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Will Knee Osteoarthritis bring Britain to its knees?

Thought Paper on Knee Osteoarthritis & AposTherapy

Overhauling the diagnosis and treatment of knee pain in the UK:

AposTherapy launches pilot results to medical community


AposTherapy held a roundtable in November 2011 at the Royal College of Surgeons of England, gathering thought leaders and decision makers in the fields of health care, biomechanics, rheumatology, arthritis and osteoarthritis, to discuss the growing macro and micro burden of knee pain and what can be done to address it.



The group explored the latest innovations in the diagnosis, treatment and long term management of knee osteoarthritis – and looked ahead to what the future might hold.  As part of this, there was commentary on the latest clinical understanding of osteoarthritis and discussion of the challenges the health system faces.  The following thought paper captures the discussion and comments made by attendees, aimed at providing the medical community with a series of actionable insights and ideas for helping deal with the growing burden of knee osteoarthritis.  


  • Professor Alan Silman, Medical Director at Arthritis Research UK
  • Dr. Katrina Herren, Medical Director, Bupa Health and Wellbeing
  • Dr. Amit Mor, Medical Director and co-inventor of AposTherapy


  • Dr Natalie Jane Macdonald, Managing Director at Bupa Health and Wellbeing
  • Alex Perry, Director of Provisioning at Bupa Health and Wellbeing
  • Professor Philip Conaghan, Professor and Chair of Musculoskeletal Medicine, University of Leeds
  • Dr Richard Jones, Senior Lecturer in Clinical Biomechanics, University of Salford
  • Dr John Chisholm, Council member, Royal College of General Practitioners         
  • Dr. Cathy Holt, Biomechanics, Motion Analysis and Rehabilitation Team Leader,Arthritis Research UK, Biomechanics and Bioengineering Centre, Cardiff University
  • Dr. Valerie Sparkes, Arthritis Research UK, Biomechanics and Bioengineering Centre, Cardiff University
  • Dr. Hasan Tahir, Consultant Rheumatologist, St Matthew’s University Hospital      
  • Dr Tonia Vincent, Honorary Clinical Research Fellow, Kennedy Institute, Imperial College London
  • Lady Valerie Cocks, AposTherapy patient

Introduction and context, by Guy Spigelman, Managing Director AposTherapy UK

The growing condition of knee osteoarthritis costs the UK economy the equivalent to 1% of GNP per year[1].  If you mix together the demographic time bomb that faces us with an ageing population that wants to remain active, you have the potential for this problem to become the climate change of the health economy. 

Let us not forget the burden on the patient, for whom this disease can be crippling through reduced or impaired mobility.  With 8.5 million people estimated to suffer from this, there is a big job to ensure treatment is widespread and available.

Professor Alan Silman, medical director, Arthritis Research UK

There are some pertinent questions we must ask when discussing this topic.  Is knee osteoarthritis a structural/skeletal problem or a patient/pain problem?  Is it a disease of the bone or pain, or both?  There are a number of schools of thought in this area.  

What we can be certain about is that osteoarthritis starts in response to abnormal biomechanics and isn’t simply ‘wear and tear’, as it can be commonly mistaken.  We need to begin to perceive any problems with the joint as a piece of engineering that’s gone wrong and needs fixing.  We need engineers and surgeons working together, learning from one another.  

Members of the pharmaceutical industry have famously withdrawn funding from this area.  There are gaps to be filled.  Osteoarthritis and knee pain are major problems for the individual as well as the health system, and needs a solution that thinks outside the box – like AposTherapy.

Dr Katrina Herren, Medical Director, Bupa Health and Wellbeing

We at Bupa are very mindful of the burden knee osteoarthritis brings to our members.  There are a number of conservative treatments recommended by NICE and other guideline bodies including non-steroidal, weight loss, anti-inflammatory drugs, physiotherapy, orthotics and CBT for pain relief.

For many of our members if they have tried these conservative options with little success, the only option available is surgery.  However, surgery has risks and not all surgical interventions for OA are fully supported by the evidence.  So these customers are looking at a knee replacement and currently, the UK performs 80,000 of these a year.

Bupa’s role as a healthcare partner is to provide choices and alternatives for members, especially in areas where there are limited alternative options.  We assess new technology and fund treatments that are proven scientifically. Where there is limited choice we will look at newer treatments and fund them on an ex gratia basis. This means they are not normally covered by the insurance policy but we will cover them on a case by case basis. We were excited by AposTherapy because the initial biological evidence looked promising and it posed no risks for consumers to try it, unlike surgery. 

With the UK population aged over 50 projected to rise by 32% between 2008 and 2030and as the prevalence of risk factors such as obesity and high levels of physical fitness such as running (causing wear and tear) also continue to rise, this trend is expected to grow exponentially. The impact of this could be staggering; particularly on what is arguably an unstable health economy.

For us then, any new treatments that offer conservative options for our members such  AposTherapy has, in the last 24 months, can only provide a positive outcome.  We are really enjoying working with AposTherapy on this service for our members and it being part of our portfolio.

A summary of AposTherapy clinical results

After 18 months pilot in UK of 1,300 patients through Bupa, patients who had experienced AposTherapy reported that they felt less pain and that they are more functional following three months of AposTherapy.  On average these patients suffered from knee pain on average for 6 years prior to treatment.  The findings were particularly encouraging[2]:

  • 95%of AposTherapy patients were satisfied with the results– the majority say it exceeded their expectations
  • 86% reported a reduction in knee pain, mostly within 5 weeks
  • 88% of AposTherapy users reported an improvement in mobility
  • 82% who’d reported that pain had adversely affected their activity levels, now found it easier to be active since starting AposTherapy
  • 67% used fewer over-the-counter pain remedies
  • And finally, a reassuring 92% would recommend AposTherapy to someone they knew
  • 6 out 10 of those who were housebound are no longer housebound

 Dr Amit Mor, Global Medical Director and co-inventor of AposTherapy

It’s plain to see that the healthcare economy cannot meet the growing burden of knee osteoarthritis – needing more beds, staff, technology and skills.

Over the many years we have spent working to treat knee pain and osteoarthritis, it is very clear that lasting and impactful solutions must be bespoke and based on delivering to a patient in their own home.

Biomechanics – treating the muscle and the nerve – is central to treatment of knee osteoarthritis.  As NICE has stated, exercise needs to be at the core of treatment.  But we understand that this is often problematic for sufferers, particularly if they are in some (often, constant) pain; unfortunately exercise needs to be repetitive to retrain certain muscles but across the board, people don’t like prescribed exercise.

This is why we developed AposTherapy.

AposTherapy is based on the understanding of the central role that biomechanics play in osteoarthritis: its development and its progression. It has been shown to reduce pain and improve knee function.  

Based on the premise that the development and progression of osteoarthritis can depend on the way you walk, AposTherapy works by analysing and correcting the way you move.  The treatment off-loads pressure from the affected area in the knee and re-educates the muscles and systems around the joint by introducing mild, controllable perturbation (or instability) as you walk.

AposTherapists are registered physiotherapists trained to provide AposTherapy, use state-of-the-art technology to assess if the way you walk is contributing to patients’ pain. They analyse patients’ gait, conduct a full clinical analysis of their problem joints, gain a thorough understanding of their level of pain, and discuss their day-to-day restrictions (e.g. climbing stairs). This helps decipher whether their walking patterns are contributing to their knee pain.

We’ve treated over 25,000 patients to date, and are constantly refining the algorithms and methodology we use over the last eight years.  AposTherapy fits around people’s lives, and the shoe only needs to be worn for 1-2 hours per day for full effect with a patient – a big bonus as we know that patients find it very difficult to comply with existing treatments.

Surgery is appropriate only some of the time – even straight after an operation, a patient can find it difficult to rehabilitate and get back to healthy joint function, as the same tissues and muscles are still affected. As well as this, often, the other knee can deteriorate and require surgery as well.  Surgery is not the only option and the health care system simply cannot sustain surgery rates given the ageing population.  We need a range of tailored solutions to meet the current demand, and importantly, for the generations of growing number of patients to come. 

Emerging themes

A number of interesting themes and issues were raised in the group discussion, and are captured below.

A growing burden

The growing burden of knee pain and osteoarthritis is threefold:

1.  Healthcare - It is threatening to crush the healthcare economy through cost of medication and painkillers, surgery and the number of hospital beds required in post-treatment.  The current framework and tools within it simply do not meet the burden of osteoarthritis.

2.  Economic - It is impacting on the work economy through the impact of reduced mobility in the workplace.  Keeping patients out of hospital and in the same work for longer (not needing to retrain them) has mutual benefits for the national economy.

3.  Patient - On a personal level for the patient, knee pain can be crippling and severely impact on quality of life, weight management and overall mental health.  It is vital that sufferers do not feel like this is a natural part of simply ageing, or that they should suffer in silence.  

“This is an enormous burden for the NHS and alternative ways to treat knee osteoarthritis are of considerable interest to commissioners, particularly new clinical pathways that result in reduced costs for the system.  The working age population feels the benefits of this too - keeping people in work or helping them return to work – has cost saving implications that impact on the economy as a whole.  GPs diagnose a large number of osteoarthritis sufferers each year, and so interventions that make a lasting difference to patients’ experience and function are clearly very welcome.”  Dr John Chisholm, Council member, Royal College of General Practitioners      

Misunderstood disease

Osteoarthritis is a misunderstood disease; even the term and its definition are debated.  There is not yet enough information or research to enable healthcare professionals and patients to make considered decisions about treatment.  Continued research is vital for the progression of suitable methods of treatment for future patients. The importance of biomechanics should not be underestimated in future studies of the disease.

“People don’t really understand what this problem is – they understand cancer because it can kill you, but they don’t understand knee osteoarthritis. In fact, around half of people with severe knee pain do not go to the doctors, possibly through a misconception that nothing can be done, that it’s simply part of getting old.  So how do you treat people?  Well we would welcome anything that helps people.  Patient compliance is ultimately what it comes down to.”  Professor Philip Conaghan, Professor and Chair of Musculoskeletal Medicine, University of Leeds

Compliance is a hurdle

There are major problems with compliance in current treatment.  Regular patients don’t necessarily have time for regular exercise, and therefore physiotherapy does not work. People don’t like prescribed and repetitive exercise which causes further pain. So systems that make it simple to exercise in everyday lives are attractive. 

“A patient would have to spend a long time addressing each of the affected muscles through physiotherapy, and whilst athletes have time for sustained exercise, a person who is at work or has a busy lifestyle may not.  This sometimes means patients aren’t compliant with a treatment such as physiotherapy, through no fault of their own.  Therefore a system that encourages simple repetition is a very good thing in rehabilitation, and obviously attractive to the patient.”  Dr. Valerie Sparkes, Arthritis Research UK, Biomechanics and Bioengineering Centre, Cardiff University

“I wear the shoes most mornings, just a few hours every day.  It’s been the greatest thing, a real godsend and the biggest boon of my life really.  I’m thrilled to bits, it took me three months or so and I suddenly realised I was walking around with no pain.  I don’t ever ‘not’ wear them.  I wear them every day, even when on cruises!”  Lady Valerie Cocks, AposTherapy patient

Personalisation is key to successful treatment

The key facets of successful treatment are the ability to treat in the home, to make it easy to go about one’s everyday life and to ensure there is little for the patient to need to comply with, such as complicated exercise.  In this sense, by using compliable treatment, the control is handed back to the patient, which experience has shown is empowering and results in a greater affinity with the chosen treatment.  Personalisation is absolutely critical to the success of treatment in this area. Tailoring is especially important when considering that patients have multiple joint pains – some studies have shown that the median number of simultaneous joints in pain for sufferers of OA is 4, and all this needs to be taken into consideration during treatment.

“Personal targeting of biomechanical interventions for knee osteoarthritis patients is vital.  There is currently an unmet need in the treatment of osteoarthritis and the biggest challenge is finding a range interventions which help meet patients’ very differing needs.”  Dr Richard Jones, Senior Lecturer in Clinical Biomechanics, University of Salford              

Greater health expectations

Certainly among younger generations, and even baby boomers, there exist greater expectations about having healthier, fuller, pain-free lifestyles.  This increase in expectations speaks volumes about the high standards of healthcare in the UK, but could become increasingly burdensome to the funding behind it.

“Currently around half or people with knee pain don’t visit their doctor.  This may well change however, with Generations X and Y coming through who are more demanding about healthcare provision.” Professor Philip Conaghan, Professor and Chair of Musculoskeletal Medicine, University of Leeds

Better understanding of biomechanics

Research behind the proof of success of rocker or toner shoes is minimal.  To assert that one-size-fits all shoes work in the same way for all sufferers, is the same as providing the same pair of glasses to anyone with eyesight problems.  It simply can’t work – treatment should be tailored to the sufferer’s (often changing) needs.  It could even be argued that the very term knee osteoarthritis carries with it too many inaccuracies – perhaps a more appropriate definition would be to term this a biomechanical knee problem.

  “Osteoarthritis as a disease, starts in response to abnormal biomechanics, and there is increasing evidence that if you have abnormal biomechanics, through birth or by injury, that it could be the initiating event.”  Professor Alan Silman, Medical Director at Arthritis Research UK

 “The osteoarthritis research community accepts that biomechanical interventions will theoretically be a good thing - what we need is the evidence that this can happen.  It’s great to see that AposTherapy are serious about looking into the mechanisms by which their therapy might be effective.”  Professor Philip Conaghan, Professor and Chair of Musculoskeletal Medicine, University of Leeds

[1](NICE report: Osteoarthritis draft scope for consultation, 2007)

[2]Two surveys were done to register patient reported outcomes. They were carried out by Network Research. The first survey had 150 patients. The second, carried out 8 months later, had 150 patients – with 50 from the first group to show lasting benefits.  Both subjective (questionnaires) and objective (computerised gait analysis) measurements have improved following the therapy, supporting previous findings. As well as clinical surveys conducted as part of the therapy, we commissioned Network Research to conduct two telephone surveys amongst 250 patients.


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