Clinical Context

Osteoarthritis (OA) is one of the most common reasons for chronic pain, and it has no cure. Moreover, available conservative treatments, including analgesics, are all limited in their efficacy in reducing pain and improving physical function. Exercise is recommended frequently for patients with OA, but how effective is it? A review by Fransen and colleagues, which appeared in the January 9, 2015, issue of The Cochrane Database of Systematic Reviews, attempted to answer this question.^[1]

Researchers found 54 clinical trials of land-based exercise for OA. Overall, exercise produced a modest effect in alleviating pain, with an average improvement of 12 points on a 100-point scale compared with control conditions. The authors note a similar degree of relief from the pain of OA associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs).

In a similar manner, compared with control conditions, exercise was associated with an average improvement of 10 points for physical function on a 100-point scale. Quality-of-life scores were also higher in the exercise vs control groups immediately after treatment. Back or knee pain could be exacerbated by exercise, but no serious adverse events were associated with exercise therapy.

A total of 12 studies observed patients for up to 6 months after the exercise program was complete. They found that exercise was related to sustained improvements in pain and function, although with significant waning of effect to levels that are most likely not clinically significant.

What if treatment for OA of the knee could be augmented with an online-based support program for exercise therapy and pain management? The current study by Bennell and colleagues evaluates outcomes of such an intervention.

Study Synopsis and Perspective

A suite of online interventions provided substantial pain relief and improved mobility for patients with chronic knee pain, according to a study published online February 21 in the Annals of Internal Medicine.^[2] The interventions included physiotherapy via Web-based video conferencing, as well as a pain management course and educational materials.

Arthritis causes persistent knee pain in approximately one-quarter of adults, often inhibiting everyday activities, note Kim L. Bennell, PhD, from the Centre for Health, Exercise, and Sports Medicine at the University of Melbourne in Melbourne, Australia, and colleagues.

It is also a problem that is expected to become more common in the United States as the population ages, writes Lisa A. Mandl, MD, MPH, from the Hospital for Special Surgery and Weill Cornell Medicine, New York City, in an accompanying editorial.^[3]

Existing therapies have many drawbacks. Currently used medications have adverse effects or may be cost prohibitive. Nonpharmacologic therapies, such as physiotherapist-directed exercise and pain-coping training, may be difficult to access, especially for those in rural areas, Dr Bennell and colleagues note.

Therefore, the authors tested whether they could improve access to treatment and patient outcomes using a suite of online interventions. They enrolled 148 people from 7 Australian states, including 43% of whom were from rural or remote areas.

The researchers randomly assigned participants to receive either 7 sessions with a physiotherapist via Skype, free video conferencing software, an online pain-coping skills course, and educational materials, or a control intervention, which consisted of the educational materials alone. The interventions took place during the course of 3 months. Patients participating in the intervention also received resistance bands; ankle weights; and, on request, a pedometer.

At 3 months, patients in the intervention group reported significant reductions in pain compared with those in the control group, with an average difference of 1.6 units on an 11-point pain scale (95% confidence interval [CI], 0.9-2.3 units).

The intervention group also reported improved physical function compared with the control group, with an average difference of 9.3 units on the Western Ontario and McMaster University Osteoarthritis Index (95% CI, 5.9-12.7 units).

Much of this improvement was sustained at 9 months, with an average pain difference of 1.1 units and physical function of 7.0 units between the 2 groups.

In addition, participants reported high satisfaction with the intervention. They also had high rates of completion, with 78% accessing the educational materials, an average of 6.3 of 7 Skype physiotherapy sessions completed, and an average of 6.4 of the 8 pain management modules completed.

Increased knee pain was the most common adverse event reported in both groups, with 15 people in the intervention group reporting it, as well as 3 participants in the control group.

"These results are encouraging and show that 'telemedicine' is clearly ready for prime time," writes Dr Mandl. "An Internet-based intervention circumvents multiple issues related to access to care, making this an inexpensive and easily scalable option for people living in remote areas or any location with an inadequate supply of health care providers."

However, Dr Mandl noted that the study may not be widely generalizable, as it excluded patients with worse pain in other joints and those whose pain limited exercise. It also did not use radiography to evaluate a patient's knee pain.

"[E]valuating the 'low-hanging fruit' (patients who are more likely to respond) is an entirely reasonable approach to establish proof of concept before embarking on wider dissemination of this novel intervention," Dr Mandl noted.

Future studies will be needed to test whether this intervention will be effective in minorities or other subpopulations, she continued.

The study authors plan to make their pain management modules available to the public free online.

Dr Bennell discloses receiving personal fees from Physitrack and royalties from ASICS Oceania, as well as personal fees from Peking University and Brigham and Women's Hospital Boston outside of the submitted work. Dr Dobson discloses personal fees for editorial contributions to Elsevier Oracle outside of the submitted work. The remaining others have disclosed no relevant financial relationships. Dr Mandl discloses receiving personal fees from the American College of Physicians and Wolters Kluwer and grants from Boehringer Ingelheim outside of the editorial.

Ann Intern Med. Published online February 21, 2017.

Clinical Implications

• A previous systematic review by Fransen and colleagues found that exercise could modestly relieve pain and improve function among patients with OA, with improvements in pain levels similar to those associated with NSAIDs. There was some durability of the effects of exercise beyond the intervention period.
• The current study by Bennell and colleagues demonstrates that an Internet-based program focused on general education, specific techniques for coping with pain, and physiotherapy sessions can reduce pain and improve function at 3 and 9 months.
• Implications for the Healthcare Team: The current study provides hope for practices that lack resources for chronic disease management in cases of OA. Internet-based interventions might not only be efficient but also effective for important patient outcomes.

CME Test