Does targeting pain-related beliefs in people with knee osteoarthritis increase physical activity? A pilot, feasibility trial.

Explain Pain Group (enhanced education + graded walking program) Participants randomised to this group will attend four, 60-90 minute, one-on-one sessions with a Physiotherapist at weekly intervals, during which they will receive enhanced pain education (Explain Pain) as well as receiving a graded walking program. The overall aim of Explain Pain is to shift participants’ conceptualisation of pain from that of a marker of tissue damage to that of a marker of the perceived need to protect the body. The Explain Pain enhanced education will also expand upon general information about osteoarthritis and activity (received by control group). The physiotherapist will have received specific training in Explain Pain including a 2-day course and 4 months of specific training with the research team. Explain Pain is a cutting edge educational approach that moves away from didactic lectures/seminars. It aims to educate participants that pain is a protective feature of our system, not a ‘damage-meter’; thus, pain can be modulated by other things besides tissue damage and danger messages (i.e. nociception). It will aim to reduce the perceived danger associated with the knee, using proven principles and strategies of conceptual change science. Conceptual change strategies informed by contemporary theory will be used, including: challenging existing knowledge and refining learning strategies for new concepts using principles of multimedia learning will be used. A detailed curricula has been created for this intervention. The following pain education topics will be covered in the one-on-one sessions: Basic nervous system anatomy/function; distinction between nociception and pain; protective function of pain; peripheral/central sensitization; up-regulation of brain mechanisms that serve protection; the state of ‘hyper-protection’ offered by normal bio-logical adaptations; the concept of an internal ‘Protectometer’ (modulated by multifaceted danger and safety cues). Further, a discussion of the participants’ own knee xray will be undertaken with the aim being to ‘de-threaten’ radiological findings (e.g., focusing on positive features such as excellent bone density) using standardised wording. Education about the poor correlation between x-ray findings and pain will be provided. Specific education about physical activity will be provided, namely that it does not increase joint damage but does have wide-ranging health benefits and OA-specific benefits. Last, it will be discussed that physical activity is key to bioplasticity – i.e., inducing changes in our system – and that it decreases overprotectiveness of our system, a change that often occurs with persistent pain. Participants will receive the Explain Pain book to take home which discusses concepts from this intervention. In the one-on-one sessions, participants will also receive a graded walking problem. This will involve first establishing participant’s baseline walking tolerance (i.e. how far, on average, they are able to walk before their pain level increases). They will then reduce this time/distance by 20% - with this activity level becoming their ‘start’ walking level. Participants will be guided to set a weekly program (beginning at this ‘start’ level) and then plan gradual weekly increases at a rate of approximately 10% each week. Participants will also be guided to set activity-related short and long-term goals. One of these goals will be a walking goal (if appropriate) – such that the ‘pacing’ approach can be demonstrated and practiced. Following completion of the one-on-one sessions, participants will perform 4 weeks of at-home workbook activities combined with further progression of a graded walking program. This will include weekly individualised walking goals that aim to promote graded activity progression. Participants will also receive the Protectometer handbook, which is an interactive and educational Explain Pain workbook. Participants will be asked to complete tasks at home which will involve using the Protectometer handbook to identify the unique safety and danger cues that are present for activity tasks and that may influence pain levels during activity. During the 4 weeks of at-home treatment activities, the treating clinician will call participants 1x/week to check in and follow their progress. A home diary will be used to record workbook/walking goal completion.