Pain-Coping Skills Training Program Effective for Managing Chronic Knee Pain

A recent study of an interactive online exercise intervention designed specifically for the management of chronic knee pain showed it was highly effective in reducing pain and improving function for more than 6 months after therapy. The results of the multinational randomized trial published in the Annals of Internal Medicine indicated significant improvements in both primary and secondary outcomes for the active interventions compared with controls.¹

The investigators recruited 2 groups of 74 patients aged >50 years from the general community in Melbourne, Australia, who reported almost daily knee pain of at least 3 months’ duration as the intervention and control groups. Mean age was 60.8 and 61.5 years, respectively. The active intervention included a 3-part protocol delivered via internet over the course of 12 weeks, including 8 educational modules (35-45 minutes each), a novel automated pain-coping skills training program called PainCOACH, and 7 Skype sessions with an experienced physiotherapist lasting 30 to 45 minutes. The control group received the educational materials only.

Both groups showed improvements during walking in primary outcomes of pain, measured on an 11-point numeric rating scale, and of physical function, measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score.

Significantly greater reductions in pain were observed in the intervention group at 3 months, with a mean difference of 1.6 unit (95% confidence interval [CI], 0.9-2.3 units) compared with controls. The intervention group also demonstrated mean improvements in WOMAC physical function of 9.3 units (95% CI, 5.9-12.7 units) compared with controls. The between-group differences were maintained at 9 months, with mean differences of 1.1 unit (95% CI, 0.4-1.8 units) for pain and 7.0 units (95% CI, 3.4-10.5 units) for physical functioning.

In addition, the intervention group showed significant improvements in secondary outcomes (knee pain, quality of life, self-efficacy of pain and function, and pain catastrophizing) at 3 months and 9 months, with the exception of function-related self-efficacy. The control group showed improvements only in WOMAC self-efficacy pain scores at 3 months and WOMAC self-efficacy scores relating to pain and function at 9 months, as reported by fewer respondents.

Participants in the intervention group reported a high degree of satisfaction with both the Skype physiotherapy and the PainCOACH components of the program. Adherence matched that previously reported with in-person physiotherapy.² “The larger benefits in our study are likely due to the combination of exercise and [pain-coping skills training],” the authors wrote.

Lead author Kim Bennell, PhD, director of the Centre for Health, Exercise and Sports Medicine in Melbourne, Australia, told Clinical Pain Advisor, “We know that exercise is an effective intervention that is recommended for all patients. PainCOACH is a useful adjunctive treatment that many people may find helps them to manage their pain.”

The improvements reported by the control group were solely based on the completion of the education modules (88% access rate).

“Education should always be a key part of an intervention, although on its own, it generally does not have much effect on the outcomes of pain and function,” Dr Bennell said. “It is important to help with self-management,’ she added.

Summary and Clinical Applicability

Together, the 3 components showed a robust effect on knee pain that was apparent after 3 months of therapy, and continued for at least an additional 6 months. Given the high satisfaction reported by patients using the PainCOACH component, and the fact that this training does not require interaction with a clinician for effective use, the investigators will offer a free public access version of PainCOACH online in the near future.

Limitations and Disclosures

• The individual contributions of the 3 components to outcomes could not be evaluated
• Patients were not blinded to treatment
• The study did not control for nonspecific treatment effects
• The researchers did not perform a clinical examination or radiography to confirm knee osteoarthritis

Dr Bennell reports receiving grants from the National Health and Medical Research Council during the conduct of the study; personal fees from Physitrack, ASICS Oceania, Peking University, and Brigham and Women’s Hospital outside the submitted work; and other support from ASICS Oceania outside the submitted work. Dr Dobson reports grants from the National Health and Medical Research Council during the conduct of the study and personal fees from Elsevier Oracle outside the submitted work. Dr Keefe reports a program grant from the National Health and Medical Research Council during the conduct of the study. Dr Hinman reports a grant from the National Health and Medical Research Council outside the submitted work. Authors not named here have disclosed no conflicts of interest.

Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1714.

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References

1. 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 [published online February 21, 2017]. Ann Intern Med. doi: 10.7326/M16-1714
2. Bennell KL, Campbell PK, Egerton T, et al. Telephone coaching to enhance a home-based physical activity program for knee osteoarthritis: a randomized clinical trial. Arthritis Care Res 2017;69:84-94. doi: 10.1002/acr.22915