BMJ  2006;333:981-982 (11 November), doi:10.1136/bmj.39024.417813.BE

Editorials

Treatment of knee pain in primary care

Pharmacists and physiotherapists need to be a part of the team

In the United Kingdom, general practitioners have traditionally been seen as the key players in primary care delivery, with support from a multidisciplinary team. As primary care extends its remit into areas such as minor surgery, team members are likely to come from diverse health disciplines. Recent studies show that patients presenting to primary care with knee pain receive little information on pain management, rehabilitation,¹ or use of non-steroidal anti-inflammatory drugs and few are referred to specialist services.² In this week's BMJ, a trial by Hay and colleagues assesses the impact of pharmacy and physiotherapy on the management of older people with pain or stiffness of one or both knees in primary care.³

The trial compared three interventions: enhanced pharmacy review (pharmacological management in accordance with an algorithm), community physiotherapy (advice about activity and pacing and an individualised exercise programme), and standard treatment (control; advice leaflet reinforced by telephone call). Compared with standard treatment at three months, pharmacy review and physiotherapy improved pain and function scores, improved patient satisfaction, and reduced use of non-steroidal anti-inflammatory drugs. Importantly, neither of the interventions had adverse effects.

The findings are encouraging, but the effects were not sustained beyond three months, which may be because adherence to treatment diminished over time. This could not be assessed, however, as measurement of adherence was limited. As with any trial, fidelity to the intervention (adherence),⁴ on the part of people who provide the intervention and those who receive it, is always an important consideration. Also the "dosage" of the intervention and the requirement for top-up treatments may have been too low to produce long term benefits.³ Benefits have been shown to be additive when exercise is delivered with other interventions, such as weight loss strategies.⁵ If the pharmacy and physiotherapy interventions had been combined instead of being given separately they may have been more effective.

The role of pharmacists in helping patients to manage medication is widely accepted, and prescribing rights have been extended to pharmacists.⁶ Physiotherapy for musculoskeletal conditions has been shown to be beneficial and cost effective in primary care.⁷ A systematic review has shown that substituting general practitioners (GPs) with appropriately trained nurses can produce comparable health outcomes for patients.⁸ What was less clear was the impact on doctors' workload and potential cost savings. Another study found that nurse practitioners did not reduce the workload of GPs,⁹ perhaps because they were being used as supplements rather than substitutes for GP care. The trial by Hay and colleagues did not report effects on GPs' workload, but it did note that during the six month follow-up more people in the control group consulted their GP for knee pain than did those in the other two groups.

Evidence suggests that factors that promote success in changing skill mixes include introducing services or treatments of proved efficacy; appropriate staff education and training; removal of unhelpful boundary demarcations between staff or service sectors, such as lack of integration between health and social care; appropriate pay and reward systems; and good strategic planning and human resource management.¹⁰ The approach described by Hay and colleagues hits the mark on the first two criteria (evidence based treatments and education and training), but implementation of the others would require changes on a much broader scale for implementation across trusts.³

The pharmacy intervention was delivered by a pharmacist in GP surgeries. Could the intervention be delivered in a community pharmacy? Research suggests that the community pharmacy setting is not viewed positively as a site for the delivery of more clinically demanding services.¹¹ Physiotherapy was performed under supervision of community physiotherapists (mean of three consultations), and patients were asked to continue their exercises at home. Supervised exercise sessions are superior to home exercises in the management of knee injury,¹² and although one to one supervision is best, group classes can be successful. This approach requires a specific diagnosis (beyond knee pain and stiffness as was used in Hay and colleague's model) as patients are usually grouped according to injury type and prognosis. None the less, group sessions could maximise patient compliance and therapist time in the long term and offer a pragmatic option for primary care management.

¹ School of Pharmacy, Queen's University, Belfast BT9 7BL , ² Health and Rehabilitation Sciences Research Institute, University of Ulster, Jordanstown, Newtownabbey BT37 0QB

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Competing interests: None declared.

References

1. Victor CR, Ross F, Axford J. Capturing lay perspectives in a randomized controlled trial of a health promotion intervention for people with osteoarthritis of the knee. J Eval Clin Pract 2004;10:63-70.[CrossRef][ISI][Medline]
2. Jordan KM, Sawyer S, Coakley P, Smith HE, Cooper C, Arden NK. The use of conventional and complementary treatments for knee osteoarthritis in the community. Rheumatology 2004;43:381-4.[Abstract/Free Full Text]
3. Hay EM, Foster NE, Thomas E, Peat G, Phelan M, Yates HE, et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ 2006 doi: 10.1136/bmj.38977.590752.0B
4. Dumas JE, Lynch AM, Laughlin JE, Phillips Smith E, Prinz RJ. Promoting intervention fidelity. Conceptual issues, methods and preliminary results from the EARLY ALLIANCE prevention trial. Am J Prev Med 2001;20(1S):38-47.
5. Bennell K, Hinman R. Exercise as a treatment of osteoarthritis. Curr Opin Rheumatol 2005;17:634-40.[CrossRef][ISI][Medline]
6. Avery AJ, Pringle M. Extended prescribing by UK nurses and pharmacists. BMJ 2005:331:1154-5.
7. Pinnington MA, Miller J, Stanley I. An evaluation of prompt access to physiotherapy in the management of low back pain in primary care. Fam Pract 2004;21:372-80.[Abstract/Free Full Text]
8. Laurant M, Reeves D, Hermens R, Braspenning J, Gorl R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2004;(4):CD001271.
9. Laurant MGH, Hermens RPMG, Braspenning, JCC, Sibbald B, Grol RPTM. Impact of nurse practitioners on workload of general practitioners: randomised controlled trial. BMJ 2004;328:927-32.[Abstract/Free Full Text]
10. Sibbald B, Shen J, McBride A. Changing the skill-mix of the health care workforce. J Health Services Res Policy 2004;9(suppl 1):28-38.
11. Hughes CM, McCann S. Perceived interprofessional barriers between community pharmacists and general practitioners: a qualitative assessment. Br J Gen Pract 2003;53:600-6.[ISI][Medline]
12. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev 2001;(2):CD004376.

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