A pain science education and walking program to increase physical activity in people with symptomatic knee osteoarthritis: a feasibility study

Tasha R Stanton, Emma L Karran, David S Butler, Melissa J Hull, Sarah N Schwetlik, Felicity A Braithwaite, Hannah G Jones, G Lorimer Moseley, Catherine L Hill, Christy Tomkins-Lane, Carol Maher, Kim Bennell, Tasha R Stanton, Emma L Karran, David S Butler, Melissa J Hull, Sarah N Schwetlik, Felicity A Braithwaite, Hannah G Jones, G Lorimer Moseley, Catherine L Hill, Christy Tomkins-Lane, Carol Maher, Kim Bennell

Abstract

Introduction: Nine of 10 people with knee osteoarthritis are inactive. Unhelpful pain beliefs may negatively influence physical activity levels. Targeting these unhelpful pain beliefs, through contemporary pain science education (PSE), may provide benefit.

Objectives: To evaluate the feasibility of conducting a clinical trial to determine the effect of adding PSE (vs adding sham ultrasound) to an individualised, physiotherapist-led education and walking program in people with painful knee osteoarthritis.

Methods: Twenty participants were randomised (1:1) into the PSE group or Control group, each receiving 4 in-person weekly treatments, then 4 weeks of at-home activities (weekly telephone check-in). Clinical outcomes and physical activity (7 days of wrist-worn accelerometry) were assessed at baseline, 4 (clinical outcomes only), 8, and 26 weeks. A priori feasibility criteria for recruitment, intervention adherence, viability of wrist-based accelerometry, and follow-up retention were set. Perceived intervention credibility, acceptability, and usefulness from participants and clinicians were assessed (ratings, written/verbal feedback).

Results: Most feasibility criteria were met. On average, 7 adults/wk were eligible, with 70% recruited. Treatment compliance was high (in-person: 80% PSE; 100% Control; at-home: 78% PSE; 75% Control). Wrist-based accelerometry had >75% valid wear-time. Sufficient follow-up rates were not achieved (26 weeks: 65%). Participant and clinician feedback highlighted that PSE was too complex and did not match patient expectations of "physiotherapy", that sham ultrasound was problematic (clinician), but that both treatments had high credibility, acceptability, and usefulness.

Conclusions: Progression to a full trial is warranted. Strategies to increase participant retention, refine the PSE content/delivery, and replace/remove the sham intervention are required.

Keywords: Osteoarthritis; Pain; Pain science education; Physical activity; Sham ultrasound; Walking program.

Conflict of interest statement

T.R. Stanton received travel and accommodation support from Eli Lilly Ltd for speaking engagements (2014; unrelated to the present topic). In the past 5 years, G.L. Moseley has received support from: ConnectHealth UK, Seqirus, Kaiser Permanente, Workers' Compensation Boards in Australia, Europe, and North America, AIA Australia, the International Olympic Committee, Port Adelaide Football Club, Melbourne Football Club, and Arsenal Football Club. Professional and scientific bodies have reimbursed him for travel costs related to presentation of research on pain at scientific conferences/symposia. He has received speaker fees for lectures on pain and rehabilitation. G.L. Moseley and D.S. Butler receives book royalties from NOIgroup publications, Dancing Giraffe Press & OPTP, including the 2 books used in the PSE group in this trial. T.R. Stanton is supported by a National Health & Medical Research Council (NHMRC) Career Development Fellowship (ID1141735). G.L. Moseley is supported by an NHMRC Leadership Investigator Grant (ID1178444). K. Bennell is supported by a NHMRC Investigator Fellowship (ID1174431) and has received funding from the NHMRC and Medibank Private for research related to osteoarthritis. This work was supported by an Arthritis Australia & State/Territory Affiliate grant from Arthritis Australia (2018) and by an internal research grant from the Sansom Institute of Health Research, The University of South Australia. The funders had no role in study design, data collection and analyses, decision to publish, or preparation of the manuscript.

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.

Figures

Figure 1.
Figure 1.
Details of study interventions. In both groups, the in-person and at-home treatment durations were inclusive of both the general content (provided in both groups) and the group-specific content. LTGs, long-term goals; OA, osteoarthritis; PSE, pain science education; STGs, short-term goals.
Figure 2.
Figure 2.
Graded walking program and goal setting procedure undertaken in both intervention groups. The number of walks per week was individualised to the participant, but in all cases, during week 2, we aimed to add one additional walk per week at a lower time/distance (ie, 4–5 walks per week is provided as an example here). At 8 weeks (not shown here), the walking program was reviewed and progressed (or maintained) for the following 4 weeks. Short-term and long-term activity goals were also reviewed at 8 weeks.
Figure 3.
Figure 3.
Study procedure, treatment sessions, and outcome assessment timing. ACR OA criteria, American College of Rheumatology Osteoarthritis clinical diagnosis criteria; DASS, depression, anxiety, and stress scale; F/U, follow-up; IPAQ-SF, International Physical Activity Questionnaire—Short Form; Knee XR, knee x-ray or other imaging report; PA Measures, physical activity measures; PSE, pain science education; Pain NRS, average pain intensity over the last week (at rest and while walking) using a 0 to 100 numerical rating scale (only used for initial telephone screening); Pain VAS, average pain intensity over the last week (at rest and while walking) via 0–100 mm visual analogue scale; PBQ, pain beliefs questionnaire; PSEQ, pain self-efficacy questionnaire; Brief FoM, brief fear of movement scale for OA; PCS, pain catastrophizing scale; PSFS, patient-specific functional scale; rNPQ, revised Neurophysiology of Pain Questionnaire measuring pain knowledge; Rx, treatment; TC, telephone call; WOMAC, the Western Ontario McMaster Universities OA Index.
Figure 4.
Figure 4.
The CONSORT flow diagram for feasibility studies. ACR, American College of Rheumatology; NRS, numeric rating scale; OA, osteoarthritis; PSE, pain science education; RA, rheumatoid arthritis.
Figure 5.
Figure 5.
Participant ratings of the study interventions. (A) Perceived credibility; (B) perceived acceptability; (C) perceived usefulness. PSE, pain science education.

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