Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial

Abstract

Objectives: To evaluate the effectiveness of two primary care strategies for delivering evidence based care to people aged 55 or over with knee pain: enhanced pharmacy review and community physiotherapy.

Design: Pragmatic multicentre randomised clinical trial.

Setting: 15 general practices in North Staffordshire.

Participants: 325 adults aged 55 years or over (mean 68 years) consulting with knee pain; 297 (91%) reached six month follow-up.

Interventions: Enhanced pharmacy review (pharmacological management in accordance with an algorithm); community physiotherapy (advice about activity and pacing and an individualised exercise programme); control (advice leaflet reinforced by telephone call).

Main outcome measure: Change in Western Ontario and McMaster Universities osteoarthritis index (WOMAC) at 3, 6, and 12 months.

Results: Mean baseline WOMAC pain score was 9.1 (SD 3.7), and mean baseline function score was 29.9 (SD 12.8). At three months, the mean reductions in pain scores were 0.41 (SD 2.8) for control, 1.59 (3.2) for pharmacy, and 1.56 (3.4) for physiotherapy; reductions in function scores were 0.80 (8.5), 2.61 (9.8), and 4.79 (10.8). Compared with control, mean differences in change scores for physiotherapy were 1.15 (95% confidence interval 0.2 to 2.1) for pain and 3.99 (1.2 to 6.8) for function; those for pharmacy were 1.18 (0.3 to 2.1) for pain and 1.80 (-0.8 to 4.5) for function. These differences were not sustained to six or 12 months. Significantly fewer participants in the physiotherapy group reported consulting their general practitioner for knee pain in the follow-up period, and use of non-steroidal anti-inflammatory drugs was lower in the physiotherapy and pharmacy groups than in the control group.

Conclusions: Evidence based care for older adults with knee pain, delivered by primary care physiotherapists and pharmacists, resulted in short term improvements in health outcomes, reduced use of non-steroidal anti-inflammatory drugs, and high patient satisfaction. Physiotherapy seemed to produce a shift in consultation behaviour away from the traditional general practitioner led model of care.

Trial registration: UK National Research Register N0286046917; Current Controlled Trials ISRCTN55376150 [controlled-trials.com] .

Fig 1 Pharmacy algorithm. GP=general practitioner; NSAID=non-steroidal anti-inflammatory drug; SR/MR=sustained/modified release

Fig 2 Trial profile. GP=general practitioner; TKR=total knee replacement

Fig 3 Mean Western Ontario and McMaster Universities osteoarthritis index (WOMAC) scores at recruitment and at 3, 6, and 12 months' follow-up. Top: WOMAC pain scores. Bottom: WOMAC function scores