Elsevier

Physiotherapy

Volume 95, Issue 2, June 2009, Pages 94-102
Physiotherapy

Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain

https://doi.org/10.1016/j.physio.2009.01.005Get rights and content

Abstract

Background

Chronic knee pain is a major cause of disability in the elderly. Management guidelines recommend exercise and self-management interventions as effective treatments. The authors previously described a rehabilitation programme integrating exercise and self-management [Enabling Self-management and Coping with Arthritic knee Pain through Exercise (ESCAPE-knee pain)] that produced short-term improvements in pain and physical function, but sustaining these improvements is difficult. Moreover, the programme is untried in clinical environments, where it would ultimately be delivered.

Objectives

To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy.

Design

Pragmatic, randomised controlled trial.

Setting

Outpatient physiotherapy department and community centre.

Participants

Sixty-four people with chronic knee pain.

Interventions

Outpatient physiotherapy compared with ESCAPE-knee pain.

Outcomes

The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index. Secondary outcomes included pain, objective functional performance, anxiety, depression, exercise-related health beliefs and healthcare utilisation. All outcomes were assessed at baseline and 12 months after completing the interventions (primary endpoint). ANCOVA investigated between-group differences.

Results

Both groups demonstrated similar improvements in clinical outcomes. Outpatient physiotherapy cost £130 per person and the healthcare utilisation costs of participants over 1 year were £583. The ESCAPE-knee pain programme cost £64 per person and the healthcare utilisation costs of participants over 1 year were £320.

Conclusions

ESCAPE-knee pain can be delivered as a community-based integrated rehabilitation programme for people with chronic knee pain. Both ESCAPE-knee pain and outpatient physiotherapy produced sustained physical and psychosocial benefits, but ESCAPE-knee pain cost less and was more cost-effective.

Clinical Trial Registration No.: ISRCTN63848242.

Introduction

Chronic knee pain, often diagnosed as knee osteoarthritis [1], is a significant public health problem [2]. It causes pain and disability, impairs psychosocial function and quality of life, and places a large socio-economic burden on health services [2], [3], [4], [5], [6], [7]. As the incidence and prevalence of chronic joint pain is age related, these problems will increase as the number of elderly people increases.

Evidence-based management guidelines [8], [9], [10] advocate exercise and patient education/self-management interventions (SMIs) as effective ways of improving pain and physical function in chronic knee pain. In spite of these guidelines, only one-third of people reportedly receive exercise-based rehabilitation, and this is usually in the form of a short one-off course of physiotherapy involving exercise and advice [11], [12]. Moreover, therapeutic benefits diminish if people do not continue to exercise regularly, and most patients do not adhere to therapeutic advice following discharge [13], [14], [15], [16], [17], [18]. SMIs help people to understand and cope with their problems more effectively, improve adherence to management advice and reduce healthcare utilisation [19], [20], [21].

Exercise and SMIs are frequently delivered separately; SMIs explain the benefits of exercise but rarely have a participatory exercise component, while the patient education element of exercise regimens focuses on how to perform exercise. However, the benefits of exercise and SMIs might be enhanced if programmes integrate the physical approach of exercise with the educational approach of SMIs. In addition, self-management skills could improve adherence to regular exercise and sustain the benefits [22]. Unfortunately, most integrated rehabilitation programmes are long, complex and expensive, and consequently have limited clinical application [23], [24].

To address these issues, an integrated rehabilitation programme entitled ‘Enabling Self-management and Coping with Arthritic knee Pain through Exercise’ (ESCAPE-knee pain) was devised. This improved physical functioning, pain and other psychosocial variables [25], and was more cost-effective than usual primary care [26]. It included elements that enhance adherence, such as using simple equipment, low intensity, functional exercises that were tailored to address each individual's needs, the benefits were experienced quickly and it was supplemented with written information [15], [27]. Although the benefits of the intervention were sustained 6 months after rehabilitation, there was an overall trend towards decline in outcome variables over time. The programme did not incorporate two features known to promote regular exercise: delivery of the programme in the community, and ongoing support from a healthcare professional to reinforce health messages and remotivate people [15], [16], [17], [18], [27]. Delivering the programme in the community makes inherent sense as this is the setting where the majority of people with the condition are managed. Whether or not ESCAPE-knee pain would be as effective if delivered by a clinician in the community is unknown, but efficacious interventions (carried out in ideal conditions) are often disappointing when delivered in less controllable conditions that prevail in clinical contexts, and frequently require adaptation to ensure clinical feasibility, practicality and maximise effectiveness.

To make the ESCAPE-knee pain programme clinically applicable and to promote long-term adherence to regular exercise, the programme was shortened slightly, delivered in a community centre, and a review session was introduced 4 months after completion of the programme. This study evaluated the feasibility of delivering this programme, and compared its clinical and cost-effectiveness with outpatient physiotherapy. It was hypothesised that: (1) both interventions would increase physical functioning and reduce pain in the short term, but ESCAPE-knee pain would sustain these benefits for longer than outpatient physiotherapy; and (2) ESCAPE-knee pain participants would have lower healthcare utilisation.

Section snippets

Method

The aims, design, conduct and data analysis followed a pre-specified protocol (Clinical Trial Registration No.: ISRCTN63848242) and observed the CONSORT recommendations for reporting non-pharmacological interventions [28] and pragmatic trials [29].

Results

The flowchart of trial participants (Fig. 1) shows that of the 170 potential participants approached, 64 were randomised. At 12 months, 16 (25%) participants had withdrawn, eight from each intervention.

At baseline, there were no differences in the anthropometric characteristics or clinical variables of participants allocated to outpatient physiotherapy or ESCAPE-knee pain (Table 1). There were no differences in any of the baseline characteristics between participants who remained in the trial

Discussion

This pragmatic study established the feasibility of delivering ESCAPE-knee pain – a community-based rehabilitation programme that integrated patient education, self-management strategies and exercise for people with chronic knee pain – and compared it with outpatient physiotherapy management. The hypothesis that ESCAPE-knee pain would sustain greater benefits than outpatient physiotherapy was not supported as both interventions produced similar sustained improvements in physical function and

Acknowledgements

The authors thank the staff at the local general practitioners’ surgeries, Sevenoaks Hospital who hosted this project, and Sandy Sheffield who delivered ESCAPE-knee pain. The authors also wish to thank the trial participants for their time, effort and goodwill. Finally, the authors are grateful to the anonymous reviewers who made constructive comments on an early manuscript of this paper. At the time of the trial, Mike Hurley and Nicki Walsh were supported by the Arthritis Research Campaign; a

References (58)

  • J. Bedson et al.

    Labelling chronic illness in primary care: a good or a bad thing?

    Br J Gen Pract

    (2004)
  • A.D. Woolf et al.

    Burden of major musculoskeletal conditions

    Bull World Health Organ

    (2003)
  • R.J. Gatchel

    Psychological disorders and chronic pain: cause and effect relationships

  • G. Peat et al.

    Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care

    Ann Rheum Dis

    (2001)
  • J. Dawson et al.

    Impact of persistent hip or knee pain on overall health status in elderly people: a longitudinal population study

    Arthritis Care Res

    (2005)
  • S. Gupta et al.

    The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition

    Rheumatology

    (2005)
  • G. Leardini et al.

    Direct and indirect costs of osteoarthritis of the knee

    Clin Exp Rheumatol

    (2004)
  • R.D. Altman et al.

    Recommendations for the medical management of osteoarthritis of the hip and knee

    Arthritis Rheum

    (2000)
  • K.M. Jordan et al.

    EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

    Ann Rheum Dis

    (2003)
  • National Institute for Health and Clinical Excellence. Osteoarthritis: the care and management of osteoarthritis in...
  • M.A. Holden et al.

    Physical therapists’ use of therapeutic exercise for patients with clinical knee osteoarthritis in the United Kingdom: in line with current recommendations?

    Phys Ther

    (2008)
  • Walsh NE, Hurley MV. Evidence based guidelines and current practice for physiotherapy management of knee...
  • W.J. Rejeski et al.

    Compliance to exercise therapy in older participants with knee osteoarthritis: implications for treating disability

    Med Sci Sports Exerc

    (1997)
  • E.M. Sluijs et al.

    Correlates of exercise compliance in physical therapy

    Phys Ther

    (1993)
  • M. Hillsdon et al.

    Interventions for promoting physical activity

    Cochrane Collaboration

    (2007)
  • B.H. Marcus et al.

    Physical activity behavior change: issues in adoption and maintenance

    Health Psychol

    (2000)
  • A. Warsi et al.

    Arthritis self-management education programs: a meta-analysis of the effect on pain and disability

    Arthritis Rheum

    (2003)
  • K.L. Lorig et al.

    Patient self-management: a key to effectiveness and efficiency in care of chronic disease

    Public Health Rep

    (2005)
  • P.S. Newman et al.

    Self-management interventions for chronic illness

    Lancet

    (2004)
  • M.F. Pisters et al.

    Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review

    Arthritis Care Res

    (2007)
  • N.E. Walsh et al.

    Effectiveness of rehabilitation programmes combining exercise and self-management interventions for hip and knee osteoarthritis: a systematic review

    Phys Ther Rev

    (2006)
  • M.V. Hurley et al.

    Effectiveness and clinical applicability of integrated rehabilitation programs for knee osteoarthritis

    Curr Opin Rheumatol

    (2009)
  • M.V. Hurley et al.

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

    Arthritis Rheum

    (2007)
  • M.V. Hurley et al.

    Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain

    Arthritis Rheum

    (2007)
  • A.H. Taylor et al.

    Physical activity and older adults: a review of health benefits and the effectiveness of interventions

    J Sports Sci

    (2004)
  • I. Boutron et al.

    CONSORT Group. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration

    Ann Intern Med

    (2008)
  • M. Zwarenstein et al.

    Improving the reporting of pragmatic trials: an extension of the CONSORT statement

    BMJ

    (2008)
  • Cited by (0)

    View full text