VBCR - February 2013, Volume 2, No 1 - Practice Management

By Wayne Kuznar

Washington, DC—A rehabilitation program that integrates exercise and self-management, called the Enabling Self-Management and Coping of Arthritic Knee Pain through Exercise (ESCAPE-knee pain), is more cost-effective than outpatient physiotherapy in the management of patients with knee pain, said Michael V. Hurley, PhD, Professor of Rehabilitation Sciences, St. George’s University of London, and Kingston University, London, United Kingdom, at the 2012 American College of Rheumatology meeting.

The personal and socioeconomic consequences of chronic knee pain are increasing with the aging of society. Evidence-based guidelines recommend exercise and self-management interventions as core treatments. These are usually delivered separately, but their benefits may be enhanced by integrating physical and educational approaches. “The problem is that the integrated rehabilitation programs are long, complex, and expensive, and, therefore, they have limited clinical applications,” he said.

The ESCAPE-Knee Pain Program

The ESCAPE-knee pain program integrates patient education, self-­management, and coping strategies with a challenging exercise regimen. The integrated program changes patients’ health beliefs and behaviors, “and they learn that they can control their symptoms and alter the course of their condition,” said Dr Hurley.

The ESCAPE-knee pain program produced short-term improvements in pain and physical function compared with usual primary care, but sustaining these improvements is problematic. In addition, the program is untried in the community, where it is most likely to be delivered. The study evaluated the feasibility of delivering ESCAPE-knee pain in a community setting, and compared its clinical effectiveness and costs with outpatient physiotherapy.

A total of 64 patients with chronic knee pain were randomized to outpatient physiotherapy or to the ESCAPE-knee pain program in a local adult education community center in London. “Our inclusion criteria were kept very broad, because we wanted to capture the representative population who were knocking on their general practitioners’ doors,” Dr Hurley said.

The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included pain, objective functional performance, anxiety, depression, exercise-related health beliefs, exercise self-efficacy, and healthcare utilization. All outcomes were assessed at baseline and 12 months after completion of the interventions (the primary end point).

The patients who were randomized to outpatient physiotherapy followed usual clinical practice and were asked to record the number of sessions and treatment modalities in which they participated. They were allowed a 30- to 45-minute initial assessment and up to 10 treatment sessions.

The ESCAPE-knee pain program involves 2 sessions weekly for 5 weeks. A psychosocial intervention was provided for the first 15 to 20 minutes of each session that involved an informal group discussion to improve the patients’ understanding of their condition; cognitive restructuring; simple pain control techniques; reassurance about what they should and should not be doing; specific goal-setting; and self-management.

The next 40 to 45 minutes consisted of an individualized progressive exercise regimen devised by a physiotherapist to improve strength, balance, coordination, and functional performance. After the 10 sessions, the patients were discharged with a home exercise program. Four months after completing the program, they were offered a 1-hour review session to reinforce the key messages and to review the exercises.

Of the 64 patients randomized, 8 from each group withdrew by the end of year 1.

WOMAC function improved similarly in both groups, and the improvement was sustained to 12 months. There were no differences between the groups in the secondary clinical outcomes of pain, function, anxiety, and depression, “except beliefs and self-efficacy, which improved more in the people who had undergone ESCAPE, and were sustained at 12 months,” said Dr Hurley.

The intervention “costs about half as much as outpatient physiotherapy,” he added. Specifically:

  • Outpatient physiotherapy costs £130 per person
  • Healthcare utilization costs of physiotherapy for 1 year were £583
  • The ESCAPE-knee pain program costs £64 per person
  • Healthcare utilization costs were £320 in the program.

“It was largely because people didn’t seem to be accessing secondary care,” Dr Hurley said. The group therapy with the ESCAPE-knee pain program also minimized costs.

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