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It’s a bit ironic that when injured people are in pain—and their mobility is reduced—they are often expected to travel to a physical therapy clinic. For millions of people, such trips are a burden. In Australia, however, some patients are “letting movement come to them.” Novel research from The University of Melbourne shows that taking physical therapy (PT) and pain-coping skills into the home via Skype and an online program results in pain reduction and increased function in patients with knee problems.1
Kim L. Bennell, BAppSci(Physio), is director of the Centre for Health, Exercise and Sports Medicine (CHESM), professor in physiotherapy at the School of Health Sciences, University of Melbourne, and NHMRC principal research fellow and director of the NHMRC Centre of Research Excellence in Translational Research in Musculoskeletal Pain. Professor Bennell, lead author on the study, says, “Knee pain is a major contributor to global morbidity, and it needs to be addressed with innovative thinking. Our prior studies suggest that adding a psychological component to the physical aspect of treatment might be beneficial. And since it’s fairly unlikely that someone would be referred to a psychologist in dealing with knee pain, we decided to add a cognitive behavioral element to the physical therapy.”
Using print, radio and social media, the researchers recruited 148 patients into the study, a randomized controlled trial. All patients were over 50 years of age and experiencing chronic knee pain.
Training the Trainers
Professor Bennell
“We worked with Francis Keefe, PhD, from Duke University and Christine Rini from University of North Carolina, who developed an Internet-based pain-coping skills training [PCST] program,” says Professor Bennell. They essentially took elements of face-to-face therapy and put them online. The program addresses such issues as low self-efficacy, poor pain coping and pain catastrophizing.”
The physical therapists received instruction on PCST, and the researchers divided the study participants into two groups. The intervention group received PT, PCST and online educational material; those in the control group had access only to the online educational material.
The Study & Results
Each member of the intervention group received three Internet-delivered treatments. The first was online educational material about exercise, pain management, emotions and the like. The second was an interactive PCST program that involved progressive relaxation, activity-rest cycling, scheduling pleasant activities, changing negative thoughts, pleasant imagery and distraction techniques and problem solving. The third treatment was a series of seven Skype sessions with a physical therapist over 12 weeks (the same therapist on each occasion). Patients were also assigned a home exercise program to do three times per week. They were provided with instructions, video demonstrations and equipment.
“The results were as we had hoped,” says Professor Bennell. “There was a significant improvement in patient pain and functioning, our two core measurements—and these benefits were sustained over nine months. While we did not use X-rays, a diagnosis of chronic knee pain in this age group is consistent with osteoarthritis.”
“Because the therapist comes into the home [via Skype], our participants felt that it was very patient focused,” says Professor Bennell. “Many patients want nondrug, nonsurgical options. With this program, we can give them what they want. And there is another way we are putting control back into the hands of patients. In a traditional PT model, the therapist says, for example, ‘I am going to prescribe exercise for you, and you need to come here three times a week for six weeks.’ With a patient-centered approach, the therapist will say, ‘What would you like to be able to do that you can’t currently do? There is good evidence to show that exercise is effective for knee pain. Are you interested in learning these exercises? You can do these at home. Are there any issues that might get in the way of you doing these regularly?’ The patient sets goals that are relevant to them, and the therapist helps the patient achieve these goals.”
Bringing This Program to the U.S.
Lindsey A. MacFarlane, MD, MPH, is a member of the Rheumatology Division, Immunology & Allergy at Brigham and Women’s Hospital in Boston. She says, “An increasing number of studies show that cognitive behavioral treatments can be helpful for knee pain and/or osteoarthritis. There are patients for whom traveling to PT appointments is a real hardship, so this is a great alternative.”
As to whether such a program would be practical in the U.S., Dr. MacFarlane says, “The upside is that so many people have Internet access. The problem area is insurance coverage. That may change with time, however, as insurers recognize that patients cite time and cost as barriers to PT. Many of these individuals are just not in a position to take so much time off from work. If patients are able to have the same quality treatment in their homes for less money, then I think insurers will take another look at this option. I would definitely consider it for my patients.”
Going Forward
So what may the future be for Dr. Bennell’s related research? “We are testing models of care and how to make them more accessible. We are also looking at ways to change the culture of physical therapists and their training. [Although] some conditions necessitate a hands-on approach to PT, at times, this is not the case. Our team is digging into which conditions respond best to Internet-based therapy and telemedicine. … There are areas in every nation that have no access to physical therapy. … My message to my colleagues is, ‘We need better ways to support patients in meeting their goals. Weight management, exercise and coping skills should be an integral part of our treatment plans so that patients can adhere to behavioral changes over the long term.’”
Elizabeth Hofheinz, MPH, MEd, is a freelance medical editor and writer based in the Greater New Orleans area.
Reference
- Bennell KL, Nelligan R, Dobson F, et al. Effectiveness of an Internet-delivered exercise and pain-coping skills training intervention for persons with chronic knee pain: A randomized trial. Ann Intern Med. 2017 Apr 4;166(7):453–462.
