclear whether similar effects are also evident in Germany, where, unlike in Australia, a bachelor's degree is not required as an entry qualification for practicing physiotherapy [18]. In Germany, non-academic physiotherapists may even benefit more from the training, as clinical practice guidelines are not a fixed part of the curriculum in vocational school teaching and knowledge about guideline-based care may be more limited prior to the training. Therefore, the aim of this study was to investigate the effect of the two-day training course on the subjectively perceived knowledge and confidence of physiotherapists in the treatment of hip and knee osteoarthritis.

Method

Study design

This pre-post analysis is based on questionnaire data collected as part of an ongoing mixed-methods study to evaluate the implementation of GLA:D in Germany. The study involves a longitudinal survey immediately before and 2 weeks as well as 12 months after the two-day GLA:D training course for therapists. Since sufficient data from the third survey was not yet available at the time when this analysis was conducted, only the results of the first and second rounds of surveys were taken into account. The main study was registered in the German Clinical Trials Registry (DRKS00 032 853) and reviewed and approved by the Ethics Committee of Brandenburg University of Technology Cottbus-Senftenberg (EK2022–9). The survey was conducted in accordance with the principles of the Declaration of Helsinki [19]. All participants gave their informed consent to participate in the survey.

The reporting of this study follows the recommendations of the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) clinical practice guideline for observational studies [20] and the CROSS checklist (Checklist for Reporting of Survey Studies) [21].

Data collection

The survey was created using the web-based tool LimeSurvey (Hamburg, Germany). The questionnaire (see supplementary material) was developed based on previous research evaluating GLA:D Australia [17] [22] and collected information on three topics:

1. Demographic and professional characteristics (age, gender, professional qualification, professional experience, work setting)

2. Knowledge, confidence and beliefs in managing patients with hip and knee osteoarthritis

3. Awareness of clinical practice guidelines

In total, the questionnaire included 14 items presented on 9 screens. If no entry was made for an item, participants received a corresponding notification when continuing. Participants had the option to ignore this notification and not answer the question, or to select the option “Prefer not to say”. Participants could return to the previous page of the questionnaire at any time and change their answers. Estimated completion time was approximately 10 minutes. The questionnaire has already been tested by the Australian team of authors. As it was developed in close consultation with the Australian team, only a pilot test was carried out within the project team in the German setting.

Before the survey began, participants were provided with comprehensive information about the objectives and content of the survey as well as their rights in relation to participation on a separate page. By ticking a box, they confirmed that they had read and understood the information about the study and agreed to participate. Participation in the survey was voluntary and anonymous. No cookies or automatic IP address checks were set up to prevent intentional or unintentional multiple participation by storing user data.

The questionnaire for the first (T₀) and second (T₁) rounds of the survey was identical, with the exception of the collection of sociodemographic data, which was not required in the second round. Participants were asked to provide an email address and an individually generated code consisting of numbers and letters in order to participate in the second survey, and to ensure that the two questionnaires could be matched to each other.

Participants and recruiting

The survey was made available to all physiotherapists who participated in a GLA:D training course in Essen (Germany) between November 2022 and May 2024 via a QR code. It was to be completed immediately before the start of the training. The physiotherapists were free not to open the link to the survey if they did not wish to participate. Participation or non-participation did not result in any advantages or disadvantages, and no incentives were offered for participation. The invitation to participate in the follow-up survey was sent two weeks after the initial survey exclusively to those individuals who had completed the first questionnaire in full, providing an email address and the individually generated code. No sample size calculation was performed.

Intervention

The GLA:D therapist training courses took place on 2 consecutive days, with a training period of 8 hours per day. The number of participants per course was limited to a maximum of 20. The courses were run by 2 certified GLA:D instructors who had been trained by the Danish initiators of the program.

The training was divided into a theoretical and a practical part. The theoretical part presented the background of the GLA:D program, results from healthcare research on osteoarthritis as well as the content of patient education provided as part of the GLA:D program. A special focus was placed on communicating the current evidence for various interventions for the treatment of hip and knee osteoarthritis. During the practical part, the functional tests (40-meter walk test, 30-second chair-stand test, Single Leg Hop Test), which are used as standardized assessment tools in GLA:D, were introduced and the exercise program was performed.

The training content is standardized and taught in the same way in all participating countries. The same presentation material, translated accordingly, is used in all countries, and is regularly updated and adapted to the respective cultural environment.

Data analysis

The data was analyzed using the statistics software R (version 2022.07.2, The R Project for Statistical Computing, Vienna, Austria). Only fully filled-in questionnaires were included in the analysis.

The descriptive analysis of all data was performed using absolute and relative frequencies. For metric, normally distributed variables, mean value, standard deviation and range were calculated. The demographic characteristics of all participants in the initial survey (T_0total) were compared with those who also participated in the second survey (T_0sub) in order to identify possible differences and biases between the two groups.

To examine the effectiveness of the training in a before-and-after comparison, bivariate analyses were performed using the McNemar test for paired samples. The significance level was set at p < 0.05. The effect size (ES) was determined using Cohenʼs g , as this measure is particularly suitable for dichotomous variables and allows quantification of changes in paired samples. Effects were classified as negligible (< 0.05), small (0.05–0.15), moderate (0.15–0.25) or large (> 0.25) [23]. The before-and-after comparison was carried out exclusively for participants whose questionnaires could be clearly assigned using the individually generated code to match the initial survey (T_0sub) and second survey (T₁).

The data was dichotomized as follows: The response categories “strongly agree” and “agree” were subsumed as agreement with statements on osteoarthritis care, while the remaining response options (“neither agree nor disagree”, “disagree” and “strongly disagree”) were assigned to a separate category. Missing values were excluded from the calculations on a case-by-case basis.

Results

Participation rate

Of the 290 physiotherapists who participated in one of the 19 GLA:D training courses, a total of 254 individuals completed the questionnaire immediately before the start of the course (response rate: 87.6 %). 85 respondents completed the same questionnaire again after a period of 2 weeks (response rate: 29.3 %). The data from 81 individuals were included in the evaluation to verify effectiveness ([Fig. 1]).

Fig. 1 Flowchart participation rate.

Participants

Of the 254 physiotherapists who participated in the first round of the survey, 114 were women (44.9 %) and 140 were men (55.1 %). The average age was 35 (± 10.7), and the average duration of professional experience was 10.7 years (± 9.8). A total of 83 individuals (32.7 %) held an academic degree in addition to their state examination. At 90.9 percent (231/254), the majority of physiotherapists worked in an outpatient practice. No discernible differences in demographic and professional characteristics were found between the participants in the first survey (T_0total) and those who also completed the second questionnaire (T_0sub). A complete overview of characteristics can be found in [Table 1].

Table 1 Characteristics of the participants.

		T0total (n = 254)	T0sub (n = 81)
Age in years		35 ± 10,7 (22–68)	34,6 ± 11,1 (22–63)
Gender
	female	114 (44,9)	41 (50,6)
	male	140 (55,1)	40 (49,4)
Highest qualification
	State examination	167 (65,7)	53 (65,4)
	German Diplom degree	4 (1,6)	1 (1,2)
	Bachelor’s degree	64 (25,2)	23 (28,4)
	Master’s degree	14 (5,5)	4 (4,9)
	PhD	1 (0,4)	0 (0,0)
	Prefer not to say	4 (1,6)	0 (0,0)
Professional experience in years		10,7 ± 9,8 (0–40)	10,4 ± 10,5 (0–40)
Primary work setting
	Outpatient clinic	231 (90,9)	76 (93,8)
	Hospital	6 (2,4)	2 (2,5)
	Rehabilitation center	10 (3,9)	1 (1,2)
	Other	6 (2,4)	2 (2,5)
	Prefer not to say	1 (0,4)	0 (0,0)

n = number, T_0total: total population in first round of survey, T_0sub: subgroup in first round of survey
Values are given as mean ± standard deviation (range) or number (n (%))

Beliefs regarding abilities to provide guideline-based therapy

Participation in the two-day training course led to consistently positive changes in subjectively perceived knowledge and confidence in providing guideline-based treatment for patients with hip and knee osteoarthritis ([Table 2]). Over 98 percent (T₁: 80/81) of participants stated after the training that they believed themselves capable of providing exercise therapy and patient education in accordance with current clinical practice guidelines. The greatest uncertainty existed both before (T_0total: 116/254, 45.7 %; T_0sub: 35/81, 43.2 %) and after the training (T₁: 64/81, 79 %) with regard to the belief that guideline-based care could be provided even to unmotivated patients. The improvements were significant in a before-and-after comparison for almost all items, and the training had predominantly medium to large effects (ES > 0.18) on subjectively perceived knowledge and confidence in performing guideline-based therapy (see supplementary material).

Table 2 Beliefs about abilities in delivering guideline-based therapy for hip and knee osteoarthritis.

	Strongly agree (n (%))	Agree (n (%))	Neither agree nor disagree (n (%))	Disagree (n (%))	Strongly disagree (n (%))	Prefer not to say (n (%))
I know how to deliver exercise and education to people with hip and/or knee osteoarthritis following current guidelines.
T0total (n = 254)	37 (14,6)	156 (61,4)	39 (15,4)	15 (5,9)	0 (0,0)	7 (2,8)
T0sub (n = 81)	7 (8,6)	57 (70,4)	12 (14,8)	4 (4,9)	0 (0,0)	1 (1,2)
T1 (n = 81)	49 (60,5)	30 (37,0)	2 (2,5)	0 (0,0)	0 (0,0)	0 (0,0)
∆ T1–T0sub	+ 42 (51,9)	–27 (33,3)	–10 (12,3)	–4 (4,9)	0 (0,0)	–1 (1,2)
I have been trained in delivering exercise and education to people with hip and/or knee osteoarthritis following current guidelines.
T0total (n = 254)	27 (10,6)	118 (46,5)	66 (26,0)	29 (11,4)	8 (3,1)	6 (2,4)
T0sub (n = 81)	6 (7,4)	40 (49,4)	22 (27,2)	12 (14,8)	0 (0,0)	1 (1,2)
T1 (n = 81)	55 (67,9)	25 (30,9)	0 (0,0)	1 (1,2)	0 (0,0)	0 (0,0)
∆ T1–T0sub	+ 49 (60,5)	–15 (18,5)	–22 (27,2)	–11 (13,6)	0 (0,0)	–1 (1,2)
I have the skills to deliver exercise and education to people with hip and/or knee osteoarthritis following current guidelines.
T0total (n = 254)	30 (11,8)	144 (56,7)	58 (22,8)	13 (5,1)	3 (1,2)	6 (2,4)
T0sub (n = 81)	4 (4,9)	63 (65,4)	19 (23,5)	4 (4,9)	0 (0,0)	1 (1,2)
T1 (n = 81)	48 (59,3)	32 (39,5)	1 (1,2)	0 (0,0)	0 (0,0)	0 (0,0)
∆ T1–T0sub	+ 44 (54,3)	–31 (38,3)	–18 (22,2)	–4 (4,9)	0 (0,0)	–1 (1,2)
As a physiotherapist, it is my job to deliver exercise and education to people with hip and/or knee osteoarthritis following current clinical practice guidelines.
T0total (n = 254)	80 (31,5)	128 (50,4)	25 (9,8)	11 (4,3)	3 (1,2)	7 (2,8)
T0sub (n = 81)	26 (32,1)	38 (46,9)	11 (13,6)	5 (6,2)	0 (0,0)	1 (1,2)
T1 (n = 81)	56 (69,1)	22 (27,2)	1 (1,2)	0 (0,0)	0 (0,0)	2 (2,5)
∆ T1–T0sub	+ 30 (37,0)	–16 (19,8)	–10 (12,3)	–5 (6,2)	0 (0,0)	0 (0,0)
I am confident I can deliver exercise and education to people with hip and/or knee osteoarthritis following current guidelines.
T0total (n = 254)	41 (16,1)	138 (54,3)	55 (21,7)	12 (4,7)	0 (0,0)	8 (3,1)
T0sub (n = 81)	10 (12,3)	50 (61,7)	18 (22,2)	2 (2,5)	0 (0,0)	1 (1,2)
T1 (n = 81)	43 (53,1)	36 (44,4)	1 (1,2)	0 (0,0)	0 (0,0)	1 (1,2)
∆ T1–T0sub	+ 33 (40,7)	–14 (17,3)	–17 (21,0)	–2 (2,5)	0 (0,0)	0 (0,0)
I am confident I can deliver exercise and education to people with hip and/or knee osteoarthritis following guidelines, even when the patient is not motivated.
T0total (n = 254)	16 (6,3)	100 (39,4)	77 (30,3)	48 (18,9)	4 (1,6)	9 (3,5)
T0sub (n = 81)	4 (4,9)	31 (38,3)	26 (32,1)	18 (22,2)	0 (0,0)	2 (2,5)
T1 (n = 81)	20 (24,7)	44 (54,3)	12 (14,8)	5 (6,2)	0 (0,0)	0 (0,0)
∆ T1–T0sub	+ 16 (19,8)	+ 13 (16,0)	–24 (29,6)	–13 (16,0)	0 (0,0)	–2 (2,5)
If I deliver exercise and education to people with hip and/or knee osteoarthritis following current clinical practice guidelines, patient outcomes will be optimized.
T0total (n = 254)	53 (20,9)	150 (59,1)	34 (13,4)	5 (2,0)	0 (0,0)	12 (4,7)
T0sub (n = 81)	18 (22,2)	47 (58,0)	11 (13,6)	1 (1,2)	0 (0,0)	4 (4,9)
T1 (n = 81)	25 (30,9)	50 (61,7)	2 (2,5)	0 (0,0)	0 (0,0)	4 (4,9)
∆ T1–T0sub	+ 7 (8,6)	+ 3 (3,7)	–9 (11,1)	–1 (1,2)	0 (0,0)	0 (0,0)
If I deliver exercise and education to people hip and/or knee osteoarthritis following current clinical practice guidelines, patients will be more active.
T0total (n = 254)	36 (14,2)	159 (62,6)	46 (18,1)	5 (2,0)	0 (0,0)	8 (3,1)
T0sub (n = 81)	11 (13,6)	51 (63,0)	16 (19,8)	2 (2,5)	0 (0,0)	1 (1,2)
T1 (n = 81)	23 (28,4)	45 (55,6)	6 (7,4)	5 (6,2)	0 (0,0)	2 (2,5)
∆ T1–T0sub	+ 12 (14,8)	–6 (7,4)	–10 (12,3)	+ 3 (3,7)	0 (0,0)	+ 1 (1,2)
In the organization I work, all necessary resources are available to deliver exercise and education to people with hip and/or knee osteoarthritis following current clinical practice guidelines.
T0total (n = 254)	108 (42,5)	115 (45,3)	13 (5,1)	11 (4,3)	1 (0,4)	6 (2,4)
T0sub (n = 81)	25 (30,9)	46 (56,8)	4 (4,9)	4 (4,9)	0 (0,0)	2 (2,5)
T1 (n = 81)	48 (59,3)	27 (33,3)	0 (0,0)	5 (6,2)	0 (0,0)	1 (1,2)
∆ T1–T0sub	+ 23 (28,4)	–19 (23,5)	–4 (4,9)	+ 1 (1,2)	0 (0,0)	–1 (1,2)

n = number, T_0total  = total population in first round of survey, T_0sub  = subgroup in first round of survey, T₁  = second round of survey, ∆ = difference

Perceived confidence in performing therapeutic interventions

Before participating in the training course, the majority of physiotherapists surveyed stated that they felt confident in performing exercise therapy to treat people with hip and knee osteoarthritis (T_0total: 113/254, 44.5 %; T_0sub: 40/81, 49.4 %). In contrast, just over a quarter of respondents felt very confident (T_0total: 71/254, 28 %; T_0sub: 22/81, 27.2 %). Two weeks after the two-day training course, the proportion of those who felt very confident rose by 45.7 to a total of 72.8 percent (T₁: 59/81). A positive trend could also be observed with regard to patient education: the proportion of those who felt confident rose by 13 percent, while the proportion of those who felt very confident increased by 17 percent. While at least half of the respondents felt confident or very confident about education on physiotherapy topics (e. g., physical activity) before the training, this was the case for less than one-third of therapists with regard to education on the benefits and risks of oral pain medication (T_0total: 47/254, 18.5 %; T_0sub: 15/81, 18.5 %), injections (T_0total: 44/254, 17.3 %; T _0sub : 7/81, 8.6 %) and arthroscopic procedures (T_0total: 75/245, 29.5 %; T_0sub: 19/81, 23.5 %).

After the training, an increase in perceived confidence of 20–50 percent was observed in all areas, but a certain degree of uncertainty remained, particularly with regard to weight management and education on interventions that go beyond the usual scope of physiotherapy. However, less significant changes were observed for other physiotherapy interventions such as manual therapy, electrotherapy, and taping. It was also noticeable that these passive interventions – with the exception of manual therapy – were used less frequently overall. More than 40 percent of participants stated even before the training course that they did not use electrotherapy to treat hip and knee osteoarthritis (T_0total: 113/254, 44.5 %; T_0sub: 35/81, 43.2 %). After the training, there was no significant change (T₁: 34/81, 42.0 %). Similarly, many therapists stated that they did not use braces/orthoses (T_0total: 98/254, 38.6 %; T_0sub: 29/81, 35.8 %) or taping (T_0total: 81/254, 31.9 %; T_0sub: 26/81, 32.1 %). After the training course, this proportion decreased only slightly to 25.9 % (T₁: 21/81) and 23.5 % (T₁: 19/81), respectively. A complete overview of the individual interventions is provided in the supplementary material.

Level of recommendation for treatment interventions

Even before the training course, almost all physiotherapists surveyed (over 90 percent) rated exercise therapy, education and weight management as highly recommended or recommended for the treatment of patients with hip and knee osteoarthritis. The picture was less clear for other physiotherapy interventions, and this hardly changed even after the training course. Most participants rated the degree of recommendation for manual therapy, electrotherapy, taping and braces as unclear, with manual therapy and braces tending to be considered recommended, and electrotherapy and taping tending to be considered not recommended.

More significant changes resulting from the training course were observed with regard to non-physiotherapy interventions. While the proportion of those who did not want to give an answer was significantly higher before the training, more participants felt confident enough to make a clear decision after the training. While many previously considered the evidence unclear, after the training, the proportion of those who classified paracetamol, opioids, corticosteroid injections, stem cell therapy and arthroscopy as not recommended increased by more than 25 percent. A complete overview of the assessment of the recommendation level of the individual interventions can be found in the supplementary material.

Awareness of clinical practice guidelines

Before participating in the training course, approximately 15 percent (T_0total: 38/254, 14.6 %; T_0sub: 12/81, 14.8 %) of respondents stated that they were aware of clinical practice guidelines for the treatment of hip and knee osteoarthritis (see supplementary material). The majority of these therapists were able to name at least one specific clinical practice guideline. The German guidelines for hip and knee osteoarthritis published by the Deutsche Gesellschaft für Orthopädie und Unfallchirurgie (DGOU, German Society for Orthopedics and Trauma Surgery) were cited most frequently, followed by the Dutch guidelines published by the Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF). When comparing the responses before and after the training course, the number of those who stated that they were aware of a clinical practice guideline doubled. However, the proportion of physiotherapists who did not want to comment on this question was quite high at both points in time (T_0total: 104/254, 40.9 %; T_0sub: 29/81, 35.8 %; T₁: 33/81, 40.7 %).

Discussion

Participation in the two-day GLA:D training course led to an increase in physiotherapistsʼ subjectively perceived knowledge and confidence regarding the implementation of guideline-based therapy for patients with hip and knee osteoarthritis. Participants felt better prepared to provide exercise therapy and patient education in accordance with current guideline recommendations. In particular, uncertainties regarding the level of recommendation and education on pharmacological and non-conservative interventions were reduced. However, the overall proportion of therapists who were aware of clinical practice guidelines for the treatment of osteoarthritis remained low after the training. Due to a significant loss to follow-up, the results refer to only one-third of the participants originally surveyed and should therefore be interpreted with caution.

Despite structural differences in physiotherapy training between Germany and Australia, the subjectively perceived increase in knowledge and confidence in the present study was comparable to the results of Barton et al. [17]. The standardized implementation of the GLA:D training course therefore appears to create a uniform level of knowledge and compensate for potential differences in clinical practice guideline awareness. This highlights the relevance of standardized training programs for evidence-based care.

Although the participating physiotherapists considered it their responsibility and over 75 percent of them stated before the training that they knew how exercise therapy and education should be provided to patients with hip and knee osteoarthritis in accordance with current guideline recommendations, many therapists felt uncertain, particularly when it came to implementing education. This result emphasizes the need for targeted training programs. There is substantial uncertainty concerning interventions beyond physiotherapy, such as injections, medications, and surgery. This was evident both in the wide variation in the assessment of the level of recommendation and in the low level of certainty in the education provided on the benefits and risks of these interventions. Participation in the training course resulted in notable improvements in these domains, although some uncertainties persisted.

Uncertainties could be due to the fact that physiotherapists are not authorized to prescribe medication and receive little knowledge about medication and surgical procedures during their vocational training. Furthermore, physiotherapists do not consider it their responsibility to provide information about such interventions [24], and patients also tend to expect this type of information from physicians, whom they regard as more competent sources of information in this regard [25]. Nevertheless, sound knowledge of the various treatment options is described as an essential core competence for healthcare professionals involved in the care of patients with osteoarthritis [26] [27]. Physiotherapists should therefore be able to explain the potential benefits and risks of common medications, injections and surgical procedures to ensure that patients are fully informed about their treatment options [26] [27].

Physiotherapists often spend more time with patients than physicians and can use this time to provide more comprehensive information. Especially in view of the increasing demand for direct access in Germany, the ability to advise on non-physiotherapy interventions is becoming increasingly important.

The low number of physiotherapists who stated that they were aware of clinical practice guidelines for the treatment of osteoarthritis is also striking. Before the GLA:D training course, this figure amounted to just over 15 percent of participants. This percentage is even smaller than the already poor results of German nationwide online surveys on low back pain (29.4 %) [28], stroke (47.1 %) [29] and hip and knee osteoarthritis (49.3 %) [12]. At the same time, the number of those who did not provide any comment on this question is relatively high at 35–40 percent. However, it can be assumed that these individuals tend to belong to the group that is not familiar with the clinical practice guidelines.

Although the number of respondents who were aware of a clinical practice guideline doubled after the training course, it remained low at 29.6 percent. While the GLA:D training course discusses the content and evidence of individual interventions from clinical practice guidelines, the clinical practice guidelines themselves remain largely ignored against the backdrop of the internationally standardized GLA:D teaching materials. It therefore seems reasonable to include training in researching and understanding clinical practice guidelines in future training courses, as well as providing an overview of existing clinical practice guidelines and their advantages and disadvantages in order to promote their use.

The present results reflect short-term effects that were assessed two weeks after completion of the training course. Whether and to what extent these positive effects persist over a longer period of time should be further investigated. The registered study plans to conduct a follow-up assessment after one year, but at the time of the current analysis, too little feedback was available. Long-term studies of this kind are crucial for assessing the sustained effectiveness of training programs such as GLA:D and, where necessary, make adjustments to ensure the long-term development of participants' skills.

Limitations

Due to the relatively small number of participants, generalization to a larger population is only possible to a limited extent. At 29.3 percent, the response rate for the second round of the survey was very low. Thus, it cannot be ruled out that results are biased. However, the characteristics of the participants in both surveys hardly differ in terms of age, professional qualifications, professional experience and work setting, so that the sample can still be assumed to be reasonably representative. The low response rate is comparable to that in the study by Barton et al. [17]. Here, too, the reasons for the low response rate could not be clearly resolved. Lack of interest and time were among the suspected causes. Various interventions have proven effective in increasing the response rate for online surveys, including targeted reminders and financial or non-financial incentives [30]. As this is an ongoing study, reminders will be sent via email in the future, one week after the second questionnaire is sent out, in order to increase the response rate.

Furthermore, the results are likely to be biased, as the study mainly involved physiotherapists who showed a keen interest in the treatment of osteoarthritis and may have been better informed than the average even before the training course. In addition, the proportion of participants with a university degree was well over 30 percent, significantly higher than the assumed proportion of physiotherapists with academic qualifications (3 %) in Germany [31]. This could have led to an underestimation of the actual effectiveness of the training course in a broader context. At the same time, bias due to socially desirable response behavior cannot be ruled out. Positive response behavior in the first round of the survey could have led to an underestimation, while in the second survey it could have led to an overestimation of the actual effect.

Since access to the first survey was via a QR code, physiotherapists who did not have a suitable device may have been excluded. As a result, groups of people who may have a different perspective and level of knowledge regarding the treatment of osteoarthritis may be underrepresented in the results.

Many participants selected the answer option “prefer not to say” for individual questions, which may indicate problems understanding the questions or a lack of interest in certain topics. Possible explanations could include insufficient cultural adaptation of the questionnaire, which was taken from an Australian context, and the decision not to conduct a pilot study within the target group. As a result, potential comprehension difficulties or cultural differences could not have been identified and addressed, which could have compromised the validity of the data collected and thus the reliability of the results.

The effectiveness of the training course was mainly assessed by the subjectively perceived increase in knowledge and confidence in providing guideline-based therapy. However, in order to measure the objective increase in competence and to better evaluate the actual transfer of the acquired knowledge into clinical practice, future studies should include standardized competence tests in addition to subjective assessments. In addition, the use of established theoretical models for the assessment of training interventions, such as the Kirkpatrick model [32] or the Learning Transfer Evaluation Model (LTEM) [33], could provide valuable additional insights.

Conclusions

Participation in the two-day GLA:D training course was associated with improvements in physiotherapists’ self-reported knowledge and confidence in managing hip and knee osteoarthritis, particularly regarding non-physiotherapy interventions. These results emphasize the importance of targeted training interventions to ensure comprehensive implementation of evidence-based care in clinical practice. However, the low level of awareness of specific clinical practice guidelines both before and after training suggests that training programs should also aim to promote skills in researching, understanding and applying clinical practice guidelines. Long-term studies are required to evaluate the sustainability of the skills learned and to make adjustments to the training program if necessary.

Conflict of interests

All authors are involved in the implementation of GLA:D in Germany. SNK, JH, CJS, and AG are employed by Deutsche Arzt Management GmbH (DAMG), which is responsible for administering the selective contract in accordance with Section 114 of the German Social Code, Book V (SGB V).

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Publikationsverlauf

Eingereicht: 17. September 2024

Angenommen: 12. April 2025

Artikel online veröffentlicht:
27. Juni 2025