Barriers to and Facilitators of Maintaining Physical Activity Behaviour for people with Hip and Knee Osteoarthritis: Protocol for a Mixed-methods Systematic Review.

Introduction

Osteoarthritis (OA) is a disease affecting the tissues surrounding the joint such as muscles, cartilage, bones, and ligaments and most commonly affects the hands, hips and knees. It often causes pain, hinders quality of sleep and interferes with activities of daily living (Hunter & Felson, 2006). OA has become one of the fastest growing health problems in the world, having risen by 48% globally from 1990 to 2019 and now affects over 528 million people worldwide (Vos et al., 2020). People with OA experience a loss in function, increased joint pain, lower levels of physical activity (PA), more comorbidities and higher medication consumption than the general population (French et al., 2022; Gay et al., 2019; Muckelt et al., 2020). Although no cure exists for OA, the primary focus is to optimise the long-term management of OA, and this study aims to further address that.

Management of hip and knee OA imposes a significant financial burden on the healthcare system. Costs are high globally for surgical interventions, hospital stays, and indirect factors like absenteeism, as well as presenteeism, productivity losses, early retirement, and premature death (Hunter et al., 2014). In 2014 OA-related expenses in Ireland equated to approximately €13.6 million, rising to €52.1 million in 2015 for Total Hip and Total Knee Arthroplasties (THA, TKA) alone (Doherty & O'Neill, 2014; Jabakhanji et al., 2021). Additionally, surgical treatments such as THA and TKA can also increase the risk of complications such as deep veinous thrombosis (Liddle et al., 2014). With a large OA-affected population and prevalent use of surgical interventions, long waiting lists persist. In 2018, 16–23% of patients waiting for a THA and TKA, respectively, faced delays of over 12 months (Brick & Connolly, 2021). An international review and meta-analysis further revealed that roughly 65% of OA patients do not receive adequate education on exercise recommendations and self-management (Hagen et al., 2016). These statistics reveal and highlight the urgent need for improved access to healthcare for people with hip and knee OA and indeed, a better long-term and more viable management option is needed for OA.

Recently studies have shifted to focus on self-management, and the benefits of PA for OA; to offer a more sustainable management pathway for lasting results. Although there are variations in PA dosage, both structured PA such as exercise programmes and un-structured activities such as unsupervised community walking programmes have shown to be beneficial in the management of OA symptoms and functional capacity (Holden et al., 2021; Juhl et al., 2014; O'Connor et al., 2015). Currently, the World Health Organisation (WHO) recommends 75–150 minutes of moderate-vigorous aerobic PA, which 40% of patients with hip or knee OA fail to meet (Wallis et al., 2013). Additionally, the WHO further recommends that older adults with chronic conditions should engage in muscle strengthening and balance exercises 2–3 times per week (World-Health-Organisation, 2020). Increased levels of PA for people with OA has also shown lower rates of depression, an improved quality of life and a greater functional capacity (Mesci et al., 2015). A systematic review and meta-analysis of observational studies identified that 67% of people with OA present with at least one other chronic condition or comorbidity, compared to 56% of non-OA controls (Swain et al., 2020). Furthermore, for people with OA; the level of PA behaviour and physical performance outcomes (e.g., 30-second sit-to-stand and walking speed) decrease significantly with each additional comorbidity, highlighting the need for PA to offset progression of comorbidities (Muckelt et al., 2020).

Interventions which offer a long-term change in PA behaviour could play a pivotal role in reducing the rate of disease progression and in the development of secondary conditions. The GLA:D® programme which consists of structured exercise and education, has shown increases of 110-120% on PA participation at 3 and 12-months post intervention, respectively and significant decreases in pain and medication consumption (Baumbach et al., 2023; Bell et al., 2023; Skou & Roos, 2017). Unfortunately, the contrary is also true; people with OA that disengage in PA following cessation of activity programmes often negate the benefits of exercise developed, making their management of OA increasingly difficult (Pisters et al., 2010; Raposo et al., 2021). It is clear the benefits PA can have on the management of OA and secondary conditions; however, a greater emphasis must be placed on identifying and promoting best practice for maintaining these activity levels.

To better understand the determinants of behaviour, consideration should be attributed with the social cognitive theory (SCT); one of the most widely used theories for explaining motivation to maintain activity in health research (Bandura, 2004). Various intrinsic factors are attributed to SCT such as a lack of motivation and poor self-efficacy which hinder both adherence and maintenance of PA behaviour for people with OA (Hinman et al., 2023). Furthermore, extrinsic factors such as a poor therapeutic alliance may deter this population from engaging in and maintaining long-term PA behaviour (Moore et al., 2020). Although research has identified various factors such as pain, stiffness and fear of worsening condition reducing adherence to PA behaviour (Hunt & Papathomas, 2020), an extensive list of barriers to and facilitators of maintaining PA behaviour must be further developed and subsequently, their role in the long-term management of OA further explored.

In understanding the term ‘maintenance’ with relevance to behavioural science and physical activity, there is a lack of consensus on determining an appropriate definition with differences in conceptual and operational definitions (Dunton et al., 2022; Rhodes & Sui, 2021). The most widely accepted conceptual definition is a period of sustained behavioural engagement above a threshold that improves health and well-being (Dunton et al., 2022; Seymour et al., 2010). Operationally various thresholds (e.g. volume of physical activity) have been used in the maintenance literature e.g. meeting the physical activity guidelines of 150 minutes of moderate to vigorous physical activity or person-specific thresholds such as meeting a stated personal goal (Dunton et al., 2022). The duration indicating that the behaviour has been sustained has also varied e.g. for a period of at least 3- or 6-months (Clarkson et al., 2022; Dunton et al., 2022; McDonough et al., 2025; Prochaska & Velicer, 1997). For the purpose of this study, ‘maintenance duration’ will be defined in terms the Transtheoretical Model (TTM). The TTM, defines maintenance as a stage after behaviour has been performed consistently for ≥ 6-months (Prochaska & Velicer, 1997).

Although research for adherence to PA behaviour is growing; investigation into the maintenance of PA behaviour for people with OA remains under-researched. For example, a recent systematic review of digital tools to support PA maintenance across 18 long-term conditions identified 23 studies, but only four in OA, highlighting the gap for further research in maintaining PA for people with OA (Howes et al., 2024). There is currently no systematic review that compiles, analyses and forms a thematic synthesis on the barriers to and facilitators of maintaining PA behaviour for people with hip and knee OA. Furthermore, knowledge of these elements and their role in effective PA behaviour maintenance interventions will help to design future interventions for the long-term management of hip and knee OA. This may offer a more viable method for long-term OA management within the healthcare system. It will therefore be the purpose of this study protocol to design the methodology for an in-depth mixed-methods systematic review to identify and address the barriers to and facilitators of maintaining PA behaviour for hip and/or knee OA. This mixed-methods approach will capture both qualitative and quantitative studies enabling a greater understanding of barriers and facilitators to PA and shed light on the impact and persistence these factors have on OA management. It is anticipated that identification of these key elements affecting long-term engagement with PA will help in the design of future hip and knee OA management programmes.

Methods

This study has been registered on the PROSPERO database of systematic reviews (registration number: CRD42024591820). The reporting protocol for this systematic review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) checklist.

Study selection

The literature for this study will be stored and managed using the referencing software Endnote 21 (Version 21.2, Clarivate analytics, Australia). The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines will be used when identifying and selecting articles for review within this study and will be in compliance with the flow chart below. See Figure 1. Articles will be imported to Endnote following the initial search and any duplicates removed. The remaining articles will be screened and reviewed using Covidence software (Covidence, Veritas Healthy Innovation, Melbourne, Australia) for their titles and abstracts by two independent reviewers (PH, CT) and any discrepancies which may arise will be resolved following discussion among authors. Furthermore, the remaining full-text articles will be retrieved and screened for eligibility using the eligibility criteria pre-determined in Covidence. The full-text articles will be divided amongst the team into two teams of two reviewers and a verifier in each team (PH and Reviewer 2, Reviewer 3 and Reviewer 4). Any additional articles using an extended search through additional databases; or through citation tracking will also be included and screened for eligibility using the above process. To assess the articles for risk of bias, the Mixed-Methods Appraisal Tool (MMAT-version 2018) (Hong et al., 2018) will be used to address the qualitative, quantitative and mixed-methods studies for inclusion in this review and any discrepancies between authors will be solved using an additional verifier.to cross-check any inconsistencies and to reach a conclusion on study selection.

Figure 1. PRISMA Flow chart diagram.

Adapted by (Page et al., 2021).

Discussion

Currently, there is no cure for OA however; PA has shown to play a pivotal role in symptom relief and management of hip and knee OA; resulting in improvements in physical function and in joint pain relief (Raposo et al., 2021). There are many different opportunities and programmes available for promoting PA for people with hip and knee OA however, opportunities to sustain long-term adherence to PA appear less frequent. Unfortunately, for people with OA; the long-term opportunities are sparce and they often cease exercising once a programme comes to completion which diminishes the benefits gained (Pisters et al., 2010; Raposo et al., 2021). A lack of moderate-to-vigorous intensity activity for people with OA not only reduces physical function but can nearly double the likelihood of deteriorating physical limitations (Dunlop et al., 2005). The focus of the research should therefore aim to address the determinants for long-term sustainability of PA to promote best practices for the management of hip and knee OA.

To understand the determinants of PA behaviour maintenance, it is important to consider the factors both at the level of the individual such as behaviour guided factors and at the environmental level such as setting, accessibility or opportunities available. At the personal level, self-efficacy has shown to be a prominent theme. People with OA who engage in activity tend to reap the rewards more than those who chose to commit partially or not at all (Hinman et al., 2023). When addressing the barriers to and facilitators of PA for people with OA, there is quite a large overlap in both short-term adherence and in the long-term maintenance. In short-term adherence to exercise, personal barriers to exercise such as a lack of incentive to exercise during pain free periods, pain or other physical symptoms, a lack of motivation and lower levels of self-efficacy often influence maintenance of PA behaviour. Interestingly, these same factors affect long-term maintenance of PA behaviour however with the additional barriers of a lack of social support to exercise and on receipt of conflicting advice received from physiotherapists (Moore et al., 2020). Opposingly, participants who associate being ‘naturally active’ as part of their identity, have developed strong therapeutic alliances with their physiotherapist or those which have developed a strong motivation to prevent further pain often describe these elements as facilitators of PA behaviour maintenance (Moore et al., 2020). Although the presence of reviews on the barriers and facilitators of both adoption and adherence to PA for people with OA exist, an extensive review identifying their role in the maintenance of PA for people with OA remains, which this study aims to address. This knowledge in conjunction with understanding intervention elements to improve the maintenance of PA behaviour for people with hip and knee OA could be instrumental to long-term OA management.

In an attempt to address the potential factors which, cause such a disparity in PA behaviour maintenance, this mixed-methods systematic review aims to identify the personal experiences through qualitative studies on both people with hip and/or knee OA and professionals who deliver PA programmes to greater illustrate the barriers to and facilitators of PA behaviour maintenance. Subsequently, this study also aims to quantitatively identify and evaluate the presence and influence of these barriers and facilitators for maintaining PA behaviour for people with hip and knee OA. It is anticipated that the personal experiences captured will represent the diverse intrinsic and extrinsic themes of engagement with long-term PA behaviour. Furthermore, through understanding the themes attributed to maintaining PA behaviour, it is anticipated these elements will be identified and facilitators enacted within OA interventions, creating a pivotal step in building a paradigm for the long-term management of OA. These findings could assist and guide the implementation of evidence-based practice for healthcare systems in the long-term management of hip and knee OA.