سود و زیان بالینی دراز مدت از برنامه توانبخشی یکپارچه در مقایسه با فیزیوتراپی سرپایی برای درد مزمن زانو

Background Chronic knee pain is a major cause of disability in the elderly. Management guidelines recommend exercise and self-management interventions as effective treatments. The authors previously described a rehabilitation programme integrating exercise and self-management [Enabling Self-management and Coping with Arthritic knee Pain through Exercise (ESCAPE-knee pain)] that produced short-term improvements in pain and physical function, but sustaining these improvements is difficult. Moreover, the programme is untried in clinical environments, where it would ultimately be delivered. Objectives To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy. Design Pragmatic, randomised controlled trial. Setting Outpatient physiotherapy department and community centre. Participants Sixty-four people with chronic knee pain. Interventions Outpatient physiotherapy compared with ESCAPE-knee pain. Outcomes The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index. Secondary outcomes included pain, objective functional performance, anxiety, depression, exercise-related health beliefs and healthcare utilisation. All outcomes were assessed at baseline and 12 months after completing the interventions (primary endpoint). ANCOVA investigated between-group differences. Results Both groups demonstrated similar improvements in clinical outcomes. Outpatient physiotherapy cost £130 per person and the healthcare utilisation costs of participants over 1 year were £583. The ESCAPE-knee pain programme cost £64 per person and the healthcare utilisation costs of participants over 1 year were £320. Conclusions ESCAPE-knee pain can be delivered as a community-based integrated rehabilitation programme for people with chronic knee pain. Both ESCAPE-knee pain and outpatient physiotherapy produced sustained physical and psychosocial benefits, but ESCAPE-knee pain cost less and was more cost-effective. Clinical Trial Registration No.: ISRCTN63848242.

Chronic knee pain, often diagnosed as knee osteoarthritis [1], is a significant public health problem [2]. It causes pain and disability, impairs psychosocial function and quality of life, and places a large socio-economic burden on health services [2], [3], [4], [5], [6] and [7]. As the incidence and prevalence of chronic joint pain is age related, these problems will increase as the number of elderly people increases. Evidence-based management guidelines [8], [9] and [10] advocate exercise and patient education/self-management interventions (SMIs) as effective ways of improving pain and physical function in chronic knee pain. In spite of these guidelines, only one-third of people reportedly receive exercise-based rehabilitation, and this is usually in the form of a short one-off course of physiotherapy involving exercise and advice [11] and [12]. Moreover, therapeutic benefits diminish if people do not continue to exercise regularly, and most patients do not adhere to therapeutic advice following discharge [13], [14], [15], [16], [17] and [18]. SMIs help people to understand and cope with their problems more effectively, improve adherence to management advice and reduce healthcare utilisation [19], [20] and [21]. Exercise and SMIs are frequently delivered separately; SMIs explain the benefits of exercise but rarely have a participatory exercise component, while the patient education element of exercise regimens focuses on how to perform exercise. However, the benefits of exercise and SMIs might be enhanced if programmes integrate the physical approach of exercise with the educational approach of SMIs. In addition, self-management skills could improve adherence to regular exercise and sustain the benefits [22]. Unfortunately, most integrated rehabilitation programmes are long, complex and expensive, and consequently have limited clinical application [23] and [24].

This pragmatic study established the feasibility of delivering ESCAPE-knee pain – a community-based rehabilitation programme that integrated patient education, self-management strategies and exercise for people with chronic knee pain – and compared it with outpatient physiotherapy management. The hypothesis that ESCAPE-knee pain would sustain greater benefits than outpatient physiotherapy was not supported as both interventions produced similar sustained improvements in physical function and other clinical outcomes. Lower intervention costs and reduced healthcare utilisation did support the hypothesis that ESCAPE-knee pain would be less costly and more cost-effective than outpatient physiotherapy. However, these results need to be confirmed in larger studies. It is not surprising that both of these interventions demonstrated good short-term improvements in function and pain, since both comprised exercise and self-management advice which are known to be effective [8], [9], [10], [19], [20], [21], [46], [47], [48] and [49]. What is surprising is the extent of the improvement and that these improvements were sustained. A 25% improvement in self-reported function is well above the level considered to be clinically meaningful [41] and [50], and occurred in people with comparatively good baseline function. These findings confirm exercise-based rehabilitation as an effective way of managing chronic knee pain, with benefits sustained for longer than previously thought. An important difference between the interventions was cost. Innovative healthcare interventions are usually more expensive than current treatments. ESCAPE-knee pain is unusual because although the differences in the clinical outcomes were marginal, the programme's group delivery and reduced healthcare utilisation made it more cost-effective. These cost differences were calculated at the level of the individual participant. If the cost differential was extrapolated to the large population of people with chronic knee pain, the programme could have substantial healthcare savings. Moreover, as chronic knee pain is slowly progressive with increasing healthcare costs, the savings could be greater over time.