EXERCISE MANAGEMENT OF KNEE OSTEOARTHRITIS 

Researchers from Australia, America and the United Kingdom published a narrative review outlining recent research highlights and uncertainties in the exercise management of knee osteoarthritis (OA) published in the past five years. 

The lead author, Travis Haber, agreed to answer some questions about the review. You reviewed highlights of recent uncertainty in the evidence on whether exercise meaningfully reduces pain and improves function in knee OA. 

What implications does this have for future research and clinical practice? 

Recent high-quality systematic reviews and randomised controlled trials (RCTs) highlight greater uncertainty about whether exercise meaningfully improves knee OA outcomes. Exercise therapy probably improves pain and physical function; however, whether these benefits are clinically meaningful remains unclear based on established minimal clinically important differences. 

This evidence base has several limitations: many systematic review findings are informed by low-quality RCTs, designing a placebo exercise intervention remains challenging and the minimal clinically important differences used to interpret findings vary across research. 

Future studies should evaluate what outcome changes are meaningful from the perspective of people living with knee OA. 

Future research should focus on a broader range of health outcomes that matter to people with knee OA (eg, quality of life) and identity the types of exercise patients enjoy or prefer. 

Despite the uncertainty we highlighted in our review, clinicians may wish to educate patients about the potential broader health benefits of exercise when helping them choose treatments. 

Given that there is no strong evidence that any one type of exercise is more effective than another for knee OA, clinicians can feel free to guide patients to choose the types of exercise they prefer or feel most able to do. 

Your study found that exercise adherence was not associated with better outcomes. Why do you think that is and what implications does it have for clinical practice? 

Much of the observed effects of exercise may relate to natural history, placebo and contextual effects, and regression to the mean. 

This is supported by two key findings. First, evidence has largely failed to demonstrate a dose–response relationship between exercise and changes in pain and physical function in patients with knee OA. 

Second, the effects of exercise on pain and function are not meaningfully explained by changes in strength, range of motion or proprioception. 

Given that exercise dosage appears weakly related to clinical outcomes in knee OA and the physiological effects of exercise mediate the benefits from exercise, higher adherence to exercise interventions (ie, completing a greater overall dosage) may not produce better outcomes compared to lower adherence. 

However, the current evidence base has considerable limitations. 

Very few trials have evaluated whether exercise interventions with targeted behavioural support outperform those without such support. 

Many RCTs on knee OA do not adequately report adherence, preventing a large proportion of these trials from being pooled in meta-analyses and limiting the confidence in systematic review findings. 

Studies that do report adherence largely rely on self-reporting of session completion, which is prone to recall bias (ie, over- or under-reporting of actual sessions completed).

Due to these limitations, we cannot confidently conclude whether adherence is important for clinical outcomes or to what extent it matters. 

Targeting adherence in clinical practice may be less important for reducing pain and improving self-reported function. 

However, adherence could be important for other health outcomes where dose–response relationships have been observed. 

Your study highlights the need for better reporting of exercise adherence in clinical trials. What specific recommendations would you give to researchers designing future trials on exercise interventions for knee OA? 

Future trials need to ensure that they adequately report participants’ adherence to exercise interventions and clearly outline how this adherence has been measured. 

There are currently no perfect solutions to measuring adherence and many trials rely on self-reported data.

Compared to measures of adherence with a device (eg, using accelerometers with Therabands), self-reported adherence tends to overestimate exercise compliance.

However, using device measures is not always possible, depending on the type of intervention and resources available to researchers. 

Advances in digital solutions will likely provide solutions in the future. 

For now, more work is needed to develop user-friendly, scalable approaches suitable for varying clinical populations, such as those with low health and digital literacy levels. 

You reviewed research on remotely delivered exercise programs. What does the evidence say about the effectiveness of telehealth and digital platforms for knee OA care? 

The number of RCTs evaluating digital programs has increased greatly over the past five years. 

Overall, these trials suggest that digital programs are likely to be effective and safe for managing knee OA. 

Notably, digitally delivered exercises by a physiotherapist have similar effectiveness levels to in-person-delivered care for pain and function—some patients may even prefer it.

Digital programs, unsupervised by a clinician or combined with some asynchronous support, also appear to be effective and may help overcome cost barriers to exercise care for knee OA. 

Stepped interventions, where patients receive increasing levels of support from a clinician, could help reduce the burden of knee OA on the healthcare system by funnelling resources to patients who are unresponsive to unsupervised, digital care. 

>>Travis Haber is a physiotherapist and clinical researcher. He is a postdoctoral researcher at the Centre for Health, Exercise and Sports Medicine at the University of Melbourne. His research focuses on improving nonsurgical management, including
exercise therapy, for hip and knee osteoarthritis.

PATIENT PERCEPTIONS OF MUSCULOSKELETAL PAIN LABELS 

Researchers from the United Kingdom, Australia and Ireland analysed data from 18 qualitative studies to investigate patient and public perceptions of diagnostic labels for musculoskeletal pain. Lead author Stephen Martin agreed to answer some questions about the study. 

What inspired this review on diagnostic labels for musculoskeletal pain—and why now?

There is increasing interest in how diagnostic labels shape beliefs, behaviours and treatment preferences in people with musculoskeletal pain. 

While labels are commonly used in clinical settings, they vary widely and may have unintended consequences. 

We were interested in how patients perceive these labels and how these perceptions influence emotions, understanding and treatment expectations. 

Given the high prevalence of musculoskeletal pain, growing concern about overtreatment and rising healthcare costs, now is a crucial time to reflect on how diagnostic communication can best support recovery and potentially reduce unnecessary interventions. 

Your findings suggest that patients often prefer specific labels, even though these can lead to fear and unnecessary interventions. 

How should physiotherapists navigate this tension in day-to-day practice? 

Specific labels (eg, disc bulge) can offer patients a sense of validation and clarity but they may also increase fear, reinforce structural beliefs and drive demand for imaging or surgery. 

Our review suggests that such labels should generally be used with caution. However, there may be situations where a specific diagnosis is strongly desired by the patient or required for administrative reasons, such as insurance. 

In these cases, offering a specific label may be appropriate but it should be accompanied by reassurance and a clear explanation to minimise potential harm. 

Education about the multifaceted nature of pain can also support patient understanding and help reduce fear. 

Many patients reported that their diagnosis wasn’t explained clearly or was full of jargon.

What can physiotherapists do differently when discussing diagnostic labels? 

Many patients in our review felt unclear about what their diagnosis meant—often due to inadequate explanations or unfamiliar medical jargon. 

Using plain, non-technical language is a starting point but it’s equally important to tailor explanations to the patient’s existing beliefs, concerns and level of health literacy.

Strategies like the teach-back method (asking patients to explain the diagnosis in their own words) can be useful for checking shared understanding. 

Non-specific labels were linked with more positive beliefs about recovery and conservative treatment. But they also led to confusion. 

What’s the best way to use non-specific labels effectively?

Non-specific labels (eg, non-specific low back pain) can reduce fear and encourage conservative management but only if explained thoroughly. 

Without explanation, they may be interpreted as vague or dismissive. 

Our review suggests that how labels are explained makes a big difference. 

When paired with a thoughtful, biopsychosocial explanation of pain, they may offer a less threatening but still meaningful way for patients to make sense of their experience. 

Your study suggests that how a diagnosis is explained may matter as much as the diagnosis itself. How can we train or support physiotherapists to communicate more effectively?

Communicating diagnoses in a way that validates patients’ experiences without causing harm is a challenging skill. 

University education should include training on diagnostic uncertainty and the psychological impact of language. 

In practice, clinicians can benefit from mentorship, observation and feedback on their communication style. 

Further research is also required to determine how best to communicate diagnoses to patients, particularly when uncertainty exists. 

What message would you most like physiotherapists to take away from this research—and what changes might it prompt in their clinical conversations? 

Words matter. The way we label and explain pain can either support recovery or undermine it. 

We hope that this research prompts physiotherapists to reflect on how they use diagnostic labels and to consider whether their explanations align with best evidence, reduce fear and foster patient understanding. 

>>Stephen Martin is a lecturer in physiotherapy at the University of Winchester and a PhD student. His research explores how diagnostic labels influence patient beliefs, behaviours and outcomes in people with musculoskeletal pain.

THE UNTAPPED ROLE OF PHYSIOTHERAPISTS IN SUICIDE PREVENTION 

A team of researchers from Belgium, Australia and the United Kingdom published an editorial highlighting the overlooked but vital role physiotherapists could play in suicide prevention efforts. 

Lead author Davy Vancampfort agreed to answer some questions about the article. 

Your editorial suggests that physiotherapists are an untapped resource in suicide prevention. What led you to focus on this issue? 

Our team noticed that physiotherapists regularly build deep, trusting relationships with patients who are known to be at high risk for suicidal thoughts—especially those with chronic conditions or life-changing injuries. 

Research shows that over 50 per cent of physiotherapists encounter disclosures of suicidal ideation at least once a year and nearly half have heard about plans for suicide during their career. 

Yet despite this reality, suicide prevention training hasn’t traditionally been part of a physiotherapist’s education. 

This gap prompted us to rethink the public health approach to suicide prevention, shifting from a model that depends solely on mental health specialists to one that recognises physiotherapists as vital frontline responders. 

Some clinicians might feel that suicide prevention falls outside the traditional scope of physiotherapy. What would you say to them? 

Physiotherapists don’t need to function as psychotherapists or psychiatrists but instead can serve as sentinels and connecters, trained to spot warning signs, ask the right questions, listen without judgement and safely guide patients to help. 

Their role aligns perfectly with the principle of ‘every door is the right door’ in healthcare.

Physiotherapists are already crossing into these conversations informally; what’s missing is the structure, confidence and training to do it well and safely. 

You mention that many physiotherapists already receive disclosures of suicidal thoughts from patients. Why do you think this happens? 

There are two key reasons. The first is therapeutic rapport.

Physiotherapists often work with patients for months at a time, allowing people to feel heard and seen. 

That trust makes it more likely for vulnerable patients to open up. 

The second is our patient population. 

We work a lot with individuals living with chronic pain, disability or significant injury. 

Within these populations, nearly 25–50 per cent report suicidal thoughts or behaviour. This overlap isn’t accidental; it’s systemic. 

When emotional pain coincides with physical pain and the listener cares and stays present over time, people talk. 

What practical steps can a physiotherapist take if a patient discloses suicidal ideation?

 Here’s a quick guide that practitioners can follow: 

• stop and listen—pause what you are doing; create a safe, confidential space
• acknowledge and empathise—‘That sounds really hard. I’m concerned about you.’
• ask directly but sensitively—‘It’s really common for people who feel overwhelmed or in pain to think about suicide. Are you currently having, or have you ever had, thoughts of suicide? Do you have a plan?’
• assess risk—listen for a plan, intent or means; follow clinical judgement
• collaborate on the next steps—offer to call crisis lines (eg, local suicide hotlines), GPs or mental health services with the patient
• create a safety plan—if trained, help develop a safety plan, ie, identify personal coping strategies, supportive people and distractions
• escalate if needed—in emergencies, call crisis services or emergency responders, even without consent if there’s immediate danger
• document thoroughly—date, time, what was said, who was told and what happened next
• follow up—check in at subsequent sessions, reinforce the plan and show continued care. These steps align with international guidance for allied health professionals. 

How could education and training better prepare physiotherapists to respond to psychological distress without overstepping professional boundaries? 

Training should cover core competencies, eg, recognising warning signs, asking about suicidal thoughts and knowing when/how to refer. 

Educators should make use of interactive methods such as role-play, decision trees and safety-plan checklists to build confidence in real scenarios. 

An important aspect is clarifying boundaries. 

Non-specialised physiotherapists are not qualified to treat mental disorders; their role is to initiate conversations and guide patients to expert care. 

Training should also include ethics and principles of self-care, eg, duty to warn, avoidance of vicarious trauma and knowing when to step back and get support. 

Physiotherapists should become competent trauma-informed care providers, equipped with the awareness needed to give gentle, person-centred responses. 

Embedding these elements into entry-level programs and ongoing development would help physiotherapists step into this role safely and confidently. 

What is the one message you hope clinical physiotherapists take away from your editorial? 

You already matter. You are a trusted point of contact for people in distress, even if you don’t realise it. 

With just a bit of training and backing, you can bridge the gap, start vital conversations and guide someone toward help that may save their life. 

You don’t have to be a mental health expert; you just have to care.

>>Professor Davy Vancampfort is the academic coordinator for the Rehabilitation in Mental Health Care specialisation within the Master of Rehabilitation Sciences and Physiotherapy program at KU Leuven, Belgium. Davy has a particular interest in investigating the intersection of mental and
physical health.