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