Knee osteoarthritis is a leading worldwide cause of disability, affecting 368 million people globally.1 It is therefore a primary reason people seek rehabilitation,2 and physical therapists are a major provider of these services.3 It also places substantial burdens on healthcare systems and limits workforce participation.4-6 Alleviating the burden of osteoarthritis is thus essential for reducing global disability and preventing unsustainable increases in healthcare costs.1,5,7

The World Health Organization defines person-centered care as an “approach to care that consciously adopts the perspectives of individuals, families, and communities and sees them as participants as well as beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways.8” Guidelines recommend that rehabilitation for osteoarthritis should align with the principles of person-centered care.9,10 Such approaches can improve health outcomes and patient satisfaction while reducing healthcare costs.11-13

Individuals with knee osteoarthritis experience disability across health domains, including difficulties with function (e.g. walking), daily activities (e.g. self-care), and meaningful activities (e.g. socializing with family).14-17 These individuals expect treatments to relieve pain and increase their capacity for functional activities,18 while also addressing their broader psychosocial health problems and goals.19,20 Although the multi-domain impact of knee osteoarthritis is well documented, less is known about how individuals prioritize their knee problems and rehabilitation goals, both within and across health domains. Therefore, the aim of this qualitative study is to explore what individuals with painful knee osteoarthritis identify as the worst aspect of their knee problems, along with their 3-month rehabilitation goals.

Table 1 describes the characteristics of the 387 participants (98% of 394 eligible) who provided data in this study. Seven participants did not complete the pre-consultation survey and were thus excluded. Reasons for non-completion were not wanting to be allocated to the telehealth group (n=2), sickness (n=1), no longer interested in participating (n=1), and no reason given (n=3).

Worst aspect of having knee problems

Participant-reported knee problems are presented in Table 2, with exemplar quotes (explanations of knee problems are presented in Supplementary Table 2). Fig. 1 summarises these problems mapped to the ICF framework. Using the ICF framework, impairments, activity limitations, and participation restrictions all featured as the worst aspects of knee osteoarthritis problems. Impairments such as knee pain (ranging from intermittent to constant), mental health, and emotional concerns were common. These included fear of reinjuring the knee, along with worry and uncertainty about the future with knee pain. Other impairments included sleep problems (difficulty falling asleep or staying asleep), reduced strength and flexibility, or broader health problems, such as difficulty losing weight.

Table 2.

Worst aspect of having knee problems.

ICF Domain	Problem	Exemplar quotes (participant number and sex)
Impairments of body functions	Knee pain and stiffness	“Intermittent pain and discomfort.” (254, F)“Consistent and regular pain.” (380, F)“Move more freely without my knees feeling stiff and swollen.” (56, F)
	Mental health and emotional concerns	“The fear that I will damage it again and make it worse.” (297, F)“The loss of confidence as I cannot live the life I envisage.” (155, F)“Feeling frustrated and a bit depressed because I can't do the physical stuff I used to do.” (119, F)
	Sleep problems	“The pain wakes me through the night.” (384, F)“Almost constant pain and waking in the night or struggling to sleep due to pain.” (354, F)“Just the pain because I don't sleep well, and so don't ever feel rested.” (77, F)
	Muscle and joint impairments	“Lack of flexibility and mobility, also increasing instability.” (393, M)“Not being able to bend the knees very much.” (256, F)
	Broader health problems	“Gaining weight because can’t exercise properly.” (266, F)“I feel my overall health/activity is deteriorating.” (392, F)“The insecurity of not knowing if it will give way at any time. This is very frustrating!” (326, F)
Limitations with activities	Reduced walking capacity	“Not being able to walk for too long a distance.” (13, F)“Can't do brisk walking.” (55, F)“Not being able to walk comfortably. I walk with a limp all the time." (61, M)
	Reduced capacity executing physical movements	“Sitting down or standing up from a chair or sofa.” (112, F)“Hard to get up and down from floor position.” (379, F)“Inability to use ladders and stairs.” (171, M)
Participation restrictions	Restricted performance in outdoor walking (leisure) activities	“Unable to complete most bush tracks, walking trails (I really enjoy).” (83, F)“I can't go for walks longer than 10-15 mins and especially cannot go hiking in National Parks as my knee gets so painful I start hobbling, so it's been more than a year since I've got out for a decent hike, I really miss that.” (360, M)
	Restricted performance in physical activity, exercise, and/or sports	“I used to participate in Body Pump classes 3-5 times a week, which kept my weight under control (about 10kg lighter); however, these now aggravate my knee for the next 24-48 hours.” (190, M)“I cannot participate in hockey fully, I find it very painful to complete a full round of golf, and some days it is very hard to properly coach hockey.” (344, M)“I would like to be able to do more exercise but the pain is uncomfortable. Would really like to be able to play netball again.” (377, F)
	Reduced performance to undertake activities of daily living	“Not being able to do things like yard work, certain housework, shopping in big shopping centres, driving long distances.” (276, F)“Working around the house, cooking, gardening, house maintenance.” (142, M)“Gardening and mowing are difficult these days and I don't look after them like I should.” (78, F)
	Restricted performance in other meaningful activities	“I struggle to do things I enjoy- camping, kayaking, gardening, hiking.” (223, F)“Not being able to play with my grandchildren or walk my dog.” (389, F)“I can put up with the pain, but I want to travel, and it is impeding my ambitions.” (328, F)
	Restricted performance in work or caring responsibilities	“I can’t work at the moment as I work as a Carer in Aged Care, and it is quite physical work." (131, F)“I am a carer for my husband, and the recent knee-locking episode meant I was unable to do that” (136, F)

Fig. 1.

Worst problems of knee osteoarthritis. Categories (mapped to ICF domains) in darke orange boxes and subcategories in pale orange.

For people who reported activity limitations, reduced walking capacity was often considered the worst aspect of their knee problem. These difficulties included reduced walking distance, speed, and ease (e.g., ability to walk on uneven ground). Reduced capacity in physical tasks was also often reported, such as difficulty standing from a chair, getting out of bed, and using stairs.

Participation restrictions were common and wide-ranging. Restricted hiking and/or bushwalking were often reported as the worst aspect of knee osteoarthritis, together with reduced cycling or running performance and restrictions to sports (e.g., tennis and golf), gym activities, and unstructured sports activities (such as kicking a football). Restricted activities of daily living included performing housework (e.g., cleaning), self-care tasks (e.g., showering), and community activities (e.g., driving and shopping). Problems relating to meaningful activities were also reported, such as playing with and caring for family and pets, gardening, traveling (e.g., sightseeing), and participating in outdoor activities (e.g., camping).

Three-month rehabilitation goals

Short-term goals, subgoals, and exemplar quotes are presented in Table 3 (explanations of three-month goals and additional quotes are presented in Supplementary Table 3). Fig. 2 summarises three-month goals and subgoals. Many participants wanted to walk more and with fewer restrictions, often desiring to walk as they did before they had knee pain (i.e., returning to activity). Walking goals focused on walking longer distances, walking in nature environments, including in the bush (i.e., forest) and on the beach, and walking with greater ease (e.g., more vigorously). Some participants’ goals focused on physical activity and exercise, ranging from improving overall fitness to engaging in specific sports (e.g., golf). Running and cycling goals were also common, including returning to prior running or cycling levels and doing it for longer, at higher intensities (e.g., hills), and with less pain.

Table 3.

Three-month functional rehabilitation goals and subgoals.

Goals	Sub-goal	Exemplar quotes (participant number and sex)
Improve walking	To walk longer	“Do more than 6000 steps a day without having to rest leg.” (330, F)“Walk every day starting from 10 minutes to reach 30 minutes.” (69, F)
	To increase the intensity of walking and with more ease	“Regular brisk walking.” (55, F)“Walk at least 2km (including up/down hills) without aggravating knee.” (60, M)
	Hike and walk in nature	“Bushwalking carrying a pack.” (394, F)“Go for a day walk on a moderate trail, say 8 - 12 km return.” (360, M)
	To walk with a normal gait	“Walk without shuffling.” (71, F)
Become more physically active and/or return to physical activity	Do more gym and exercise classes	“Leg strengthening activities as part of gym routine.” (88, M)“Exercise (Zumba) classes that involve twisting the knees.” (15, M)
	Exercise more and be more physically active	“Get fit and healthy, get back into some physical activity.” (123, F)
	Participate in more sports and related activities	“Surf again!!!!!!” (251, M)“Go back to playing golf and playing tennis.” (239, M)
	Run more, with more ease and less pain	“Maintain regular exercise routine involving walking and running.” (177, M)“Run 3-4 times a week.” (394, F)
	Cycle more and with more ease	“Be able to ride my bike regularly (2 times/week 8-12km) at a leisurely pace without aggravating knees.” (60, M)“Cycle with more strength, especially on the hills.” (262, M)
Improve performance of activities of daily living	Improve performance and/or ease with stairs, steps, and ladders.	“Use a step ladder without it causing pain to knee; climb up a flight or two of stairs without my knee feeling like it will burst.” (196, F)“Manage the stairs more safely.” (78, F)
	Perform specific physical movements more freely and with less pain	“Not having to watch out for my knees when I kneel or crouch.” (355, F)“Get up from the couch without pain.” (185, F)
	Improve capability to perform activities of daily living	“If I can bend my knee that would make my job (personal carer) easier.” (85, M)“Be able to do up shoelaces & put on socks more easily.” (268, F)
	Sit or stand for longer without pain	“Remain on feet for more than 5 hrs.” (151, M)
Participate in meaningful activities	Increase capability to garden	“Kneeling in the garden to do the weeding and planting.” (237, F)“Do all gardening tasks, including those involving a ladder for pruning.” (59, F)
	Increase social activities	“Take daily walks with my daughter and grandbaby.” (110, F)“Take my grandchildren to a bike park and keep up with them on their cycles.” (41, F)
	Travel more and do more on holidays	“Go on a coach holiday with confidence to go up and down steps.” (7, F)“Holidays with lots of walking around town, museum tours etc.” (122, M)
	Do more recreational activities	“Fishing” (317, M)
	Improve overall participation and health	“Establish a better exercise routine to improve my general health, fitness and balance.” (225, F)
Improve health and wellbeing	Improve sleep	“Sleep all night and not be woken by knee pain.” (103, F)“Sleep without knee pain.” (319, F)
	Reduced knee symptoms	“Be with less pain.” (335, F)“Experience pain free.” (124, M)
	Lose weight	“More varied and frequent exercise more to lose weight.” (110, F)
	Improve mental and emotional health	“Be less frustrated by the pain.” (318, M)
	Improve knee stability, flexibility and strength	“Strength & stability.” (229, M)
	Reduce the use of pain medication	“Not rely on anti-inflammatories.” (236, M)

Fig. 2.

Three-month rehabilitation goals for knee osteoarthritis. Goals in dark blue boxes and subgoals in pale blue boxes.

Many participants specified goals related to activities of daily living, including reduced pain during activity and increased safety and stability with steps. Many also wanted to improve their capacity to perform physical tasks such as squatting, getting out of chairs and beds, and kneeling. A few participants wanted reduced pain with sustained postures (such as sitting and standing). Others wanted to enhance their capability to perform activities of daily living, such as cleaning (often high or low surfaces), work-related activities (lifting or kneeling), and driving (e.g., longer distances).

Goals commonly focused on social and recreational activities. Many participants wanted to garden more and with fewer restrictions. Social goals varied, including walking with family, friends and pets and playing with grandchildren. The desire to travel was common, with goals often framed around specific tasks enabling them to travel or to do more while traveling, such as the improved ability to use stairs or to walk (e.g., using public transport and walking tours). A few participants expressed specific recreational activity goals, including camping and fishing.

Some goals were directly linked to improving a specific health outcome, such as reducing knee pain, reducing pain medication use, or improving sleep. Less commonly, goals were to lose weight (often through exercising more) or improve flexibility, stability, strength, and mental health. Mental health goals were often linked to emotional and cognitive aspects of pain, such as reducing rumination and frustration about pain and the fear of falling.

Goals for males and females were similar across most categories, with walking the most common goal and participating in meaningful activities the least common across both groups. Females more often expressed goals related to activities of daily living (e.g., household activities). For males, a greater proportion of goals focused on becoming more physically active and returning to sports. (See Supplementary Table 4 for proportions of goals mapped to males and females.)

People with painful knee osteoarthritis express a wide variation in their primary knee problems and rehabilitation goals. Problems spanned impairments (such as knee pain and sleep disturbances), activity limitations (such as reduced walking capacity), and participation restrictions (such as reduced performance in sports, social activities, and carer responsibilities). Three-month rehabilitation goals commonly focused on physical function, including walking and using stairs. Beyond physical functioning, many participants also identified goals related to participation (e.g., gardening, social activities, and travel), which were sometimes high-level (e.g., running and sports), and to health (e.g., pain reduction and improved sleep). Goals were generally similar between females and males, though females more often reported activities of daily living goals, while males more often reported physical activity and sports goals.

A recent systematic review of qualitative studies (n=79) highlighted that people with osteoarthritis report a wide range of features associated with the condition. It found that problems spanned multiple domains, including disease (e.g., chronicity), symptoms (e.g., pain), function (e.g., work), psychological impacts (e.g., worry), and social impacts (e.g., isolation).17 Our findings extend this multidomain picture by showing substantial diversity in which of these features individuals view as the worst problems of osteoarthritis. Worst problems were also multidomain, encompassing impairments, activity limitations, and participation restrictions. Consistent with prior qualitative literature,14,28 we found that pain and associated difficulties with everyday activities (e.g., walking and using stairs) were central problems. However, for many individuals, the most problematic aspects of knee osteoarthritis extend beyond these daily activities to include sleep disturbances, emotional distress (e.g., frustration and low mood), and restrictions in high-level physical activities such as sport. Together, these findings show that people with knee osteoarthritis vary widely not only in the problems they experience, but also in which of these are most problematic for them.

Our findings help build our understanding of patient rehabilitation goals in knee osteoarthritis. Previous qualitative studies show that patients want rehabilitation to address not only their knee pain, but also the activity limitations and participation restrictions arising from it.19,20,29 Our findings extend this research by highlighting both the breadth and depth of these goals among this patient group. Notably, we found that rehabilitation goals were sometimes high-level (e.g., running or multiday trekking) and often highly individualised. For example, a walking goal may relate to walking speed, distance, terrain (e.g., hills or on the beach), or an associated activity (e.g., hiking). In a similar study in individuals with psoriatic arthritis, participants also reported widely varying treatment goals, including reducing pain, becoming more active, and participating more in work and recreational activities.30 Diverse rehabilitation goals may therefore not be unique to knee osteoarthritis, but reflect broader patterns across rheumatological conditions.

Our findings challenge the common preconception that individuals with osteoarthritis commonly seek to limit their activities.31-34 On the contrary, we found that some people with osteoarthritis wanted to return to high-level physical and sporting activities. Indeed, our findings were similar to those of a study of individuals with hip pain resulting from femoroacetabular impingement,35 which is typically diagnosed and managed in a younger, more active sporting population.36 Most individuals with femoroacetabular impingement similarly wanted physical therapy to help them return to their previous exercise and sporting levels, improve their capacity with activities of daily living and physical function, and reduce their hip pain.35

Our findings are relevant to clinicians. Clinicians often prioritize assessment of knee joint functions/structures, such as range of motion, muscle strength, and pain experience (e.g., pain intensity measured with a numerical rating scale).18,37 Clinicians could also aim to use assessment techniques and outcome measures that can capture activity limitations and participation restrictions. For example, the Knee Injury and Osteoarthritis Outcome Score asks participants about several activity limitations and sporting and recreational performance.38 However, standardized measures may not always capture individualized goals—for instance, travel is not included in recommended patient-reported outcome measures for osteoarthritis.38,39 For this reason, clinicians should also consider outcomes that can capture individual patient goals for osteoarthritis rehabilitation (e.g., patient-specific functional scale).40 Therapeutic conversations (e.g., open dialogue that explores a patient’s narrative and expectations) could also help guide goal-setting and ensure tailored treatment planning and progression aligned with those goals.41 Researchers should similarly consider the outcome measures selected in clinical trials involving people with knee osteoarthritis. Our prior research has shown that people perceived rehabilitation for knee osteoarthritis to benefit them in ways that are not necessarily captured by common osteoarthritis outcome measures, such as with specific sporting activities and daily tasks.42

Rehabilitation approaches for knee osteoarthritis should reflect the diverse, sometimes physically demanding goals people with osteoarthritis seek to achieve through therapy. For example, there is limited evidence suggesting that any particular exercise prescription (e.g., dosage or type) is most effective for treating osteoarthritis.43 Notably, a recently updated Cochrane review of exercise for knee osteoarthritis did not find that one type of exercise is more effective than any other (e.g., strength versus aerobic exercise) for improving knee pain and physical function.44 This suggests that clinicians could instead focus on personalizing care to patient goals,8,45,46 rather than focusing treatment on impairments in joint functions/structures (e.g., muscle weakness or aerobic fitness). A patient might have a goal of returning to hiking, for example. A clinician could thus work with the patient to prescribe and engage them in a graded progressive walking program on increasingly unstable terrain. At the same time, a clinician could work with this patient to identify and address any modifiable physical, cognitive, psychological, or environmental barriers that may prevent the patient from achieving their goal of hiking.

Clinicians should work with patients to collaboratively develop goals, supporting them in setting realistic, achievable goals that focus on what matters to them, while managing misconceptions and expectations where relevant.47 However, it is not entirely clear to what extent clinicians are both working with patients to set goals and tailoring rehabilitation to meet them. Qualitative research and survey data broadly suggest that physical therapists tend to focus osteoarthritis treatment on lower limb strengthening exercises.48-51 Such an approach is unlikely to address the diverse range of rehabilitation goals we observed in this study. It is possible that clinicians are potentially underestimating what people with OA can, or want to, achieve with rehabilitation. Fatalistic, pessimistic views of osteoarthritis and its outcomes appear to persist among varying types of health professions.18,32,52 For example, general practitioners often believe that osteoarthritis is degenerative and will only worsen, and that patient expectations for improvement are in conflict with what is realistic with nonsurgical care.32,53 Even though running and various weightbearing exercise types have been shown not to be associated with worsening patient outcomes and radiological signs or markers of knee OA,54-56 some clinicians appear to remain reticent to encourage certain types of activities (e.g., weight-bearing or what they consider ‘excessive’ exercise) for fear of worsening joint ‘damage’.57,58 More research is needed, however, to evaluate whether person-centered rehabilitation approaches help people with knee osteoarthritis achieve their individualized rehabilitation goals.

A strength of this study was the involvement of a consumer researcher across all aspects of study design and delivery. RB drew on their lived experience of knee pain and healthcare to inform coding (i.e., interpreting meaning in raw participant responses) and data categorization (e.g., sorting, labelling, and discussing groups of codes). Another strength of the study is using the ICF, which is widely taken up in international health systems and policy, including for guiding the assessment and measurement of disability.59 By mapping health problems arising from knee osteoarthritis to the ICF, our findings may be more readily implemented by clinicians (i.e., when assessing patients with knee osteoarthritis).

However, participants were explicitly asked about their functional goals, which may have led to body structure impairment goals, such as pain reduction, being underrepresented in our findings. Furthermore, while the ICF uses a biopsychosocial framework, our open-text questions also did not explicitly ask participants to consider emotional, cognitive, or other psychosocial problems and goals relating to knee osteoarthritis and its rehabilitation. This may explain why relatively fewer patients reported goals relating to emotional or mental health, along with the fact that this study was conducted in the context of an overarching physical therapy trial. This may explain why our findings differ somewhat from other research, highlighting that emotional and mental health problems are common among those with knee osteoarthritis.14,15 Another limitation of this study is that only English-speaking Australians were included. Thus, it is unclear if our findings are transferable to people from other countries or non-English speaking backgrounds. As this study was nested within a trial of physical therapy rehabilitation, and participant goals were ascertained in the context of physical therapy care, our findings may also not transfer to other types of healthcare, such as medical care.

People with knee osteoarthritis vary widely in the knee problems they consider most problematic and the rehabilitation goals they prioritize, which may be centered on high-level physical activities. Based on our findings, clinicians and researchers should consider using outcome measures that capture individualized goals.