Development of an internet-delivered cognitive behavioral therapy program for use in combination with exercise therapy and education by patients at increased risk of chronic pain following total knee arthroplasty

Turid Rognsvåg, Maren Falch Lindberg, Anners Lerdal, Jan Stubberud, Ove Furnes, Inger Holm, Kari Indrekvam, Bjørn Lau, Daniil Rudsengen, Søren T Skou, Mona Badawy, Turid Rognsvåg, Maren Falch Lindberg, Anners Lerdal, Jan Stubberud, Ove Furnes, Inger Holm, Kari Indrekvam, Bjørn Lau, Daniil Rudsengen, Søren T Skou, Mona Badawy

Abstract

Background: Approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA). Due to the growing number of TKA procedures, this will affect an increasing number of people worldwide. Catastrophic thinking, dysfunctional illness perception, poor mental health, anxiety and depression characterize these non-improvers, and indicate that these patients may need individualized treatment using a treatment approach based on the bio-psycho-social health model. The present study developed an internet-delivered cognitive behavioral therapy (iCBT) program to be combined with exercise therapy and education for patients with knee osteoarthritis (OA) at increased risk of chronic pain after TKA.

Methods: The development process followed the first two phases of the UK Medical Research Council framework for complex interventions. In the development phase, the first prototype of the iCBT program was developed based on literature review, established iCBT programs and multidisciplinary workshops. The feasibility phase consisted of testing the program, interviewing users, condensing the program, and tailoring it to the patient group. A physiotherapist manual was developed and adapted to physiotherapists who will serve as mentors.

Results: The development process resulted in an iCBT program consisting of 10 modules with educational texts, videos and exercises related to relevant topics such as goalsetting, stress and pain, lifestyle, automatic thoughts, mindfulness, selective attention, worry and rumination. A physiotherapist manual was developed to guide the physiotherapists in supporting the patients through the program and to optimize adherence to the program.

Conclusions: The iCBT program is tailored to patients at risk of chronic pain following TKA, and may be useful as a supplement to surgery and/or exercise therapy. A multicentre RCT will evaluate the iCBT program in combination with an exercise therapy and education program. This novel intervention may be a valuable contribution to the treatment of OA patients at risk of chronic pain after TKA.

Trial registration: The RCT is pre-registered at ClinicalTrials.gov: NCT03771430 11/12/2018.

Keywords: Cognitive behavior therapy; Osteoarthritis; Physical exercise; Total knee arthroplasty.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Flow chart describing the process of developing the electronic version of a Cognitive Behavioral Theory-based (iCBT) intervention

References

    1. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S. A randomized, controlled trial of Total knee replacement. N Engl J Med. 2015;373(17):1597–1606. doi: 10.1056/NEJMoa1505467.
    1. Lange JK, Lee YY, Spiro SK, Haas SB. Satisfaction rates and quality of life changes following Total knee arthroplasty in age-differentiated cohorts. J Arthroplast. 2018;33(5):1373–1378. doi: 10.1016/j.arth.2017.12.031.
    1. Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2(1):e000435. doi: 10.1136/bmjopen-2011-000435.
    1. Lindberg MF, Miaskowski C, RustoEn T, Rosseland LA, Cooper BA, Lerdal A. Factors that can predict pain with walking, 12 months after total knee arthroplasty. Acta Orthop. 2016;87(6):600–606. doi: 10.1080/17453674.2016.1237440.
    1. Beswick AD, Wylde V, Gooberman-Hill R. Interventions for the prediction and management of chronic postsurgical pain after total knee replacement: systematic review of randomised controlled trials. BMJ Open. 2015;5(5):e007387. doi: 10.1136/bmjopen-2014-007387.
    1. Pabinger C, Lothaller H, Geissler A. Utilization rates of knee-arthroplasty in OECD countries. Osteoarthr Cartil. 2015;23(10):1664–1673. doi: 10.1016/j.joca.2015.05.008.
    1. Nguyen LC, Lehil MS, Bozic KJ. Trends in total knee arthroplasty implant utilization. J Arthroplast. 2015;30(5):739–742. doi: 10.1016/j.arth.2014.12.009.
    1. Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States - an alternative projection model. Osteoarthr Cartil. 2017;25(11):1797–1803. doi: 10.1016/j.joca.2017.07.022.
    1. Wylde V, Dieppe P, Hewlett S, Learmonth ID. Total knee replacement: is it really an effective procedure for all? Knee. 2007;14(6):417–423. doi: 10.1016/j.knee.2007.06.001.
    1. Valdes AM, Warner SC, Harvey HL, Fernandes GS, Doherty S, Jenkins W, Wheeler M, Doherty M. Use of prescription analgesic medication and pain catastrophizing after total joint replacement surgery. Semin Arthritis Rheum. 2015;45(2):150–155. doi: 10.1016/j.semarthrit.2015.05.004.
    1. Scott CE, Howie CR, MacDonald D, Biant LC. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Joint Surg Br. 2010;92(9):1253–1258. doi: 10.1302/0301-620X.92B9.24394.
    1. Petersen KK, Simonsen O, Laursen MB, Nielsen TA, Rasmussen S, Arendt-Nielsen L. Chronic postoperative pain after primary and revision total knee arthroplasty. Clin J Pain. 2015;31(1):1–6. doi: 10.1097/AJP.0000000000000146.
    1. Kuijer PP, Kievit AJ, Pahlplatz TM, Hooiveld T, Hoozemans MJ, Blankevoort L, et al. Which patients do not return to work after total knee arthroplasty? Rheumatol Int. 2016;36(9):1249–1254. doi: 10.1007/s00296-016-3512-5.
    1. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578-89.
    1. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med. 2015;49(24):1554–1557. doi: 10.1136/bjsports-2015-095424.
    1. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Rasmussen S, Simonsen O. Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials. Osteoarthr Cartil. 2018;26(9):1170–1180. doi: 10.1016/j.joca.2018.04.014.
    1. Burns LC, Ritvo SE, Ferguson MK, Clarke H, Seltzer Z, Katz J. Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res. 2015;8:21–32. doi: 10.2147/JPR.S64730.
    1. Vissers MM, Bussmann JB, Verhaar JA, Busschbach JJ, Bierma-Zeinstra SM, Reijman M. Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review. Semin Arthritis Rheum. 2012;41(4):576–588. doi: 10.1016/j.semarthrit.2011.07.003.
    1. Harmelink KEM, Zeegers A, Hullegie W, Hoogeboom TJ, Nijhuis-van der Sanden MWG, Staal JB. Are There Prognostic Factors for One-Year Outcome After Total Knee Arthroplasty? A Systematic Review. J Arthroplasty. 2017;32(12):3840–3853. doi: 10.1016/j.arth.2017.07.011.
    1. Khatib Y, Madan A, Naylor JM, Harris IA. Do psychological factors predict poor outcome in patients undergoing TKA? A systematic review. Clin Orthop Relat Res. 2015;473(8):2630–2638. doi: 10.1007/s11999-015-4234-9.
    1. Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Man Ther. 2010;15(3):220–228. doi: 10.1016/j.math.2009.12.004.
    1. Kanavaki AM, Rushton A, Efstathiou N, Alrushud A, Klocke R, Abhishek A, Duda JL. Barriers and facilitators of physical activity in knee and hip osteoarthritis: a systematic review of qualitative evidence. BMJ Open. 2017;7(12):e017042. doi: 10.1136/bmjopen-2017-017042.
    1. Hunt MA, Birmingham TB, Skarakis-Doyle E, Vandervoort AA. Towards a biopsychosocial framework of osteoarthritis of the knee. Disabil Rehabil. 2008;30(1):54–61. doi: 10.1080/09638280701189960.
    1. Beck J. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York: The Guilford Press; 2011.
    1. Turner JA, Romano JM. Cognitive-behavioral therapy for chronic pain. In: Loeser JD, Bonica JJ, editors. Bonica’s management og pain. 3. Philadelphia: Lippincoll Williams & Wilkins; 2001. pp. 1751–1758.
    1. Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153–166. doi: 10.1037/a0035747.
    1. Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;11(11):Cd007407.
    1. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971–979. doi: 10.1126/science.150.3699.971.
    1. Mendell LM. Constructing and deconstructing the gate theory of pain. Pain. 2014;155(2):210–216. doi: 10.1016/j.pain.2013.12.010.
    1. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of Meta-analyses. Cognit Ther Res. 2012;36(5):427–440. doi: 10.1007/s10608-012-9476-1.
    1. Turk DT, Monarch ES. Biopsychosocial perspective on chronic pain. Psychological approaches to pain management. 2nd ed. New York: Guilford Press; 2002.
    1. Turner JA, Aaron LA. Pain-related catastrophizing: what is it? Clin J Pain. 2001;17(1):65–71. doi: 10.1097/00002508-200103000-00009.
    1. Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17(1):52–64. doi: 10.1097/00002508-200103000-00008.
    1. Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85(3):317–332. doi: 10.1016/S0304-3959(99)00242-0.
    1. Arnstein P, Caudill M, Mandle CL, Norris A, Beasley R. Self efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain. 1999;80(3):483–491. doi: 10.1016/S0304-3959(98)00220-6.
    1. Litt MD. Self-efficacy and perceived control: cognitive mediators of pain tolerance. J Pers Soc Psychol. 1988;54(1):149–160. doi: 10.1037/0022-3514.54.1.149.
    1. Benyon K, Hill S, Zadurian N, Mallen C. Coping strategies and self-efficacy as predictors of outcome in osteoarthritis: a systematic review. Musculoskeletal Care. 2010;8(4):224–236. doi: 10.1002/msc.187.
    1. Creamer P, Lethbridge-Cejku M, Hochberg MC. Factors associated with functional impairment in symptomatic knee osteoarthritis. Rheumatology (Oxford) 2000;39(5):490–496. doi: 10.1093/rheumatology/39.5.490.
    1. McCracken LM, Eccleston C. Coping or acceptance: what to do about chronic pain? Pain. 2003;105(1–2):197–204. doi: 10.1016/S0304-3959(03)00202-1.
    1. Somers TJ, Keefe FJ, Pells JJ, Dixon KE, Waters SJ, Riordan PA, Blumenthal JA, McKee DC, LaCaille L, Tucker JM, Schmitt D, Caldwell DS, Kraus VB, Sims EL, Shelby RA, Rice JR. Pain catastrophizing and pain-related fear in osteoarthritis patients: relationships to pain and disability. J Pain Symptom Manag. 2009;37(5):863–872. doi: 10.1016/j.jpainsymman.2008.05.009.
    1. Riddle DL, Keefe FJ, Nay WT, McKee D, Attarian DE, Jensen MP. Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study. Arch Phys Med Rehabil. 2011;92(6):859–865. doi: 10.1016/j.apmr.2011.01.003.
    1. Keefe FJ, Blumenthal J, Baucom D, Affleck G, Waugh R, Caldwell DS, Beaupre P, Kashikar-Zuck S, Wright K, Egert J, Lefebvre J. Effects of spouse-assisted coping skills training and exercise training in patients with osteoarthritic knee pain: a randomized controlled study. Pain. 2004;110(3):539–549. doi: 10.1016/j.pain.2004.03.022.
    1. Hunt MA, Keefe FJ, Bryant C, Metcalf BR, Ahamed Y, Nicholas MK, Bennell KL. A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study. Knee. 2013;20(2):106–112. doi: 10.1016/j.knee.2012.07.008.
    1. Bennell KL, Nelligan R, Dobson F, Rini C, Keefe F, Kasza J, French S, Bryant C, Dalwood A, Abbott JH, Hinman RS. 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. doi: 10.7326/M16-1714.
    1. Cuijpers P, van Straten A, Andersson G. Internet-administered cognitive behavior therapy for health problems: a systematic review. J Behav Med. 2008;31(2):169–177. doi: 10.1007/s10865-007-9144-1.
    1. Holm I, Pripp AH, Risberg MA. The Active with OsteoArthritis (AktivA) Physiotherapy Implementation Model: A Patient Education, Supervised Exercise and Self-Management Program for Patients with Mild to Moderate Osteoarthritis of the Knee or Hip Joint. A National Register Study with a Two-Year Follow-Up. J Clin Med. 2020;9(10):3112. doi: 10.3390/jcm9103112.
    1. Duncan E, O'Cathain A, Rousseau N, Croot L, Sworn K, Turner KM, Yardley L, Hoddinott P. Guidance for reporting intervention development studies in health research (GUIDED): an evidence-based consensus study. BMJ Open. 2020;10(4):e033516. doi: 10.1136/bmjopen-2019-033516.
    1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013;50(5):587–592. doi: 10.1016/j.ijnurstu.2012.09.010.
    1. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K, Harvey WF, Hawker G, Herzig E, Kwoh CK, Nelson AE, Samuels J, Scanzello C, White D, Wise B, Altman RD, DiRenzo D, Fontanarosa J, Giradi G, Ishimori M, Misra D, Shah AA, Shmagel AK, Thoma LM, Turgunbaev M, Turner AS, Reston J. 2019 American College of Rheumatology/Arthritis Foundation guideline for the Management of Osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72(2):220–233. doi: 10.1002/art.41142.
    1. Bay S, Kuster L, McLean N, Byrnes M, Kuster MS. A systematic review of psychological interventions in total hip and knee arthroplasty. BMC Musculoskelet Disord. 2018;19(1):201. doi: 10.1186/s12891-018-2121-8.
    1. Cai L, Gao H, Xu H, Wang Y, Lyu P, Liu Y. Does a program based on cognitive behavioral therapy affect Kinesiophobia in patients following Total knee arthroplasty? A randomized, controlled trial with a 6-month follow-up. J Arthroplast. 2017;33(3):704–710. doi: 10.1016/j.arth.2017.10.035.
    1. Ismail A, Moore C, Alshishani N, Yaseen K, Alshehri MA. Cognitive behavioural therapy and pain coping skills training for osteoarthritis knee pain management: a systematic review. J Phys Ther Sci. 2017;29(12):2228–2235. doi: 10.1589/jpts.29.2228.
    1. Carlbring P, Andersson G, Cuijpers P, Riper H, Hedman-Lagerlof E. Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cogn Behav Ther. 2018;47(1):1–18. doi: 10.1080/16506073.2017.1401115.
    1. Dear BF, Gandy M, Karin E, Staples LG, Johnston L, Fogliati VJ, Wootton BM, Terides MD, Kayrouz R, Perry KN, Sharpe L, Nicholas MK, Titov N. The pain course: a randomised controlled trial examining an internet-delivered pain management program when provided with different levels of clinician support. Pain. 2015;156(10):1920–1935. doi: 10.1097/j.pain.0000000000000251.
    1. O'Moore KA, Newby JM, Andrews G, Hunter DJ, Bennell K, Smith J, et al. Internet cognitive-behavioral therapy for depression in older adults with knee osteoarthritis: a randomized controlled trial. Arthritis Care Res (Hoboken) 2018;70(1):61–70. doi: 10.1002/acr.23257.
    1. Rini C, Porter LS, Somers TJ, McKee DC, DeVellis RF, Smith M, et al. Automated internet-based pain coping skills training to manage osteoarthritis pain: a randomized controlled trial. Pain. 2015;156(5):837–848. doi: 10.1097/j.pain.0000000000000121.
    1. Filardo G, Merli G, Roffi A, Marcacci T, Berti Ceroni F, Raboni D, Bortolotti B, Kon E, Marcacci M. Kinesiophobia and depression affect total knee arthroplasty outcome in a multivariate analysis of psychological and physical factors on 200 patients. Knee Surg Sports Traumatol Arthrosc. 2017;25(11):3417–3423. doi: 10.1007/s00167-016-4201-3.
    1. Sale JE, Gignac M, Hawker G. The relationship between disease symptoms, life events, coping and treatment, and depression among older adults with osteoarthritis. J Rheumatol. 2008;35(2):335–342.
    1. Hawker GA, Gignac MA, Badley E, Davis AM, French MR, Li Y, et al. A longitudinal study to explain the pain-depression link in older adults with osteoarthritis. Arthritis Care Res (Hoboken). 2011;63(10):1382–1390. doi: 10.1002/acr.20298.
    1. Lewis GN, Rice DA, McNair PJ, Kluger M. Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesth. 2015;114(4):551–561. doi: 10.1093/bja/aeu441.
    1. Braive A/S. Braive - building healthy minds 2020 [Available from: .
    1. Norman CD, Skinner HA. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res. 2006;8(2):e9. doi: 10.2196/jmir.8.2.e9.
    1. Miller WR, Rollnick S. Motivational interviewing: helping people change. New York: Guilford Press; 2013.
    1. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, Altman DG, Barbour V, Macdonald H, Johnston M, Lamb SE, Dixon-Woods M, McCulloch P, Wyatt JC, Chan AW, Michie S. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348(mar07 3):g1687. doi: 10.1136/bmj.g1687.
    1. Turk DC, Meichenbaum D, Genest M. Pain and Behavioural medicine: A cognitive Bahavioural Perspective. 2nd ed. New York: The Guilford Press; 1983.
    1. Kabat-Zinn J. Full Catastrophe living. New York: Dell Publishing; 1990.
    1. Chekroud SR, Gueorguieva R, Zheutlin AB, Paulus M, Krumholz HM, Krystal JH, Chekroud AM. Association between physical exercise and mental health in 1·2 million individuals in the USA between 2011 and 2015: a cross-sectional study. Lancet Psychiatry. 2018;5(9):739–746. doi: 10.1016/S2215-0366(18)30227-X.
    1. Birch S, Stilling M, Mechlenburg I, Hansen TB. No effect of cognitive behavioral patient education for patients with pain catastrophizing before total knee arthroplasty: a randomized controlled trial. Acta Orthop. 2020;91(1):98–103. doi: 10.1080/17453674.2019.1694312.
    1. Buvanendran A, Sremac AC, Merriman PA, Della Valle CJ, Burns JW, McCarthy RJ. Preoperative cognitive-behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial. Reg Anesth Pain Med. 2021;46(4):313–321. doi: 10.1136/rapm-2020-102258.
    1. Riddle DL, Keefe FJ, Ang DC, Slover J, Jensen MP, Bair MJ, Kroenke K, Perera RA, Reed SD, McKee D, Dumenci L. Pain coping skills training for patients who catastrophize about pain prior to knee arthroplasty: a multisite randomized clinical trial. J Bone Joint Surg Am. 2019;101(3):218–227. doi: 10.2106/JBJS.18.00621.
    1. Higgins DM, Buta E, Williams DA, Halat A, Bair MJ, Heapy AA, Krein SL, Rajeevan H, Rosen MI, Kerns RD. Internet-based pain self-Management for Veterans: feasibility and preliminary efficacy of the pain EASE program. Pain Pract. 2020;20(4):357–370. doi: 10.1111/papr.12861.
    1. de Boer MJ, Versteegen GJ, Vermeulen KM, Sanderman R, Struys MM. A randomized controlled trial of an internet-based cognitive-behavioural intervention for non-specific chronic pain: an effectiveness and cost-effectiveness study. Eur J Pain. 2014;18(10):1440–1451. doi: 10.1002/ejp.509.
    1. Schuster R, Topooco N, Keller A, Radvogin E, Laireiter AR. Advantages and disadvantages of online and blended therapy: replication and extension of findings on psychotherapists’ appraisals. Internet Interv. 2020;21:100326. doi: 10.1016/j.invent.2020.100326.
    1. Chalmers I, Glasziou P. Avoidable waste in the production and reporting of research evidence. Lancet. 2009;374(9683):86–89. doi: 10.1016/S0140-6736(09)60329-9.
    1. Bleijenberg N, de Man-van Ginkel JM, Trappenburg JCA, Ettema RGA, Sino CG, Heim N, Hafsteindóttir TB, Richards DA, Schuurmans MJ. Increasing value and reducing waste by optimizing the development of complex interventions: enriching the development phase of the Medical Research Council (MRC) framework. Int J Nurs Stud. 2018;79:86–93. doi: 10.1016/j.ijnurstu.2017.12.001.

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