Phenomenological exploration of perceptions, experiences, facilitators, and inhibitors in patients with knee osteoarthritis during physiotherapy rehabilitation in a low- and middle-income country

Abstract

Background

Perceptions and experiences of knee osteoarthritis (KOA) and physiotherapy (PT) rehabilitation, as well as the facilitators and inhibitors (barriers) of access and adherence to PT rehabilitation in patients with KOA (PKOA), may be influenced by lifestyle and contextual factors. Hence, we aimed to investigate the perceptions and experiences of KOA and PT, and facilitators and inhibitors influencing access and adherence to PT rehabilitation among PKOA in a low- and middle-income country (LMIC), India.

Methods

A qualitative design with a phenomenological approach was employed. Fifteen PKOA were recruited through purposive sampling. Patients demographic data were collected. One-to-one, semi-structured interviews were conducted face-to-face or by telephone, audio-recorded, and transcribed verbatim. Data were analysed using thematic analysis.

Results

Fifteen PKOA (10 females, 5 males) with a mean age of 56.3 years participated in in-depth individual interviews. Four themes were identified, namely perceptions, experiences, inhibitors, and facilitators. Twelve sub-themes were identified within these four themes.

Conclusion

The perceptions and experiences of PKOA regarding PT care in a LMIC like India share similarities and differences with those in other countries. PKOA have both positive and negative experiences with PT care, and there is a limited knowledge about KOA and its symptoms. PKOA face physical and social barriers, such as time and place constraints, whereas personal, family, and organisational factors facilitate access to and adherence to PT treatment.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12891-026-09813-x.

Background

Knee osteoarthritis (KOA) is the most common chronic musculoskeletal condition, characterised by pain, functional limitation, and reduced health-related quality of life (QoL) [1]. Physiotherapy (PT) programmes (exercise, electrotherapy, and education) are recommended as first-line treatment, and play a vital role in rehabilitation by reducing pain and improving physical function and quality of life [1, 2]. Pain and physical limitations often influence patients’ lived experience of KOA and drive healthcare-seeking behaviour, yet quantitative measures alone do not fully capture the condition’s subjective impact on daily life, emotions, and engagement with treatment [3].

Central sensitisation refers to alterations in pain processing within the central nervous system and has been associated with widespread pain, increased symptom severity, and reduced QoL in KOA and other musculoskeletal conditions, such as fibromyalgia [4–6]. In KOA, features of central sensitisation and related psychological processes have been associated with greater disability and less favourable therapeutic outcomes [6]. A biopsychosocial perspective recognises that patients’ perceptions of pain and function are shaped not only by structural joint changes but also by psychological responses (e.g., fear of movement, emotional distress) and social contexts (e.g., support systems, access to care), which together influence how individuals interpret symptoms and approach PT rehabilitation [4–9]. Subjective interpretations of pain, beliefs about movement, and emotional responses significantly influence patients’ engagement with PT rehabilitation, including exercise adherence, activity participation, and coping strategies [10]. Qualitative studies in KOA indicate that psychosocial and contextual factors, such as fear of movement, beliefs about pain and treatment, social support, and logistical challenges, shape rehabilitation experiences and can either facilitate or hinder engagement with PT interventions [11].

In Low- and middle-income countries, particularly in culturally diverse settings such as India, socio-cultural values, health beliefs, family dynamics, and access to healthcare resources further shape how individuals make sense of KOA and engage with treatment [12]. However, these contextual nuances are often underexplored in the literature. Previous research suggests that patients may conceptualise OA differently and experience unique daily challenges that affect self-management and engagement with care within the Indian population [12]. Qualitative research has shown that patients with KOA (PKOA) describe not only pain and functional difficulties but also the emotional and social burdens of the condition, including adaptations to daily activities, an altered sense of self, and the influence of personal beliefs on activity engagement [13]. While patients appreciate professional guidance and therapeutic exercises, they face several challenges. These include limited access to healthcare, difficulty in adhering to prescribed exercises, and dissatisfaction with the lack of individualized exercise and regular monitoring [13].

Despite these insights, the existing qualitative evidence on patients’ experiences of PT rehabilitation has primarily been explored in high-income settings [13–24], with limited understanding of how socio-cultural and healthcare system factors in LMICs influence patients’ perceptions, engagement, and adherence to guideline-based physiotherapy care. In LMICs, particularly in rural contexts, daily challenges such as work demands, poverty, and access constraints influence patients’ experiences of KOA and its management in ways that differ from Western contexts, underscoring the need to understand how cultural, social, and environmental factors affect their perceptions, treatment engagement, and self-management strategies [12, 25, 26]. This research gap in qualitative inquiry is needed to understand how to develop patient-centred rehabilitation strategies that are more responsive to real-world challenges and patient priorities across diverse settings, particularly in KOA, the lived experiences of KOA, therapeutic expectations, and the psychosocial and environmental factors influencing PT rehabilitation engagement [3, 11, 13]. So, the purpose of the study was to explore the perceptions, experiences, and facilitators and inhibitors (barriers) of access to and adherence to PT rehabilitation among PKOA in a LMIC, India.

Methods

Study design

To examine patients’ perceptions and experiences of KOA and the factors influencing PT rehabilitation for KOA, a qualitative phenomenological design was employed. This design was selected because it enables in-depth exploration of subjective experience and directly addresses the aim of understanding patients’ voices from their perspectives. A phenomenological study design could guide physiotherapists in gaining a deeper understanding of patients’ perspectives, experiences, facilitators, and inhibitors during PT rehabilitation.

Ethical considerations

The qualitative study obtained approval from the Scientific Review Board (SRB/PhD/77/2024) of Yenepoya Physiotherapy College, Naringana, Mangaluru, India and the Yenepoya Ethics Committee-2 (YEC2/2024/161) of Yenepoya (Deemed to be University), Deralakatte, Mangaluru, India. The study adhered to the ethical principles stated in the Declaration of Helsinki (2024), and the Indian Council of Medical Research’s (ICMR) National Ethical Guidelines for Biomedical and Health Research involving Human Participants (2017).

Study sample and recruitment

The principal investigator (PI) used purposive sampling to recruit participants from a tertiary-care teaching hospital, thereby ensuring rich, in-depth data and the inclusion of patients with relevant and diverse experiences of KOA and PT rehabilitation [27]. Purposive sampling was used to recruit patients, aligning with the study objectives by targeting individuals likely to provide information-rich data relevant to the study’s research question [28, 29]. Patients radiographically diagnosed with KOA according to the Kellgren and Lawrence (KL) Classification of osteoarthritis, PKOA, aged 40 years and above, who had received PT treatment for either unilateral or bilateral KOA, such as exercise therapy and electrotherapy, and PKOA who could speak Kannada and/or English, were included, as the PI could communicate with patients only in English and Kannada [30, 31]. Patients with serious psychological disorders, cognitive decline, communication problems, other musculoskeletal disorders, or a history of spine, abdominal, or lower-limb surgery within the last 12 months were excluded [32]. Selection criteria confirmed that the study participants had adequate experience with KOA and PT rehabilitation, thereby directly supporting this study’s aim of understanding the lived experiences, inhibitors, facilitators, and personal perceptions related to PT rehabilitation for KOA. Clinical physiotherapists treating PKOA were requested to inform the PI of patient availability. The PI screened and recruited PKOA in accordance with the selection criteria. Patients were informed of the study details and provided written informed consent to participate prior to their enrollment.

Semi-structured interviews

Semi-structured, in-depth individual interviews were conducted using open-ended questions to explore patients’ perceptions and experiences of living with KOA, perceived benefits of PT treatment, and inhibitors, facilitators to PT treatment, and coping strategies associated with KOA, all directly relevant to the research questions. A semi-structured interview guide [33] is provided as a supplementary file (Supplementary file 1).

Before each interview, participants provided informed consent and demographic data [age, height, weight and body mass index (BMI)], the duration of KOA symptoms, and the number of PT sessions attended. Educational and socioeconomic status of PKOA were collected using the Modified Kuppuswamy Scale 2024 (Table 2) [34]. The study involved face-to-face and telephone interviews conducted by the principal investigator (C.B.), a physiotherapist with a strong background in qualitative research on KOA. Each interview lasted between 10 and 30 min (approx.) and took place in a private, comfortable environment, such as a medical facility. Of the 15 interviews, 13 were face-to-face, and 2 were conducted by telephone due to participants’ availability. All sessions were recorded using a Sony ICD-UX570F audio recorder. To ensure the credibility of the data, methodological triangulation was employed by audio-recording the interview and taking field notes. Member checking was implemented by inviting patients to review and validate the findings and clarify any colloquial terms, with translations from Kannada to English. Reflexivity was ensured through comprehensive documentation; negative case analysis was incorporated; and an audit trail was organised to trace analytical decisions and enhance transparency. Transcribed files were anonymised, with each participant assigned a coded number and stored on a password-protected device to ensure confidentiality. Data saturation was confirmed with 15 PKOA, as no new information was obtained. This is consistent with the recommended sample size for phenomenological qualitative studies, which typically range from 3 to 10 participants or until data saturation is reached [35].

Table 2.

Demographic dimensions of the entire sample of interview participants

Demographic dimensions	Mean ± SD	Median (IQR)	Range
Age (years)	56.3 ± 8.6	56 (52, 62)	44 to 73
Height (cm)	157.2 ± 8	154 (152, 162)	147 to 180
Weight (kg)	70.1 ± 13.2	71 (55, 78)	49 to 92
BMI (kg/m2)	28.5 ± 6	28.6 (23.5, 33.8)	20.4 to 38.8
KOA symptoms (days)	3248.5 ± 4006.8	1460 (730, 6570)	183 to 14,600
PT session (days)	339.1 ± 563.7	90 (40, 300)	5 to 1825

Abbreviations: BMI Body Mass Index, PT Physiotherapy, SD Standard deviations, IQR Interquartile range

Analysis

The data, described at the individual level, and the demographic data, including age (years), height (cm), weight (kg), body mass index (BMI) (kg/m2), KOA symptoms (days), and PT session (days), were analysed using descriptive statistics, including means, standard deviations, and interquartile ranges at the group level. Data were analysed using thematic analysis, following the six-step framework developed by Braun and Clarke [36] to ensure the rigorous and systematic examination of qualitative data, including credibility, transferability, dependability, and confirmability [37]. Thematic analysis was conducted within a descriptive phenomenological framework, focusing on patients’ perceptions and experiences of KOA, as well as the facilitators and inhibitors to PT treatment for KOA [20].

Codes identified for transcripts by CB using NVivo software, version 15 (United States), were reviewed and discussed with AJS, a qualitative research expert and the research supervisor. The data analysis was inspected and validated to ensure its dependability. Final pattern coding was performed, with closely related codes examined and collated to generate themes and subthemes within subgroups relevant to the research question. Agreement was strong among the research team members (CB, AJS); no additional input on theme generation was sought. Four main domains, namely perceptions, experiences, inhibitors, and facilitators, served as predefined analytic categories. Although these domains provided a theoretical framework for interpreting the data, all codes were generated solely from the interview transcripts and subsequently aligned with the predefined domains during the analytical process. This inductive approach ensured that the analysis remained aligned with patient experiences and responsive to existing theoretical constructs, consistent with community-accepted standards for qualitative research reporting. To ensure the credibility of the data, methodological triangulation was employed by audio-recording the interview and taking field notes. Member checking was implemented by sending patients’ findings for validation via WhatsApp to patients and/or caregivers when patients lacked a WhatsApp account. Reflexivity was ensured by maintaining no relationship between the researcher and patients who were treated by other physiotherapists. A negative case analysis was incorporated, and an audit trail was ensured through external validation by a researcher who had no role in data collection. Thematic saturation was confirmed using the “New information threshold” method. This study confirms data saturation at 13^{+ 2}, indicating that 13 patients contributed new information, and the last 2 contributed no new information [38].

Results

Fifteen PKOA (10 females, 5 males), with a mean age of 56.3 years, took part in in-depth individual interviews. Three females (20%) participated via telephone interviews, while the others (80%) participated face-to-face. Educational and socioeconomic status were assessed using MKS, with participants distributed across lower class (13.33%), upper lower (6.67%), lower middle class (60%), upper middle class (20%), illiterate (26.67%), primary school certificate (20%), middle school certificate (33.33%), high school certificate (13.33%), graduate (6.67%); and rural (66.66%) and urban areas (33.33%). Individual demographic characteristics of PKOA recruited for the semi-structured interview are presented in Table 1. The demographic dimensions of the entire interview sample are presented in Table 2.

Table 1.

Individual Demographic characteristics of PKOA recruited for Semi-structured Interview

Participant ID	Age (years)	Gender	Height (cm)	Weight (kg)	BMI (kg/cm2)	Side	Kellgren-Lawrence Grade	Modified Kuppuswamy Scale score	No of days having knee osteoarthritis symptoms	No of days underwent Physiotherapy treatment	Interview Duration (min: sec)
P1	66	Female	153	55	23.5	Left	3	9	14,600	5	19:49
P2	44	Female	162	75	28.6	Bilateral	3	10	1460	90	14:37
P3	52	Female	151	81	35.5	Bilateral	1	7	730	183	15:30
P4	62	Male	165	92	33.8	Bilateral	3	4	6570	45	27:41
P5	53	Female	153	71	30.3	Bilateral	2	18	1095	730	20:16
P6	73	Male	180	66	20.4	Bilateral	3	9	7300	50	17:59
P7	56	Male	160	70	27.3	Left	3	10	1825	1825	12:23
P8	69	Male	162	65	24.8	Left	2	10	7300	300	17:56
P9	56	Female	153	55	23.5	Bilateral	3	4	1460	1460	23:05
P10	45	Female	152	75	32.5	Bilateral	2	10	2190	60	16:10
P11	53	Male	156	75	30.8	Right	2	11	365	35	11:08
P12	59	Female	152	49	21.2	Bilateral	3	730	183	40	13:23
P13	53	Female	154	92	38.8	Bilateral	1	183	730	90	9:49
P14	59	Female	158.5	53	21.1	Left	1	730	730	8	15:06
P15	45	Female	147	78	36.1	Bilateral	4	2190	2190	166	11:08

Four themes and 12 sub-themes were developed. Themes included perceptions, experiences, inhibitors, and facilitators. Of the 15 PKOA, three responded and confirmed the data. A negative case analysis was conducted, examining the language barrier, the physiotherapist’s prescription of traditional medicine, and the proposal to provide government health services to low-income people. These rigorous methods ensure data credibility. Themes and sub-themes, with patients’ quotes, are presented in Table 3.

Table 3.

Themes and Sub-themes with Patients’ Quotes

S. NO	Themes	Sub-themes	Quotes
1.	Perceptions	1.1. Poor understanding of OA	…My knee osteoarthritis problem in started by itself… (P11)
		1.2. Opinions towards physiotherapy	... Exercise is better than tablets… (P8)
		1.3. Faith in medicine and surgery	...I go to the pharmacy, and I used to take a tablet for knee pain; I experienced a kidney infection later… (P8)
2.	Experiences	2.1. Positive experience of physiotherapy	…They are asking me whether I am doing exercises regularly, so I am feeling happy for their concern… (P10) …I feel relaxed after doing exercise, so I feel that I should do it every day… (P8) …If pain and stiffness should reduce, we need to know exercises… (P5)
		2.2. Negative experience of physiotherapy	… I’ve not seen any changes; they used to give physiotherapy… (P15) … I can’t walk and stand due to knee pain… (P3) …I am expecting from physiotherapists that they will help me relieve pain and help me to improve… (P1)
3.	Inhibitors	3.1. Personal factors	… Exercises are a bit challenging to do as we are not used to them, but the result that I’m getting drives interest and keeps me motivated… (P13) … I skip the exercises due to my laziness (P5)
		3.2. Physical factors	… The hospital is far from my home… Two or three buses have to reach the hospital. Nearby, no physiotherapy centres and hospitals… (P3) … Exercises are easy, but I don’t have enough time to do them… (P3)
		3.3. Social factors	… I was not permitted to rest, and I have been overwhelmed with a heavy workload. I cannot conclude that physiotherapy is ineffective… (P7) … No time for going walking due to more household work… (P2) … Nobody is there nearby to help me because some caste issues are there… (P9)
4.	Facilitators	4.1. Personal factors	…family members are very supportive of me for doing exercise... (P11) …Personally, I’m interested in doing my exercises... (P14)
		4.2. Physical factors	…I am doing exercise with children at the school…(P5) …Physically, I don’t have such barriers; I do my exercises regularly. Neighbours are good, but more than them, my kids are very supportive and encourage me to do physiotherapy…(P14)
		4.3. Social factors	… Neighbours are helping me to exercise correctly with mobile guidance… (P2)
		4.4. Physiotherapists' contribution	… Here in the hospital, physiotherapists will come to teach the exercises. They will ask me to do the exercise. They will support me if I am unable to do it. They are available at any cost (P8) … The physiotherapist reminded me by phone to perform exercises regularly. (P10)

Theme 1: perceptions

Perception refers to an individual’s (patients’) view, making it a powerful driver of a action. Patients’ perceptions of KOA and its PT rehabilitation are influenced by poor understanding, attitudes towards PT rehabilitation, and beliefs in tablets, injections, and surgery, which were developed as a sub-theme. Some PKOA believe OA develops due to ageing, while others believe OA is caused by side effects of medicines. A lack of education about KOA among PKOA and ineffective communication between healthcare providers and patients were major issues.

…I was not aware of (KOA) it …(P12, female, aged 59 years, K-L grade 3)… Due to ageing, it (KOA) is developing. That’s why I am getting knee pain.…(P6, male, aged 73 years, K-L grade 3)…According to me, due to my work, which involves moving here and there, I started getting pain in my knee…(P15, female, aged 45 years, K-L grade 4).

Patients expect exercise instructions and supervision, believing that PT rehabilitation will cure their KOA symptoms. However, severe knee pain is often managed with analgesics, highlighting the need for better communication.

… my knee osteoarthritis will be cured, and everything will be fine, and I have hope that I can walk like earlier… (P13, female, aged 59 years, K-L grade 3) … Exercise is better than tablets…But I take analgesics from the medical by giving 5/10 rupees if the pain is severe …(P8, male, aged 69 years, K-L grade 2).

Theme 2: experiences

Experience is a subjective event, felt only by the person who has the experience. PKOA experienced difficulties with physical activities and emotional challenges that affected their QoL. KOA symptoms affects their ability to perform functional tasks independently, leading to feelings of resentment and frailty. Regular follow-ups with physiotherapists are enhanced by monitoring improvements and adjusting treatment plans. Patients reported positive experiences with rehabilitation, having overcome unsuccessful alternative medicines and experiencing improved symptoms after PT rehabilitation.

…I’ve undergone several medications in Puttur. I underwent oil and mud treatment; it still didn’t reduce. But after coming here and because of physiotherapy treatment, it is better now, and it feels like it’s getting cured… (P11, male, aged 53 years, K-L grade 2).

PKOA reported that they progressed from supportive environment provided by physiotherapists and their personal responsibilities. However, some patients reported negative experiences, such as increased pain and difficulties with physical activities. A lack of exercise education and supervision reduced treatment efficacy and adherence. Effective communication using analogies helps patients understand the importance of exercise and adherence in rehabilitation. Patients expressed expectations and positive experiences with PT rehabilitation, while others believe PT could be a potential cure for KOA.

…I am expecting that physiotherapy will cure my knee osteoarthritis… (P4, male, aged 62 years, K-L grade 3) …because of physiotherapy, I am better now, and it (knee) feels like it is getting cured… many improvements and betterment in my knee… Physiotherapists are giving me effective and hopeful results. … (P11, male, aged 53 years, K-L grade 2) … I’ve not seen any changes; they used to give physiotherapy… (P15, female, aged 45 years, K-L grade 4).

PKOA used strategies to manage OA symptoms, including using mobility aids for functional activities; self-management at home, including applying hot packs, oil massage, taking rest, and engaging in alternative work to manage knee pain; and exercising in the early morning to manage time.

… I am giving an ice pack, or a hot pack with salted hot water… (P10, female, aged 45 years, K-L grade 2) …I can’t walk independently, but with walker support, I can walk… (P7, male, aged 56 years, K-L grade 3).

Patients have both positive and negative experiences, which were identified as sub-themes. Negative experiences of PT rehabilitation, include OA symptoms affect functional activities, and poor exercise supervision, whereas positive experiences, include, patient education provided, satisfaction with regular follow-up sessions, and realising the importance of treatment consistency.

Theme 3: inhibitors

Inhibitors are factors that impede access to treatment and adherence. PKOA often prioritises personal and family commitments over their KOA treatment, which affects KOA, leads to increased frustration and decreased self-efficacy. Inhibitors to PT treatment include severe knee pain, increased workload, lack of holidays, and family commitments.

… I am doing exercises. But feeling pain and difficulties in the evening due to household work …(P10, female, aged 45 years. KL grade 2) …Exercises are easy only, but I do not have enough time to do them… (P3, female, aged 52 years, K-L grade 1).

Patients often struggle with time constraints, finding suitable places to exercise, and dealing with negative societal comments. The lack of PT clinics and hospitals in their physical and social environment also hampers rehabilitation.

…no physiotherapy centre near me… (P2, female, aged 44 years, K-L grade 3) … everybody is teasing me about whether I am using a walking stick… (P9, female, aged 56 years, K-L grade 3).

Cultural inequalities, such as prejudice and social discrimination in health care needs, affect their QoL. Economic factors affecting PT treatment: PKOA as unaffordable in the private health sector. Health issues, such as age-related visual impairment (cataract), chest pain, and kidney infection, also hinder functional activities. Poor organisational support and inadequate staffing in hospitals impact treatment efficacy.

…I don’t have enough money to take treatment there. In a government hospital, treatment is free, but no one is there to provide clear education. So, I stopped taking treatment there due to no benefit and no cure… (P4, male, aged 62 years, K-L grade 3) … They are teaching exercises in English, somewhat understanding and following them… (P6, male, aged 73 years, K-L grade 3) … For 4 months, I have been having blindness. Then I stopped my activities… (P1, female, aged 66 years, K-L grade 3).

Personal factors influence treatment adherence; physical factors reduce exercise performance; social factors affect therapeutic compliance; cultural diversity reduces treatment efficacy; economic issues limit physiotherapy sessions; health-related factors affect treatment consistency; organisational factors affect treatment effectiveness; and varied patient motivation to participate were categorized as sub-themes.

Theme 4: facilitators

Facilitators are factors that support access to and adherence with treatment. PKOA are self-motivated to participate in PT treatment and exercise because of their interests and physical health. Family members were advised to reduce symptoms, manage weight, understand KOA, and take preventive measures. Social environments, such as government facilities and neighbours, provide physical, mental, and financial support.

… I’m motivated and eager to do my exercises… family members and neighbours are very supportive of me for doing exercise… (P11, male, aged 53 years, K-L grade 2) … Neighbours are helping me perform exercises correctly with mobile guidance… (P2, female, aged 44 years, K-L grade 3).

Physiotherapists educate and treat PKOA using exercise therapy, electrotherapy, and manual therapy, which contributes to treatment effectiveness. Teleconsultation and regular follow-ups are used to maintain a healthy relationship between patients and physiotherapists.

… The physiotherapist reminded me by phone to perform exercises regularly.(P10, female, aged 45 years, K-L grade 2)… The physiotherapist was highly competent in her role. As I was the only patient, I got full attention, and she was excellent at her work…(P13, female, 53 years, K-L grade 1).

Health centres provide facilities, support, and government funding for older adults. A good physical, mental, and social environment enhances therapeutic adherence in KOA rehabilitation.

…Good health service from the doctor, sisters (Nurses) and physiotherapists. Getting help for food, and health schemes for taking treatment in the hospital… (P1, female, aged 66 years, K-L grade 3) … here in the hospital, physiotherapists will come to teach the exercises. They will ask me to do the exercise. They will support me if I am unable to do it. They are available at any cost… (P7, male, aged 56 years, K-L grade 3).

Self-motivation improves participation in PT rehabilitation, physical factors impulse treatment, family support for PT treatment, social factors encourage the sustainability in PT management, physiotherapists encourage in adherence with PT rehabilitation, reminders from the physiotherapists help in treatment adherence, organisational factors support OA management, and a good mental, physical and social environment to therapeutic compliance were categorized as sub-themes.

Discussion

The current qualitative study investigated patients’ perceptions and experiences of KOA and PT treatment, as well as the facilitators and barriers to PT rehabilitation for KOA in LMICs. The study indicated that PKOA have diverse attitudes and limited understanding of the condition. Consistent with our findings, previous research has highlighted that PKOA often lack a clear grasp of KOA primarily due to the information they receive from healthcare professionals [14, 25, 39–41]. PKOA requires clear explanations of exercises, preferably accompanied by demonstrations. This aligns with previous literature, which has shown that while patients benefit from PT rehabilitation, they often remain unaware of how it helps alleviate the symptoms of KOA [42]. PKOA reported side effects from medications taken for KOA, including digestive problems and kidney infections. These results are consistent with a previous study reporting side effects associated with medications used for KOA [14].

PKOA had mixed experiences (both positive and negative) with PT rehabilitation, as tabulated in Table 3. Many patients were satisfied with physiotherapists’ supervision, whereas others received follow-up calls. PKOA received exercise supervision from physiotherapists, whereas others did not, resulting in lower therapeutic adherence. PKOA also experienced reminders through telecommunications. Our study results were similar to previous studies exploring facilitators for first-line treatments in KOA, including regular reminders and follow-ups from physiotherapists, which improved treatment adherence and motivation, highlighting interprofessional relationships [14, 22, 43–46]. Some patients reported that there were no reminders from physiotherapists to continue PT exercises. In contrast, the patients received website and SMS supported self-directed exercises, associated with an eHealth intervention, and physiotherapists facilitated regular exercises [46]. PKOA showed improvements in functional movements, daily living activities, QoL, and treatment adherence. These were similar to recent studies focused on the experience of patients who followed guideline-based PT for KOA [44, 47–51].

PKOA had negative experiences during PT, including recurrent pain, long-term pain after PT, and beliefs about medicines and surgery. Our results are consistent with a previous study exploring PKOA experiences of PKOA, reported hopelessness about the prognosis and a strong faith in surgery. These negative experiences, addressed in previous studies through rehabilitation strategies, include stratified exercise therapy, behavioural change techniques, individualised programs, regular follow-ups, and subgrouping [50, 51]. In contrast, the current study shows that PKOA employed coping strategies, including mobility aids, resting, alternative work, self-management at home, and early-morning exercise. These results are consistent with previous studies on PKOA, that investigated the coping strategies they followed [40, 50].

PKOA expressed the expectation that PT rehabilitation would relieve KOA symptoms. Patients reported severe knee pain and stiffness, as well as difficulty with standing, sitting, kneeling, sleeping, and walking. Similarly, previous research reported limitations in physical and functional activities associated with PKOA [3, 15, 52–54]. Patients experienced a lack of supervision, which led to reduced empathy, lower treatment efficacy and a less personalised approach in rehabilitation. This was supported by a previous study focused on activity monitoring by physiotherapists using digital support, which highlighted the need for professional input to monitor exercise performance through both standard and digital OA care [55].

The current study identified a multilayered set of inhibitors that impede engagement in PT rehabilitation among people with KOA, including health-related barriers such as comorbidities, physical activity limitations, fluctuating motivation, socioeconomic constraints, time and place constraints, and pain-related emotions, including fear of movement. These findings align with qualitative evidence showing that physical limitations, personal beliefs, social support, and environmental conditions significantly influence adherence to exercise and rehabilitation in OA care, underscoring the importance of cognitive, social, and contextual determinants in sustained engagement [30, 31, 51]. However, our study extends this understanding by highlighting how LMIC-specific realities, such as limited access to services, travel burdens, and financial barriers, amplify these challenges and overlap with the lived experiences of comorbid conditions in patients with KOA.

In addition to barriers, patients described facilitators of PT rehabilitation, including strong family involvement, community encouragement, and supportive hospital health policies, which are consistent with the literature identifying social support and environmental enablers as key to promoting long-term engagement in rehabilitation [56]. The current study findings indicate that these dynamics persist in this context, reflecting the interplay between social status and participation in PT rehabilitation, whereas previous studies suggest that factors such as social discrimination may not always limit healthcare access in other settings [57]. Together, these insights emphasise that adherence to PT treatment is influenced by both universal and context-specific factors, thereby arguing for tailored strategies that recognise social and economic determinants to improve patient engagement in LMIC settings [41, 49].

The relatively small sample size limited the scope of exploration and precluded a detailed K-L Grade sub-analysis that has not been explored in previous research [12, 25, 26, 42]. Future research could recruit a larger, more diverse sample to enable stratified analyses by severity [33]. Member checking was incomplete because twelve participants did not respond; future studies should incorporate additional follow-up strategies to enhance participants’ validation of findings. Despite these limitations, this qualitative inquiry across diverse geographic and socioeconomic settings in India provides valuable insights into the facilitators and inhibitors to PT engagement among PKOA to ensure PT care for KOA aligns with guideline-based management. Future research can examine how customised PT rehabilitation (e.g., booster sessions, enhanced patient education, digital home-based care) affects adherence and outcomes in LMIC contexts, such as India [56, 58, 59] and can evaluate organisational supports such as expanded PT services, ergonomic workplace strategies with micro- and macro-breaks, and hospital-level workforce investments, such as recruiting more physiotherapists to cope with the inhibitors identified in this study.

The current study acknowledges the importance of involving PKOA in tailoring successful rehabilitation [56]. Direct patient involvement was implemented during the pilot interviews. Outcome selection will be informed by priorities identified in patient-reported outcomes from this study and the KOA rehabilitation literature. The findings of this study will be disseminated and translated into knowledge during the dissemination and knowledge translation phase, where patient feedback will guide the interpretation, communication, and contextualisation of the review findings for community and clinical use.

Conclusion

PKOA’s perceptions and experiences of PT care in LMIC like India share similarities and differences with those in other countries. PKOA have both positive and negative experiences with PT care, and there is a lack of knowledge about KOA and its symptoms. PKOA face physical and social barriers, such as time and place constraints; whereas personal, family, and organisational factors facilitate access to and adherence to PT treatment.

Abbreviations

OA

Osteoarthritis

KOA

Knee osteoarthritis

PKOA

Patients with knee osteoarthritis

PT

Physiotherapy

LMIC

Low- and middle-income countries

MKS

Modified Kuppuswamy Scale

QoL

Quality of life

Authors’ contributions

C.B. contributed to the conceptualisation, methodology, data curation, formal analysis, investigation, and writing – original draft, and A.J.S. provided conceptualisation of the study, methodology, writing – review and editing, project administration, and supervision.

Funding

This research was supported by Yenepoya (Deemed to be University), Deralakatte, Mangaluru, Karnataka, India by providing necessary academic and research facilities, and sufficient area to conduct face-to‐face semi‐structured interviews.

Data availability

Data are available in the Mendeley online dataset, which can be accessed through [https://data.mendeley.com/datasets/j35vs6ggg7/1].

Declarations

Ethical approval and consent to participate

The qualitative study obtained Scientific Review Board (SRB/PhD/77/2024) approval Yenepoya Physiotherapy College, Naringana, Mangaluru, India on 15 May 2024 and subsequently received ethical approval from Yenepoya Ethics Committee-2 (YEC2/2024/161) of Yenepoya (Deemed to be University), Deralakatte, Mangaluru, India on 2 July 2024. The study adhered to the ethical principles stated in the Declaration of Helsinki (2024), the World Medical Association (2013), and the Indian Council of Medical Research’s (ICMR) National Ethical Guidelines for Biomedical and Health Research involving Human Participants (2017). Written informed consent was obtained from all participants prior to their enrolment in the study.

Consent for publication

Informed consent has been obtained from all the participants for the presentation of their data in this manuscript.

Competing interests

The authors declare no competing interests.