WORKPLAN#3: NON-SURGICAL ALTERNATIVES
There is an imperative to find alternative care pathways/interventions for the 15% of people who are unlikely to benefit from TJR. While multidisciplinary osteoarthritis (OA) chronic care programs have been shown to improve pain and function, even for those awaiting TJR, they have not been tested specifically on this group and so whether they would benefit from this traditional approach is unknown. Chronic low back pain (CLBP), shares a similar multi-dimensional risk profile to joint OA. Much effort has been directed to developing targeted treatment to subgroups of people with CLBP who have poor prognosis based on their group profiles. In keeping with this, our group has developed an individualised model of care for CLBP that effectively targets the multidimensional complexity of the disorder. While this has been adapted to OA knee, to date it is not known whether this approach is also applicable to people with end stage OA who are at risk of poor outcome from knee TJR. As knee OA appears to share similar multidimensional complexity with CLBP, such an approach may offer a promising alternative to knee TJR in those patients at risk of poor outcome with the procedure.
We have developed and tested a promising personalised therapy approach in a small-scale, efficacy RCT in CLBP. The approach is termed ‘cognitive functional therapy’ (CFT), and is best briefly described as an integrated, personalised, behavioural approach to the identification and management of modifiable multidimensional factors underlying a person’s pain and disability. CFT comprehensively operationalises and integrates a self-management program, targeting psychological, physical and lifestyle factors. The intervention addresses these targets using a tailored plan depending on which factors are dominant for each individual. It has been proposed that patients with knee OA be considered similar to other chronic pain populations in that the pain experience may be present depending on genetic, structural, psychological, physical and lifestyle factors, which in turn influence the body and mind of the individual – Illustrated in our NHMRC (APP1035810) to date.
Work will focus on the development and testing of personalised therapy approach for those at risk of poor outcome after knee TJR. We have adapted a personalised CFT approach from CLBP for the management of end-stage OA and will assess the effectiveness of this approach, offering a promising alternative to knee TJR in those patients at risk of poor outcome with the procedure. Whilst the significant body of evidence for existing non-surgical management options for knee OA is acknowledged, we seek to build upon this best practice, with key points of difference being, drawing on relevant models of health behaviour such as the Fear Avoidance Model and Common Sense Model to facilitate development of the patients understanding of their condition, the drivers of their pain and disability as well as opportunities for change.
Lead by Senior researchers who have developed and tested the CFT intervention in CLBP, they will provide experience in prognostic and subgrouping methodology. A post-doctoral fellow will also apply experience in mixed methods and models of health behaviour in CLBP to play a key role in understanding the application of CFT from several clinical angles in a 2 phase approach:
Phase 1: Development of an understanding of factors driving pain and disability
Phase 2: Development of a CFT intervention
Expected Outcomes and Significance
This body of work will lead to new knowledge about treatment alternatives for those patients at risk of no benefit for knee TJR that can be further tested in RCT’s. Significant reductions in healthcare costs can be expected through provision of alternatives to the primary surgical procedure and elimination of costly ongoing care after surgery.