Journal of Medical Internet Research
Translating Comprehensive Conservative Care for Chronic Knee Pain Into a Digital Care Pathway
Chronic knee pain (CKP) is one of the most common health conditions  and is a characteristic presenting symptom of knee osteoarthritis (OA) . People living with CKP experience a reduced quality of life  and are at risk of developing concomitant musculoskeletal and mental health conditions [4,5]. CKP is most effectively treated by comprehensive chronic pain programs, comprising not only physical exercise but also education, psychosocial support, and weight loss [6-9]. Such programs have shown clinically relevant reductions in pain that last up to 5 years [10,11] and medical cost savings due to a reduced need for injections, drugs, and surgery , with one intervention for CKP due to knee OA showing a 75% (8/41 had knee replacement in control vs 2/42 in treatment) reduction in rate of total knee replacements . Comprehensive care for CKP due to knee OA is also more effective at reducing pain in the long-term compared with physical therapy only [13-16]. However, chronic pain programs are rare for CKP, and over 80% of individuals with CKP due to knee OA receive suboptimal conservative care . Furthermore, CKP patients show poor adherence to existing treatments .
The lack of widespread best-practice conservative care for those suffering from CKP drives patients toward total knee arthroplasty (TKA), an expensive intervention which almost doubled in rate between 2000 and 2010 in the United States . Further exacerbated by an aging population, TKAs now represent one of the main cost drivers for self-insured employers and the largest in-patient cost for Medicare, alongside hip replacements. Despite the popularity of the procedure, many patients undergoing TKA may have avoided or at least delayed surgery through comprehensive conservative care , with 34% of TKAs performed in the United States regarded as inappropriate . For those that do undergo TKA, the benefits are partly offset by serious adverse events [21,22]. Even more wasteful are arthroscopic debridement surgeries, which have no discernible effect on the patient beyond placebo yet remain one of the most common interventions with 500,000 procedures every year in the United States alone . As such, there is huge scope for effective nonsurgical treatment solutions to improve patient outcomes and drive down the surging costs associated with CKP.
A digital care program (DCP), whereby each facet of evidence-based care is digitized, aims to deliver care more efficiently, effectively, and in a way that would improve outcomes while decreasing costs. In particular, a DCP for CKP administered remotely would allow patients access to the program at any time and place, provide a single touchpoint for every aspect of care, enable rich data collection on patient behavior and progress, and drastically reduce the marginal cost of additional patients receiving treatment. Furthermore, as poor adherence can limit long-term effectiveness of a program for CKP , a DCP incorporating remote sensing would enable very precise monitoring of adherence levels to exercise therapy, affording personalized and timely interventions during the course of treatment. Digital health is moving into many different domains of health care, ranging from cognitive behavioral therapy (CBT) for pain and depression to remote monitoring of heart patients [24-26]. In diabetes prevention, a digital health program has shown positive outcomes that persisted up to 2 years after completion of the program , and a digital sleep therapy program was found to be effective in a randomized controlled trial . However, the musculoskeletal field has seen relatively little digital innovation and was judged to be “in its infancy” in this regard .
The American College of Rheumatology recommends those suffering from CKP to participate in cardiovascular and strengthening exercise, self-management training, psychosocial intervention, and weight loss for overweight patients . In line with these recommendations, we have developed a 12-week DCP for CKP. The program builds on previous work in digital musculoskeletal care, which studied individual components of digital care in isolation, such as diagnosis , CBT , exercise with telephone-based coaching , exercise with pain coping training , and behavioral change approaches .
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Conservative Care for Chronic Knee Pain
Methods and Results
Individuals with CKP were recruited onto the 12-week program, comprising sensor-guided physical exercises, weekly education, activity tracking, and psychosocial support such as personal coaching and cognitive behavioral therapy (CBT). We used a single-arm design with assessment of outcomes at baseline, 12 weeks, and 6 months after starting the program. We used a linear mixed effects model with Tukey contrasts to compare timepoints and report intention-to-treat statistics with last observation carried forward.
Between baseline and week 12, participants reported clinically significant improvements in the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS) function scales of 16 points (95% CI 12-21, P<.001) and 10 points (95% CI 6-14, P<.001), respectively.
Significant reductions of 57% (mean difference 30, 95% CI 21-38, P<.001) and 51% (mean difference 25, 95% CI 16-33, P<.001) in visual analog scale (VAS) knee pain & stiffness, were observed at 12 weeks as well as a 67% reduction in surgery interest (mean reduction 2.3 out of 10, 95% CI 1.5-3.1, P<.001).