Knee osteoarthritis is a common and increasing cause of pain and disability. Exercise and self-management interventions reduce pain and improve function. These interventions are usually delivered separately but, theoretically, the benefits of the physical approach of exercise and the educational approach of self-management interventions could be additive. If correct, rehabilitation programmes that integrate exercise and self-management components might be more effective. This review summarizes and comments on the clinical effectiveness, practicality, cost and implementation of recent studies of integrated rehabilitation programmes.
The programmes varied considerably in content and duration, but in general were safe and effective (improving pain, physical function and other relevant variables). The length, complexity and burden of some programmes limit their acceptability, clinical applicability and increase costs. The most recent programmes have addressed these issues producing programmes that are more clinically and cost-effective than usual care. Implementation of these programmes will require considerable effort and commitment.
Integrated rehabilitation programmes that are acceptable, clinically effective, deliverable and affordable may be the best way of managing the large and increasing number of people suffering chronic knee pain.
"In fact, self-management programmes [11-14] and exercise [15,16] improve physical and psychosocial health and wellbeing. These interventions are usually delivered separately, but integrating self-management strategies with active participation on an exercise regimen might enhance the separate effects [17,18]. "
[Show abstract][Hide abstract] ABSTRACT: To explore the health beliefs, experiences, treatment and expectations of people with chronic knee pain, and investigate if, how and why these change after taking part on an integrated exercise-based rehabilitation programme--Enabling Self-management and Coping with Arthritis knee Pain through Exercise, ESCAPE-knee pain.
Semi-structured interviews were conducted with people with chronic knee pain, before (n=29) and after (n=23) participation on the programme. Thematic analysis was used to document people's baseline health beliefs, attitudes and cognitions, and to see if how and why these changed after completing the programme.
Initially people had poor understanding and negative, fatalistic beliefs about the management or prognosis for knee pain. Following the programme the majority of participants had positive experiences describing improvement in pain, physical and psychosocial functioning, greater knowledge and understanding of their condition and treatment options, and in their ability to use exercise to control symptoms. Beliefs about the causation and prognosis of knee pain were unchanged, but their concerns about possible dangers of exercise had decreased, they appreciated how exercise could reduce symptoms (treatment beliefs) and their confidence in their ability to use exercise to effect improvements (exercise self-efficacy) increased. These improvements were attributed to the content and structure of the programme, and the care and guidance of the physiotherapist. Several expressed a need for on-going support.
ESCAPE-knee pain appears to achieve improvements by increasing people's treatment belief in safety and the utility of exercise to control symptoms, rather than alteration in their beliefs about causation or prognosis.
Current Controlled Trials ISRCTN94658828.
[Show abstract][Hide abstract] ABSTRACT: Kommentar zur Publikation von Jessep SA, Walsh NE, Ratcliffe J, Hurley MV. Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain. Physiotherapy 2009; 95: 94-102
[Show abstract][Hide abstract] ABSTRACT: 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.
To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy.
Pragmatic, randomised controlled trial.
Outpatient physiotherapy department and community centre.
Sixty-four people with chronic knee pain.
Outpatient physiotherapy compared with ESCAPE-knee pain.
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.
Both groups demonstrated similar improvements in clinical outcomes. Outpatient physiotherapy cost pound 130 per person and the healthcare utilisation costs of participants over 1 year were pound 583. The ESCAPE-knee pain programme cost pound 64 per person and the healthcare utilisation costs of participants over 1 year were pound 320.
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.
P. Wang, L. Yang, C. Liu, X. Wei, X. Yang, Y. Zhou, H. Jiang, Z. Lei, J. D. Reinhardt, C. He
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