On the surface, osteoarthritis seems a fairly simple condition resulting from a lifetime of (ab)using our joints which causes wear and attrition of bone and cartilage, causing pain and leading to disability. However, the aetiology of osteoarthritis is much more complex, with no direct association between biological changes (radiographic joint damage), symptoms (pain) and consequences (impaired functioning). Osteoarthritis is a complex interaction of biopsychosocial and economic effects, and effective management requires recognizing this complexity and understanding these interactions. This article reviews the developments of integrated rehabilitation programmes based on a biopsychosocial philosophy to address the complexity of osteoarthritis management.
(In)effective physiotherapy modalities
Physiotherapy utilizes relatively safe, nonpharmacological, conservative modalities (electrotherapy, manipulation, acupuncture, etc.) to reduce pain and disability. These modalities are popular with patients and have very powerful placebo effects, but evidence demonstrating their efficacy is limited. In addition, interventions requiring a therapist or specialized equipment or both create patients who are passive recipients of healthcare and reliant on others, which is an inefficient, expensive and impractical way to manage chronic conditions in the long term. However, these modalities may be useful adjuncts to core strategies that have good evidence supporting their effectiveness, such as exercise and self-management [1–4].
The biomedical model and rationale for exercise
The biomedical model views illness as a pathological change in our biological system that gives rise to symptoms. Correcting the underlying disease eliminates the symptoms and cures the patient. In osteoarthritis, biochemical, anatomical and biomechanical changes cause bone and cartilage damage, giving rise to pain that leads to disability. The effectiveness of exercise in knee osteoarthritis  is attributed to its ability to reverse muscle sensorimotor dysfunction (weakness, fatigue, poor control) preventing abnormal movement and restore normal biomechanics, effecting better gait, relieving pain and improving function.
The biopsychosocial model and the complexity of osteoarthritis
However, most health problems are more complex than the biomedical model posits . Often there is no identifiable cause or the cause cannot be eliminated, so we cannot cure the condition, and people have to live with chronic illness. Moreover, an individual's emotional and cognitive reaction to symptoms and consequences is frequently unrelated to extent of their underlying problem. The effects of illness are a complex interaction between biological (joint damage, muscle dysfunction, altered biomechanics), psychological (pain, health beliefs, cognitions, perceptions, fears, experiences, impaired functioning), socioeconomic (social support, occupation, relationships) and environmental (climate, safety, availability of required facilities) factors. The biopsychosocial model of illness enables better understanding and management of complex conditions. It acknowledges the important influence of biological, psychological, socioeconomic and environmental factors on how people perceive, react to and cope with their problems, and in acknowledging these influences allows us, indeed forces us, to address them.
The psychosocial effects of osteoarthritis can be profound. Chronic pain that has no discernable cause with an episodic variable and unpredictable course is bewildering and gives rise to health beliefs and behaviours that can exacerbate the problems and interfere with effective management. For example, people with knee osteoarthritis usually associate activity with onset and increase in pain which is relieved by rest. Fearing that the pain is signalling joint damage, to minimize pain and prolong the life of their joints people reduce their activity – ‘fear-avoidance behaviour’ . Challenging erroneous beliefs and reassuring people about the safety, physical and psychosocial benefits of physical activity are vital to promote better understanding and more ‘appropriate’ behaviour.
Inappropriate health beliefs can be challenged in patient education/self-management interventions (SMIs), which help people understand and cope with their condition, minimize its effects and adopt healthy lifestyles and behaviours [8–12]. The content of SMIs varies but generally includes advice and education about healthy lifestyles (regular exercise/physical activity, healthy eating, weight control), simple pain-management techniques, joint protection, problem solving and planning skills. They aim to promote behavioural change and overcome barriers to implementation, encourage adherence to treatment and reduce healthcare utilization thereby minimizing the economic burden of chronic ill health. For osteoarthritis, the disease-specific Arthritis Self-Management Programme (ASMP)  and more generic Chronic Diseases Self-Management Programme (CDSMP)  have been used.
Integrated rehabilitation programmes
Exercise and SMIs are frequently delivered separately. Many SMIs describe the benefits of exercise and encourage exercise but do not have a participatory exercise component, whereas the patient education element of exercise regimens focuses narrowly on getting people to exercise rather than wider aspects of self-management. Theoretically, the individual effects of exercise and SMIs might be additive, so programmes combining exercise with SMI could maximize the benefits from both physical and educational approaches. In particular, skills learnt during SMIs may encourage regular exercise to sustain its short-term benefits .
A systematic review of rehabilitation programmes that integrated exercise and SMIs [16•] highlighted wide variation in duration, delivery format and content [17–24,25•,26]: most regimens lasted 6–8 weeks, some lasted 10–12 weeks, one lasted 18 months; interventions were delivered to small groups or individuals, at home or in community centres, clinics or hospitals; the exercises generally aimed to improve strength, flexibility, mobility and balance/coordination; the self-management component generally included the elements described above, and two studies based their intervention on the ASMP. In spite of this heterogeneity, meta-analyses demonstrated significant improvement in pain and function following intervention, similar to meta-analyses of exercise-only  and self-management-only [8,27] interventions (Table 1) . Interestingly, though a meta-analysis of drug studies demonstrates greater pain relief, this does not translate into better function (Table 1).
Excess body weight is a major risk factor for knee osteoarthritis . The systematic review included one of the few trials, and arguably the best to date, showing the benefits of reducing excess body weight and exercise, the Arthritis Diet and Activity Promotion Trial (ADAPT) [25•]. It showed that moderate exercise and modest weight loss improved pain and function better than exercise or diet alone. Its success is encouraging but clinical application may be limited by the effort and burden involved in such a long (18 months) and complex intervention.
Since the systematic review was prepared and published, several other integrated rehabilitation programmes have been reported.
Hay et al.[30•] reported an intervention consisting of home-based exercises and patient education (delivered in three to six sessions over 10 weeks) that found improvements in pain and function, 3 months after the intervention.
The community-based intervention ‘Fit and Strong!’ compared an exercise and a behavioural change programme (90-min sessions held three times a week for 8 weeks) with the Arthritis Handbook and exercise advice. Improvements were found in pain and function, self-efficacy, exercise adherence and performance measures [31•]. The programme is described as ‘low cost’, but no cost data are presented. High loss to follow-up weakens the findings and may indicate unacceptability of the programme questioning its clinical applicability.
An intensive in-patient programme of exercise, SMI and several other physiotherapy modalities (delivered for at least 7 h a week over 3–4 weeks)  showed short-term improvements in pain and physical function, and pain improvements were maintained for 2 years; functional improvements were lost within 2 years. No cost data are presented, but the resource implications (personnel, facilities and financial) may be significant and preclude application. Moreover, the burden of participation may limit its acceptability by many people.
Improvements in pain, function and arthritis self-efficacy were evident following a supervised intervention that integrated exercise into an adapted version of the ASMP (2-h sessions, held once a week for 6 weeks, and home exercises)  and sustained for 1 year [34•]. Again, high loss to follow-up detracts from the results. Similarly, the CDSMP was adapted to include a participatory exercise component (one 90-min session each week for 6 weeks) for people with severe osteoarthritis [35•]. They found that pain and function and self-efficacy improved in all patients. Although the study was not powered to determine whether there were differences between people who had been referred for knee arthroplasty and people who had not, the authors found people who had been referred for surgery had less improvement and speculate that surgical referral may lower compliance with exercise and advice, undermining their response to conservative management.
Activity strategy training involves active coping techniques such as rest–activity cycling to help control symptoms and encourage physical activity. Murphy et al.[36•] integrated exercise with activity strategy training (eight 90-min sessions, over 4 weeks, and two follow-up sessions over 6 months) and compared it with exercise and patient education. Physical activity increased and pain decreased in both groups, and though improvements in the exercise and activity strategy training were greater, these differences were not significant, probably because the study was insufficiently powered to investigate between-group differences in very similar interventions.
Veenhof et al.[37•] compared a ‘behavioural-graded activity’ programme (maximum of 18 sessions in first 12 weeks, then seven sessions over 40 weeks) with usual physiotherapy care for 200 people. Both groups showed similar improvements in subjective and objective measures of pain and function, though behavioural-graded activity showed slightly greater (but not significantly greater) increases and less cost (but not significantly less) −€773 (−€2360 to €772) .
Enabling Self-management and Coping of Arthritic knee Pain through Exercise (ESCAPE-knee pain) is an integrated programme which was delivered to either groups of eight to 10 participants or individually and compared with usual primary care (45–60 min sessions, twice a week for 6 weeks) [39••]. Improvements in physical function, pain, subjective and objective psychosocial outcomes were sustained for 6 months after completing the programme, and a parallel economic evaluation indicated healthcare costs were lower making it more cost-effective than usual primary care [40•].
Clinical applicability of integrated rehabilitation programmes
To be clinically applicable, healthcare interventions must be safe, acceptable and clinically effective for patients, deliverable by clinicians, implementable and affordable by healthcare providers. Integrated rehabilitation programmes need to be considered against these criteria.
SMIs have no reported adverse events. Exercise programmes may be unsuitable for people with unstable medical conditions, but controlled exercise is beneficial for most people with few adverse effects apart from mild transient muscle soreness that is commonly reported for a few days after performing unusual activities. Consequently, integrated rehabilitation programmes are comparatively safe, and few adverse events have been reported.
All the programmes involve significant time and effort, and the high loss to follow-up evident in some studies [16•,25•,31•,32,34•,41,42] suggests their complexity and burden may be unacceptable to less committed participants and may limit uptake.
As discussed above, all of the interventions were efficacious, improving pain, physical function and other variables under ideal controlled research conditions. Although the effects of some programmes appear to be small and unimpressive, this is often because the experimental and control interventions were very similar (in content, delivery, etc.) and both were likely to have benefits [36•,37•]. These trials were too small and statistically ‘underpowered’ to detect meaningful differences between the interventions. Programmes that used ‘usual care’ as the control intervention  had comparatively greater effects [39••].
Affordability, costs and healthcare utilization
Although knee osteoarthritis is very costly, it is regarded as a nonurgent, benign condition, ‘competing’ for finite healthcare resources with other more ‘urgent’ problems. Self-management-only interventions do not reduce healthcare costs [44,45,46•,47], suggesting people are not dissuaded from using healthcare simply by telling them they do not need them. As healthcare providers are unlikely to commission programmes without evidence of clinical and cost-effectiveness, an important aspect of integrated rehabilitation programmes would be to show they can reduce healthcare utilization. Unfortunately, most studies of integrated rehabilitation programmes have not evaluated costs or healthcare utilization, but given the lengthy, complex nature of some programmes their costs are likely to be substantial. Programmes that have carried out economic evaluation demonstrate they are relatively inexpensive [30•,38,40•] and without the direct and indirect hidden costs associated with adverse side effects of prolonged drug therapy . This confirms exercise-based rehabilitation as a relatively cheap, cost-effective intervention that reduces healthcare utilization, justifying their description as a ‘best buy’ in public health .
Complex and unwieldy programmes are difficult to implement, and efficacious research programmes are often not as effective when applied in clinical practice. A recent evaluation of the implementation of the ‘People with Arthritis Can Exercise (PACE)’ programme (16, 45-min sessions delivered twice a week over 8 weeks) which has been around for some time [41,42] has highlighted problems with implementation [50••]. The evaluation was performed against the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework  that assesses whether a healthcare programme reaches the target population (an individual or organization), effectively helps them and is adopted, implemented and maintained long term. Although healthcare providers were convinced about the need and usefulness of the PACE programme and sent people to be trained to deliver it (i.e. adoption was good), few people with arthritis enrolled when the programme was offered to them (reach was low), and, consequently, the providers discontinued it (maintenance was poor) [50••].
Wider implementation has been achieved by the ASMP [52•] and CDSMP  but only after frequent, prolonged and intensive dissemination strategies. To facilitate their implementation further, innovative ways have been devised to deliver these programmes to people who cannot or do not want to attend a programme. A mailed variant of the ASMP over 12–18 months was shown to be as effective as attendance on an ASMP course [54•], and internet-based versions of the ASMP [46•] and CDSMP  (accessing internet 1–2 h three times a week for 6 weeks) improve health status and self-efficacy outcomes. These studies emphasize the substantial effort and commitment needed to get these programmes ‘on the streets’. With their participatory exercise component, implementation of integrated rehabilitation programmes may require even greater effort.
One integrated rehabilitation programme included in the systematic review  has been successfully implemented on a larger scale [55•], but its ability to reduce healthcare utilization seems limited . Wide implementation of integrated rehabilitation programmes needs to be justified by studies that show these interventions have better clinical and cost-effectiveness and reduced healthcare utilization compared with other forms of management. Although preliminary evidence suggests they may be better in these areas, better and closer evaluation is still required.
To address the complexity of osteoarthritis, rehabilitation programmes integrating exercise and SMIs have been devised that reduce pain, improve physical function and other physical and psychosocial variables. Earlier programmes were long, complex, burdensome and expensive. More recently, programmes have been devised that are safer, more effective, acceptable, deliverable and affordable. Information regarding their ability to reduce healthcare utilization is needed. Although implementation of these programmes will require great effort, commitment and resources, they have the potential to help reduce the personal suffering and socioeconomic burden of the large and increasing number of people with chronic knee pain.
The authors have been funded by the Arthritis Research Campaign, a registered, nonprofit-making charity. They have no commercial affiliations or sources of funding sources.
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 196).
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