Telephone coaching to enhance a physiotherapist-prescribed home-based physical activity program for knee osteoarthritis: A randomised clinical trial

Abstract

Purpose: Physical activity and exercise are recommended by osteoarthritis (OA) clinical and general health guidelines. Amongst people with OA, physical activity levels are low, there is a global under-utilisation of exercise, and benefits are generally not sustained because adherence is typically suboptimal and declines over time. Health coaching, often delivered by telephone, is increasingly used for chronic disease self-management. It aims to improve patient adherence to treatment recommendations and facilitate health behavior change. Aim: To investigate whether telephone coaching improves effectiveness of a physiotherapist-prescribed home-based physical activity and exercise program for knee OA. Methods: Design: Randomised controlled trial. Participants: 168 inactive adults aged ≥50 with knee pain and clinically-diagnosed knee OA were recruited from the community. Eighty-four participants were randomly allocated to Coaching (27M, 57F; age 61.1±6.9 years; mass 89.0±19.5 kgs) and 84 to Control (35M, 49F; 63.4±7.8 years, 87.5±22.0 kgs). Intervention: All participants received 5x30 minute face-to-face consultations with a physiotherapist over 6 months for education, prescription of a home exercise program (4–6 lower limb strengthening exercises, 3 times per week) and physical activity advice. Coaching participants also received 6–12 telephone coaching sessions by clinicians trained in health coaching for physical activity and exercise behaviour change support. Outcomes: Measures were assessed at baseline, 6, 12 and 18 months. Primary outcomes were average knee pain over the past week assessed using an 11-point numeric rating scale (NRS; 0-10) and physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; 0-68) at 6 months. Secondary outcomes included these measures at 12 and 18 months, NRS walking pain, WOMAC pain score, quality-of-life (AQoL-6D) and physical activity assessed by the Physical Activity Scale for the Elderly (PASE), Active Australia Survey, 7 day activity monitor and perceived change (7-point Likert scale). Exercise adherence was assessed every 3 months. Statistical analysis: The study was powered to detect a minimum clinically important difference (MCID) in NRS pain of 1.8 and in WOMAC function of 6 non-normalized units with standard deviations of 2.2 and 11.6 respectively. Analyses were by intention-to-treat with multiple imputation for missing data. The mean (95% confidence interval) difference in change (baseline minus follow-up) between groups was estimated using a linear mixed model including random effects for physiotherapists and telephone coaches and baseline outcome score as a covariate. Results: 142 (85%), 136 (81%) and 128 (76%) participants completed 6, 12 and 18 month measurements, respectively, with completion rates comparable between groups. Most participants attended all 5 physiotherapy sessions with the mean (SD) being 4.4 (1.2) for coaching and 4.3 (1.4) for control (p>0.05). The mean (SD) number of telephone coaching sessions was 5.4 (2.0). Change in NRS pain (mean difference 0.4 units; 95%CI −0.4 to 1.3) or WOMAC function (1.8; 95%CI −1.9 to 5.5) did not differ between groups at 6 months, with both showing clinically relevant improvements. Most secondary outcomes related to physical activity and exercise behaviour favoured coaching at 6 months (PASE, mean difference −28.3; 95%CI −54.9 to −1.8; Home exercise completion, mean difference 14%, 95%CI 4 to 24; Self-rated exercise adherence on NRS, mean difference 1.7, 95%CI 0.8 to 2.6; Global increase in physical activity, Odds ratio 2.1; 95%CI 1.0 to 4.4) but generally not at 12 or 18 months. There were no between-group differences in most other secondary outcomes. Adverse events were mild (mostly transient increased knee pain), similar between groups and reported by approximately one-third of participants during the intervention, but were infrequent during follow-up. Co-intervention use was also similar across groups. Conclusions: Addition of telephone coaching did not augment pain and function benefits of a physiotherapist-prescribed physical activity and exercise program, although physical activity levels and adherence to home exercise were generally increased in the short-term. Our study provides novel information about the effects of telephone coaching and extends the limited research in telephone coaching for OA.View Large Image Figure ViewerDownload Hi-res image Download (PPT)