CHAIN (Cycling against Hip pAIN) is a programme of exercise and education first launched in 2013 to promote the self-management of osteoarthritic symptoms through lifestyle change.

Based on NICE guidelines – the UK’s National Institute for Health and Care Excellence – the programme drove strong results from the outset, improving pain, function and quality of life for patients as well as enhancing confidence and motivation to exercise.

Osteoarthritis is one of over 20 chronic diseases where increasing physical activity is the first-line treatment

Fast-forward to 2025 and CHAIN hit the headlines again, this time courtesy of a study – published in The Lancet – which compared CHAIN with standard physiotherapy for hip osteoarthritis. It found CHAIN achieved the greater improvements in pain and function.

We dive into the details with Professor Tom Wainwright, who co-created CHAIN alongside Professor Rob Middleton, both of the Orthopaedic Research Institute (ORI) at Bournemouth University (see Leading their field box out at the end of the feature).

Why the focus on osteoarthritis?

Osteoarthritis isn’t life-threatening, but it is very much life-limiting in terms of quality of life. It’s also something most of us will have to a greater or lesser extent as we get older: by the time we get into our fifth and sixth decades of life, a large proportion of us will have osteoarthritis of the hip or knee.

Over 100,000 hip replacements are done every year in England and they’re very successful – but they’re costly. So there’s a real societal need to look at how we best manage osteoarthritis, exploring ways we can support people to manage it themselves.

You need to exercise in the right way for specific osteoarthritic joints. For hips, cycling seems to work really well.

How beneficial is exercise?

Historically, osteoarthritis was always seen as a biomechanical condition: wear and tear of the joints. We’re now understanding that it’s much more of a biological, systemic condition – one that probably develops over a long period of time, alongside other factors such as inflammation. Additionally, there’s a strong association between patients who have osteoarthritis and who also have a background of cardiovascular or metabolic disease.

And so we’re recognising that treating osteoarthritis could be similar to treating cardiovascular and metabolic diseases. These are all hypotheses at the moment, but we certainly know osteoarthritis to be one of over 20 chronic diseases where increasing physical activity is the first-line treatment.

Why cycling specifically?

You need to exercise in the right way for specific osteoarthritic joints – and for hips, cycling seems to work really well.

Our story goes back over 10 years. My colleague Rob [Middleton] was part of the NICE committee and on a body reviewing the evidence around treating osteoarthritis. For the hip and knee specifically, three frontline treatments emerged. First, exercise – both local muscle strengthening and cardiovascular. Second, education on osteoarthritis as a condition and on the benefits of exercise and other lifestyle modifications. And third, where relevant, weight loss.

Exercise works for osteoarthritis only for as long as you keep exercising

But what sort of exercise? I was asked what we were doing in the physiotherapy department, but I felt we were selling patients short, massively under-dosing them by giving them outdated exercise sheets with a few mobilisation exercises for 10 reps, three times a day. They weren’t getting any intervention I felt would really make a difference.

Meanwhile, Rob and I were keen cyclists and had just completed a Land’s End to John o’Groats ride with 400–500 others – many of whom shared their aches and pains once they found out I was a physio and he an orthopaedic surgeon. Over the week, it became clear people had moved to cycling from team sports and running because cycling didn’t hurt their hips as much.

We then remembered the story of Floyd Landis, the 2006 Tour de France winner. He was subsequently stripped of his medal for using performance-enhancing drugs – but the point is, he had a hip replacement just three months after the race. Every evening of the Tour, his hip pain was so bad he was carried to his bedroom. Yet when he got on the bike, he could still cycle.

How did this inspire CHAIN?

We started experimenting with our patients, using indoor cycling as one of the most inclusive forms of group exercise; everyone can do it at their own level.

We embraced learnings from cardiac rehab, where education sessions are used to explain the need to exercise

We also embraced learnings from my time as a junior physio running cardiac rehab sessions, where everyone was scared stiff of raising their heart rate for fear of another heart attack. Education sessions were used explain the need to exercise, raise heart rates and get fitter to avoid another heart attack.

There’s a similar need for education on osteoarthritis. When something hurts, our instinct is to stop doing it – but not moving osteoarthritic joints causes them to stiffen and become more painful. Moving the joint mobilises it and has an analgesic effect, as well as recruiting the muscles around it so they become stronger.

And of course, if we exercise in a way that promotes an aerobic response, we also train the cardiovascular system and release endorphins, further regulating pain.

This model of education plus exercise – specifically indoor cycling for our audience – inspired CHAIN. We secured funding for a pilot from our local GP practice and took 96 patients through what was then a six-week programme; in response to patient feedback, it’s now eight weeks.

Tell us about CHAIN.

Designed specifically for those with hip pain and hip osteoarthritis, CHAIN is a weekly group programme of 30 minutes’ education on self-managing the condition, followed by 30 minutes of modified indoor cycling. The group aspect – ideally 12–15 people – enables a sense of camaraderie and mutual encouragement.

Our education sessions consist of a five-minute video on a different topic each week, followed by a group discussion. We’re very open and fluid around what the participants want to know and will signpost them towards any specific advice they want.

We cover topics such as the benefits of exercise; planning for continued physical activity after the programme; lifestyle modifications such as smoking cessation and diet – there’s good evidence linking high levels of processed foods with arthritis; and assistive devices such as walking poles. We even discuss gadgets and supplements, from copper bracelets to turmeric, taking a neutral stance by simply presenting the scientific evidence as it exists.

For the cycling, we’ve designed our own interval-based programme. The first couple of weeks are relatively sedate and, as we build up, it’s initially with a focus on cadence rather than resistance. We don’t want to put people off with muscle soreness in the early weeks, preferring to shift the work to the heart and lungs.

By the end of the eight weeks, it’s similar to a light, entry-level indoor cycling class at the local leisure centre.

We keep it pretty simple and we aren’t precious about it. The important thing is they’re pedalling.

We encourage participants to stay in the saddle, we make sure they’re comfortable on the bike and we talk to them about technique – about recruiting muscles on the up- as well as the down-stroke. But to be honest, we keep it pretty simple and we aren’t precious about it. The important thing is they’re pedalling.

As they get into it, some really get a sweat on. Others just turn their legs for half an hour, but that may be far more than they’ve done for a very long time. Even just turning their legs at an RPM of 60 or 70, they’ll do thousands of hip mobilisations in the space of half an hour, all in a range they might normally struggle to do.

How is CHAIN delivered?

From the outset, CHAIN has been delivered in partnership with local leisure trust BH Live, which operates the Littledown Leisure Centre opposite Bournemouth Hospital.

This is critical, because exercise works for osteoarthritis only for as long as you keep exercising. By conducting our sessions in a leisure centre, we open the door to all the other activities on offer and show our patients they belong there. They might carry on cycling after the eight weeks – there’s a Nice & Easy Spin class timetabled right after CHAIN – or they might choose something else. The point is, they’re in the right place to stay active.

Even just turning legs at an RPM of 60 or 70 means thousands of hip mobilisations in half an hour

The education session is always facilitated by a senior physiotherapist from the hospital, but the cycling class is delivered by a BH Live instructor. That’s important. We give the instructor the workout profile, but we limit the clinical knowledge we share – we don’t want to negatively impact their belief in anyone’s abilities – and they bring their own personality and music to class, de-medicalising the experience and making it fun.

The physiotherapist takes part in the cycling, too. They can jump off and help if anyone’s struggling, but riding alongside the patients helps normalise the experience.

This integrated, supportive group approach – bringing together the hospital’s and the leisure centre’s respective expertise – is key. It simply doesn’t work as well if patients are blindly referred to an indoor cycling class where no-one else has the same problem as them. It takes a certain type of patient and personality to brave that out.

What results have you achieved?

In our initial pilot, over 80 per cent of patients had improved function, less pain and improved strength after the programme, with 100 per cent saying they would recommend CHAIN to a friend.

We followed up five years later and found that 45 per cent had not returned to their GP for further treatment of their hip pain; 57 per cent had avoided surgical intervention; 96 per cent felt CHAIN had increased their ability to self-manage their hip pain; and 100 per cent were engaged in physical activity at least once a week.

There wasn’t a control group in our study and there isn’t any national data to benchmark against, but we believe these to be strong findings.

Over 80 per cent of patients had improved function, less pain and improved strength after the programme

We then did a second study among patients referred to a surgeon, this time with funding from the hospital. Where surgery was deemed not presently necessary, patients were referred to CHAIN rather than to physiotherapy.

Between February 2018 and September 2019, 167 patients completed the CHAIN programme and demonstrated similar improvements to the original cohort in terms of pain, function, quality of life and motivation to exercise. There were slightly more patients who didn’t benefit – likely because their osteoarthritis had progressed to the point of surgical referral – but the results were still positive.

Tell us about your latest study.

Our success allowed us to apply to the National Institute for Health Research to do a randomised controlled trial – since published in The Lancet – to evaluate the CHAIN intervention versus standard NHS one-to-one physiotherapy.

From a total of 221 participants, 111 were randomly allocated to physiotherapy and 110 to CHAIN. Our primary outcome measure was the ADL (Activities of Daily Living) score, looking at patients’ reported pain and hip function before intervention and at 10 weeks post-treatment.

With physiotherapy, the average ADL score increased by 6.1 points. With CHAIN, it increased by 12.7 points – 6.6 points more than with physiotherapy.

Economic analysis showed CHAIN to be economically far more effective than standard physiotherapy

Note that we had been looking for a minimum 7.4 point difference between the groups. However, subsequent published studies have found any difference over 6.0 points to be clinically significant.

Alongside this, economic analysis showed CHAIN to be economically far more effective than standard physiotherapy. NICE has a cost-effectiveness threshold of £20,000–30,000 per Quality Adjusted Life Year (QALY) to decide whether a treatment is an acceptable use of NHS resources. CHAIN cost just £3,000–4,000 per QALY.

Should the physio model change?

Some patients need one-to-one care, but for high-volume conditions, it’s worth looking for commonalities that might allow for group-based treatment. One physiotherapist seeing 15 patients at a time is an effective way to manage NHS waiting lists.

Additionally, the NHS isn’t going to have the money to support everyone being treated for every condition moving forward. Self-management will be key.

Of course, just because it works in hips, doesn’t mean it will work exactly the same for other specialities; we’ve responsibly researched CHAIN and evaluated it against standard care, so we know we’re doing the right thing. However, there probably are lots of other groups of patients we could treat in a similar way. We should certainly be looking at this.

For high-volume conditions, it’s worth looking for commonalities that might allow for group-based treatment

The key point, though, is that it has to be choreographed. You can’t just hand a patient off to a leisure centre. You have to invest in the relationship, as we have with BH Live, working closely together, understanding each other’s needs, respecting each other’s strengths and appreciating the value we each bring.

Is CHAIN an ongoing programme?

CHAIN takes place at Littledown Leisure Centre every Tuesday, funded as part of normal NHS practice: patients are referred to the hospital’s physio department; suitable patients are referred on to CHAIN; and the hospital pays the leisure centre to host the sessions and run the cycling classes. A new cohort starts every eight weeks; we have 18 in the current group.

We’re rolling CHAIN out, making all our content available for free. We’ve also created a toolkit for other hospitals.

We’re also rolling CHAIN out, making all our content available for free. The cycling sessions can be found on YouTube, while our free ORI Education app – available on Apple and Android – shares all the educational videos, educational material and cycling videos, so people can do the programme from home if they don’t live close enough for an in-person referral.

We’ve also created a toolkit for other hospitals: launching in early 2026, it will be accessible via our web page. And we’ve already trained the team at the Royal Orthopaedic Hospital in Birmingham, which is now [October 2025] on its second cohort, partnering with Cocks Moors Woods Leisure Centre.

Increasingly, this is the way we’re going to have to work. We don’t have the capacity in the NHS to see everyone as much as we’d like, so we have to promote self-management. We have to step outside of the NHS, recognise the expertise and willingness that exists in the health and fitness industry and embed these partnerships within our standard practice.

Leading their field

Tom Wainwright is a professor of orthopaedics at Bournemouth University, deputy head of the university’s Orthopaedic Research Institute and a physiotherapist at University Hospitals Dorset NHS Foundation Trust. He has worked in the field of hip osteoarthritis for over 20 years, is recognised as an international expert in Enhanced Recovery After Surgery (ERAS) protocols in orthopaedics and was lead author of the first ERAS Society guidelines for hip and knee replacement.

Rob Middleton is a professor of orthopaedics at Bournemouth University and a consultant orthopaedic surgeon specialising in robotic hip replacement procedures. He was previously national clinical lead in hip and knee replacement at the NHS Institute of Innovation and Improvement, specialising in the development of enhanced techniques for faster recovery and better outcomes from surgery.

The Lancet-published study was a collaboration between the team at Bournemouth University’s Orthopaedic Research Institute, the University Hospitals Dorset NHS Foundation Trust physiotherapy department and BH Live.

CHAIN resources

• Find out more on the CHAIN web page
• Read The Lancet article
• Download the Android app
• Download the iPhone app
• View the CHAIN content on YouTube