Condition-specific rehabilitation pathways: design, delivery, and evaluation

Condition-specific pathways aim to make rehabilitation for common joint pain both reproducible and individualized. In contrast to generic referral-to-physiotherapy routes, these pathways define who does what, when, and how, using pre-specified entry criteria, assessment steps, and decision points for step-up or de-escalation. The design intent is pragmatic: align resources to need, avoid unnecessary delay, and reduce variation that does not add value. In musculoskeletal care, this often translates to structured triage, early education and exercise, targeted adjuncts, and clear thresholds for imaging, injections, or surgical opinion.

At the heart of this approach is condition-specific rehabilitation, which prioritizes mechanisms relevant to the presenting problem. For lower-limb osteoarthritis, emphasis typically falls on progressive strengthening, neuromuscular control, and behaviorally informed self-management. For shoulder pain, load management and scapular or rotator cuff protocols may take precedence, while for tendinopathy, graded exposure and energy-storage exercises dominate. Across conditions, the pathway architecture seeks to reduce fragmentation by defining transitions: when to continue community-based exercise, when to add 1:1 review, when to access group classes, and how to re-enter care if symptoms flare.

Implementation in routine services requires attention to both clinical logic and operational flow. Clinicians need shared assessment templates and practical guardrails rather than rigid scripts. Patients need to understand why a specific route is proposed and how to activate support between visits. Service leaders need signals of performance that matter at the front line: demand capture, time to first meaningful contact, session completion, and onward referral proportions. The evaluation summarized here focuses on those workaday elements, assessing not only what was planned but what was delivered, and how it was experienced.

Intervention architecture and rationale

The pathway was organized around staged decision-making. Entry began with condition-specific screening to establish safety, identify red flags, and assign an initial track. Tracks were differentiated by intensity and delivery mode. A low-intensity track emphasized early activation, education, and simple home-based exercise with remote check-ins; a moderate-intensity track added supervised sessions or group classes; a high-intensity track allowed closer monitoring, adjunct modalities, and coordination with medical input when indicated. Transitions between tracks were permitted at set reassessment points.

Three design principles underpinned the pathway. First, a shared assessment core ensured that the information needed for decisions was consistently captured. This typically included pain and function measures, load tolerance, goal setting, and risks for persistent symptoms, alongside safety checks. Second, goal-oriented planning framed rehabilitation as a means to restore specific activities that matter to the individual, not merely to reduce pain intensity. Third, continuity was preserved through named contacts and standardized handovers to prevent patients from repeating histories or losing momentum when moving between components.

Delivery modalities blended in-person and remote interaction. Remote components were used for education, monitoring, and progression of exercise where safe, particularly for stable or improving presentations. In-person sessions were prioritized for initial assessment, technique coaching, and complex or fluctuating presentations. Group formats broadened access and normalized self-management strategies, while 1:1 sessions offered tailored progressions and problem-solving for barriers such as fear of movement or difficulties integrating exercise into daily routines.

Behavioral strategies were integrated to support adherence. These included collaborative goal setting, graded exposure to feared movements, self-efficacy building through early wins, and environmental cues for habit formation. For joint pain linked to osteoarthritis, clinicians emphasized gradual loading with realistic timelines for strength adaptation, helping to recalibrate expectations that meaningful improvements in function often precede large changes in pain intensity. Education covered the rationale for exercise in osteoarthritis, differentiating appropriate training discomfort from warning signs that require modification.

Operationally, the pathway specified access routes. Referrals from primary care, self-referral, and internal step-ups from community services were accepted, with standardized information collected at the outset to support triage. Triage itself combined algorithmic prompts with clinician judgment, aiming to assign the least intensive option likely to succeed while preserving a clear plan for escalation. The pathway also codified re-entry during flares, encouraging early contact to adjust load rather than pausing activity altogether.

Governance features included routine case review for complex or nonprogressing cases, shared documentation templates across the team, and pragmatic criteria for imaging or interventional referral, aligned with best evidence to reduce low-value care. Service metrics were chosen to reflect both patient and system priorities: time to first meaningful contact, proportion of patients completing the initially assigned track, rates of step-up or step-down, and onward referral to medical or surgical services when threshold criteria were met.

Evaluation approach and measurement

The evaluation used a mixed-methods service lens to understand what was delivered, how it was received, and what mechanisms plausibly linked pathway features with observed experiences. Quantitatively, descriptive implementation metrics were abstracted from service records, focusing on flow and delivery rather than long-term clinical outcomes. These typically included demand capture at entry, time from referral to first contact, attendance and completion across tracks, and proportions requiring step-up to higher-intensity components or onward referral for medical review.

Qualitatively, semi-structured interviews and focus groups with patients and clinicians explored acceptability, perceived coherence, burden, and utility. Patient participants represented both new-onset and longstanding joint pain presentations and included those who completed the initial track, those who stepped up, and those who disengaged. Clinician participants included physiotherapists delivering group and 1:1 components, triage clinicians allocating tracks, and service leads responsible for coordination and data oversight. Interviews probed understanding of the pathway, experiences of transitions, adequacy of information and support, and specific barriers such as technology access, transport, or competing responsibilities.

Data analysis prioritized practical insights that could inform iterative improvement. Administrative metrics were summarized at the service level and, where feasible, stratified by entry route or condition track to identify pressure points. Qualitative data were coded for themes aligned to implementation constructs such as coherence (did the pathway make sense to users), cognitive participation (willingness to engage), collective action (workability in practice), and reflexive monitoring (perceived effects and suggestions for change). Particular attention was given to moments where the pathway felt different from usual care, as these often illuminate mechanisms of benefit or friction.

Importantly, the evaluation did not attempt to isolate causal effects on clinical outcomes. Rather, it centered on feasibility, fidelity, acceptability, and operational learning under real-world constraints. Where patient-reported outcomes were available, they were considered descriptively and in context, recognizing that pathway adoption and consolidation precede robust outcome evaluation. This approach reflects a staged implementation logic: first get the work to fit, then measure comparative effectiveness once delivery is stable.

Throughout, investigators maintained sensitivity to equity. For remote components, access to devices, digital literacy, and preferences for in-person interaction were documented. For group delivery, suitability for individuals with mobility limitations, caregiving responsibilities, or language needs was considered. The evaluation also examined whether the pathway unintentionally created thresholds that disadvantaged those with fluctuating symptoms or comorbidities, and whether named contacts and re-entry options mitigated these risks.

Implementation findings and practice implications

Participants reported that the pathway had a distinct feel compared with usual care, characterized by clearer early direction, explicit goals, and predictable follow-up. For patients with osteoarthritis, starting with a concrete plan for progressive strengthening and walking tolerance reduced uncertainty, even when pain was expected to fluctuate. Clinicians noted that the shared assessment core made triage conversations more efficient and aligned expectations: individuals understood why group classes or remote check-ins were recommended initially and how escalation would occur if progress stalled.

Coherence was bolstered by consistent messaging and visual aids outlining the pathway. Patients appreciated seeing where they were and what the next step might be, which reduced anxiety about being discharged or left without support. Named contacts and timely responses to questions during early load progression were particularly valued. When problems arose, they often related to transitions: switching between remote and in-person formats, moving from a group to a 1:1 setting, or navigating onward referral. In these moments, continuity mechanisms such as standardized handovers and brief re-orientation at the start of new components were helpful.

Workability depended on operational details. Remote components were efficient for education, adherence checks, and minor progressions, but they worked best when the initial in-person session established rapport and technique. Group classes expanded capacity and fostered peer support; however, they required careful triage to ensure participants could benefit safely and felt comfortable. Clinicians emphasized the importance of a clear plan for those who struggled in a group environment, including rapid conversion to 1:1 review without restarting the entire process.

Technological and social context mattered. Some patients lacked reliable internet access or comfort with video platforms; others simply preferred in-person contact. Offering alternatives and avoiding a one-size-fits-all requirement for digital engagement improved inclusivity. Transport, work schedules, and caregiving roles also shaped attendance. Services that coordinated session times with local transit or offered early/late slots saw fewer avoidable non-attendances. For those with pain flares, providing early adjustment of load and reassurance prevented unnecessary pauses or dropouts.

Clinicians reported that the pathway redistributed workload rather than simply reducing it. Early triage and shared documentation saved time downstream, but administrative work increased during the initial phase. Group delivery and remote check-ins improved reach, yet required focused preparation to maintain quality and safety. Teams that used brief huddles and shared dashboards found it easier to spot who needed step-up or who was ready for self-directed progression, enabling more proactive care.

Fidelity was generally achievable when tools and training were aligned. Templates that were too long or duplicative undermined use, whereas concise prompts kept assessments focused on decisions that mattered. Similarly, exercise libraries with simple progressions facilitated self-management; overly complex protocols impaired adherence. Supervisors encouraged a flexible mindset: follow the pathway where it helps; adapt thoughtfully when individual circumstances warrant a different route, and document the rationale.

Perceived effects clustered around clarity, confidence, and consistency. Patients felt more prepared to continue activity between appointments and less concerned about occasional symptom spikes when brief check-ins were available. Clinicians found it easier to explain why imaging or injections were not first-line, as the pathway provided a ready-made narrative that linked goals, loading strategies, and expected timelines for progress. In osteoarthritis, this framing helped decouple short-term discomfort from long-term harm, aligning with evidence that progressive strengthening and weight-bearing are compatible with joint health for most individuals when dosed appropriately.

Where friction emerged, it often reflected gaps at interfaces. For example, onward referral thresholds needed to be clear and consistently applied to avoid repeated assessments. Communication with primary care about pathway scope and expected outcomes reduced mismatched expectations, particularly regarding sick notes, analgesia, or imaging. Involving primary care clinicians in co-design sessions improved shared understanding and smoothed referrals.

Equity considerations surfaced practical changes. Providing printed exercise handouts alongside digital resources reduced exclusion for those with limited connectivity. Translating key materials and using plain language made content more accessible. Allowing phone-based check-ins as an alternative to video expanded reach. Importantly, measuring who did not engage or who disengaged early prompted targeted outreach and iterative fixes.

From a service perspective, the most useful implementation metrics were those directly linked to decisions and flow: time to first meaningful contact, completion of the initially assigned track, step-up rates for nonprogressing cases, and onward referral proportions when criteria were met. These measures flagged whether triage was calibrating intensity appropriately and whether transitions were functioning as intended. While not substitutes for patient-reported outcomes, they provided rapid feedback during early adoption.

Several practical lessons follow for teams considering similar pathways. First, invest in the first contact. A clear explanation of the pathway, co-created goals, and a demonstration of key exercises or activities set the tone for self-management and appropriate expectations. Second, make escalation easy and visible. Patients and clinicians should know exactly how to trigger a step-up and what will happen next. Third, streamline documentation to items that change decisions. If a data field does not inform action, reconsider collecting it.

Fourth, use groups and remote contacts where they make sense, but offer alternatives without penalty. People vary in their preferences and circumstances; choice increases engagement. Fifth, protect continuity. Named contacts, standardized handovers, and short re-orientation at transitions reduce the feeling of starting over. Sixth, measure what matters to flow and learn in cycles: review metrics and qualitative feedback regularly, test small changes, and scale what works.

Limitations of early implementation evaluations also deserve emphasis. Without comparative designs or stable delivery, it is not possible to attribute clinical outcomes to the pathway. Generalizability may be constrained by local resources, staffing, and digital infrastructure. Furthermore, experiences captured during early adoption may differ from those in steady state. Recognizing these boundaries helps align expectations and plan for later-stage effectiveness and cost evaluations.

For osteoarthritis and other common joint pain presentations, the logic of condition-specific pathways is conceptually strong: standardize core decisions and messaging, personalize exercise and support, and clarify when and how care changes. The evaluation here supports feasibility and acceptability and identifies practical levers for improvement. Future work can build on this foundation with quasi-experimental or randomized designs, longer follow-up, and cost analyses to determine whether observed operational gains translate into sustained clinical benefit and more efficient use of resources.

In the interim, teams can act on the actionable insights: clarify thresholds and transitions; tailor delivery modes to preference and access; ensure early, meaningful contact; and support clinicians with concise tools that prioritize function-focused goals. These steps are compatible with current evidence for osteoarthritis rehabilitation and can be adapted to shoulder, spine, and tendinopathy pathways with condition-appropriate content.