This is a copy of my presentation from the 2024 British Hip Society Meeting in Belfast. The presentation describes the development of the CHAIN programme and was part of a session focussed on the conservative management of hip osteoarthritis.
#hip #pain #arthritis #cycling #exercise #selfmanagement
Well good afternoon uh my name’s uh Professor Tom way uh I’m a physiotherapist uh and professor of Orthopedics uh in Bournemouth on the south coast of uh England firstly uh thank you so much to the organizing committee for inviting me to be part of this session uh and my apologies I can’t
Be with you in person today my presentation this afternoon is going to be about our chain program cycling and education program for patients with hip osteoarthritis so so as we’ve heard from some of the other speakers osteoarthritis is a disease and condition that affects many
Of us as we age in fact around 10% of adults aged over 45 years in England have osteoarthritis of the hip so therefore we have a significant proportion of patients that need treatment so what treatment should we provide these patients well if we look at International guidelines such such as
The AY guidelines they recommend that everyone should receive education to be active exercise interventions and advice and support to manage their weight if it’s appropriate they recognize that some patients May benefit from drugs or injections and as if you look at all patients combined very few will actually need surgery these International
Guidelines are reflected from the local and UK nice guidelines and we’ve heard about these already in the session and nice recommends Three core treatments for osteoarthritis education and advice and access to information to allow patients to self-manage their condition with confidence exercise both local muscle strengthening around the affected joint and also cardiovascular
Exercise and weight loss if overweight or obese now my colleague and long-term collaborator Professor Robert Middleton who’s a hip surgeon down here in Bournemouth was part of this nice guideline committee and some years back when he was part of those um initial meetings he would come back to clinic
And he would ask me so Tom what actually are you providing for these patients what are the physios doing for um exercise he wanted to know the details of the program I could tell in my practice but when I look more broadly across the practice of other clinicians
Across our trust and others it was interesting to see what we found we we completed a snapshot audit a physiotherapy practice uh we use social media to get uh the survey out across physiotherapists across the the country and what we found was wide variation in practice we also found that very few
Patients got those three core treatments as part of their physiotherapy practice so we started to think about how could we um standardize and protocolized treatment for these patients taking in account the evidence and the nice guidelines so we reflected on a couple things that we’ve been observing at that time
Firstly I reflected on my experience of delivering cardiac Rehabilitation some years previously when I was a junior physiotherapist now cardiac Rehabilitation is all about encouraging patients to exercise and change their lifestyle after they’ve had a heart attack or significant heart surgery where everything in themselves is saying
Them they don’t want to raise their heart rate but we need to educate them to know that raising their heart rate will help make them fitter now that’s the same with osteoarthritis because people don’t want to move the effective joint and we need to get the message
Across that moving it will actually help them the other things that we observed was some patients were reporting to us that they changed their running for cycling and that had helped their hip so we thought about that and we looked a bit more now myself and Rob were Keen
Cyclists but we also thought about what we knew from the professional cycling pelaton the picture in the top corner is a Floyd Landing this now he won the Tour to France in 2006 a 3-we endurance event broadly recognized as one of the toughest inur urance events in professional sport now the title was
Taken away from him subsequently because he was exposed as a drug cheat but what you also may not know is two months after the tour he had a hit replacement during the tour to France he was able to pedal and be the best in the world at
Cycling yet he could hardly walk and could hardly go upstairs and we also knew to noticed from our patients undertaking cpex testing ahead of hip replacement surgery that quite often they would walk in very diffic with great difficulty but then when we put them on the bike they would actually be
Able to cycle for a significant period of time showing us that actually cycling was a movement that our hips liked so there was born the chain program at that that point a six- week program consisting of half an hour of education on a different topic relative to OST
Arthritis each week and then half an hour spinning class the spinning class and and education session were held in a Leisure Center quite deliberately so we removed uh it from the hospital environment and the messaging to patients was that they could do more than they perhaps thought they could the
First spinning session was very gentle getting them used to the bike but by the end of the six weeks the spinning session would be analogous to any that you or I may go to now cyclings are very inclusive um in spe spefic specifically static cycling is a very inclusive
Activity for patients that are younger and fitter they don’t go ahead of the ahead of the rest of the group everyone can work at their own um level of resistance and encourage each other and participate as one in our initial program for the chain program we had the following outline
Where we covered a different Education topic and this was facilitated by a senior physiotherapist and then a spinning instructor took the spinning component as you can see this was accompanied by home exercise program of that first iteration of the chain program we had excellent results from the first 120
Patients that went through it over 80% of patients improved their function and ability to complete daily activities as measured by proms over 80% of them improved their leg strength 80% improved their walking speed and crucially 100% of participants said they would recommend the program to their friends
Or families or others with the same condition what was interesting and what we were learning is that patients were capable of a lot more than we perhaps thought they were before running the program this case study and case report that we published shows that a patient probably some years before we’d started
Chain if they come and seen me in physiotherapy i’ would have probably dealt with them very gently and not put them through uh a six week spinning cycle program in actual fact this gentleman with quite a range of different co-morbidities and a complex past medical history as you can see make
Very good improvements and he changed his lifestyle completely having gone through the program following the success of this initial program where we took patients from physiotherapy Department referrals we then repeated the program but this time took participants from secondary care referrals so these were patients that were referred to the orthopedic
Outpatient department for a surgical opinion from primary care so theoretically patients slightly later in their ostearthritis progression and further down the pathway these were patients that we saw in clinic and judged that surgery wasn’t quite relevant for them yet and we were offering them chain as a conservative option again participants made improved
Outcomes improvements the eq5d pain on weight bearing function as measured by The Who The Oxford hip score and improve strength and improveed walking distance and this was over 160 pages Pati so we were finding encouraging results and after some time had passed we then went back and looked at our
Initial cohort of patients from the first um study to see what had happened to them subsequently encouragingly at 5 years 96% of participants reported that the intervention had increased their ability to self-manage their hip pain 45% of participants had not returned to their GP or other health professionals
For further treatment of their hip pain just over 50% of them had avoided any need for surgical intervention and 100% of participants continue to be engaged in physical activity at least once a week now this is important because exercise will work for osteoarthritis but for only as long as you keep doing
It we therefore designed an RCT it’s not without difficulty looking at a group intervention versus a onetoone intervention so we made some methodological considerations and had some solutions such as engaging with clinicians and patients to help inform the design of our trial we did patient and public involvement sessions where
The patients who had gone through the program wanted the it to be an 8-week program instead of a six- we program they wanted better recording of exercise in an exercise diary and they suggested how we could disseminate our findings better with a virtual app as well as um an in-person uh
Program this work subsequently led us to get rfpb funding from the NIH nhr to run a randomized control trial looking at the chain intervention versus one toone physiotherapy that protocol has been published and we finished Recruitment and the statisticians are just analyzing the final result results now I don’t
Know the results as Chief investigator because they’ve not been shown to me yet but I really look forward to sharing them with you next year and telling you all about what we’ve learned about our group intervention versus standard onet toone Care thank you your attention and if
Anyone has any questions please do uh reach out to me via my email or social media thank you