Online intervention reduces knee pain, improves mobility

A suite of online interventions provided substantial pain relief and improved mobility for patients with chronic knee pain, according to a study published online February 21 in the Annals of Internal Medicine. The interventions included physiotherapy via web-based video conferencing, as well as a pain management course and educational materials.

Bridget M. Kuehn, Medscape February 21, 2017

Arthritis causes persistent knee pain in about one quarter of adults, often inhibiting everyday activities, note Kim L. Bennell PhD, from the Centre for Health, Exercise, and Sports Medicine at the University of Melbourne in Australia, and colleagues.

It is also a problem that is expected to become more common in the United States as the population ages, writes Lisa A. Mandl, MD, MPH, from the Hospital for Special Surgery and Weill Cornell Medicine, New York City, in an accompanying editorial.

Existing therapies have many drawbacks. Currently used medications have adverse effects or may be cost prohibitive, Nonpharmacological therapies, such as physiotherapist-directed exercise and pain-coping training, may be difficult to access, especially for those in rural areas, Dr Bennell and colleagues note.

Therefore, Dr Bennell and colleagues tested whether they could improve access to treatment and patient outcomes using a suite of online interventions. They enrolled 148 people from seven Australian states, including 43% of whom were from rural or remote areas.

The researchers randomly assigned participants to receive either seven sessions with a physiotherapist via Skype, free video conferencing software, an online pain-coping skills course called PainCOACH, and educational material, or a control intervention, which consisted of the educational materials alone. The interventions took place over the course of 3 months. Patients participating in the intervention also received resistance bands, ankle weights, and on request, a pedometer.

At 3 months, patients in the intervention group reported significant improvements in pain compared with those in the control group, with an average difference of 1.6 units on an 11-point pain scale (95% confidence interval [CI], 0.9 – 2.3 units).

The intervention group also reported improved physical function compared with the control group, with an average difference of 9.3 units on the Western Ontario and McMaster University Osteoarthritis Index (95% CI, 5.9 – 12.7 units).

Much of this improvement was sustained at 9 months, with an average pain difference of 1.1 units and physical function of 7.0 units between the 2 groups.

In addition, participants reported high satisfaction with the intervention. They also had high rates of completion, with 78% accessing the educational materials, an average of 6.3 of seven Skype physiotherapy sessions completed, and an average of 6.4 of the eight pain-management modules completed.

Increased knee pain was the most common adverse event reported in both groups, with 15 people in the intervention group reporting it, as well as three in the control group.

“These results are encouraging and show that ‘telemedicine’ is clearly ready for prime time,” writes Dr Mandl. “An Internet-based intervention circumvents multiple issues related to access to care, making this an inexpensive and easily scalable option for people living in remote areas or any location with an inadequate supply of health care providers.”

However, Dr Mandl noted that the study may not be widely generalizable, as it excluded patients with worse pain in other joints and those whose pain limited exercise. It also did not use radiography to evaluate patient’s knee pain.

“Evaluating the ‘low-hanging fruit’ (patients who are more likely to respond) is an entirely reasonable approach to establish proof of concept before embarking on wider dissemination of this novel intervention,” Dr Mandl noted.

Future studies will be needed to test whether this intervention will be effective in minorities or other subpopulations, she continued.

The study authors plan to make their PainCOACH pain management modules available to the public free online.

Source Medscape


Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial, Kim L. Bennell, BAppSci(Physio), PhD; Rachel Nelligan, BPhysio; Fiona Dobson, BAppSci(Physio), PhD; Christine Rini, PhD; Francis Keefe, BA, MS, PhD; Jessica Kasza, BSc(Hons), PhD; Simon French, BAppSc(Chiro), MPH, PhD; Christina Bryant, MA(Clin Psych), PhD; Andrew Dalwood, BAppSci(Physio), GradDipManipTherapy; J. Haxby Abbott, PhD, DPT; Rana S. Hinman, BPhysio(Hons), PhD. Ann Intern Med. 2017 [Epub ahead of print 21 February 2017] doi: 10.7326/M16-1714

Internet-delivered physiotherapist-prescribed exercise and pain-coping skills training is beneficial for people with chronic knee pain [commentary], Østerås H, Bentsen L. J Physiother. 2017 Oct;63(4):260. doi: 10.1016/j.jphys.2017.07.010. Epub 2017 Sep 19. Full text

Improving Symptoms in Knee Osteoarthritis: Can We Get There From Here? Lisa A. Mandl MD MPH. Ann Intern Med. 2017. DOI: 10.7326/M17-0330. Full text

Internet-Delivered Exercise and Pain-Coping Skills Training for Chronic Knee Pain, K.L. Bennell, R. Nelligan, F. Dobson, C. Rini, F. Keefe, J. Kasza, S. French, C. Bryant, A. Dalwood, J.H. Abbott, and R.S. Hinman. Ann Intern Med. 2017 [Epub ahead of print 21 February 2017] doi: 10.7326/P17-9031

Automated Internet-based pain coping skills training to manage osteoarthritis pain: a randomized controlled trial, Rini C, Porter LS, Somers TJ, McKee DC, DeVellis RF, Smith M, Winkel G, Ahern DK, Goldman R, Stiller JL, Mariani C, Patterson C, Jordan JM, Caldwell DS, Keefe FJ. Pain. 2015 May;156(5):837-848. doi: 10.1097/j.pain.0000000000000121. Full text

Internet-mediated physiotherapy and pain coping skills training for people with persistent knee pain (IMPACT – knee pain): a randomised controlled trial protocol, Dobson F, Hinman RS, French S, Rini C, Keefe F, Nelligan R, Abbott JH, Bryant C, Staples MP, Dalwood A, Bennell KL. BMC Musculoskelet Disord. 2014 Aug 13;15:279. doi: 10.1186/1471-2474-15-279. Full text

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