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SHP 08-180 – HSR&D Study

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SHP 08-180
Pilot study of group physical therapy for knee osteoarthritis
Kelli Dominick Allen PhD
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: May 2008 - September 2008

BACKGROUND/RATIONALE:
Osteoarthritis (OA) is the one of the most common chronic conditions among veterans, and over half of VA health care users with OA report being limited in their daily activities because of joint symptoms. Physical therapy and ongoing exercise help to reduce pain and improve physical function. However, the majority of veterans with OA are physically inactive. Furthermore, physical therapy appointments in the VA health care system are a limited resource, with demand often exceeding supply, resulting in long wait periods and a limited number of visits (1 or 2) per patient. Extending physical therapy services to a larger number of veterans with OA, in a cost effective manner, may play a key role in improving outcomes in this large patient group.

OBJECTIVE(S):
The objective of this pilot study is to perform preliminary evaluation of group-based physical therapy program for veterans with knee OA, in preparation for a larger grant submission. This pilot work will allow us to assess the feasibilty of group-based sessions, refine the intervention session components as needed, assess the planned recruitment and enrollment methods, estimate the number of potentially eligible veterans at the Durham VAMC, and conduct sample size and power analyses for a larger clinical trial.

METHODS:
All participants will be involved in a 12-week group-based physical therapy program, with study measures being obtained at baseline and immediately following program completion. Participants will be Durham VAMC patients with symptomatic knee OA. Our goal is to enroll 20 participants who complete the program and follow-up measures, but we may recruit up to 25 participants total, if some participants drop out of the program before completion. Participants will attend group physical therapy sessions bi-weekly for twelve weeks (total of six visits), with each session lasting approximately one hour. Two study team members, a licensed physical therapist and research assistant with training in exercise for knee OA, will lead each session. The research assistant will lead group exercises, and the physical therapist will assess the progress and monitor for any potential problems or special needs of individual patients. During the first 10-15 minutes of each group session, one study team member will talk with participants about a topic related to OA care, such as joint protection, weight management, joint injections and surgery, and stress management. The remainder of the session will involve group warm-up / stretching exercises, then a series of strengthening exercises tailored for patients with knee OA. Participants will also be instructed to perform stretching exercises daily and strengthening exercises three times total each week. Primary outcome measures will be self-reported pain and function, assessed using the Western Ontario and McMaster Universities OA Index (WOMAC). Statistical analyses will compare pre- and post-intervention pain and function, including effect size calculations to assist with sample size estimates for a larger study.

FINDINGS/RESULTS:
Among 24 participants who consented to be in the study, 14 completed both baseline and follow-up assessments. Of the remainder, reasons for discontinuing the program were:
- Program held at inconvenient time of day; needed a time before or after work (N=3)
- Injury unrelated to the study (N=1)
- Personal life event unrelated to the study (N=1)
- Decided did not want to exercise (N=1)
- Unknown - could not re-contact by telephone (N=4)
Among participants who completed baseline and follow-up assessments, WOMAC total, pain, and function scores increased by 21%, 32%, and 18%, respectively. Participants also showed increases in weekly activity levels. At the end of the program, 93% of participants were performing strengthening and strengthening exercises weekly. In addition, although this program did not focus on aerobic activity, there was also a trend for this type of exercise to increase following the program.
At the end of the program, we also asked participants questions about the helpfulness of specific components of the program. The questions and mean scores were as follows:
1. Overall, on a scale of 1-10 (with 1 being not helpful and 10 being very helpful), how much did this program help you to start and keep up with an exercise program? Mean score = 8.9
2. Overall, on a scale of 1-10 (with 1 being not helpful and 10 being very helpful), how much did the home exercises help you to manage your arthritis pain? Mean score = 7.8
3. Overall, on a scale of 1-10 (with 1 being not helpful and 10 being very helpful), how helpful was the individual evaluation and instruction you received from the physical therapist? Mean score = 9.6
Based on study findings, we have identified strategies to enhance adherence and retention in a larger study. These strategies include: increase options for physical therapy session times, enroll participants in groups that they will stay with for the entire physical therapy program, provide scheduled consulation times with the physical therapist within the context of the group sessions, and utilize attendance contracts.


IMPACT:
This study is significant because it examines a novel health services delivery method for improving outcomes among patients with OA - a highly prevalent condition that is also one of the main causes of pain among veterans. Specifically, this pilot study is a key first step toward examining the efficacy and cost-effectiveness of a method for delivering physical therapy services to a larger number of veterans with OA. This delivery method could also be applied to other common orthopedic and neurologic conditions that require physical therapy service.

PUBLICATIONS:
None at this time.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Arthritis, Exercise, Functional
MeSH Terms: none

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