The effectiveness of exercise therapy and education plus cognitive behavioral therapy, alone or in combination with total knee arthroplasty in patients with knee osteoarthritis - study protocol for the MultiKnee trial

Behavioral Therapy-Based Digital Interventions for Treating Osteoarthritis: Systematic Review and Meta-Analysis

BACKGROUND

Osteoarthritis (OA) is characterized by pain, functional impairments, muscle weakness, and joint stiffness. Since OA heightens reliance on heath care resources and exacerbates socioeconomic burden, remote OA rehabilitation using digital technologies is rapidly evolving.

OBJECTIVE

The aim of this study was to analyze the efficacy of behavioral therapy-based digital interventions for patients with OA.

METHODS

This study is a systematic review of randomized controlled trials (RCTs) that assessed the effects of behavioral therapy-based digital intervention tools for OA. These RCTs were searched from inception to June 2023 in the Web of Science, Embase, Cochrane Library, Ovid, and PubMed databases.

RESULTS

Ten eligible RCTs comprising 1895 patients with OA were included. Digital tools based on either cognitive behavioral therapy (CBT) or behavior change technique (BCT) were investigated. All studies demonstrated low-to-moderate effects on pain reduction in the short term (standardized mean difference [SMD] -0.20, 95% CI -0.35 to -0.05). Six studies reported improvement in physical function (SMD -0.20, 95% CI -0.41 to 0.00), and 5 confirmed increased pain self-efficacy (SMD 0.22, 95% CI 0.02-0.42). In subgroup analysis, compared with CBT, BCT-based digital interventions demonstrated their effects on pain reduction (SMD -0.25, 95% CI -0.49 to 0.00) and physical function (SMD -0.26, 95% CI -0.54 to -0.01) in the short term. In addition, physiotherapist involvement in treatment had a positive effect on pain control (SMD -0.14, 95% CI -0.27 to -0.02). Furthermore, web-based digital tools improved physical function in the short term (SMD -0.28, 95% CI -0.54 to -0.01).

CONCLUSIONS

Moderate- and low-quality evidence supported that behavioral therapy-based digital tools improved pain intensity, physical function, and self-efficacy in the short term. However, affective interactions between patients and professionals may affect the clinical outcomes.

TRIAL REGISTRATION

PROSPERO CRD42023430716; https://tinyurl.com/yc49vzyy.

Rethinking Osteoarthritis Management: Synergistic Effects of Chronoexercise, Circadian Rhythm, and Chondroprotective Agents

Osteoarthritis (OA) is a chronic and debilitating joint disease characterized by progressive cartilage degeneration for which no definitive cure exists. Conventional management approaches often rely on fragmented and poorly coordinated pharmacological and non-pharmacological interventions that are inconsistently applied throughout the disease course. Persistent controversies regarding the clinical efficacy of chondroprotective agents, frequently highlighted by pharmacovigilance agencies, underscore the need for a structured evidence-based approach. Emerging evidence suggests that synchronizing pharmacotherapy and exercise regimens with circadian biology may optimize therapeutic outcomes by addressing early pathological processes, including low-grade inflammation, oxidative stress, and matrix degradation. Recognizing the influence of the chondrocyte clock on these processes, this study proposes a 'prototype' for a novel framework that leverages the circadian rhythm-aligned administration of traditional chondroprotective agents along with tailored, accessible exercise protocols to mitigate cartilage breakdown and support joint function. In addition, this model-based framework emphasizes the interdependence between cartilage chronobiology and time-of-day-dependent responses to exercise, where strategically timed joint activity enhances nutrient and waste exchange, mitigates mitochondrial dysfunction, supports cellular metabolism, and promotes tissue maintenance, whereas nighttime rest promotes cartilage rehydration and repair. This time-sensitive, comprehensive approach aims to slow OA progression, reduce structural damage, and delay invasive procedures, particularly in weight-bearing joints such as the knee and hip. However, significant challenges remain, including inter-individual variability in circadian rhythms, a lack of reliable biomarkers for pharmacotherapeutic monitoring, and limited clinical evidence supporting chronoexercise protocols. Future large-scale, longitudinal trials are critical to evaluate the efficacy and scalability of this rational integrative strategy, paving the way for a new era in OA management.

Rehabilitation Applications Based on Behavioral Therapy for People With Knee Osteoarthritis: Systematic Review

BACKGROUND

The development of digital applications based on behavioral therapies to support patients with knee osteoarthritis (KOA) has attracted increasing attention in the field of rehabilitation. This paper presents a systematic review of research on digital applications based on behavioral therapies for people with KOA.

OBJECTIVE

This review aims to describe the characteristics of relevant digital applications, with a special focus on the current state of behavioral therapies, digital interaction technologies, and user participation in design. The secondary aim is to summarize intervention outcomes and user evaluations of digital applications.

METHODS

A systematic literature search was conducted using the keywords "Knee Osteoarthritis," "Behavior Therapy," and "Digitization" in the following databases (from January 2013 to July 2023): Web of Science, Embase, Science Direct, Ovid, and PubMed. The Mixed Methods Assessment Tool (MMAT) was used to assess the quality of evidence. Two researchers independently screened and extracted the data.

RESULTS

A total of 36 studies met the inclusion criteria and were further analyzed. Behavioral change techniques (BCTs) and cognitive behavioral therapy (CBT) were frequently combined when developing digital applications. The most prevalent areas were goals and planning (n=31) and repetition and substitution (n=27), which were frequently used to develop physical activity (PA) goals and adherence. The most prevalent combination strategy was app/website plus SMS text message/telephone/email (n=12), which has tremendous potential. This area of application design offers notable advantages, primarily manifesting in pain mitigation (n=24), reduction of physical dysfunction (n=21), and augmentation of PA levels (n=12). Additionally, when formulating design strategies, it is imperative to consider the perspectives of stakeholders, especially in response to the identified shortcomings in application design elucidated within the study.

CONCLUSIONS

The results demonstrate that "goals and planning" and "repetition and substitution" are frequently used to develop PA goals and PA behavior adherence. The most prevalent combination strategy was app/website plus SMS text message/telephone/email, which has tremendous potential. Moreover, incorporating several stakeholders in the design and development stages might enhance user experience, considering the distinct variations in their requirements. To improve the efficacy and availability of digital applications, we have several proposals. First, comprehensive care for patients should be ensured by integrating multiple behavioral therapies that encompass various aspects of the rehabilitation process, such as rehabilitation exercises and status monitoring. Second, therapists could benefit from more precise recommendations by incorporating additional intelligent algorithms to analyze patient data. Third, the implementation scope should be expanded from the home environment to a broader social community rehabilitation setting.

Total Knee Arthroplasty Versus Education and Exercise for Knee Osteoarthritis: A Propensity-Matched Analysis

OBJECTIVE

We estimate the treatment effect of total knee arthroplasty (TKA) versus an education and exercise (Edu+Ex) program on pain, function, and quality of life outcomes 3 and 12 months after treatment initiation for knee osteoarthritis (OA).

METHODS

Patients with knee OA who had undergone TKA were matched on a 1:1 ratio with participants in an Edu+Ex program based on a propensity score fitted to a range of pretreatment covariates. After matching, between-group differences in improvement (the treatment effect) in Knee Injury and Osteoarthritis Outcome Score 12-item version (0, worst to 100, best) pain, function, and quality of life from baseline to 3 and 12 months were estimated using linear mixed models, adjusting for unbalanced covariates, if any, after matching.

RESULTS

The matched sample consisted of 522 patients (Edu+Ex, n = 261; TKA, n = 261) who were balanced on all pretreatment characteristics. At 12-month follow-up, TKA resulted in significantly greater improvements in pain (mean difference [MD] 22.8; 95% confidence interval [95% CI] 19.7-25.8), function (MD 21.2; 95% CI 17.7-24.4), and quality of life (MD 18.3; 15.0-21.6). Even so, at least one-third of patients receiving Edu+Ex had a clinically meaningful improvement in outcomes at 12 months compared with 75% of patients with TKA.

CONCLUSION

TKA is associated with greater improvements in pain, function, and quality of life, but these findings also suggest that Edu+Ex may be a viable alternative to TKA in a meaningful proportion of patients, which may reduce overall TKA need. Confirmatory trials are needed.

Cognitive behavioral therapy achieves better benefits in relieving postoperative pain and improving joint function: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cognitive behavioral therapy (CBT) is a structured, short-term psychotherapy approach that may have positive effects in terms of relieving postoperative pain. The main objective of this study was to determine the effect of CBT on pain and joint function in patients after total joint arthroplasty.

METHODS

We searched 3 electronic databases including randomized controlled studies (RCTs) using CBT as an intervention. The main results of this study were to determine pain intensity by NRS, VAS, WOMAC pain Scale, PCS, and joint function by HHS, OKS, EQ-5D, ROM. Data extraction and quality assessment of included RCTs were independently performed by the authors and date analysis was performed by RevMan V.5.4.

RESULTS

Among the 605 studies, 9 RCTS were included in this systematic review and meta-analysis. The study showed that the difference between CBT and usual care groups in PCS (≤3months), NRS, VAS (≤3months) were statistically significant (P < 0.05); the difference between CBT and usual care groups in PCS (≥12months), WOMAC Pain Scale, and VAS (≥12months) were not statistically significant (P > 0.05), indicating that CBT can improve pain in patients after arthroplasty in the early term. In addition, the difference between CBT and usual care groups in OKS (≤3months), HSS, ROM (≤3months), EQ-5D (≤3months) were not statistically significant (P > 0.05); the difference between CBT and usual care groups in EQ-5D (≥12months) were statistically significant (P < 0.05), indicating that the quality of life in patients after total joint arthroplasty were improved with the extension of follow-up time.

CONCLUSIONS

This study shows that CBT can relieve pain in patients with total joint arthroplasty in the early postoperative period and improve quality of life to some extent over time.

Exercise therapy, education, and cognitive behavioral therapy alone, or in combination with total knee arthroplasty, in patients with knee osteoarthritis: a randomized feasibility study

BACKGROUND

One in five patients experience chronic pain 1 year after total knee arthroplasty (TKA), highlighting the need for enhanced treatment strategies to improve outcomes. This feasibility trial aimed to optimize the content and delivery of a complex intervention tailored to osteoarthritis (OA) patients at risk of poor outcome after TKA and assess the feasibility of initiating a full-scale multicenter randomized controlled trial (RCT).

METHODS

Patients scheduled for TKA were included between August 2019 and June 2020 and block-randomized into one of three groups: (a) 12-week exercise therapy and education (ExE) and 10-module internet-delivered cognitive behavioral therapy (iCBT), (b) TKA followed by ExE and iCBT and (c) TKA and standard postoperative care. Outcomes were (i) recruitment and retention rate, (ii) compliance to the intervention and follow-up, (iii) crossover, and (iv) adverse events, reported by descriptive statistics.

RESULTS

Fifteen patients were included in the study. Only 1 out of 146 patients screened for eligibility was included during the first 4 months. During the next 3 months, 117 patients were not included since they lived too far from the hospital. To increase the recruitment rate, we made three amendments to the inclusion criteria; (1) at-risk screening of poor TKA outcome was removed as an eligibility criterion, (2) patients across the country could be included in the study and (3) physiotherapists without specific certification were included, receiving thorough information and support. No patients withdrew from the study or crossed over to surgery during the first year. Nine out of 10 patients completed the ExE program and six out of 10 completed the iCBT program. Fourteen out of 15 patients completed the 1-year follow-up. One minor adverse event was registered.

CONCLUSIONS

Except for recruitment and compliance to iCBT, feasibility was demonstrated. The initial recruitment process was challenging, and necessary changes were made to increase the recruitment rate. The findings informed how a definitive RCT should be undertaken to test the effectiveness of the complex intervention.

TRIAL REGISTRATION

The MultiKnee RCT, including the feasibility study, is pre-registered at ClinicalTrials.gov: NCT03771430 11/12/2018.

Treating Sleep Disorders After Total Hip and Total Knee Arthroplasty

Disorders of sleep are common after total hip and knee arthroplasty and may contribute to patient dissatisfaction and poorer outcomes in the early postoperative period. Multiple factors contribute to sleep disorders, including poorly controlled pain, opioid medication, perioperative stress, and anxiety. Both pharmacologic and nonpharmacologic methods have been used for perioperative sleep disorders, but there is no consensus on the optimal treatment.

Study on the effect of internet plus continuous nursing on functional recovery and medication compliance of patients with knee joint replacement

OBJECTIVE

To evaluate the effect of "Internet + " continuity of care on postoperative functional recovery and medication compliance in patients with knee arthroplasty.

METHODS

In this retrospective study, 100 patients who underwent knee replacement in our hospital between January 2021 and December 2022 were recruited and assigned to receive routine care (routine group) or "Internet + " continuity of care (continuity group), with 50 patients in each group. Outcome measures included knee function, sleep quality, emotional state, medication compliance, and self-care ability.

RESULTS

Patients in the continuity group showed better knee function after discharge and during follow-up versus those in the routine group (P < 0.05). Continuity care resulted in significantly lower Pittsburgh Sleep Quality Index (PSQI), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) scores versus routine care (P < 0.05). Patients in the continuity group showed higher treatment compliance, ability of daily living (ADL) scores, and nursing satisfaction than those in the routine group (P < 0.05).

CONCLUSION

The "Internet + " continuity of care is highly feasible and can effectively promote the postoperative functional recovery of knee replacement patients, improve patients' medication compliance, sleep quality, and self-care ability, mitigate negative emotions, and provide enhanced home care.

Can perioperative psychological interventions reduce chronic pain after surgery?

Chronic post-surgical pain is a relatively common adverse effect following surgery. Several prognostic factors for chronic post-surgical pain have been identified, including psychological states and traits. Psychological factors are modifiable, and perioperative psychological interventions may reduce the incidence of chronic post-surgical pain. A meta-analysis showed preliminary evidence for the benefits of such interventions for the prevention of chronic post-surgical pain. Further research must be conducted to better understand the specific type, intensity, duration and timing of interventions that are most effective. The number of studies in this area has recently increased, with additional randomised controlled trials currently being carried out, which may allow for the development of more robust conclusions in the coming years. In order to implement perioperative psychological care alongside routine surgical interventions, efficient and accessible interventions should be available. In addition, demonstration of cost-effectiveness may be a prerequisite for wider adoption of perioperative psychological interventions in regular healthcare. Offering psychological interventions selectively to patients at risk of chronic post-surgical pain could be a means to increase cost-effectiveness. Stepped-care approaches should also be considered, where the intensity of psychological support is adapted to the needs of the patient.