Physical Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis: Randomized Controlled Trial

Clinical Question

In patients with osteoarthritis of the knee or hip, is a combination of Physical Therapist-Delivered Pain Coping Skills Training (PCST) and exercise more efficacious and cost-effective than either therapy alone at improving osteoarthritis pain?

Bottom Line

The use of pain coping skills training in addition to strength exercises for patients with osteoarthritis are not more effective or than exercise alone.

Major Points

The current treatment guidelines suggest self-management and non-pharmacologic exercise treatments for associated osteoarthritis pain. There are limited recommendations in psychological treatment in establishing PCST, but this study evaluates the efficacy and cost-effectiveness of a combination of non-pharmacologic strength exercises and pain coping skills training. PCST is a treatment derived from cognitive behavioral therapy, delivered by psychologists. Combining PCST and exercise to be delivered by a single practitioner, such as a physical therapist, there could be several potential advantages such as better integration, greater access, and reduced healthcare costs. PCST targets psychological factors, such as self-efficacy and pain catastrophizing, which contribute to patient morbidity. This approach was used to determine if a 12-week combination PCST and exercise led to better improvements in self-reported pain and function than either therapy alone. The 2016 Physical Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis trial randomized 222 participants with knee osteoarthritis to either PCST, exercise, or the combination of both therapies. After 12 weeks, 201 of the remaining participants’ pain and physical function were evaluated as well as cost-effectiveness of the different therapies. There was found to be no significant difference in pain reduction or cost-effectiveness between therapies: PCST/exercise versus exercise (mean difference 5.8 mm [95% confidence interval (95% CI) 21.4, 13.0]) and PCST/exercise versus PCST (6.7 mm [95% CI 20.6, 14.1]). There was, however, significantly greater improvements in physical function between therapies: PCST/exercise versus exercise (3.7 units [95% CI 0.4, 7.0]) and PCST/exercise versus PCST (7.9 units [95% CI 4.7, 11.2]) Further evaluation is needed in determining the results of physical therapist versus psychologist intervention in PCST, as primary outcomes showed an improvement in physical function but not pain in physical therapist initiated treatment. The limitations of this study should also be looked into for future evaluations as the study could have varied in therapy outcomes from different physical therapists who took part in the study. Despite the results of the primary outcomes listed in the study, the results did not support the combination exercise and PCST treatment to be cost-effective. Although not considered a significant difference between groups, the study suggests benefit in incorporating exercise treatment alongside psychological intervention to establish pain coping skills treatment.

Guidelines

Although the 2019 American College of Rheumatology Osteoarthritis Guidelines refer to the psychological impacts of pain coping, they make no recommendation regarding the use of pain coping skills training. The guidelines mention that patients may experience additional symptoms resulting from pain and functional limitations due to their OA. They state that measures aimed at improving symptoms that result from pain and functional limitations may improve the patient’s overall well-being and OA treatment success.

Design

• Multicenter, accessor-blinded, parallel-group, randomized, controlled trial
• N=222
  • Exercise only (n=75)
  • PCST only (n=74)
  • PCST& exercise (n=73)
• Setting: Australia; Departments of Physiotherapy, University of Melbourne and University of Queensland
• Enrollment: 2010-2013
• Mean follow-up: Follow-up at weeks 4, 8, 12, 32, and 52
• Analysis: Intention-to-treat
• Primary outcome: self-reported average knee pain (visual analog scale, range 0–100 mm) and physical function (range 0–68) at week 12.

Population

Inclusion Criteria

• Ages ≥50 years
• Knee OA fulfilling the American College of Rheumatology criteria
  • pain on most days in the past month and radio-graphic changes
• Knee pain for ≥3 months,
• Average pain during previous week ≥40 on 100-mm visual analog scale
• At least moderate difficulty with daily activities (Western Ontario and McMaster Universities Oste-oarthritis Index [WOMAC] physical function subscale ≥25 of 68 units)

Exclusion Criteria

• Current doctor‐diagnosed depression
• Systemic arthritic conditions such as rheumatoid arthritis
• Medical condition precluding safe exercise such as uncontrolled hypertension or heart condition
• Self-reported history of serious mental illness, such as schizophrenia, or self reported diagnosis of current clinical depression
• Neurological condition such as Parkinson’s disease, multiple sclerosis or stroke
• Knee surgery including arthroscopy within the past 6 months or total joint replacement
• Awaiting or planning any back or lower limb surgery within the next 12 months
• Current or past (within 3 months) oral or intra-articular corticosteroid use
• Physiotherapy, chiropractic or acupuncture treatment or exercises specifically for the knee within the past 6 months
• Walking exercise for >30 minutes continuously daily
• Participating in a regular (more than twice a week) structured and/or supervised exercise program such as attending exercise classes in a gym or use of a personal trainer
• Participating in or previous participation in a formal PCST program
• Inability to walk unaided
• Inadequate written and spoken English
• Inability to comply with the study protocol such as inability to attend physical therapy sessions or attend assessment appointments at the University.

Baseline Characteristics

Combined Exercise and PCST Group:

• Sample size
• Age(years)
• Gender-Women
• BMI (kg/m2)
• Average symptom duration (years)
• Unilateral Symptoms
• Employment status
• Level of education
• Comorbidities (Heart disease/HTN, Osteoporosis/osteopenia, Depression, Stomach ulcer/pains

Cancer)

• Radiographic disease severity
• Medication use (Any Analgesia, NSAIDs, COX-2 Inhibitors, Topical NSAIDs, Opioids, Glucosamine/chondroitin pdts, Oral Corticosteroids)
  • Just exercise group= high stomach pain incidence

Interventions

Participants of the study had 10 sessions with a physical therapist over a 12 week period. Sessions for those receiving PCST met for 45 minutes, 25 minutes for those using exercise alone, and 70 minutes for the combination group. After the 12 weeks, follow up was continued through week 52 on primary outcomes of pain reduction and functionality. The pain coping skills training included pain education and training in common coping skills. During the initial 12 weeks of treatment, participants were asked to practice the coping skills daily and then as needed for the follow-up weeks. The exercise program focused on 6 strength training exercises which the participants were asked to perform 4 times a week for the initial 12 weeks and then 3 times weekly for the follow-up weeks. Those in the combined group utilized both of these therapies for the 12 weeks and subsequent follow-up weeks.

Outcomes

Comparisons are PCSt/Exercise vs. Exercise, PCSt/Exercise vs PCST, and PCST vs Exercise.

Primary Outcomes

• = significant

VAS Overall Pain

5.8 (-1.4, 13.0) vs. 6.7 (-0.6, 14.1) vs -0.9 (-8.1, 6.3)

WOMAC Function

3.7 (0.4, 7.0)* vs 7.9 (4.7, 11.2)* vs -4.2(-7.6, -0.9) Exercise (0.03 units, 95% CI -0.01, 0.07, p=0.07) and with PCST (0.03, 95% CI -0.01, 0.06, p=0.13)

There was no difference comparing PCST vs Exercise (0.01, 95% CI -0.03, 0.04, p=0.64).

Secondary Outcomes

VAS walking pain

8.1 (0.2, 16.0)* VS 7.2 (-0.2, 14.7) VS 0.9 (-6.8, 8.5)

WOMAC pain

0.7 (-0.3, 1.6) VS 1.5 (0.5, 2.5)* VS -0.9 (-1.9, 0.1)

Self-efficacy

-1.1 (-2.3, 0.1) VS -2.0 (-3.2, -0.70)* VS 0.9 (-0.4, 2.1)

Sit-to-stand

0.4 (-0.5, 1.3) VS -1.1 (-2.0, -0.2)* VS 1.5 (0.6, 2.4)

Pain coping

-0.3 (0-0.5, -0.2)* VS 0.0 (-0.2, 0.1) VS -0.3 (-0.4, -0.2)

Step Test

0.4 (-0.7, 1.6) VS -1.5 (-2.7, -0.3)* VS 1.9 (0.8, 3.0)

Adverse Events

Significant Adverse Events Based on Group

• Exercise
  • Increased knee pain during treatment (31%)
  • Pain in other regions during treatment (15%)
  • Pain in other regions during follow-up (11%)
• PCST
  • No significant adverse events reported (<10% of population)
• Exercise + PCST
  • Increased knee pain during treatment (21%)
  • Pain in other regions during treatment (15%)

Criticisms

• Internal:
  • Although participant and physical therapist blinding was not possible, the hypothesis was blinded to participants to limit performance bias.
  • The varying treatment outcomes due to individual physical therapists was controlled for and used in determining sample sizes.
  • Loss to follow up during the complete 52-weeks was 17%; baseline characteristics were presented as complete cases to make up for this.
• External:
  • Primary outcomes do not consider number of prior attempts at PCST
    • “Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial”
    • This study takes into account the number of prior attempts at pain-coping skills training whereas our study does not document previous use of psychological intervention. This information would be helpful in determining if patients had higher success rates in primary outcomes of pain management with multiple attempts at exposure to these coping skills.
  • Study does not take into account other possible methods to improve cost effectiveness such as online exercise programs and pain coping skills training.
    • “An online exercise program plus automated coping skills training improved pain and function in chronic knee pain”
    • Study analyzed the cost effectiveness of the treatment groups and established it was extensive. Internet based education studied here helped to lower costs as compared in-person or provider training with similar primary outcomes conducted in our study.

Funding

Beyond Blue, the Collier Charitable Trust, NIH, and the American Cancer Society

Further Reading

Article On;

• Bennell K, et al. “Physical Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis: Randomized Controlled Trial.” Arthritis Care & Research, U.S. National Library of Medicine. 2016 May. 68(5):590-602.