Self-Management and Rehabilitation in Osteoarthritis: Is There a Place for Internet-Based Interventions?

Abstract

The electronic databases Cochrane, MEDLINE, and SCOPUS were searched to collect evidence on the impact of community-based Internet interventions for adult patients with osteoarthritis (OA) on health outcomes. Five studies met our review criteria. We found that Internet-based OA self-management interventions modestly but significantly improved four of six health status measures compared with usual care and have been met with high acceptance and high user satisfaction. Preventive physiotherapy exercise delivered via videoconferencing for patients with OA-related knee pain significantly improved health measures including pain, stiffness, and physical function compared with the initial health status. Postoperative rehabilitation performed by a physical therapist via videoconferencing and “in-person” resulted in similar health measure improvements. The review findings show that the Internet may be successfully used as a medium for providing community-based self-management and rehabilitation interventions in OA.

Introduction

Osteoarthritis (OA) is the most common musculoskeletal disease in Australia and a leading cause of pain and disability. It affects around 3 million people in Australia.¹ The corresponding prevalence statistics for the Untied States report about 27 million adults diagnosed with OA in 2005.² Its incidence is age related, and at the age of 65 years and over it affects about 49% of people.¹

The approach to OA management is multidisciplinary. Treatments include surgical and pharmacological interventions and nonpharmacological interventions such as exercise and physical activity, psychological counseling, and education/self-management support.

The most common surgical interventions for OA are total hip and knee replacements, which have been shown to be successful at reducing pain and improving function.³ About 41,000 OA-related total hip and knee replacements were performed in Australia in 2005.⁴ In the United States, there were about half a million total knee replacements and a quarter of a million total hip replacements performed in 2004, primarily for arthritis.⁵

The need for total joint replacement surgery and surgery-related rehabilitation is likely to increase because of a combination of increasing risk factors (age, obesity, injury), increasing expectations for improved quality of life, and improved surgical and anesthetic techniques making surgery possible for more people.¹

Previous studies have shown that providing information about the disease is a vital component of self-management. Lack of knowledge may lead to depression, anxiety, and poor coping skills, which may affect the patient's quality of life, while health education is an effective intervention and can reduce pain and disability.⁶

OA sufferers require exercise, physical activity, and self-management support to manage their disease and control pain.⁷ When their knee or hip joints reach the stage of surgical intervention, OA patients require extensive postoperative rehabilitation after the hospital discharge.⁸

Internet-based solutions can play an important role in all areas of OA management and rehabilitation. To date there has been no review focused on the role of Internet-based interventions in OA management and rehabilitation.

The aim of this article is to provide a short review of published literature investigating the effectiveness of community and home-based Internet interventions to self-manage, improve OA-related health outcomes, and provide rehabilitation in OA.

Materials and Methods

The Cochrane, MEDLINE, and SCOPUS databases were searched using a combination of MESH terms and key words that described the mode of communication and the disease (“Internet” OR “telemedicine” OR “telehealth” OR “e-health” OR “online” OR “Web-based”) AND (“osteoarthritis”). These databases were searched separately and results were combined. Searches were performed on November 11, 2011. Additionally, reference lists of identified publications were screened for relevant articles.

The review was restricted to peer-reviewed journal articles published in English and to studies that investigated telehealth interventions delivered directly to patients. Studies investigating interventions delivered between healthcare providers were excluded. Populations of interest included adult patients suffering from diagnosed OA or diagnosed OA-related joint pain or those who underwent OA-related joint replacement surgery. Outcomes of interest included any health-related benefit. With the exception of case studies, studies of all designs were included. However, when multiple publications resulted from one study, feasibility and preliminary studies were excluded, and only final results of randomized control trials were included if available.

Results

There were 61 titles and abstracts screened, and 9 articles were retrieved in full. Five studies that investigated online interventions for OA included health outcomes of interest and were eligible for the final inclusion (Table 1).^9

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Table 1.

Characteristics and Results of Studies on Telemanagement of Osteoarthritis

STUDY	STUDY CHARACTERISTICS	INTERVENTIONS, OUTCOMES, OUTCOME MEASURES	RESULTS
Effect of online patient self-management, education, and activation on OA-related health outcomes and healthcare satisfaction
Sciamanna et al.¹⁰ (2005), United States	n=121 Aim: to evaluate the effect of online educational program on patient OA guideline adherence and satisfaction with quality of their OA care Population: participants with knee joint symptoms for at least the past 3 months, who have been told by a doctor that they have OA Quality: RCT; method of randomization unclear Limitation: sample selection, recruited by mail from publicly available list of individuals with self-reported OA (16% participation rate) Analysis: chi-squared tests for categorical variables and ANOVA for continuous	Intervention: The intervention group was directed to the Web site to read personalized, interactive guidelines on managing arthritis. The control group did not read guidelines, although it could do it after the assessment. Both groups answered patient satisfaction with OA care questionnaire. The intervention and all measurements were done during a single online session that lasted approximately 30 min. Outcomes: satisfaction with the Web site, satisfaction with OA care Outcome measures: questionnaire for measuring satisfaction with computerized healthcare applications (Web site), modified Patient Satisfaction Questionnaire 18 (OA care)	On average, participants received 8.7 recommendations to change their OA care, most commonly about taking tramadol and receiving a steroid knee injection. The Web site was well accepted, and most participants rated it as excellent or very good and easy to use. Most subjects believed that the Web site would help them get better care from their doctor (77.7%), and most would recommend it to others (94.3%). Satisfaction with OA care did not differ between the groups, and the feedback appeared to have no detrimental effects on satisfaction with OA care. Conclusion: Overall, the Web site is well accepted and has no negative effect on patients' satisfaction with their OA care.
Lorig et al.⁹ (2008), United States	n=855 Aim: to evaluate the efficacy of the Internet-based ASMP Population: patients with OA, RA, or FM and Internet and e-mail access, unable or unwilling to attend small-group ASMPs. Patients often had more than one diagnosis; 64% of them had OA. Quality: RCT; patients recruited online; method of randomization unclear; flow of patients throughout the study presented; 71% and 82% in intervention and control groups, respectively, completed 1 year. Level II evidence Limitations: not blinded; limited to computer literate with access to the Internet Analysis: ITT, ANCOVAs for results at 6 months and 12 months	Intervention: Internet-based ASMP (n=433) Control: usual care (n=422), which did not involve face-to-face ASMP Outcome: health status, health behavior, self-efficacy, and healthcare utilization Outcome measures: 6 health status variables (pain, fatigue, activity limitation, health distress, disability, self-reported global health), 4 health behaviors variables (aerobic exercise, stretching and strengthening exercise, practice of stress management, communication with physicians), 5 utilization variables (physician visits, emergency room visits, chiropractic visits, physical therapist visits, nights in hospital), and self-efficacy	At 1 year, the intervention group significantly improved in 4 of 6 health status measures and in self-efficacy (health distress, activity limitation, self-reported global health, pain) compared with control. Changes were modest, with average effect size of 0.3. The proportion of participants with improved ≥3 health indicators was higher in the treatment group compared with the usual care group (44% versus 30%) (p<0.001). Improvements were significant for patients with OA but not for those with RA or FM. If patients with OA were analyzed separately, the results would be more pronounced. There were no significant differences in health behaviors or healthcare utilization between groups. Conclusion: The Internet-based ASMP proved effective in improving health status measures at 1 year and is a viable alternative to the small-group ASMP.
Effect of physiotherapy delivered by videoconferencing OA-related health outcomes
Wong et al.¹¹ (2005), Hong Kong	n=22 Aim: to evaluate the feasibility and efficacy of an exercise program for elderly people with knee pain conducted via videoconferencing Population: community-dwelling subjects ≥60 years old with knee pain Quality: flow of patients throughout the study presented; all patients completed Limitations: no control, assessment not blinded	Intervention: physiotherapy delivered by videoconferencing at two community centers (multisite connection). Twelve-week exercise program, once a week, that included strengthening and balance training; education in self-management and home exercises Outcomes: primary, change in WOMAC from baseline to 12 weeks; eight secondary outcomes (including muscle strength, balance, quality of life, user satisfaction) Outcome measures: WOMAC, Berg's Balance Scale, SF-36, and subjects' degree of acceptance of videoconferencing	At the end of the study, there were significant reductions in the scores of WOMAC domains of pain, stiffness, and physical function (44%, 37%, and 38%, respectively) compared with baseline. In secondary outcomes, muscle strength increased by almost 50%, functional performance increased by 21%, and 2 of the 8 domains of SF-36 (physical functioning and bodily pain) improved. User satisfaction with videoconferencing was high in over 80% of subjects. Most of them felt that the system was user-friendly and convenient. Conclusion: Videoconferencing appears to be a useful method of delivering a resistance-training program for community-dwelling elderly persons with knee pain.
Comparison of rehabilitation for a total knee replacements delivered by videoconferencing and face to face
Russell et al.¹² (2011), Australia	n=68 Aim: to compare the efficacy of Internet-based telerehabilitation with conventional outpatient physical therapy Population: patients with a total knee replacement Quality: RCT; noninferiority; prospective; randomization concealed; numbers computer-generated; assessment blinded. Flow of patients throughout the study presented; 1 patient in each group lost to follow-up. Level I/II evidence Analysis: Noninferiority was assessed through the comparison of group differences with a noninferiority margin and with linear mixed model statistics.	Intervention: telerehabilitation performed via real-time interaction videoconferencing across a low-bandwidth (18 kilobits/s) system. Therapists and patients were situated in separate hospital rooms. Control: rehabilitation performed in person in the outpatient clinic of the hospital. Both groups had 6 weeks of therapy, daily 45-min sessions. Outcomes: Primary, change in WOMAC after 6 weeks; secondary, Patient-Specific Functional Scale, the timed up-and-go test, pain intensity, knee flexion and extension, quadriceps muscle strength, limb girth measurements, and an assessment of gait Outcome measures: WOMAC, 24 items (Likert scale), covering three domains: pain, stiffness, and physical function	All participants in both groups had significant clinical improvement after 6 weeks (p<0.01 for all). Participants in both groups achieved comparable outcomes on WOMAC score and on most secondary outcomes (flexion and extension range of motion, muscle strength, limb girth, pain, timed up-and-go test, quality of life, clinical gait). The telerehabilitation group achieved better outcomes for the Patient-Specific Functional Scale and the stiffness subscale of the WOMAC score (p<0.05). The telerehabilitation intervention was well received by participants, who reported a high level of satisfaction with the technology. Conclusion: The outcomes achieved via telerehabilitation at 6 weeks following total knee arthroplasty were comparable with those after conventional rehabilitation.
Tousignant et al.¹³ (2011), Canada	n=48 Aim: to compare the effectiveness of home telerehabilitation with conventional in-person rehabilitation Population: patients with a total knee arthroplasty Quality: RCT; randomization concealed; numbers computer- generated; assessment blinded. Flow of patients throughout the study presented, 7 patients (15%, 4%, and 3%) lost to follow-up. Level II evidence Analysis: Wilcoxon test for two related samples; Mann–Whitney test for two independent samples. Assessed at baseline, at the end of therapy, and after 2 months of follow-up	Intervention: telerehabilitation performed at home, via high-speed Internet. Internet access provided, telerehabilitation equipment installed, and quality of the connection checked by study team. The equipment was collected at the end of the telerehabilitation period (2 months). Control group: usual home care services (home visits by physiotherapists) Outcomes: change in disability (range of motion, balance, lower body strength) and function (knee function, locomotor performance, functional autonomy) Outcome measures: established test scores, including WOMAC	Clinical outcomes improved significantly for all subjects in both groups between end points. At the end of the treatment, home telerehabilitation is as effective as usual care in reducing disability (range of motion, balance, muscle strength) and improving function (knee function, walking, autonomy). At 4 months improvement in some variables was smaller in the telerehabilitation group than in controls. This tendency was also noted for the general health status. Conclusion: Home telerehabilitation is as effective as usual care in the short term and has the potential to increase access to therapy in areas with high-speed Internet services.

ANCOVA, analysis of covariance; ANOVA, analysis of variance; ASMP, Arthritis Self-Management Program; FM, fibromyalgia; ITT, intention-to-treat; OA, osteoarthritis; RA, rheumatoid arthritis; RCT, randomized controlled trial; SF-36, 36-item Short Form; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Of the five included studies, three investigated improvements in health outcomes in patients with diagnosed OA or OA-related joint pain.^9
–11 The interventions included online self-management,⁹ an online education program about OA,¹⁰ and the conduct of physiotherapeutic exercise by videoconferencing.¹¹ Outcomes included changes in health and functional status^9,11 and satisfaction with OA care.¹⁰ The studies were controlled with a “usual care” group,⁹ “no intervention” group,¹⁰ and internal before–after comparison.¹¹

The next two of the included studies investigated postoperative rehabilitation for patients with total knee or hip replacement carried out using videoconferencing equipment.^12,13 In both studies rehabilitation in control groups was performed “in-person.” Outcomes included differences in functional status and disability between patients rehabilitated by video and “in-person.”

Although all of the included studies used the Internet as a medium of providing interventions, they fell into two distinct categories. The first category, which used patient self-management and education, involved online interaction between participants and an interactive Web page,^9,10 with any support from the intervention moderators provided in an asynchronous manner.⁹ The second category, which used videoconferencing for rehabilitation and therapy, involved a “real-time” interaction between participants and therapists.^11
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One study was performed in Australia,¹² one in Canada,¹³ one in Hong Kong,¹¹ and two in the United States.^9,10

Four of the studies^9,10,12,13 were randomized controlled trials, and one was a case series with pre–post comparison.¹¹ Studies on postoperative rehabilitation were well designed, randomization was performed with a random number generator, allocation was concealed, and assessment was blinded. The combined results presented by these two studies constitute Level I evidence.¹⁴

The findings of the included studies were as follows:

Participation in the Internet-based self-management program improves health status of patients with OA compared with usual care.

The study of Lorig et al.⁹ showed that the Internet-based Arthritis Self-Management Program modestly but significantly improved four of six health status measures in patients with OA compared with usual care (Level II evidence).

Personalized, interactive guidelines on managing arthritis has high acceptance and user satisfaction.

The study of Sciamanna et al.¹⁰ showed that people with knee pain were satisfied with the personalized, interactive guidelines on managing arthritis available on the Internet and reported that receiving these guidelines had no negative effect on patients' satisfaction with their OA care. Patients felt that a better understanding of their disease will help them to communicate better with their doctor and improve their treatment (Level II evidence). However, doctors' attitudes to patients quoting the Internet to improve their treatment of OA and its effect on working alliance were not investigated in this study.

Physiotherapeutic exercise delivered by videoconferencing improves health and functional status of patients with OA-related knee pain.

The study of Wong et al.¹¹ showed that 3 months of physiotherapy exercise delivered by videoconferencing for patients with OA-related knee pain significantly improved health measures, including pain, stiffness, and physical function, compared with the initial health status (Level IV evidence).

In patients with total OA-related knee replacement, postsurgical rehabilitation performed via videoconferencing is equivalent to rehabilitation performed “in-person.”

Two high-quality randomized controlled trials performed in Australia and Canada demonstrated that postsurgical rehabilitation in patients with total OA-related knee replacement resulted in similar health measure improvements when performed by a physical therapist “in-person” and via videoconferencing.^12,13

System security in online self-management studies was assured via a secured Web site,^9,10 with 128-bit encryption used to maintain security of the participants' data, for both data in transit and data stored on the server's hard drive. In the studies using videoconferencing, security of the data in transit and storage was not specified. However, in the study of Russell et al.¹² both the transfer and storage occurred behind the hospital firewall, and the TANDBERG dedicated videoconferencing equipment used in the studies of Wong et al.¹¹ and Tousignant et al.¹³ studies supports 128-bit encryption protocols.¹⁵

There were no minimum system requirements specified for the Web-based education and self-management intervention studies.^9,10 The studies using videoconferencing for patient rehabilitation used two differing types of systems. In the trial of Russell et al.,¹² the videoconferencing system was specifically engineered for the study. It required the use of a specially developed motion-analysis tool by the therapist that was able to capture still images and video sequences from the videoconference and play them back in slow motion or frame by frame. However, the computer and connection requirements were low: a conventional personal computer, low-bandwidth Internet Protocol (18 kiolbits/s) via standard modems, and low-cost Web cameras to facilitate a real-time video and audio connection were used.^12,16 The studies of Tousignant et al.¹³ and Wong et al.¹¹ used dedicated videoconferencing systems (TANDBERG models 550 and 880, respectively) connected with high-speed dedicated broadband lines, with data transmission speed of 512 kilobits/s¹³ and 10 megabits/s.¹¹

Discussion

Self-Management and Education

There is compelling evidence that educational and self-management programs performed “in-person” provide improvements in health-related behaviors, health status, and reduce health care utilization for patients with chronic diseases.^18,19 For patients with OA, self-management education reduces disability, provides pain relief beyond that achieved by medication, and reduces doctor visits and hospitalization.^6,20
–22 The benefits are significant enough for the American College of Rheumatology to call for self-management education to become a standard of care for OA.²³

In agreement with the above studies, the study of Lorig et al.⁹ showed that the Internet-based Arthritis Self-Management Program effectively improves the health status of patients with OA. The distinct advantage of the Internet-based program would be convenience for those who are unwilling or unable to attend the Arthritis Self-Management Program in person. A possible disadvantage may be decreased compliance and motivation to attend, which is often observed in Internet-based trials.²⁴ However, as there was no direct comparison between Internet-based and “in-person” programs, it is difficult to assess their relative effectiveness.

The study of Sciamanna et al.¹⁰ showed that using Internet-based education for people managing arthritis increased their understanding of the disease, potentially leading to better communication with their doctor and improved treatment (Level II evidence). However, doctors' attitudes to patients quoting the Internet to improve their treatment of OA and its effect on working alliance were not investigated in this study.

Exercise and Physical Activity

There is strong evidence that engaging in regular moderate physical activity can reduce the risk of arthritis-related disability. A systematic review showed that therapeutic exercise reduced pain and improved physical function for people with OA of the knee.⁷ Meta-analysis of 32 randomized controlled trials and 3,800 patients showed reduction in pain of about 40%.²⁵

The importance of the study of Wong et al.¹¹ comes from addressing several issues important in delivering telehealthcare. In this study improvements in health and functional status of patients with OA-related knee pain followed physiotherapeutic exercise delivered by videoconferencing.¹¹ The videoconferencing equipment, including a large TV screen, was located in two community centers. One therapist, located in a hospital, was able to conduct exercise sessions in two distant locations at once. The affordability of videoconferencing equipment and the ability to operate it by individual patients were addressed by exercising in a community center. Specialized healthcare workers, who may be underrepresented in rural and remote communities, may now be in “several places at once” through the application of videoconferencing technology. Patient compliance issues may be modified by the social nature of communal exercise, with the latter also reducing social isolation and providing social support.²⁶

Postsurgical Rehabilitation

Following inpatient acute postoperative care, postoperative rehabilitation is a necessary adjunct to surgery and an essential component in returning patients who have had a total knee arthroplasty to optimal functional levels. It is a common practice in the United States, the United Kingdom, and Australia to refer these patients for ongoing outpatient or community-based rehabilitation.²⁷

Two high-quality trials demonstrated the equivalence of postsurgical rehabilitation performed “in-person” and via videoconferencing.^12,13 In the Australian trial,¹² the videoconferencing group was undergoing telerehabilitation in a hospital room distant from the therapist. Although the study conclusively demonstrated noninferiority of the delivery method, no assessment was made as to the inconvenience of the transport to the hospital or a possibility of altered patient compliance when exercising at home. This was, however, addressed in the Canadian trial¹³ where the videoconferencing was carried out in the patient's home. The equipment, including a high-speed Internet connection, large TV screens, remote-controlled cameras, and associated user-friendly software, was installed at the patient's home and then collected at the end of rehabilitation. Patient satisfaction with the provided services was very similar in the videoconferencing and “in-person” groups.²⁸ Additionally, satisfaction of healthcare professionals was also generally high.

The three studies of Wong et al.,¹¹ Russell et al.,¹² and Tousignant et al.¹³ have practical implications for health services in remote areas and in assisted living facilities. Taking into account the high spending on OA, provision of telemanagement in the form of tele-exercise and telerehabilitation, be it at a private home, at a community center, or at an assisted living facility, may be beneficial for patients and healthcare providers. Attending a community center may be a less difficult experience than attending a hospital rehabilitation center, with potentially a less clinical atmosphere, better transport access, and shorter traveling distance.

System Security

The concerns surrounding the of security of patient data are one of the main problems inhibiting the introduction of e-health services in Australia.²⁹ However, the security concerns are not unsurmountable, as indicated by successful video delivery of health services by government or large insurance organizations.^30,31 At present, desktop videoconferencing programs that offer secure video rooms are available at a low cost ($35/month plus 6¢/min).³² The security is provided by using 128-bit AES encryption for data in transit and unique URLs for each of the online meetings to ensure that only authorized people are able to access the Web conferences. Finally, an alternative way of ensuring patient data security is to avoid sending sensitive information over the videoconferencing network.

System Requirements

The included studies used computer systems with variable requirements. Those that did not require videoconferencing did not have minimum requirements. Even those that required videoconferencing used systems ranging from personal computers with low-cost Web cameras connected via low-speed broadband to dedicated videoconferencing equipment connected via high-speed broadband. These studies show that when the Internet connection is available, the use of videoconferencing for rehabilitation is effective with a variety of equipment. Mobile dedicated videoconferencing units may be temporarily installed for quality communication, like in the study of Tousignant et al.¹³ However, with advances in technology, it becomes possible to obtain high-quality desktop videoconferencing using personal computers and Web cameras.³³

Limitations of the Review

The main limitation of this review is the small number of included studies, which is as a result of strict limits on the inclusion criteria. Additionally, in some studies, with the process of recruitment via the Internet, the populations were self-selected and restricted to those who were computer literate.^9,10 This potentially restricts the generalizability of results. Also, this review did not examine other important outcomes such as cost, training of telehealth professionals, and technology requirements, which would need to be considered in a future review.

Conclusions

Internet-based technologies increasingly serve as a platform for delivering health services, particularly in the information and education area, and in the provision of some medical services. This review indicates that the Internet may be successfully used as a medium for providing community-based self-management and rehabilitation interventions in OA, resulting in improvements in (1) health status indicators, (2) access to care, and (3) communication between OA patients and health professionals. The findings also suggest that patient satisfaction with Internet-based OA interventions is high. Overall, this review indicates that there is a need for healthcare providers managing OA patients to consider how to best utilize Internet-based technologies in order to minimize the disabling effects of joint degeneration in the OA population.

Footnotes

Acknowledgments

This review was undertaken on behalf of and funded by the E-Health Research Unit, UQ Node, CMVH.

Author Contributions

E.P. performed the searches, reviewed the literature, led the writing of the article, and contributed to its conceptualization. C.C. contributed to the conceptualization of the article and commented on drafts. P.N contributed to drafting of the article. S.P. contributed to the conceptualization of the article and commented on drafts.

Disclosure Statement

No competing financial interests exist.

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