Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial

M V Hurley, N E Walsh, H L Mitchell, T J Pimm, A Patel, E Williamson, R H Jones, P A Dieppe, B C Reeves, M V Hurley, N E Walsh, H L Mitchell, T J Pimm, A Patel, E Williamson, R H Jones, P A Dieppe, B C Reeves

Abstract

Objective: Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies (Enabling Self-management and Coping with Arthritic Knee Pain through Exercise [ESCAPE-knee pain]) with usual primary care in improving functioning in persons with chronic knee pain.

Methods: We conducted a single-blind, pragmatic, cluster randomized controlled trial. Participants age >/=50 years, reporting knee pain for >6 months, were recruited from 54 inner-city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self-reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC-func]) 6 months after completing rehabilitation.

Results: A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (-3.33 difference in WOMAC-func score; 95% confidence interval [95% CI] -5.88, -0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (-3.53; 95% CI -6.52, -0.55) or group rehabilitation (-3.16; 95% CI -6.55, -0.12).

Conclusion: ESCAPE-knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.

Figures

Figure 1
Figure 1
Flowchart of recruitment and retention of primary care practices and trial participants. GP = general practitioner.

References

    1. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis. 2001;60:91–7.
    1. Dawson J, Linsell L, Zondervan K, Rose P, Randall T, Carr A, et al. Epidemiology of hip and knee pain and its impact on overall health status in older adults. Rheumatology (Oxford) 2004;43:497–504.
    1. Alonso J, Ferrer M, Gandek B, Ware JE, Aaronson NK, Mosconi P, et al. Health-related quality of life associated with chronic conditions in eight countries: results from the International Quality of Life Assessment (IQOLA) Project. Qual Life Res. 2004;13:283–98.
    1. Cooper JK, Kohlmann T. Factors associated with health status of older Americans. Age Ageing. 2001;30:495–501.
    1. Gatchel RJ. Psychological disorders and chronic pacause and effect relationships. In: Gatchel RJ, Turk DC, editors. Psychological approaches to pain management: a practitioner's handbook. New York: Guildford Press; 1996. pp. 33–52.
    1. Gabriel SE, Crowson CS, Campion ME, O'Fallon WM. Indirect and non-medical costs among people with rheumatoid arthritis and osteoarthritis compared with nonarthritic controls. J Rheumatol. 1997;24:43–8.
    1. Leardini G, Salaffi F, Caporali R, Canesi B, Rovati L, Montanelli R, Italian Group for Study of the Costs of Arthritis Direct and indirect costs of osteoarthritis of the knee. Clin Exp Rheumatol. 2004;22:699–706.
    1. Lanes SF, Lanza LL, Radensky PW, Yood RA, Meenan RF, Walker AM, et al. Resource utilization and cost of care for rheumatoid arthritis and osteoarthritis in the managed care setting: the importance of drug and surgery costs. Arthritis Rheum. 1997;40:1475–81.
    1. World Health Organisation. The burden of musculoskeletal conditions at the start of the new millennium: technical report 919. Geneva: WHO; 2003.
    1. Dunlop DD, Lyons JS, Manheim LM, Song J, Chang RW. Arthritis and heart disease as risk factors for major depression: the role of functional limitation. Med Care. 2004;42:502–11.
    1. Hadler NM. Knee pain is the malady: not osteoarthritis. Ann Intern Med. 1992;116:598–9. [editorial]
    1. Porcheret M, Jordan K, Croft P. Primary care management of knee pain in people aged 50 years and over: a survey of current practice and comparison to published recommendations. Rheumatology (Oxford) 2006;45(Suppl 1):i74. [abstract]
    1. Hippisley-Cox J, Coupland C. Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis. BMJ. 2005;330:1366–9.
    1. Hippisley-Cox J, Coupland C, Logan R. Risk of adverse gastrointestinal outcomes in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis. BMJ. 2005;331:1310–6.
    1. Bjordal JM, Ljunggren AE, Klovning A, Slordal L. Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pameta-analysis of randomised placebo controlled trials. BMJ. 2004;329:3117–22.
    1. Solomon DH, Glynn RJ, Bohn R, Levin R, Avorn J. The hidden cost of nonselective nonsteroidal antiinflammatory drugs in older patients. J Rheumatol. 2003;30:792–8.
    1. Roddy E, Zhang W, Doherty M. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Ann Rheum Dis. 2005;64:544–8.
    1. Fransen M, McConnell S, Bell M. Therapeutic exercise for people with osteoarthritis of the hip or knee: a systematic review. J Rheumatol. 2002;29:1737–45.
    1. Van Baar ME, Assendelft WJ, Dekker J, Oostendorp RA, Bijlsma JW. Effectiveness of exercise therapy in patients with osteoarthritis of the hip and knee: a systematic review of randomized clinical trials. Arthritis Rheum. 1999;42:1361–9.
    1. Newman PS, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet. 2004;364:1523–37.
    1. Superuio-Cabuslay E, Ward MM, Lorig KR. Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal antiinflammatory drug treatment. Arthritis Care Res. 1996;9:292–301.
    1. Warsi A, LaValley MP, Wang PS, Avorn J, Solomon DH. Arthritis self-management education programs: a meta-analysis of the effect on pain and disability. Arthritis Rheum. 2003;48:2207–13.
    1. Buszewicz M, Rait G, Griffin M, Nazareth I, Patel A, Atkinson A, et al. Self management of arthritis in primary care: randomised controlled trial. BMJ. 2006;333:879–83.
    1. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006;54:226–9.
    1. Perruccio AV, Power JD, Badley EM. Revisiting arthritis prevalence projections: it's more than just the aging of the population. J Rheumatol. 2006;33:1856–62.
    1. Donner A, Klar N. Design and analysis of cluster randomization trials in health research. London: Arnold; 2000.
    1. Ukoumunne OC, Gulliford MC, Chinn S, Sterne JA, Burney PG. Methods for evaluating area-wide and organisation-based interventions in health and health care: a systematic review. Health Technol Assess. 1999;3 .
    1. Bellamy N, Buchanan W, Goldsmith C, Campbell J, Stitt L. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–40.
    1. Hurley M, Scott DL, Rees J, Newham DJ. Sensorimotor changes and functional performance in patients with knee osteoarthritis. Ann Rheum Dis. 1997;56:641–8.
    1. Gecht MR, Connell KJ, Sinacore JM, Prohaska TR. A survey of exercise beliefs and exercise habits among people with arthritis. Arthritis Care Res. 1996;9:82–8.
    1. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatrica Scandanavia. 1983;67:361–7.
    1. The EuroQol Group. EuroQol: a new facility for the measurement of health related quality of life. Health Policy. 1990;16:199–208.
    1. Dolan P, Gudex C, Kind P, Williams A. Working papers. York: Centre for Health Economics, University of York; 1995. A social tariff for EuroQol: results from a UK general population survey.
    1. Clinch J, Tugwell P, Wells G, Shea B. Individualized functional priority approach to the assessment of health related quality of life in rheumatology. J Rheumatol. 2001;28:445–51.
    1. Glasgow RE, Magid DJ, Beck A, Ritzwoller D, Estabrooks PA. Practical clinical trials for translating research to practice: design and measurement recommendations. Med Care. 2005;43:551–7.
    1. Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003;290:1624–32.
    1. Denoeud L, Mazieres B, Payen-Champenois C, Ravaud P. First line treatment of knee osteoarthritis in outpatients in France: adherence to the EULAR 2000 recommendations and factors influencing adherence. Ann Rheum Dis. 2005;64:70–4.
    1. Ganz DA, Chang JT, Roth CP, Guan M, Kamberg CJ, Niu F, et al. Quality of osteoarthritis care for community-dwelling older adults. Arthritis Rheum. 2006;55:241–7.
    1. Fontaine KR, Bartlett SJ, Heo M. Are health care professionals advising adults with arthritis to become more physically active? Arthritis Rheum. 2005;53:279–83.
    1. Mitchell HL, Hurley MV. Management of chronic knee papatients rarely get what they need—or want. Arthritis Rheum. 2005;52(Suppl 9):S730. [abstract]
    1. Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Williamson E, Jones RH, et al. Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain. Arthritis Rheum. 2007;57:1220–9.
    1. Machin D, Campbell M, Fayers P, Pinol A. Sample size tables for clinical studies. 2nd ed. Oxford: Blackwell Publishers; 1997.
    1. Angst F, Aeschlimann A, Stucki G. Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities. Arthritis Rheum. 2001;45:384–91.
    1. McCarthy CJ, Mills PM, Pullen R, Roberts C, Silman A, Oldham JA. Supplementing a home exercise programme with a class-based exercise programme is more effective than home exercise alone in the treatment of knee osteoarthritis. Rheumatology (Oxford) 2004;43:880–6.
    1. Thomas KS, Muir KR, Docherty M, Jones AC, O'Reilly SC, Bassey EJ. Home based exercise programme for knee pain and knee osteoarthritis: randomise controlled trial. BMJ. 2002;325:752–6.
    1. Hay EM, Foster NE, Thomas E, Peat G, Phelan M, Yates HE, et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ. 2006;333:995–8.
    1. Osiri M, Suarez-Almazor ME, Wells GA, Robinson V, Tugwell P. Number needed to treat (NNT): implication in rheumatology clinical practice. Ann Rheum Dis. 2003;62:316–21.
    1. Hurley MV, Mitchell HL, Walsh N. In osteoarthritis, the psychosocial benefits of exercise are as important as physiological improvements. Exerc Sport Sci Rev. 2003;31:138–43.
    1. Dekker J, Bott B, van der Woude LH, Bijlsma JW. Pain and disability in osteoarthritis: a review of biobehavioral mechanisms. J Behavioral Med. 1992;15:189–214.
    1. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469–75.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel