Online education, pain coaching and advice by video conference can reduce knee pain, an Australian study has found
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 the population growing older, finding effective ways to manage the pain from early osteoarthritis and motivate people to undertake physical activity may avoid joint surgery. These researchers wanted to see whether they could demonstrate benefit from an internet-delivered programme.
What did this study do?
This Australian randomised controlled trial included 148 people aged over 50 who had 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 weekly interactive PainCOACH skills training sessions for eight weeks; and seven video conferencing sessions with a physiotherapist 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 were paid 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 per cent confidence interval [CI] 0.9 to 2.3 units). Significant improvement in pain was sustained at nine months (MD 1.1 units, 95 per cent 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 per cent CI 5.9 to 12.7 units). Again, this between-group difference was sustained at nine months (MD 7.0 units, 95 per cent 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 per cent in the control group. At nine months the respective proportions were 67 per cent versus 51 per cent.
- Similarly, 81 per cent of the intervention group had a clinically important improvement in physical function by three months (defined as a six unit reduction in the WOMAC osteoarthritis index), compared with 39 per cent of the control group. At nine months the respective proportions were 76 per cent versus 49 per cent.
What does current guidance say?
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. Consideration 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 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 all 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 randomised trial. Ann Intern Med. 2017;166(7):453-462. This project was funded by the Australian National Health and Medical Research Council (programme grant 1091302).
The full NIHR Signal and additional expert commentary was published on 18 July 2017 and can be found here.
Anthony Gilbert adds his view
The internet, computers, tablets and smartphones are increasingly accessible. It is generally accepted that technology has the potential to transform healthcare delivery.
Standard care for knee osteoarthritis places an emphasis on the importance of education and exercise. It is encouraging to see that the intervention group in this study, an internet-based support programme, was feasible and patients gained significant clinical improvement.
Internet-based care and videoconferencing could save money for the patient by reducing travel, parking and childcare costs. It may help to reduce the time needed away from employment to attend a consultation. Patients need to access appropriate equipment and, for some, cost and technology literacy could be a barrier. Online communication does, however, present an opportunity for clinicians to assess and rehabilitate patients at home, removing the need for travel. This is particularly useful if a patient lives in a remote area or finds travel challenging.
In some circumstances, technology would not be an appropriate alternative to standard care. Physiotherapy is often viewed as ‘hands on’ – of course this is not possible over a screen. Consultations over the internet will change the patient and clinician interaction and relationship. Some patients (and clinicians) may not find this acceptable.
Although this study shows that an internet-based support programme is effective, it won’t be suitable to use for every clinical encounter. Rolling this out on a larger scale, particularly in the early stages, will require us to select the right patients.
- Physiotherapist Anthony Gilbert BSc Hons, MRes, is a Health Education England/NIHR clinical doctoral research fellow at the Royal National Orthopaedic Hospital
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