Adherence to a Digital Knee Rehabilitation Platform Among Patients With Knee Osteoarthritis and Anterior Cruciate Ligament Reconstruction in Hong Kong: Qualitative Study.

Abstract

Background: Exercise therapy is fundamental to rehabilitation for knee osteoarthritis and anterior cruciate ligament (ACL) reconstruction, yet adherence to prescribed exercise typically declines once clinical supervision ends. Digital rehabilitation platforms offer a promising means of supporting sustained exercise adherence, but qualitative evidence on how patients experience these platforms in real-world clinical practice remains limited, particularly in non-Western health care contexts.

Objective: This study aimed to explore how patients with different knee conditions experienced the Healthy Knees digital rehabilitation platform in Hong Kong and to identify the factors shaping their platform engagement and exercise adherence.

Methods: A qualitative design was adopted using reflexive thematic analysis. Fifteen adults (9 with ACL, 6 with osteoarthritis) who had been prescribed the Healthy Knees web-based platform at Prince of Wales Hospital participated in semistructured, in-person interviews (30-45 min). Interviews were conducted in Cantonese or Mandarin, transcribed verbatim, translated into English, and analyzed inductively. Ethics approval was obtained from the Chinese University of Hong Kong and the University of New South Wales.

Results: Participants were aged 21 to 79 years, with most being male (11/15). Younger participants were predominantly patients with postoperative ACL, while older participants were predominantly patients with preoperative osteoarthritis. Three interrelated themes were identified, collectively describing the fit between the platform and participants' contexts. Content fit captured the alignment between exercise content and rehabilitation needs; participants across both groups perceived substantial overlap with existing physiotherapy, and content was often mismatched to their recovery stage. Motivational fit captured the alignment between platform support features and motivational needs; pain functioned as both a driver and a deterrent to exercise, and participants ranged from highly self-directed to reliant on external scaffolding, not following a simple age pattern. Access fit captured the alignment between the platform's delivery mechanism and participants' technological circumstances; QR code-dependent access, absence of a dedicated mobile app, and display issues created friction that led several participants to migrate to alternative resources, maintaining exercise adherence while abandoning platform engagement.

Conclusions: Adherence to digital knee rehabilitation was shaped by the degree of fit between the platform and users' contexts across content, motivational, and access dimensions. When access fit failed, participants often substituted alternative exercise resources rather than ceasing exercise entirely, highlighting a distinction between platform engagement and exercise adherence. As the sample's clinical and demographic characteristics were closely linked, these findings should not be interpreted as diagnostic comparisons between ACL and osteoarthritis populations but as patterns shaped by the recovery phase and age. These findings suggest that digital rehabilitation platforms should incorporate adaptive content aligned with the recovery stage, integrated feedback mechanisms, and reduced access friction to sustain platform engagement within an ecosystem of competing alternatives.