Can you virtually improve your knee pain?

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If you’ve ever had significant or persistent knee pain, you know it can be a major problem. Climbing stairs or just walking around can be agony, and trying to exercise on a bad knee can be impossible.

For people with severe osteoarthritis of the knee — the type most closely linked with aging or prior injury — knee pain may be unrelenting and often worsens over time, causing disability and reduced quality of life. Osteoarthritis is also expensive: we spend billions of dollars taking care of this condition each year in the U.S. The prevalence of osteoarthritis and the costs of caring for it are rising due to our aging population and rising rates of obesity (which is a major risk factor for osteoarthritis).

While exercise, loss of excess weight, and medications can help, they tend to be only modestly effective and temporary at best. That’s why an estimated 700,000 knee replacements are performed each year in the United States. Though there are risks associated with any surgery and it’s not 100% effective, knee replacement surgery is the most reliably effective treatment for severe osteoarthritis of the knee.

A new study, a new approach

A recent study published in the Annals of Internal Medicine takes a unique approach to the treatment of people with osteoarthritis of the knee.

Researchers divided 148 people with osteoarthritis of the knee into two groups: one group was encouraged to access standard educational material from the web regarding osteoarthritis. This included information about medications, diet, physical activity, and exercises from the research website. The other group not only had access to these same materials, but also received:

• an interactive web-based program about how to cope with pain, with eight weekly sessions lasting 35-45 minutes in which participants learned relaxation techniques, how to balance rest and activity, ways to distract one’s attention from pain, and other strategies
• seven Skype-based sessions over three months with an experienced physical therapist. Each session lasted 30 to 45 minutes and covered home exercises to strengthen lower limb muscles. In addition to video presentations, each participant received free resistance bands, ankle weights, and a pedometer.
• email reminders that regularly encouraged participants to take full advantage of these interventions.

The study found that after the three-month period was completed, those receiving the additional pain management and physical therapy care through the internet-based programs reported significantly less pain and better function than those receiving only the standard information. And the improvement continued for at least six months after the program ended.

As is true for all studies, this one had limitations. For example, it included patients who self-reported their diagnosis. That means that some of the study participants’ knee pain could have been due to something other than osteoarthritis. And all the patients had access to the internet and the ability to use it; the result might not apply to less educated individuals or those without regular online experience. And it’s possible that the improvement noted by those receiving online pain management teaching and online physical therapy was due to the placebo effect; after all, this group had much more attention and interpersonal interaction than the standard education group. Of course, if an intervention is reliably effective, safe, and inexpensive, it may not matter much if it’s due to the placebo effect.

What’s the big deal?

While none of the interventions in this study was particularly novel, delivering them via the internet is. Increasingly, telehealth — providing medical care from a distance through telecommunications technology — is becoming more common. And in many settings, it’s already routine. A physician can talk to a patient thousands of miles away and examine certain parts of the body (such as the skin) and take good care of a patient who might otherwise be unable to get care at all. The ECG of a patient in an ambulance can be digitally transmitted to a cardiologist well before the patient arrives in the emergency room, allowing treatment advice from a specialist much sooner than in the past. Similarly, an x-ray, CT scan, or MRI can be read by a radiologist far from where the images were obtained.

What’s next?

While this study is encouraging, we still need better treatments for osteoarthritis. After all, online education, pain management modules, and physical therapy may help, but they are unlikely to prevent the need for knee surgery if the arthritis is severe.

But the results suggesting that telehealth may be able to improve the well-being of people with osteoarthritis of the knee is only the latest example of what is likely to be the widespread application of this approach to care. Considering the millions of people worldwide who lack access to basic as well as specialized medical care, the potential for telehealth to bridge this gap is enormous.