Knee pain on trial
Published on 01 April 2009
Many people will experience knee pain related to osteoarthritis and the numbers are set to rise, explained in part by our ageing population and increasing prevalence of known risk factors such as obesity and poor physical fitness.
The vast majority of knee problems are managed in primary care by GPs and other health care professionals such as physiotherapists, and yet many people with knee pain find that the current NHS services are frustratingly limited. As a result, researchers at the Arthritis Research UK National Primary Care Centre at Keele University, through a series of clinical trials, are trying to find new ways in which the treatment of knee pain problems can be improved.
Teams of researchers at Keele led by Professor Elaine Hay and Dr Nadine Foster have conducted two large clinical trials (funded by Arthritis Research UK) of different types of treatment for people aged 50 and over who have a clinical diagnosis of knee osteoarthritis.
Both studies have investigated the benefits of advice and exercise, which recent National Centre for Health and Clinical Excellence (NICE) guidelines for osteoarthritis recommend as core treatment, available to everyone irrespective of age or level of disability. In the two trials, NHS physiotherapists provided education, advice about self-help strategies and pacing of activities, and exercise therapy. The exercise treatment was based on a clinical assessment of the knee problem and included exercises to strengthen muscles around the knee, increase patient’s balance and improve the ease with which everyday activities can be completed.
Since 1999 Dr Jonathan Hill, an Arthritis Research UK lecturer in physiotherapy research at the Keele centre has helped to establish a network of NHS physiotherapists who are keen to collaborate in high quality research such as large randomised clinical trials. This partnership between Keele researchers and clinical physiotherapists has made these trials possible, and more than 125 physiotherapists from 23 NHS Trusts across the West Midlands region are now involved.
The physiotherapists not only helped to recruit and treat patients but were actively involved in helping to shape the research questions, develop the treatment protocols, interpret the results and disseminate the study findings into NHS practice.
Comparing different trials
The first of these two knee pain trials called the TOPIK trial (Treatment Options for Pain in the Knee) evaluated the clinical effectiveness of two treatment approaches. The first was a treatment delivered by a pharmacist working in an enhanced role, reviewing patients’ medication to ensure they were taking appropriate tablets for their pain. The second approach was an advice and exercise package delivered by NHS physiotherapists. These two approaches were compared to a control treatment that consisted of usual GP care, written advice and information followed up by one telephone call by a practice nurse. The results demonstrated that both the enhanced pharmacy and exercise package significantly improved patients’ knee pain compared to the control treatment. In addition, the exercise package also significantly improved patients’ knee function.
The second knee pain trial known as the APEX trial (Acupuncture, Physiotherapy and Exercise for Knee Pain), investigated the clinical effectiveness of acupuncture in addition to an advice and exercise package delivered by NHS physiotherapists. Although no additional benefit from acupuncture was found in terms of pain on activity at the follow-up time points of six and 12 months, the results for the advice and exercise package were striking, as the improvements in patients’ knee pain and function were greater than those seen in the TOPIK trial.
The researchers presented these results to their physiotherapy collaborators who had delivered the treatments in order to explore the reasons why the advice and exercise package in the APEX trial was more effective than in the TOPIK trial. The clinicians suggested that the key difference between the treatment was the extent to which they focused attention on making the exercises more specific and progressive for the individual and the way in which, overall, they ‘sold’ the exercise to patients. This finding suggests that older adults with knee pain could have a better clinical outcome if greater attention was given to the quality, intensity and progression of the exercise programme.
Arthritis Research UK went on to fund Mel Holden through an Allied Health Professional training fellowship to work on the Keele ABC-knee study (Attitudes and Behaviours Concerning knee pain). This PhD programme aims to investigate the attitudes and behaviours of older adults and of physiotherapists to exercise for knee problems. This research, alongside other research studies, has provided useful information that has identified strategies to improve both the quality of exercise interventions and ways to help ensure individuals are supported to adhere to increased physical activity levels over the longer-term.
So NHS physiotherapy partners with Keele are now being approached by the research team to collaborate in a third randomised clinical trial for older adults with clinically diagnosed osteoarthritis of the knee. This study is funded by Arthritis Research UK and the National Institute of Health Research (NIHR) and is called the BEEP trial (Benefit of Effective Exercise for Knee Pain). The new trial will investigate the benefit to patients of identifying ways of improving the quality of, and adherence to, exercise and physical activity in general. Patients will be recruited from participating NHS physiotherapy centres initially for a pilot study in 2009 and then for the main clinical trial in 2010-2011.
So if you have knee osteoarthritis what should you be doing about it?
Dr Mark Porcheret, a GP whose research has focussed on the treatment of knee osteoarthritis, recommends that firstly you should be provided with clear advice about how to manage your condition from your doctor, and that you should actively be seeking to improve your muscle strength and general physical fitness wherever possible. You may need the advice and support of a professional such as a physiotherapist to do this confidently.
Other useful treatments include losing some weight if you need to (as weight has been shown time and time again to be linked to the amount of pain people get in their knee joints), taking paracetamol (up to two 500mg tablets four times a day) or using one of the widely available (from the pharmacist or your GP surgery) non-steroidal anti-inflammatory gels such as ibuleve. If pain, or problems with mobility continue, there are a number of other treatments your GP or physiotherapist can try, such as acupuncture, stronger painkillers, local steroid injections, capsaicin (a cream containing a product of chilli peppers that gives a numbing effect) and local heat or cold. If these are not successful and the problem is getting a lot worse then surgery may be the answer.
Joint replacement, though involving major surgery, is very effective but arthroscopy (where the surgeon looks inside the joint with a special telescope) has been shown to only help a small proportion of people with knee osteoarthritis: those who have problems with mechanical locking of the knee. So remember, even though knee osteoarthritis is not curable there are many treatments that can help reduce pain and increase mobility.
About Doctor Jonathan Hill and Doctor Nadine Foster
Dr Jonathan Hill is an Arthritis Research UK lecturer in physiotherapy research, and Dr Nadine Foster is a senior lecturer and Department of Health primary care career scientist at the Arthritis Research UK national primary care centre.