The Intervention components

Cognitive Muscular Therapy is delivered through five sequential intervention components, each of which is supported through the use of animated instructional videos. A very brief description of each components is provided below, with a more detailed description in the Appendix of the published paper.

Making sense of pain: This component focuses on patient education, challenging the idea that knee osteoarthritis pain is the inevitable result of “wear and tear”. Patients are introduced to the concept that muscle overactivity can increase pain and that brain processing and psychosocial factors can shape the pain experience.

General relaxation: Patients are taught to become aware of inappropriate contraction of the quadriceps muscles and to learn a relaxed diaphragmatic breathing by minimising low-level contraction of the abdominal muscles. This component initiates the process of muscular re-education.

Postural deconstruction: A set of clinical procedures are used which enable the physiotherapist to unpick (deconstruct) patterns of postural muscle activity and associated patterns of hip/trunk muscle stiffness. Working through the procedures, the patient is provided with experiential learning of how to stand with reduced postural muscle activity and more relaxed knee muscles.

Responding differently to pain: This component aims to raise awareness of inappropriate contraction of the knee muscles which can be triggered by pain expectations. Using biofeedback, the patient is taught to minimise anticipatory muscular contraction, which can occur before initiation of movement. Patients are also encouraged to reflect on emotional responses to anticipated pain.

Functional muscle retraining: Muscle biofeedback software is used to visualise knee muscle activation during different functional task. This software contrasts the patient’s muscle patterns with those collected from a healthy group. Using the biofeedback software to guide learning, patients use motor imagery to reduce muscle overactivity, gaining experience of how to perform everyday activities with improved muscle coordination. As part of this learning, the physiotherapist continues to challenge beliefs that certain movements should be avoided.