Comparing Pain Science Education to Biomedical Education for People With Knee Osteoarthritis: A Randomized Controlled Trial

Knee osteoarthritis (OA) is one of the leading causes of persistent pain and disability among older adults worldwide. Contemporary clinical guidelines consistently recommend patient education, exercise, physical activity, and self-management as first-line interventions for individuals with knee OA. Despite these recommendations, many people with knee OA continue to hold beliefs that pain is primarily a consequence of structural joint damage, cartilage loss, or joint degeneration. These beliefs may contribute to fear of movement, reduced participation in physical activity, lower self-efficacy, and pessimistic expectations regarding recovery and long-term management. Historically, OA has often been communicated through a biomedical framework emphasizing structural pathology and "wear-and-tear" explanations. Although structural changes can contribute to symptoms, growing evidence suggests that the relationship between imaging findings and pain severity is modest. Structural abnormalities commonly observed on imaging are frequently present in asymptomatic individuals and may reflect age-related changes rather than direct causes of pain. Nevertheless, many patients continue to receive messages that reinforce damage-focused beliefs and may discourage engagement in recommended management strategies. Pain Science Education (PSE) was developed to address misconceptions regarding pain and musculoskeletal conditions. PSE aims to promote a contemporary understanding of pain by explaining the interaction of biological, psychological, and social contributors to the pain experience. In the context of knee OA, PSE emphasizes that pain is influenced by multiple factors and does not necessarily reflect ongoing tissue damage. It also promotes the understanding that movement and physical activity are generally safe, beneficial, and important components of OA management. A central objective of PSE is conceptual change. Conceptual change refers to modifications in how individuals understand and interpret their condition and pain experience. Improved conceptualization of OA may facilitate more adaptive beliefs about pain, increase confidence in self-management, and support engagement in evidence-based treatments such as exercise and physical activity. However, little is known about the effectiveness of PSE in older adults with knee OA, particularly when compared with more traditional biomedical educational approaches. A pilot randomized controlled trial conducted by the investigative team found that participants receiving PSE demonstrated improvements in osteoarthritis conceptualization, whereas participants receiving biomedical education showed little change. Although between-group differences did not reach statistical significance, the pilot study was not powered to detect treatment effects. These findings support the need for a fully powered randomized controlled trial. In addition to influencing beliefs and understanding, educational interventions may affect behavioral and physiological outcomes. One proposed mechanism is through increasing participants' confidence to engage in physical activity by changing beliefs that pain necessarily indicates tissue damage. Because daily movement behaviors are interdependent, understanding changes in physical activity requires consideration of the entire 24-hour movement composition, including sleep, sedentary behavior, and different intensities of physical activity. Compositional Data Analysis (CoDA) provides an appropriate framework for investigating these relationships. Educational interventions may also influence physiological responses associated with pain and stress processing. Chronic pain has been associated with alterations in autonomic nervous system regulation, including changes in sympathetic and parasympathetic activity. Physiological measures such as heart rate variability, electrodermal activity, eye-tracking metrics, and quantitative sensory testing may provide objective indicators of nervous system responsiveness and processing. Evaluating these measures may improve understanding of how individuals respond to different educational messages regarding pain and osteoarthritis. The present study is a two-arm randomized controlled trial comparing Pain Science Education and Biomedical Education in community-dwelling older adults with knee OA. Participants will be randomly allocated to receive one of two website-based educational interventions designed to simulate information commonly encountered when searching for OA-related information online. Both educational programs include similar formats and presentation methods but differ in the concepts and messages emphasized. The biomedical education intervention focuses primarily on structural pathology and disease-related tissue changes, whereas the PSE intervention focuses on contemporary pain science principles and a biopsychosocial understanding of osteoarthritis pain. The primary objective of the study is to determine whether PSE results in greater improvement in osteoarthritis conceptualization than biomedical education immediately following exposure to the intervention. Secondary objectives are to explore differences between groups in physiological measures of nervous system function, movement behaviors measured across the 24-hour day, and self-reported cognitive, emotional, and functional outcomes. The study will also explore how participants perceive, interpret, and engage with the educational content through a talk-aloud methodology. In addition, exploratory analyses will investigate the potential influence of sex and gender on treatment responses across outcome domains. The results of this study will contribute to the understanding of how educational interventions influence beliefs, behavior, and physiological responses in individuals with knee OA. Findings may help inform the development of evidence-based educational strategies that support self-management, physical activity participation, and patient-centered osteoarthritis care.