Background Despite well-established benefits of physical activity for knee osteoarthritis (OA), nine of ten people with knee OA are inactive. People with knee OA who are inactive often believe that physical activity is dangerous, fearing that it will further damage their joint(s). Such unhelpful beliefs can negatively influence physical activity levels. We aim to evaluate the clinical- and cost-effectiveness of integrating physiotherapist-delivered pain science education (PSE), an evidence-based conceptual change intervention targeting unhelpful pain beliefs by increasing pain knowledge, with an individualised walking, strengthening, and general education program. Methods Two-arm, parallel-design, multicentre randomised controlled trial involving 198 people aged ≥50 years with painful knee OA who do not meet physical activity guideline recommendations or walk regularly for exercise. Both groups receive an individualised physiotherapist-led walking, strengthening, and OA/activity education program via 4x weekly in-person treatment sessions, followed by 4 weeks of at-home activities (weekly check-in via telehealth), with follow-up sessions at 3 months (telehealth) and 5 and 9 months (in-person). The EPIPHA-KNEE group also receives contemporary PSE about OA/pain and activity, embedded into all aspects of the intervention. Outcomes are assessed at baseline, 12 weeks, 6 and 12 months. Primary outcomes are physical activity level (step count; wrist-based accelerometry) and self-reported knee symptoms (WOMAC Total score) at 12 months. Secondary outcomes are quality of life, pain intensity, global rating of change, self-efficacy, pain catastrophising, depression, anxiety, stress, fear of movement, knee awareness, OA/activity conceptualisation, and self-regulated learning ability. Additional measures include adherence, adverse events, blinding success, COVID-19 impact on activity, intention to exercise, treatment expectancy/perceived credibility, implicit movement/environmental bias, implicit motor imagery, two-point discrimination, and pain sensitivity to activity. Cost-utility analysis of the EPIPHA-KNEE intervention will be undertaken, in addition to evaluation of cost-effectiveness in the context of primary trial outcomes. Discussion We will determine whether the integration of PSE into an individualised OA education, walking, and strengthening program is more effective than receiving the individualised program alone. Findings will inform the development and implementation of future delivery of PSE as part of best practice for people with knee OA. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12620001041943 (13/10/2020).

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Introduction: Resizing illusions that manipulate perceived body size are analgesic in some chronic pain conditions. Little is known whether such illusions may also alter other physiological features, such as swelling. Objectives: To determine the effects of a knee resizing illusion on knee pain and swelling in symptomatic osteoarthritis. Methods: This case study was extracted from a larger study evaluating the analgesic effects of resizing illusions in people with knee osteoarthritis. A mediated reality system (alters real-time video) was used to provide resizing “stretch” and “shrink” illusions of the knee. Knee pain intensity (0–100 numerical rating scale) was measured before and after illusion and after sustained (3 minutes) and repeated (n = 10) illusions. In this case study, knee swelling (leg circumference below, at, and above the knee) was also measured. Results: The 55-year-old male participant reported a long history of episodic knee pain and swelling that was subsequently diagnosed as severe osteoarthritis in 2013. In the first testing session, the participant experienced an increase in pain with the shrink illusion and a decrease in pain with stretch illusion. A noticeable increase in knee swelling was also observed. Thus, in sessions 2/3, swelling was also assessed. The stretch illusion decreased pain to the largest extent, but resulted in increased knee swelling. Repeated and sustained stretch illusions had cumulative analgesic effects but resulted in cumulative increases in swelling. While the shrink illusion increased pain, sustained (∼10 minutes) visual minification of the entire knee and leg reduced both pain and swelling. Conclusion: Our case report suggests that both pain and swelling may be modifiable by altering body-relevant sensory input in symptomatic knee osteoarthritis.

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