Kim L. Bennell, BAppSci(Physio), PhD; Rachel Nelligan, BPhysio; Fiona Dobson, BAppSci(Physio), PhD; Christine Rini, PhD; Francis Keefe, BA, MS, PhD; Jessica Kasza, BSc(Hons), PhD; Simon French, BAppSc(Chiro), MPH, PhD; Christina Bryant, MA(Clin Psych), PhD; Andrew Dalwood, BAppSci(Physio), GradDipManipTherapy; J. Haxby Abbott, PhD, DPT; Rana S. Hinman, BPhysio(Hons), PhD
Acknowledgment: The authors thank Dr. Margaret Staples, who performed the sample size calculation and prepared the randomization schedule; Ben Metcalf for his assistance with study administration and manuscript preparation; and the physiotherapists who delivered the exercise intervention: David Bergin, Catherine Derham, Brad Fernihough, Sophie Heywood, Tim McCoy, Chantelle Pink, Christopher Snell, and Helen Walker.
Grant Support: The trial was funded by the Australian National Health and Medical Research Council (program grant 1091302). Prof. Bennell is supported by a National Health and Medical Research Council Fellowship (1058440). Dr. Rini received funding from a Multidisciplinary Clinical Research Center funded by the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases through the Thurston Arthritis Research Center at the University of North Carolina (P60AR064166). Dr. Hinman is supported by an Australian Research Council Future Fellowship (FT130100175). Dr. Abbott was funded by a Sir Charles Hercus Health Research Fellowship from the Health Research Council of New Zealand.
Disclosures: Prof. Bennell reports grants from the National Health and Medical Research Council during the conduct of the study; personal fees from Physitrack, ASICS Oceania, Peking University, and Brigham and Women's Hospital outside the submitted work; and other support from ASICS Oceania outside the submitted work. Dr. Dobson reports grants from the National Health and Medical Research Council during the conduct of the study and personal fees from Elsevier Oracle outside the submitted work. Dr. Keefe reports a program grant from the National Health and Medical Research Council during the conduct of the study. Dr. Hinman reports a grant from the National Health and Medical Research Council outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1714.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available at http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-15-279 and in the Supplement. Statistical code: Available from Dr. Kasza (e-mail, email@example.com). Data set: Available from Prof. Bennell (e-mail, firstname.lastname@example.org).
Requests for Single Reprints: Kim L. Bennell, BAppSci(Physio), PhD, Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Building, 161 Barry Street, Melbourne 3010, Victoria, Australia; e-mail, email@example.com.
Current Author Addresses: Prof. Bennell, Ms. Nelligan, and Drs. Dobson and Hinman: Centre for Health Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Building, 161 Barry Street, Melbourne 3010, Victoria, Australia.
Dr. Rini: Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Department of Health Behavior, Campus Box 7440, 319C Rosenau Hall, Chapel Hill, NC 27599-7440.
Dr. Keefe: Duke Pain Prevention and Treatment Research Program, Suite 340, 2200 West Main Street, Durham, NC 27705.
Dr. Kasza: Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne 3004, Victoria, Australia.
Dr. French: School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Louise D. Acton Building, 31 George Street, Kingston, Ontario K7L 3N6, Canada.
Dr. Bryant: Chelsea House, Suite 225, 55 Flemington Road, North Melbourne 3051, Victoria, Australia.
Mr. Dalwood: Waverley Park Physiotherapy Centre, 439 Police Road, Mulgrave 3170, Victoria, Australia.
Dr. Abbott: Centre for Musculoskeletal Outcomes Research, Orthopaedic Surgery Section, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand.
Author Contributions: Conception and design: K.L. Bennell, F. Dobson, F. Keefe, S. French, C. Bryant, A. Dalwood, J.H. Abbott, R.S. Hinman.
Analysis and interpretation of the data: K.L. Bennell, R. Nelligan, J. Kasza, J.H. Abbott, R.S. Hinman.
Drafting of the article: K.L. Bennell, R. Nelligan, F. Dobson, C. Rini, F. Keefe, J. Kasza, S. French, C. Bryant.
Critical revision of the article for important intellectual content: K.L. Bennell, R. Nelligan, F. Dobson, F. Keefe, J. Kasza, S. French, C. Bryant, J.H. Abbott, R.S. Hinman.
Final approval of the article: K.L. Bennell, R. Nelligan, F. Dobson, C. Rini, F. Keefe, J. Kasza, S. French, C. Bryant, A. Dalwood, J.H. Abbott, R.S. Hinman.
Provision of study materials or patients: K.L. Bennell, R. Nelligan, C. Rini, F. Keefe.
Statistical expertise: J. Kasza.
Obtaining of funding: K.L. Bennell.
Administrative, technical, or logistic support: K.L. Bennell, R. Nelligan, F. Dobson, C. Rini, C. Bryant, A. Dalwood.
Collection and assembly of data: R. Nelligan.
Effective, accessible biopsychosocial treatments are needed to manage chronic knee pain on a population level.
To evaluate the effectiveness of Internet-delivered, physiotherapist-prescribed home exercise and pain-coping skills training (PCST).
Pragmatic parallel-group randomized, controlled trial. (Australian New Zealand Clinical Trials Registry: ACTRN12614000243617)
148 persons aged 50 years or older with chronic knee pain.
The intervention was delivered via the Internet and included educational material, 7 videoconferencing (Skype [Microsoft]) sessions with a physiotherapist for home exercise, and a PCST program over 3 months. The control was Internet-based educational material.
Primary outcomes were pain during walking (11-point numerical rating scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index) at 3 months. Secondary outcomes were knee pain, quality of life, global change (overall, pain, and functional status), arthritis self-efficacy, coping, and pain catastrophizing. Outcomes were also measured at 9 months.
Of participants enrolled, 139 (94%) completed primary outcome measures at 3 months and 133 (90%) completed secondary outcome measures at 9 months; multiple imputation was used for missing data. The intervention group reported significantly more improvement in pain (mean difference, 1.6 units [95% CI, 0.9 to 2.3 units]) and physical function (mean difference, 9.3 units [CI, 5.9 to 12.7 units]) than the control group at 3 months, and improvements were sustained at 9 months (mean differences, 1.1 units [CI, 0.4 to 1.8 units] and 7.0 units [CI, 3.4 to 10.5 units], respectively). Intervention participants showed significantly more improvement in most secondary outcomes than control participants. At both time points, significantly more intervention participants reported global improvements.
Participants were unblinded.
For persons with chronic knee pain, Internet-delivered, physiotherapist-prescribed exercise and PCST provide clinically meaningful improvements in pain and function that are sustained for at least 6 months.
National Health and Medical Research Council.
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Bennell KL, Nelligan R, Dobson F, Rini C, Keefe F, Kasza J, et al. Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial. Ann Intern Med. 2017;166:453-462. doi: 10.7326/M16-1714
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Published: Ann Intern Med. 2017;166(7):453-462.
Published at www.annals.org on 21 February 2017
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