NIHR Signal Online education, pain coaching and advice by video conference can reduce knee pain

Published on 18 July 2017

For people with chronic knee pain from osteoarthritis, a programme including online education, interactive pain coaching and physiotherapy advice from a professional by skype gave greater improvement in pain and function at nine months than online education alone.

The small randomised control trial included 148 adults aged 50 or over in Australia. Clinically meaningful improvements in pain and physical function were achieved by around three-quarters of the comprehensive intervention group compared with just under half receiving education alone.

Internet-delivered treatment could increase access, reduce clinician face-to-face time, and in the long-term reduce the need for knee replacement surgery, if found to be cost-effective.

However, only competent users of information technology with access to the internet would be able to receive treatment in this way. Therefore, it might not be an effective alternative for everyone compared with in-person appointments with the GP or physiotherapist.

Online education, pain coaching and advice by video conference can reduce knee pain

Share your views on the research.

Why was this study needed?

In older adults, pain and stiffness in the knee is likely to be caused by osteoarthritis (degenerative arthritis), where there is damage to the protective surface of the knee bones and swelling of tissues around the joint.

Osteoarthritis is the most common reason for knee replacement surgery. This is often a last resort when conservative measures haven’t worked and pain, stiffness and disability are having adverse effects on daily life. Knee replacements can never function quite as well as a natural joint and can wear out over time needing repeat surgery. One study estimated the average cost of knee replacement surgery was £7,458 per person 10 years ago, which may have increased since.

With a growing older population in the UK, finding effective ways to manage the pain from early osteoarthritis and motivate people to undertake physical activity may avoid joint surgery and these researchers wanted to see if they could demonstrate a benefit from an internet delivered programme or not.

What did this study do?

This Australian randomised controlled trial included 148 people aged over 50 who had chronic knee pain for over three months. Exclusion criteria included past knee surgery or being on the waiting list, and treatment for knee pain in the previous six months, including strengthening exercises.

The intervention group received internet-based educational material (providing instructions about exercise, physical activity pain management, emotions and therapies) plus once-weekly interactive PainCOACH skills training sessions for eight weeks; and seven videoconferencing sessions with a physiotherapist delivered over 12 weeks. Controls received the internet-based educational material only.

Self-reported pain on walking was assessed at three months using the 11-point numerical rating scale, and physical function using the 68-point subscale of the Western Ontario and McMaster Universities Osteoarthritis Index.

All participants were included in intention-to-treat analysis. Participants received monetary compensation for their involvement.

What did it find?

  • By three months, the intervention group saw greater improvement in pain on the 11 point scale than the control group (mean difference [MD] 1.6 units, 95% confidence interval [CI] 0.9 to 2.3 units). Significant improvement in pain was sustained at nine months (MD 1.1 units, 95% CI 0.4 to 1.8).
  • Improvements in physical function at three months were also significantly greater in the intervention group (MD 9.3 units, 95% CI 5.9 to 12.7 units). Again, this between-group difference was sustained at nine months (MD 7.0 units, 95% CI 3.4 to 10.5 units).
  • Seventy three per cent of participants in the intervention group achieved a clinically important improvement in pain by three months (defined as a 1.8 unit reduction of numerical rating scale), compared with only 39% in the control group. At nine months the respective proportions were 67% vs. 51%.
  • Similarly 81% of the intervention group had a clinically important improvement in physical function by three months (defined as a 6 unit reduction in the WOMAC index), compared with 39% of the control group. At nine months the respective proportions were 76% vs. 49%.

Internet-based education, pain coping training and individual video support for people with knee arthritis

What does current guidance say on this issue?

NICE guidelines recommend that patients are offered accurate verbal and written information to enhance understanding of osteoarthritis and its management. Self-management programmes, either individual or group, should focus on the core treatments, particularly exercise. Local muscle strengthening and aerobic exercises are considered a core part of management, regardless of age, pain severity or disability. NICE state that it is not specified whether exercise should be provided by the NHS or patients should seek the intervention themselves.

Joint surgery may be considered if the person has been offered the core non-surgical treatments and symptoms are having a substantial impact on quality of life.

What are the implications?

This comprehensive internet-based support programme has been shown to be more effective than internet-based education alone in Australia. Considerations of how this could be rolled out in the NHS would be a next step. Not all interventions developed in other countries directly transfer well to the UK system. Assessment of the feasibility and acceptability for UK patients with knee pain in this age group could help. An assessment of the cost-effectiveness and affordability of the intervention would also be important.

There is other relevant research that demonstrates the effectiveness of supported self-management programmes whether delivered remotely or not. These findings should be seen in the context of this rapidly developing area of enquiry.

Addressing the central physical and psychological components of osteoarthritis may improve self-management, and if the intervention supports this and can reduce the need for joint surgery in the long-term it could be of major interest to musculoskeletal service providers.

Potentially, the internet may allow easier access for a greater number of people and reduce the need for face-to-face clinician time. However, the individual situation needs to be considered as fast internet access is not evenly distributed across the country and might not be available to those in this age group, especially those who might benefit most from remotely delivered services.

Citation and Funding

Bennell KL, Nelligan R, Dobson F, et al. Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial. Ann Intern Med. 2017;166(7):453-462.

This project was funded by the Australian National Health and Medical Research Council (program grant 1091302).

Bibliography

Arthritis Research UK. What are the possible disadvantages of a knee replacement? Chesterfield: Arthritis Research UK; 2017.

Dakin H, Gray A, Fitzpatrick R, et al. Rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set. BMJ Open. 2012;2(1).

NHS Choices. Knee pain. London: Department of Health; 2015.

NICE. Mini-incision surgery for total knee replacement. IPG345. London: National Institute for Health and Care Excellence; 2010.

NICE. Osteoarthritis: care and management. CG177. London: National Institute for Health and Care Excellence; 2014.

Why was this study needed?

In older adults, pain and stiffness in the knee is likely to be caused by osteoarthritis (degenerative arthritis), where there is damage to the protective surface of the knee bones and swelling of tissues around the joint.

Osteoarthritis is the most common reason for knee replacement surgery. This is often a last resort when conservative measures haven’t worked and pain, stiffness and disability are having adverse effects on daily life. Knee replacements can never function quite as well as a natural joint and can wear out over time needing repeat surgery. One study estimated the average cost of knee replacement surgery was £7,458 per person 10 years ago, which may have increased since.

With a growing older population in the UK, finding effective ways to manage the pain from early osteoarthritis and motivate people to undertake physical activity may avoid joint surgery and these researchers wanted to see if they could demonstrate a benefit from an internet delivered programme or not.

What did this study do?

This Australian randomised controlled trial included 148 people aged over 50 who had chronic knee pain for over three months. Exclusion criteria included past knee surgery or being on the waiting list, and treatment for knee pain in the previous six months, including strengthening exercises.

The intervention group received internet-based educational material (providing instructions about exercise, physical activity pain management, emotions and therapies) plus once-weekly interactive PainCOACH skills training sessions for eight weeks; and seven videoconferencing sessions with a physiotherapist delivered over 12 weeks. Controls received the internet-based educational material only.

Self-reported pain on walking was assessed at three months using the 11-point numerical rating scale, and physical function using the 68-point subscale of the Western Ontario and McMaster Universities Osteoarthritis Index.

All participants were included in intention-to-treat analysis. Participants received monetary compensation for their involvement.

What did it find?

  • By three months, the intervention group saw greater improvement in pain on the 11 point scale than the control group (mean difference [MD] 1.6 units, 95% confidence interval [CI] 0.9 to 2.3 units). Significant improvement in pain was sustained at nine months (MD 1.1 units, 95% CI 0.4 to 1.8).
  • Improvements in physical function at three months were also significantly greater in the intervention group (MD 9.3 units, 95% CI 5.9 to 12.7 units). Again, this between-group difference was sustained at nine months (MD 7.0 units, 95% CI 3.4 to 10.5 units).
  • Seventy three per cent of participants in the intervention group achieved a clinically important improvement in pain by three months (defined as a 1.8 unit reduction of numerical rating scale), compared with only 39% in the control group. At nine months the respective proportions were 67% vs. 51%.
  • Similarly 81% of the intervention group had a clinically important improvement in physical function by three months (defined as a 6 unit reduction in the WOMAC index), compared with 39% of the control group. At nine months the respective proportions were 76% vs. 49%.

Internet-based education, pain coping training and individual video support for people with knee arthritis

What does current guidance say on this issue?

NICE guidelines recommend that patients are offered accurate verbal and written information to enhance understanding of osteoarthritis and its management. Self-management programmes, either individual or group, should focus on the core treatments, particularly exercise. Local muscle strengthening and aerobic exercises are considered a core part of management, regardless of age, pain severity or disability. NICE state that it is not specified whether exercise should be provided by the NHS or patients should seek the intervention themselves.

Joint surgery may be considered if the person has been offered the core non-surgical treatments and symptoms are having a substantial impact on quality of life.

What are the implications?

This comprehensive internet-based support programme has been shown to be more effective than internet-based education alone in Australia. Considerations of how this could be rolled out in the NHS would be a next step. Not all interventions developed in other countries directly transfer well to the UK system. Assessment of the feasibility and acceptability for UK patients with knee pain in this age group could help. An assessment of the cost-effectiveness and affordability of the intervention would also be important.

There is other relevant research that demonstrates the effectiveness of supported self-management programmes whether delivered remotely or not. These findings should be seen in the context of this rapidly developing area of enquiry.

Addressing the central physical and psychological components of osteoarthritis may improve self-management, and if the intervention supports this and can reduce the need for joint surgery in the long-term it could be of major interest to musculoskeletal service providers.

Potentially, the internet may allow easier access for a greater number of people and reduce the need for face-to-face clinician time. However, the individual situation needs to be considered as fast internet access is not evenly distributed across the country and might not be available to those in this age group, especially those who might benefit most from remotely delivered services.

Citation and Funding

Bennell KL, Nelligan R, Dobson F, et al. Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial. Ann Intern Med. 2017;166(7):453-462.

This project was funded by the Australian National Health and Medical Research Council (program grant 1091302).

Bibliography

Arthritis Research UK. What are the possible disadvantages of a knee replacement? Chesterfield: Arthritis Research UK; 2017.

Dakin H, Gray A, Fitzpatrick R, et al. Rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set. BMJ Open. 2012;2(1).

NHS Choices. Knee pain. London: Department of Health; 2015.

NICE. Mini-incision surgery for total knee replacement. IPG345. London: National Institute for Health and Care Excellence; 2010.

NICE. Osteoarthritis: care and management. CG177. London: National Institute for Health and Care Excellence; 2014.

Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial

Published on 28 February 2017

Bennell, K. L.,Nelligan, R.,Dobson, F.,Rini, C.,Keefe, F.,Kasza, J.,French, S.,Bryant, C.,Dalwood, A.,Abbott, J. H.,Hinman, R. S.

Ann Intern Med , 2017

Background: Effective, accessible biopsychosocial treatments are needed to manage chronic knee pain on a population level. Objective: To evaluate the effectiveness of Internet-delivered, physiotherapist-prescribed home exercise and pain-coping skills training (PCST). Design: Pragmatic parallel-group randomized, controlled trial. (Australian New Zealand Clinical Trials Registry: ACTRN12614000243617). Setting: Community (Australia). Patients: 148 persons aged 50 years or older with chronic knee pain. Intervention: The intervention was delivered via the Internet and included educational material, 7 videoconferencing (Skype [Microsoft]) sessions with a physiotherapist for home exercise, and a PCST program over 3 months. The control was Internet-based educational material. Measurements: Primary outcomes were pain during walking (11-point numerical rating scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index) at 3 months. Secondary outcomes were knee pain, quality of life, global change (overall, pain, and functional status), arthritis self-efficacy, coping, and pain catastrophizing. Outcomes were also measured at 9 months. Results: Of participants enrolled, 139 (94%) completed primary outcome measures at 3 months and 133 (90%) completed secondary outcome measures at 9 months; multiple imputation was used for missing data. The intervention group reported significantly more improvement in pain (mean difference, 1.6 units [95% CI, 0.9 to 2.3 units]) and physical function (mean difference, 9.3 units [CI, 5.9 to 12.7 units]) than the control group at 3 months, and improvements were sustained at 9 months (mean differences, 1.1 units [CI, 0.4 to 1.8 units] and 7.0 units [CI, 3.4 to 10.5 units], respectively). Intervention participants showed significantly more improvement in most secondary outcomes than control participants. At both time points, significantly more intervention participants reported global improvements. Limitation: Participants were unblinded. Conclusion: For persons with chronic knee pain, Internet-delivered, physiotherapist-prescribed exercise and PCST provide clinically meaningful improvements in pain and function that are sustained for at least 6 months. Primary Funding Source: National Health and Medical Research Council.

Expert commentary

The effectiveness of non-pharmacological treatments based on biopsychosocial principals for chronic knee pain is increasingly accepted. The importance of delivering such interventions to an increasingly aging population is undisputed. The challenge now is how to achieve this – in a way that is acceptable and accessible to patients, and which delivers relevant and meaningful improvements.

A relatively high intensity, but remotely delivered, intervention comprising educational material, interactive coaching and physiotherapist supervised “Skype” exercises appears to have cracked this nut and achieved high adherence - at least in the short term for this relatively young, internet savvy population of (paid) Australian volunteers.

Will this deliver the holy grail of preventing locomotor decline in later life? That’s the next big question.

Elaine Hay, Director of Research Institute for Primary Care, Professor of Community Rheumatology, Keele University