An evaluation of TRAK physiotherapy self management intervention development and delivery for knee conditions

Purpose: TRAK intervention combines face-to-face physiotherapy treatment with remote care delivered via the TRAK website to support self-management rehabilitation. The TRAK website provides knee patients with health information, personalised exercise plans and remote clinical support. The aim of this study was to fully define TRAK intervention content, setting and context and develop the training, through an implementation study in a physiotherapy service. Methods: A mixed methods study design was used to inform TRAK intervention development by combining patient and physiotherapist experience and understanding of how TRAK works in the clinical environment. During the set-up TRAK was integrated into the local NHS IT infrastructure. Phase 1 was a qualitative interview study, whereby fifteen physiotherapists used TRAK for 1 month with a patient of their choice. There were no restrictions on how they integrated TRAK. Interviews explored patient and physiotherapist views of TRAK intervention and training requirements. In Phase 2 seventy-four patients were recruited, all patients received conventional physiotherapy, a subset of 48 patients used TRAK in addition to conventional physiotherapy. Eleven physiotherapists delivered the TRAK intervention over 12 weeks. Aspects of feasibility measured included: uptake and usage of TRAK by patients and physiotherapists. Physiotherapists were interviewed after 12 weeks. An inductive thematic approach was used for data analysis. Two researchers coded and re-coded the data, and agreed themes with a third researcher. TRAK website is accessible at: http://trakphysio.org.uk/Home Results: Patients and physiotherapists reported that TRAK was easy to use and only basic computing and Internet skills were required. Patients highlighted the therapeutic benefit of the exercise videos and personalised exercise plans to remind them of their exercises and correct technique. They reported using TRAK to plan their treatment at home. Patients reported needing to use TRAK initially with the guidance of their treating physiotherapist. Physiotherapists highlighted appointment time constraints and lack of familiarity with TRAK as factors limiting engagement. Physiotherapists didn't use the remote email support, due to concerns about increasing their workload and opted for face-to-face appointments. They also expressed concern about patients self selecting the wrong exercises and causing harm to their knee. Physiotherapists didn't change the consultation to integrate TRAK. In Phase 2, 67% patients accessed TRAK outside of the clinical environment. A total of 91% of patients were given a personalised exercise plan, but these were only updated in 34% of cases. Conclusions: TRAK intervention was integrated into routine clinical practice alongside face-to-face treatment within a NHS physiotherapy setting to support self-management of knee conditions. Patients and physiotherapists identified which components of TRAK supported self-management within a behaviour change framework. This included videos to model exercises and increase commitment to physiotherapy, provision of rehabilitation related information, personalization of exercises, goal setting, and increasing confidence and motivation. TRAK was reported to be acceptable, easy to use and appropriate for a wide range of patients. Initial engagement with TRAK was good however this declined over time. Physiotherapists reported lack of familiarity and time as factors reducing engagement. Training needs to be directed at improving practical skills on how to use TRAK within a self-management approach, this includes supporting patient users to be able to select and modifying their own exercises. This study provides a detailed description of the TRAK intervention, what training is required and how it should be delivered, ready for use in a future randomised control trial.