Can Patient Behavior Change? New Rehab Study Says “Yes”

Can patient’s commitment to a physical therapy protocol be improved? A new study offers hope that, with a technique called Cognitive Muscular Therapy, patient adherence to important and necessary physical therapy can indeed improve.

The details of this approach and the resulting study, “A new integrated behavioural intervention for knee osteoarthritis: development and pilot study,” appears in the June 8, 2021 edition of BMC Musculoskeletal Disorders.

One of the most challenging problems in orthopedics is assuring patient compliance and adherence to important physical therapy protocols. As healthcare providers know well, adherence to physical therapy programs is key to clinical efficacy of any procedure.

In this study, a United Kingdom based team tested a framework for affecting patient behavior which connects pain science and biomechanical concepts to knee muscle activity.

For the study, researchers recruited 21 patients with knee osteoarthritis (OA) who received at least two face-to-face clinical sessions. Of these 21 patients, 11 had five or six sessions of a fully formed version of the intervention. Patients were included if they satisfied the American College of Rheumatology criteria and had experienced knee OA pain for at least six months.

All patients were competent users of the internet. In addition to the patients with knee OA, researchers recruited 45 healthy individuals in order to create a database of muscle signals during everyday activities, such as walking and descending stairs.

In collaboration with physical therapists and patients, the team focused on, “…specific changeable determinants of behavior that had the potential to exacerbate pain in people with knee OA. This process consisted of a review of biomechanical concepts relating to muscle overactivity, a review of psychosocial theory related to chronic musculoskeletal pain and an exploration of patient beliefs.”

After sharing the results of a literature review with four patients with knee OA as well as four physical therapists, the researchers then probed each user’s perceptions of pain theory and sought to understand beliefs and behaviors related to knee OA pain. Underlying their iterative development process was the framework that encompassed central sensitization, motor response to pain, and the theory that increased knee muscle overactivity could result from postural compensation.

The result was a five-component protocol:

1. making sense of pain,
2. general relaxation,
3. postural deconstruction,
4. responding differently to pain and
5. functional muscle retraining.

Patients watched videos on pain and biomechanical theory and also had EMG biofeedback to facilitate visualization of muscle patterns.

As a result, according to the study authors, “Patients described the intervention as enabling them to ‘create a new normal’ and to be ‘in control of their own treatment.’ Furthermore, large reductions in pain were observed from 11 patients who received a prototype version of the intervention.”

Primary author Dr. Stephen Preece, director of the Centre for Health Sciences Research, told OTW, “The most challenging aspects were developing clinical techniques to improve posture by teaching people to reduce muscle overaction, i.e., through awareness of muscle tension, rather than through tensing muscles.”

“We used EMG biofeedback, which involves placing small electrodes on the skin. These signals are then visualized using customized software. This provides patients with feedback on whether their knee muscles are on in standing, when then should be off, and whether the muscles are overactive during movements, such as walking.”

Upending PT Traditions

“There is a well-established paradigm within the physiotherapy profession that rehabilitation should incorporate muscle strengthening/conditioning. Our approach of reducing muscle overactivity is counter to this approach and may therefore initiate a change in the way this condition is treated.”

“We have a future trial planned for which we will recruit 90 patients who have tried standard muscle strengthening (The Escape-pain programme) but not experienced any benefit. They will be randomised into two groups, control (who continue with standard general practice care) and treatment who get our new Cognitive Muscular Therapy intervention. Before we start the main trial, we are going to develop a new training course for physiotherapists. This course will be used to train the physios who deliver the Cognitive Muscular Therapy intervention in the trial.”

For details on their work, please visit the University of Salford-Manchester.