Telehealth-delivered group-based education and exercise-therapy for knee osteoarthritis: A randomised clinical trial interrupted by the COVID-19 pandemic

Abstract

Introduction: Guidelines recommend education and exercise-therapy as first-line treatments for knee osteoarthritis. The Good Life with osteoArthritis from Denmark (GLA:D®) program provides physiotherapist-led group-based education and exercise-therapy at >500 sites in Australia. It is associated with clinically meaningful improvements in pain and quality of life (QoL). However, inability to attend in-person sessions due to geography, transportation requirements, or other commitments limits access. Telehealth (videoconferencing) may improve the equity of access to GLA:D®. One-on-one telehealth services for knee musculoskeletal pain conditions including osteoarthritis are reported to be non-inferior to in-person care, but there is a lack of research evaluating group-based telehealth services. This randomised clinical trial (RCT) aimed to determine if GLAD® delivered via telehealth was non-inferior to in-person delivery for knee-related burden at 3- (primary timepoint) and 12-months. Methods: This pre-registered (ACTRN12619000235101) two-arm (telehealth, in-person), non-inferiority RCT commenced in April 2019. Knee osteoarthritis clinical diagnosis was based on NICE guidelines. Difference between groups for change in knee-related burden (primary outcome) was evaluated by averaging four Knee injury and Osteoarthritis Outcome Score subscales (KOOS4: pain, symptoms, function in daily living, QoL), measured at 3- and 12-months follow-up. The KOOS-QoL subscale was evaluated to relate findings to GLA:D® Australia registry data. Planned sample size (n=88) was powered at 90% to detect a minimal important difference between groups of 10 (SD=16) points for KOOS4. Results: Forty-four participants enrolled at baseline (22 per group), with no difference between telehealth and in-person groups for sex distribution (female/male: 14/8 v 12:10), age (years: 62±8 v 64±10), or body mass index (kg/m2: 29.8±5.3 v 31.1±5.2). Recruitment ceased in March 2020 due to COVID-19 restrictions on in-person healthcare. Forty-three (98%) and 40 (91%) participants provided 3- and 12-month follow-up data respectively. Primary outcome: There were no between group differences for changes in KOOS4, with outcomes favouring telehealth at 3-months (mean difference, 95%CI = 6, -2 to 15), and neither group at 12-months (0, -9 to 9). The lower limit of the 95%CI was within the non-inferiority margin (i.e. -10 points) at both time points. Secondary outcome: Changes in KOOS-QoL at 3- and 12-months for telehealth (18 and 14 points) and in-person (10 and 15) were comparable to published GLA:D® registry data (13 and 16). Discussion: This RCT was underpowered due to COVID-19 pandemic restrictions causing early cessation, but findings do indicate telehealth-delivered GLA:D® is unlikely to be inferior to in-person delivery for knee-related burden at 3- and 12-months. This finding builds on recently published qualitative findings indicating patient acceptability of telehealth-delivered GLA:D® and positive telehealth outcomes from the GLA:D® registry during the pandemic (submitted to SMA 2022: Ezzat et al). Further supporting implementation, findings are also consistent with published non-inferiority trials of one-on-one telehealth services for knee osteoarthritis and other musculoskeletal pain conditions, and KOOS-QoL outcomes in both groups were consistent with published GLA:D® registry data. Implications and application to the field•Telehealth-delivered group-based education and exercise-therapy for knee osteoarthritis appears unlikely to be inferior to in-person delivery.•Physiotherapists should be supported to implement telehealth-delivered GLA:D® in Australia. Conflict of interest: A/Profs Barton and Kemp lead the ‘not-for-profit’ implementation initiative, GLA:D® Australia, which trains Australian physiotherapists to implement guideline-recommended education and exercise-therapy.