Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: Pragmatic randomised trial

Primary Care Musculoskeletal Research Centre, Keele University, Keele.
BMJ (online) (Impact Factor: 17.45). 12/2006; 333(7576):995. DOI: 10.1136/bmj.38977.590752.0B
Source: PubMed


To evaluate the effectiveness of two primary care strategies for delivering evidence based care to people aged 55 or over with knee pain: enhanced pharmacy review and community physiotherapy.
Pragmatic multicentre randomised clinical trial.
15 general practices in North Staffordshire.
325 adults aged 55 years or over (mean 68 years) consulting with knee pain; 297 (91%) reached six month follow-up.
Enhanced pharmacy review (pharmacological management in accordance with an algorithm); community physiotherapy (advice about activity and pacing and an individualised exercise programme); control (advice leaflet reinforced by telephone call).
Change in Western Ontario and McMaster Universities osteoarthritis index (WOMAC) at 3, 6, and 12 months.
Mean baseline WOMAC pain score was 9.1 (SD 3.7), and mean baseline function score was 29.9 (SD 12.8). At three months, the mean reductions in pain scores were 0.41 (SD 2.8) for control, 1.59 (3.2) for pharmacy, and 1.56 (3.4) for physiotherapy; reductions in function scores were 0.80 (8.5), 2.61 (9.8), and 4.79 (10.8). Compared with control, mean differences in change scores for physiotherapy were 1.15 (95% confidence interval 0.2 to 2.1) for pain and 3.99 (1.2 to 6.8) for function; those for pharmacy were 1.18 (0.3 to 2.1) for pain and 1.80 (-0.8 to 4.5) for function. These differences were not sustained to six or 12 months. Significantly fewer participants in the physiotherapy group reported consulting their general practitioner for knee pain in the follow-up period, and use of non-steroidal anti-inflammatory drugs was lower in the physiotherapy and pharmacy groups than in the control group.
Evidence based care for older adults with knee pain, delivered by primary care physiotherapists and pharmacists, resulted in short term improvements in health outcomes, reduced use of non-steroidal anti-inflammatory drugs, and high patient satisfaction. Physiotherapy seemed to produce a shift in consultation behaviour away from the traditional general practitioner led model of care.
UK National Research Register N0286046917; Current Controlled Trials ISRCTN55376150 [] .

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    • "Usual physiotherapy care consisting of advice and exercise is the most appropriate control group for the BEEP trial given that randomised trials [15] and systematic reviews [6] consistently show that interventions that include exercise are superior to those which do not. We are not using an attention control group as this trial is designed explicitly as a pragmatic trial, building on evidence about the effectiveness of exercise interventions. "
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    ABSTRACT: Background Exercise is consistently recommended for older adults with knee pain related to osteoarthritis. However, the effects from exercise are typically small and short-term, likely linked to insufficient individualisation of the exercise programme and limited attention to supporting exercise adherence over time. The BEEP randomised trial aims to improve patients’ short and long-term outcomes from exercise. It will test the overall effectiveness and cost-effectiveness of two physiotherapy-led exercise interventions (Individually Tailored Exercise and Targeted Exercise Adherence) to improve the individual tailoring of, and adherence to exercise, compared with usual physiotherapy care. Methods/design Based on the learning from a pilot study (ISRCTN 23294263), the BEEP trial is a multi-centre, pragmatic, parallel group, individually randomised controlled trial, with embedded longitudinal qualitative interviews. 500 adults in primary care, aged 45 years and over with knee pain will be randomised to 1 of 3 treatment groups delivered by fully trained physiotherapists in up to 6 NHS services. These are: Usual Physiotherapy Care (control group consisting of up to 4 treatment sessions of advice and exercise), Individually Tailored Exercise (an individualised, supervised and progressed lower-limb exercise programme) or Targeted Exercise Adherence (supporting patients to adhere to exercise and to engage in general physical activity over the longer-term). The primary outcomes are pain and function as measured by the Western Ontario and McMaster Osteoarthritis index. A comprehensive range of secondary outcomes are also included. Outcomes are measured at 3, 6 (primary outcome time-point), 9, 18 and 36 months. Data on adverse events will also be collected. Semi-structured, qualitative interviews with a subsample of 30 participants (10 from each treatment group) will be undertaken at two time-points (end of treatment and 12 to 18 months later) and analysed thematically. Discussion This trial will contribute to the evidence base for management of older adults with knee pain attributable to osteoarthritis in primary care. The findings will have important implications for healthcare commissioners, general practitioners and physiotherapy service providers and it will inform future education of healthcare practitioners. It may also serve to delay or prevent some individuals from becoming surgical candidates. Trial registration ISRCTN: ISRCTN93634563.
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    • "Furthermore, there is evidence that patients going directly to see musculoskeletal practitioners such as physiotherapists are not at risk of having their serious medical conditions overlooked [49] and that experienced physiotherapists have the same level of knowledge as orthopedic specialists [50,51], demonstrating good clinical diagnostic accuracy [52] and management decisions [53]. There is also evidence to suggest that models of care led by musculoskeletal professionals such as physiotherapists lead to fewer prescriptions and investigations, decreased need for expensive and invasive treatments [54,55], and fewer consultations back in the health-care system [56]. "
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    ABSTRACT: Musculoskeletal pain is common across all populations and costly in terms of impact on the individual and, more generally, on society. In most health-care systems, the first person to see the patient with a musculoskeletal problem such as back pain is the general practitioner, and access to other professionals such as physiotherapists, chiropractors, or osteopaths is still either largely controlled by a traditional medical model of referral or left to self-referral by the patient. In this paper, we examine the arguments for the general practitioner-led model and consider the arguments, and underpinning evidence, for reconsidering who should take responsibility for the early assessment and treatment of patients with musculoskeletal problems.
    Preview · Article · Feb 2012 · Arthritis research & therapy
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    • "In participants not receiving hand exercises 50% will receive a leaflet and advice, and 50% will receive joint protection. We estimate that 25% of participants in the leaflet and advice group will improve using the OARSI-OMERACT responder criteria and 45% will improve in the joint protection group [42,56]. This gives a combined improvement of 35% in participants not receiving hand exercises, assuming equal allocation of participants between treatment groups. "
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    ABSTRACT: There is limited evidence for the clinical and cost effectiveness of occupational therapy (OT) approaches in the management of hand osteoarthritis (OA). Joint protection and hand exercises have been proposed by European guidelines, however the clinical and cost effectiveness of each intervention is unknown.This multicentre two-by-two factorial randomised controlled trial aims to address the following questions:• Is joint protection delivered by an OT more effective in reducing hand pain and disability than no joint protection in people with hand OA in primary care?• Are hand exercises delivered by an OT more effective in reducing hand pain and disability than no hand exercises in people with hand OA in primary care?• Which of the four management approaches explored within the study (leaflet and advice, joint protection, hand exercise, or joint protection and hand exercise combined) provides the most cost-effective use of health care resources Participants aged 50 years and over registered at three general practices in North Staffordshire and Cheshire will be mailed a health survey questionnaire (estimated mailing sample n = 9,500). Those fulfilling the eligibility criteria on the health survey questionnaire will be invited to attend a clinical assessment to assess for the presence of hand or thumb base OA using the ACR criteria. Eligible participants will be randomised to one of four groups: leaflet and advice; joint protection (looking after your joints); hand exercises; or joint protection and hand exercises combined (estimated n = 252). The primary outcome measure will be the OARSI/OMERACT responder criteria combining hand pain and disability (measured using the AUSCAN) and global improvement, 6 months post-randomisation. Secondary outcomes will also be collected for example pain, functional limitation and quality of life. Outcomes will be collected at baseline and 3, 6 and 12 months post-randomisation. The main analysis will be on an intention to treat basis and will assess the clinical and cost effectiveness of joint protection and hand exercises for managing hand OA. The findings will improve the cost-effective evidence based management of hand OA. identifier: ISRCTN33870549.
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