Table 2 Education features of the intervention groups

Overall objective(s):

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. To educate 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). To understand the three key ingredients to recovery in OA: i) increasing knowledge; ii) increasing activity; iii) reducing inflammation.

To increase participants’ knowledge about OA and the importance of physical activity in reducing osteoarthritic pain and improving general health.

Pain education topics:

Basic nervous system anatomy/function; distinction between nociception and pain; protective function of pain; peripheral/central sensitisation; up-regulation of brain mechanisms that serve protection; the state of ‘hyper-protection’ offered by normal biological adaptations; the concept of an internal ‘Protectometer’ (modulated by multifaceted danger and safety cues); the concept of bioplasticity (all tissues and systems adapt and are changeable, including cartilage, bone, muscles, the pain system, the immune system, etc.); the importance and contribution of body wide inflammation to knee symptoms.

Basic OA and pain information as per the Arthritis Australia handbook.

Activity education:

That physical activity does not increase joint damage but does have wide-ranging health benefits and OA-specific benefits.

That physical activity is key to bioplasticity – i.e., inducing change in our system – and that activity decreases the over-protectiveness of the pain system (clarifying that over-protectiveness is a change that often occurs with persistent knee pain).

That the aim of graded activity is to slowly increase loading of the joint and body systems; introducing the concept of the sweet zone (the optimal amount of activity that is not too much nor too little, but sufficient to promote bioplasticity).

That physical activity has wide-ranging health benefits as well as OA-specific benefits and that even people with severe OA benefit from activity.

X-Ray interpretation^a (if applicable):

The aim is to provide education about why scans are no longer recommended for diagnosis or to guide treatment of OA (i.e., scans do not provide sufficient or valuable information about current or future pain/function; clinical symptoms provide more reliable information). Therapists will ask participants if they have had a scan of their knee. If they have had a scan, the aim is to ‘de-threaten’ radiological findings through asking participants about what they have been told about their scans, and what information they thought scans provided them about their knee and their activity (exploring how they feel – e.g., fearful, anxious). It will also include discussing the report, focusing on positive features (e.g., normal age-related changes). If they have not had a scan, the aim is to reassure the participant that they do not need one. In both cases, education about the poor correlation between x-ray findings and pain will be provided.

The aim is to explain that scans are no longer recommended for diagnosis or to guide treatment of OA, consistent with contemporary clinical practice guidelines. Therapists will ask participants if they have had a scan of their knee. If they have had a scan, the aim is to discuss radiological findings, focusing on the interpretation section as would occur in regular practice.

Walking program

The aim is to use the concept of an internal ‘Protectometer’ in pain to purposefully vary and embed context into the graded walking program that is individualised to the participant and their unique goals.

The aim is to educate participants about the need for graded increases in walking when performing an individualised program aimed towards their unique goals.

Strengthening program

The aim is to have participants reflect on the strengthening program and its effect on knee strength/stability and on confidence in moving. The aim is also to apply the idea of a ‘Protectometer’ to strengthening exercises, by varying and embedding context into their performance.

The aim is to educate participants about the importance of continued and regular strengthening exercise of the main lower limb muscle groups to assist in maintaining knee function.