Exercise, an online pain-coping skills program and Skype sessions with a physiotherapist helped relieve patients’ chronic knee pain, according to a study published Monday in the journal Annals of Internal Medicine.
Half of all adults will develop knee pain due to osteoarthritis, one of the most common causes of knee problems. Osteoarthritis occurs when cartilage breaks down, leading to pain, swelling and difficulties moving the joint. Since a large portion of sufferers are younger than 65, they could require decades of therapy to lessen their pain.
The new study was designed to investigate “the efficacy of a combined internet delivered treatment package including education, Skype-delivered exercise physiotherapy and an Internet-based interactive pain-coping skills training program,” said Kim Bennell, lead author of the study and a research physiotherapist and professor at the University of Melbourne.
Social benefits
Bennell and her colleagues recruited 148 participants across Australia, all of them over age 50, and randomly assigned them to one of two groups.
One group of 74 participants received online educational materials, an online pain-coping skills program and seven Skype sessions over the course of three months with a physical therapist. They also received exercise-related equipment including ankle weights and resistance bands.
The second group received only identical educational materials delivered online.
Bennell and her co-researchers measured pain and physical functioning in both groups at the start of the study, at three months and again at nine months. In particular, they asked participants to rate their pain while walking based on an 11-point scale. They also asked about quality of life and possible changes in pain and functioning.
At the end of the study, all the participants from both groups reduced their knee pain and had improvements in function. Yet only the Skype call group showed significant gains. Positive results were sustained across nine months for both groups.
Participants in the group with the video conference calls reported significantly more pain relief and physical function than those in the other group at three months. At nine months, these improvements had been sustained.
Most participants were “highly satisfied” with the program, said Bennell, who is also the director of the University of Melbourne’s Centre for Health, Exercise and Sports Medicine. She also remarked on the high levels of acceptance and adherence reported by both participants and physiotherapists involved in the study.
Speculating on why the program was so successful, Bennell noted that past studies have shown the positive effects of exercise and pain-coping skills separately, so “when the two treatments are combined, these benefits are most likely magnified.”
According to Guy Eakin, senior vice president of scientific strategy at the Arthritis Foundation, the new study shows “the social benefit (and) accountability to a physiotherapist actually can be delivered via Skype.”
The study also demonstrates technologies that haven’t been available in prior years and might make a very meaningful difference in the course of a patient’s disease, said Eakin, who was not involved in the study.
“Is it something that everybody will want to take part in? Probably not, but there will probably be a significant portion of the population who find having those (Skype) calls with a physiotherapist is a really good motivator for staying involved,” said Eakin, pointing to the fact that the attrition rate over the course of the study “was actually pretty reasonable: They lost only 10% over a nine-month period.”
Another positive point is the fact that the participants weren’t obese, but they weren’t slender either, Eakin said: “So that’s actually a remarkable achievement, to be able to offer an exercise intervention in a study that involves people of what would be in our community a pretty average BMI.”
The inclusion of pain-coping skills was helpful as well. “Positive self-talk is a good pain coping strategy, and it actually has a lot of evidence behind it to say it is not just window dressing, but people who engage in those behaviors do report less pain,” Eakin said.
Still, the study had weaknesses. It is Did participants see a reduction in pain “because of the social interaction or because of the exercise itself? I can’t say that (the researchers) teased that out in the study,” Eakin said. He also would like to see the results replicated in a larger study.
The researchers also did not sort the possible benefits derived from receiving exercise equipment along with the program, which only one group received.
It is important to continue researching this program, Eakin said, because there is no cure for osteoarthritis, and exercise is the only proven preventative measure.
Bennell said it can also be “challenging” for people requiring knee pain therapy “due to cost, transport issues or geographic location, particularly in regional and rural areas where services may be limited or nonexistent.” As a result, she said, “tele-rehabilitation” could serve as “an effective, time-efficient and convenient” way for many people to access care.
Drug culture
According to Dr. Lisa A. Mandl of the Hospital for Special Surgery/Weill Cornell Medicine in New York, commonly used medical therapies for knee pain, including acetaminophen and nonsteroidal anti-inflammatory drugs, can be effective. But in older people, they can also cause serious side effects, including gastrointestinal bleeding and increased cardiovascular events, Mandl wrote in an editorial accompanying the study.
When it comes to pain, patients often have a “misplaced belief in the superiority of pills and injections” compared with non-pharmacological alternatives, said Mandl.
Since osteoarthritis has no cure, a large and diverse group of patients will be seeking treatment for knee pain “well into the foreseeable future,” according to Mandl, since the population is aging and sufferers are growing in number.
“Probably in the US, about 27 million people have osteoarthritis. That’s at all symptom levels, from very mild to total joint replacements,” Eakin said. Signs of osteoarthritis would appear on the X-rays of up to 90% people older than 65, even those who are not experiencing pain or other symptoms.
Generally speaking, Eakin said, “women are at twice the risk of males of developing osteoarthritis in any joint — both the type that occurs with the wear and tear over time but also with sports injuries.”
One of the greatest risk factors beyond age is obesity, he said. Most of us leap to the conclusion that an overweight person develops osteoarthritis and knee pain due to extra weight burdening the joint and causing more grinding and more wear and tear over time.
“The fact of the matter is, weight also increases the risk for osteoarthritis in the hand or in the spine or in the hip,” Eakin said. “There’s actually been some research to say that some of the leptin (fat cell) hormones are responsible for promoting the risk of arthritis.”
Meanwhile, the pain of osteoarthritis limits mobility, so people tend to become less active and gain weight.
“The more you stop moving, the more the arthritis can progress,” Eakin said. “It’s a vicious cycle.”
Though most people think of osteoarthritis as a geriatric condition, “the fact of the matter is, younger people can also develop osteoarthritis, particularly from traumatic injuries,” he said, including sports injuries.
He pointed out that one example would be a soccer player who, in her late teens, sustained a knee injury requiring surgery, such as an ACL reconstruction. By the time this woman reached age 30, she would have about the same risk of developing osteoarthritis in the next couple of years as a woman who is 80 or 90, he explained.
Her body is the same age as that of an 80-year-old, he emphasized.
“It is really a staggering implication,” Eakin said. “With all the focus we have on sports injuries and sports safety, that’s probably one we’re not paying enough attention to right now.”