Internet-based Exercise Research Articles

Effects of internet-based exercise intervention on depression and anxiety: A systematic review and meta-analysis.

While exercise is acknowledged for its positive effects on depression and anxiety symptoms, the benefits of internet-based exercise on mental health have not been extensively examined. This study seeks to systematically review and quantify the outcomes of high-quality randomized controlled trials (RCTs) that investigate the impact of internet-based exercise on depression and anxiety symptoms. Following the PRISMA 2020 guidelines, we conducted a comprehensive meta-analysis of RCTs. Databases, including Web of Science Core Collection, PubMed, PsycINFO, Medline, BIOSIS Previews, SPORTDiscus, and Education Source, were scoured through in September 2023. After quality assessment and data extraction, the analysis was performed using R. Using random effects models, effect sizes were determined and subsequently represented as standardized mean differences (SMD). Our analysis incorporated data from 11 RCTs, involving a cohort of 1009 participants. We observed a modest yet significant reduction in depression and anxiety symptoms, with an SMD of -0.44 [95% confidence interval (CI) (-0.63, -0.26), I^2 = 79.3%, P < .01]. Interestingly, the effects were more pronounced in individuals diagnosed with depression, as indicated by an SMD of -0.96 [95% CI (-1.55, -0.37), I^2 = 82%, P < .01]. Furthermore, participants utilizing smartphone applications as part of their intervention reported a meaningful reduction in their symptoms, evidenced by an SMD of -0.52 [95% CI (-0.90, -0.14), I^2 = 87%, P < .01]. Additionally, short-term interventions, specifically those lasting <12 weeks, indicated a notable alleviation in depression symptoms, with an SMD of -0.76 [95% CI (-1.38, -0.14), I^2 = 86%, P < .01]. Internet-based exercise interventions yield significant amelioration in depression and anxiety symptoms, with heightened efficacy observed among individuals with depression. Notably, short-term interventions, specifically those under 12 weeks, demonstrate enhanced benefits for depression relief.

The effect of telerehabilitation on improving the physical activity of patients with osteoarthritis: A systematic review

This systematic review aimed to evaluate the effect of telerehabilitation on improving physical activity, physical function, and quality of life in patients with osteoarthritis (OA). A systematic review of randomized controlled trial studies was conducted without a time limit by searching for keywords in the title, abstract, and study keywords in the scientific databases Embase, Web of Science, Scopus, and PubMed on October 20, 2021. This study was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Titles and abstracts were retrieved based on the inclusion, exclusion, and quality assessment criteria. Then, full texts were retrieved and reviewed independently by two separate authors based on the eligibility criteria. Disputes were resolved through discussion. A form with the same predefined elements was used to extract data. Totally, eight eligible articles were found through this review. The studies on telerehabilitation approaches were categorized into three categories, which are: home-based exercise programs by online mobile applications, sports counseling and physiotherapist support via telephone calls, and Internet-based exercise training (IBET). In four studies (57%), telerehabilitation was effective in the short term for some months and improved the performance, self-efficacy, and quality of life of participants. On the other hand, in the long-term effects, there was no difference in participants' improvement (43%). In long-term follow-up, there was no difference between the efficiency of traditional rehabilitation and telerehabilitation in improving the physical performance and quality of life. However, telerehabilitation can be a viable alternative to traditional physiotherapy in patients with OA.

Precision Medicine-Based Machine Learning Analyses to Explore Optimal Exercise Therapies for Individuals With Knee Osteoarthritis: Random Forest-Informed Tree-Based Learning.

We applied a precision medicine-based machine learning approach to discover underlying patient characteristics associated with differential improvement in knee osteoarthritis symptoms following standard physical therapy (PT), internet-based exercise training (IBET), and a usual care/wait list control condition. Participants (n = 303) were from the Physical Therapy vs Internet-Based Training for Patients with Knee Osteoarthritis trial. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12-month follow-up. Random forest-informed tree-based learning was applied to identify patient characteristics that were critical to improving outcomes, and patients with those features were grouped. Age, BMI, and Brief Fear of Movement (BFOM) score, all at baseline, were identified as characteristics that effectively divided participants, creating 6 subgroups. Assigning treatments according to these models, compared to assigning a single best treatment to all patients, resulted in greater improvements of the average WOMAC at 12 months (P = 0.01). Key patterns were that IBET was the optimal treatment for patients of younger age and low BFOM, whereas PT was the optimal treatment for patients of older age, high BFOM, and BMI (kg/m2) between 26.3 and 37.2. These results suggest that easily assessed patient characteristics including age, fear of movement, and BMI could be used to guide patients toward either home-based exercise or PT, though additional studies are needed to confirm these findings. (ClinicalTrials.gov: NCT02312713).

Feasibility of Internet-Based Physical-Cognitive Exercise for Health Benefits of Middle-Aged Obese Women.

Obesity in middle-aged women markedly increases the risk for non-communicable diseases, neurodegenerative diseases, and physical and cognitive problems. Exercise, particularly combined physical-cognitive exercise, has been demonstrated to have beneficial effects on both physical and cognitive health. However, middle-aged women often face barriers to engaging in exercise, which include time constraints, lack of motivation, and enjoyment. Incorporating an exercise program into a technology-based intervention in the home environment may help overcome these barriers and promote health benefits. Therefore, this study aimed to assess the feasibility of home-based, physical-cognitive internet-based exercise for middle-aged obese women. A total of 33 middle-aged obese women were enrolled in the study. Participants performed an intervention for 60 min/day, 3 days/week for 3 months. Feasibility outcomes (adherence, adverse events, physical performances, obesity parameters, and enjoyment of the program) were measured. Average exercise adherence was 91.67%, and no adverse events were reported in this feasibility study. At the end of the training period, body weight and BMI were significantly decreased compared to baseline. As for physical performances, both cardiorespiratory fitness and lower limb muscle power were significantly improved at post-training when compared to baseline. Furthermore, the participants experienced a high level of exercise enjoyment, and it was maintained over the 3-month training period. These findings suggest that home-based, internet-based physical-cognitive exercise was safe and feasible for reducing obesity parameters, improving physical function, maintaining enjoyment over the course of training, and facilitating adherence to exercise in middle-aged obese women.

Application of Heterogeneity of Treatment-Effects Methods: Exploratory Analyses of a Trial of Exercise-Based Interventions for Knee Osteoarthritis.

To evaluate heterogeneity of treatment effects in a trial of exercise-based interventions for knee osteoarthritis (OA). Participants (n = 350) were randomized to standard physical therapy (PT; n = 140), internet-based exercise training (IBET; n = 142), or wait list (WL; n = 68) control. We applied qualitative interaction trees (QUINT), a sequential partitioning method, and generalized unbiased interaction detection and estimation (GUIDE), a regression tree approach, to identify subgroups with greater improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score over 4 months. Predictors included 24 demographic, clinical, and psychosocial characteristics. We conducted internal validation to estimate optimism (bias) in the range of mean outcome differences among arms. Both QUINT and GUIDE indicated that for participants with lower body mass index (BMI), IBET was better than PT (improvements of WOMAC ranged from 6.3 to 9.1 points lower), and for those with higher BMI and a longer duration of knee OA, PT was better than IBET (WOMAC improvement was 6.3 points). In GUIDE analyses comparing PT or IBET to WL, participants not employed had improvements in WOMAC ranging from 1.8 to 6.8 points lower with PT or IBT versus WL. From internal validation, there were large corrections to the mean outcome differences among arms; however, after correction, some differences remained in the clinically meaningful range. Results suggest there may be subgroups who experience greater improvement in symptoms from PT or IBET, and this finding could guide referrals and future trials. However, uncertainty persists for specific treatment-effects size estimates and how they apply beyond this study sample.

Cost and Quality of Life Outcomes of the STepped Exercise Program for Patients With Knee OsteoArthritis Trial

ObjectivesThis study aimed to evaluate the cost-effectiveness of the randomized clinical trial STEP-KOA (STepped Exercise Program for patients with Knee OsteoArthritis). MethodsThe trial included 230 intervention and 115 control participants from 2 Veterans Affairs (VA) medical centers. A decision tree simulated outcomes for cohorts of patients receiving arthritis education (control) or STEP-KOA (intervention), which consisted of an internet-based exercise training program (step 1), phone counseling (step 2), and physical therapy (step 3) according to patient’s response. Intervention costs were assessed from the VA perspective. Quality of life (QOL) was measured using 5-level EQ-5D US utility weights. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in costs divided by the difference in quality-adjusted life-years (QALYs) between arms at 9 months. A Monte Carlo probabilistic sensitivity analysis was used to generate a cost-effectiveness acceptability curve. ResultsThe adjusted model found differential improvement in QOL utility weights of 0.042 (95% confidence interval 0.003-0.080; P=.03) for STEP-KOA versus control at 9 months. In the base case, STEP-KOA resulted in an incremental gain of 0.028 QALYs and an incremental cost of $279 per patient for an ICER of $10 076. One-way sensitivity analyses found the largest sources of variation in the ICER were the impact on QOL and the need for a VA-owned tablet. The probabilistic sensitivity analysis found a 98% probability of cost-effectiveness at $50 000 willingness-to-pay per QALY. ConclusionsSTEP-KOA improves QOL and has a high probability of cost-effectiveness. Resources needed to implement the program will decline as ownership of mobile health devices increases.

Precision medicine-based machine learning analyses to explore optimal exercise therapies for individuals with knee osteoarthritis

Purpose: Exercised-based interventions, including physical therapy (PT) are core treatments for knee osteoarthritis (OA). Patients vary considerably in their level of improvement following different exercise-based interventions, but very little is known about drivers of this variability. Precision medicine-based machine learning methods can be used to identify optimal treatments for each patient, based on individual characteristics. In these analyses, we used a precision medicine approach to discover factors underlying differential improvement in the Physical Therapy vs Internet-Based Exercise Training for Knee OA (PATH-IN) trial, which compared the effects of standard PT with internet-based exercise training (IBET), both relative to a usual care / wait list control group (WT). Methods: The PATH-IN study enrolled 350 participants with symptomatic knee OA (physician diagnosis and pain, aching or stiffness on most days of the week). Outcomes were assessed at baseline, 4-month follow-up (primary outcome time point) and 12-month follow-up. The primary outcome for both PATH-IN and these exploratory analyses was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score. Some participants were missing WOMAC scores at follow-up, resulting in sample sizes of 303 and 302 participants for analyses of 4- and 12-month outcomes, respectively. Our precision medicine approach involved estimating an “optimal treatment regime” (from among the 3 study arms of PT, IBET, and WT) for each patient. To address limitations of existing machine learning methods, particularly the ability to identify factors that drive the optimal treatment, we developed a new algorithm, Tree-based Interpretable Learning. This algorithm divides study participants into multiple disjoint subgroups where each subgroup receives a single optimal treatment among the three options. The algorithm judiciously splits the data set into two groups in a way that maximizes the average outcome after assigning estimated treatments, by random forest (which is an ensemble of multiple decision trees), to the first group and assigning one of three treatments to the other group. The algorithm then repeats splitting the group that received estimated treatments by a random forest in the previous step until the splitting no longer sufficiently improves the cross-validated estimate of the average outcome. In each loop, the improvement is evaluated by testing the difference of the cross-validated estimate of the average outcome of the estimated treatment regime and the estimate of the average outcome of the zero-order model (ZOM), which assigns a single best treatment to all patients. This methodology is meaningful in that it produces an interpretable treatment rule by utilizing random forests, which yields a low-bias estimate yet reduces the “black-box” aspect of machine learning algorithms. We conducted separate analyses for 4- and 12-month outcomes. Participant demographic, clinical, and psychosocial characteristics included as potential predictors of the optimal treatment regime are shown in Table 1. Results: For the analysis for WOMAC score at the 4-month follow-up, body mass index (BMI), Brief Fear of Movement score (BF; higher scores indicate more fear of movement), and Self Efficacy for exercise scale (SE; higher scores indicate greater self-efficacy) were identified as characteristics that effectively divided participants, creating five subgroups (Figure 1). For the analysis for WOMAC score at the 12-month follow-up, age, BMI, and BF score were identified as important features resulting in seven disjoint subgroups (Figure 2). Improvement over the average outcome was seen for both the 4- and 12-month follow-up visits (p=0.0062 and p=0.0042, respectively). Conclusions: In this study, optimal treatment regimes were identified for 4- and 12-month WOMAC outcomes, yielding significantly improved estimates compared with the average outcome. This indicates that the proposed, tailored regimes would be more beneficial to participants than assigning a single best treatment (based on overall results from the clinical trial) to all patients. Importantly, multiple subgroups of patients were assigned to IBET as the optimal treatment regime; two key characteristics of these subgroups were lower BMI and low fear of movement. Patients with these characteristics may benefit from a low-cost, self-directed program and may not require PT, which can be more costly. In contrast, results suggest that patients with higher BMI and greater fear of movement may benefit most from PT. There was a subgroup of patients for whom WT was the optimal treatment regime at 4 months, indicating that neither PT nor IBET were particularly effective. This subgroup was characterized by very high BMI; based on prior research, these patients may experience the most benefit initially with a weight loss intervention. In summary, these analyses identified easy-to-assess patient characteristics that can help tailor referrals to different exercise-based interventions for knee OA. Additional studies are needed to confirm these findings in other samples and for other exercise-based therapies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Foot-ankle functional outcomes of using the Diabetic Foot Guidance System (SOPeD) for people with diabetic neuropathy: a feasibility study for the single-blind randomized controlled FOotCAre (FOCA) trial I

BackgroundDiabetic neuropathy dramatically affects musculoskeletal structure and function of the lower limbs by impairing their muscle strength and mobility. Specific muscle strengthening through physiotherapy strategies appears to be promising; however, adherence to physiotherapy treatment is low in people with chronic diseases. Thus, an internet-based foot-ankle exercise program was created as a potential telerehabilitation alternative for people with diabetes to improve their self-monitoring and self-care management. This study assessed the feasibility, safety, acceptability, and changes in foot health and neuropathy symptoms in people with diabetes after 12 weeks of the intervention program with the Sistema de Orientação ao Pé diabético - Diabetic Foot Guidance System (SOPeD).MethodsFourteen individuals were recruited and randomized to either the usual care (control group) or usual care plus an internet-based foot-ankle exercise program through SOPeD (intervention group) three times per week for 12 weeks. For feasibility, we assessed contact and recruitment rates per week; program adherence, determined as completing over 70% of the 36 sessions; and participant satisfaction and safety assessed through a questionnaire and scored on a 5-point Likert scale. We assessed changes in neuropathy symptoms and foot health and functionality from baseline to 12 weeks estimating differences or median of differences and 95% confidence intervals in the intervention group.ResultsIn 24 weeks, of the 822 patients in the database, 192 were contacted, 65 were assessed for eligibility, and 20 were considered eligible. The recruitment rate was 0.83 participants per week. Fourteen out of the 20 eligible participants agreed to participate, resulting in recruitment success of 70%. Adherence to the program was 66.7%, and there was no dropout. Participants’ median level of satisfaction was 5.0 (IQR: 4.5–5.0) and perceived safety was 5.0 (IQR: 5.0–5.0).ConclusionThe internet-based foot-ankle exercise program using SOPeD is feasible, satisfactory, and safe. Although this study had moderate adherence and a zero-dropout rate, recruitment needs to be improved in the larger trial.Trial registrationClinicalTrials.gov, NCT04011267. Registered on 8 July 2019.

Effectiveness of Internet-Based Exercises Aimed at Treating Knee Osteoarthritis

Osteoarthritis is a prevalent, debilitating, and costly chronic disease for which recommended first-line treatment is underused. To compare the effect of an internet-based treatment for knee osteoarthritis vs routine self-management (ie, usual care). This randomized clinical trial was conducted from October 2018 to March 2020. Participants included individuals aged 45 years or older with a diagnosis of knee osteoarthritis recruited from an existing primary care database or from social media advertisements were invited. Data were analyzed April to July 2020. The intervention and control group conformed to first-line knee osteoarthritis treatment. For the intervention group, treatment was delivered via a smartphone application. The control group received routine self-management care. The primary outcome was change from baseline to 6 weeks in self-reported pain during the last 7 days, reported on a numerical rating scale (NRS; range, 0-10, with 0 indicating no pain and 10, worst pain imaginable), compared between groups. Secondary outcomes included 2 physical functioning scores, hamstring and quadriceps muscle strength, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and quantitative sensory testing. Among a total of 551 participants screened for eligibility, 146 were randomized and 105 were analyzed (mean [SD] age, 66.7 [9.2] years, 71 [67.1%] women), including 48 participants in the intervention group and 57 participants in the control group. There were no significant differences in baseline characteristics between the groups. At the 6-week follow-up, the intervention group showed a greater NRS pain score reduction than the control group (between-group difference, -1.5 [95% CI, -2.2 to -0.8]; P < .001). Similarly, the intervention group had better improvements in the 30-second sit-to-stand test (between-group difference, 3.4 [95% CI, 2.2 to 4.5]; P < .001) and Timed Up-and-Go test (between-group difference, -1.8 [95% CI, -3.0 to -0.5] seconds; P = .007), as well as the WOMAC subscales for pain (between-group difference, -1.1 [95% CI, -2.0 to -0.2]; P = .02), stiffness (between-group difference, -1.0 [95% CI, -1.5 to -0.5]; P < .001), and physical function (between-group difference, -3.4 [95% CI, -6.2 to -0.7]; P = .02). The magnitude of within-group changes in pain (d = 0.83) and function outcomes (30 second sit-to-stand test d = 1.24; Timed Up-and-Go test d = 0.76) in the intervention group corresponded to medium to very strong effects. No adverse events were reported. These findings suggest that this internet-delivered, evidence-based, first-line osteoarthritis treatment was superior to routine self-managed usual care and could be provided without harm to people with osteoarthritis. Effect sizes observed in the intervention group corresponded to clinically important improvements. ClinicalTrials.gov Identifier: NCT03545048.

Stepped Exercise Program for Patients With Knee Osteoarthritis : A Randomized Controlled Trial.

Evidence-based models are needed to deliver exercise-related services for knee osteoarthritis efficiently and according to patient needs. To examine a stepped exercise program for patients with knee osteoarthritis (STEP-KOA). Randomized controlled trial. (ClinicalTrials.gov: NCT02653768). 2 U.S. Department of Veterans Affairs sites. 345 patients (mean age, 60 years; 15% female; 67% people of color) with symptomatic knee osteoarthritis. Participants were randomly assigned in a 2:1 ratio to STEP-KOA or an arthritis education (AE) control group, respectively. The STEP-KOA intervention began with 3 months of an internet-based exercise program (step 1). Participants who did not meet response criteria for improvement in pain and function after step 1 progressed to step 2, which involved 3 months of biweekly physical activity coaching calls. Participants who did not meet response criteria after step 2 went on to in-person physical therapy visits (step 3). The AE group received educational materials via mail every 2 weeks. Primary outcome was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Scores for the STEP-KOA and AE groups at 9 months were compared by using linear mixed models. In the STEP-KOA group, 65% of participants (150 of 230) progressed to step 2 and 35% (81 of 230) to step 3. The estimated baseline WOMAC score for the full sample was 47.5 (95% CI, 45.7 to 49.2). At 9-month follow-up, the estimated mean WOMAC score was 6.8 points (CI, -10.5 to -3.2 points) lower in the STEP-KOA than the AE group, indicating greater improvement. Participants were mostly male veterans, and follow-up was limited. Veterans in STEP-KOA reported modest improvements in knee osteoarthritis symptoms compared with the control group. The STEP-KOA strategy may be efficient for delivering exercise therapies for knee osteoarthritis. Department of Veterans Affairs, Health Services Research and Development Service.

Twelve-Week Internet-Based Individualized Exercise Program in Adults With Systemic Lupus Erythematosus: Protocol for a Randomized Controlled Trial.

BackgroundSystemic lupus erythematosus is a systemic autoimmune disease, which is associated with high cardiovascular risk, a predisposition to metabolic disorders, muscle wasting, and fatigue. Exercise therapy has become an important part of the long-term treatment of comorbidities in systemic lupus erythematosus. Exercise can lead to various benefits in patients with systemic lupus erythematosus such as increased aerobic capacity and exercise tolerance, resulting in an increased quality of life, decreased depression, and decreased fatigue. At the moment, no evidence-based treatment guidelines that recommend exercise for patients with systemic lupus erythematosus exist. Also, the efficacy of different training programs requires further investigation.ObjectiveThis study focuses on the feasibility, efficacy, and safety of an internet-based exercise program in patients with systemic lupus erythematosus. Furthermore, we investigate the feasibility and efficiency of anaerobic training compared to aerobic training.MethodsOverall, patients with systemic lupus erythematosus from the Division of Nephrology, Rheumatology, and Immunology outpatient clinic of the University Medical Center Mainz who are clinically stable status are included and randomized in an aerobic exercise group (n=10), anaerobic exercise group (n=10), or treatment as usual group (n=10). After completing initial clinical testing and physical fitness tests, patients undergo supervised 12-week online exercise programs, receiving weekly individualized training plans adapted to their physical performance. The primary outcome is change in physical fitness (VO2 peak) after 12 weeks compared to baseline. Secondary outcomes are disease activity measured via laboratory results (complement, autoantibodies) and questionnaires, as well as changes in muscle mass (anaerobic exercise group), results of the Chair-Stand test, and measurements of circulating cell-free DNA and extracellular vesicles.ResultsThe study was registered in May 2019. Enrollment began in May 2019. Of 40 patients who were initially screened, 30 patients fulfilled the inclusion criteria and were included in the study; 1 participant withdrew prior to the start of the exercise program. Among the 25 patients who completed the study, no serious adverse events have been reported; 3 participants withdrew during the program (due to frequent colds, n=1; Crohn relapse, n=1; physical strain, n=1), and 1 participant has not yet completed the program. Data analysis is ongoing, and results are expected to be submitted for publication in January 2021.ConclusionsWe expect the online exercise intervention to be a feasible and efficient tool to provide regular individualized exercise for patients with systemic lupus erythematosus.Trial RegistrationClinicalTrials.gov NCT03942718; http://clinicaltrials.gov/ct2/show/NCT03942718.International Registered Report Identifier (IRRID)DERR1-10.2196/18291

Evaluating the efficacy of Internet-Based Exercise programme Aimed at Treating knee Osteoarthritis (iBEAT-OA) in the community: a study protocol for a randomised controlled trial

IntroductionKnee osteoarthritis (OA) is the most common joint disease worldwide. As of today, there are no disease-modifying drugs, but there is evidence that muscle strengthening exercises can substantially reduce pain...

Internet-based Physical Activity Promotion and Exercise Prescription for People With Multiple Sclerosis

Internet-based Physical Activity Promotion and Exercise Prescription for People With Multiple Sclerosis

Health Behaviour Theory in Health Informatics: Support for Positive Change.

The rising use of the Internet and information technology has made computerized interventions an attractive channel for providing advice and support for behaviour change. Health behaviour and behaviour change theories are a family of theories which aim to explain the mechanisms by which human behaviours change and use that knowledge to promote change. Among the best-known of these theories are the Social Learning and Social Cognitive theories, the Health Belief Model, the Theory of Reasoned Action and its successors the Theory of Planned Behaviour and the Reasoned Action Approach, and the Transtheoretical model. We discuss three examples of how behaviour change theories have been applied in computer-based interventions: a system to aid users to quit smoking, a decision aid for choice of breast cancer therapy, and an internet-based exercise program for reducing cardiovascular risk. We also discuss misapplication of theory, and reflect on how these theories can best be used. Behaviour change theory can be applied in health informatics interventions in several ways; for example, to select participants for a particular intervention, to shape the content of the intervention to effectively influence behaviour, or to tailor content to individual needs. Application of these theories to provide personalized advice ("decision support") is a young but promising area of research, and could inform other decision support interventions, including those that provide support for clinicians.

STepped exercise program for patients with knee OsteoArthritis (STEP-KOA): protocol for a randomized controlled trial

BackgroundPhysical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions.Methods / DesignStep-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA.DiscussionSTEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA.Trial RegistrationClinicaltrials.gov, NCT02653768 (STepped Exercise Program for Knee OsteoArthritis (STEP-KOA)), Registered January 12, 2016.

Fall Risk and Utilization of Balance Training for Adults With Symptomatic Knee Osteoarthritis: Secondary Analysis From a Randomized Clinical Trial.

Knee osteoarthritis (KOA) is a common disease that hinders activity participation in older adults. Associated symptoms and physiological changes can increase risk of falling in individuals with KOA. Balance training can decrease fall risks in older adults. Limited evidence exists regarding utilization of balance training in physical therapy (PT) for this population. This secondary data analysis investigated the proportion of participants at high risk for falling in the PhysicAl THerapy vs. INternet-based Exercise Training for Patients with Osteoarthritis (PATH-IN) study and the frequency with which balance training was utilized as an intervention in PT. PATH-IN study participants (N = 344) performed the Four-Stage Balance Test and the Timed Up and Go (TUG) test during baseline assessment. Participants were randomly allocated to PT, an Internet-based exercise program, or a control group. Participants were classified as being at high risk for falling if they did not progress to the single-leg stance (SLS) during the Four-Stage Balance Test, were unable to maintain SLS for 5 seconds, or took longer than 13.5 seconds to complete the TUG test. The proportion of participants at high risk for falling was calculated for all participants and separately for those allocated to PT. In addition, PT notes were coded for balance training and the frequency of balance training utilization was calculated. Upon enrollment, 35.5% (N = 122) of all participants and 36.2% (N = 50) of those allocated to PT were at high risk for falling. Of participants allocated to PT with documentation available for coding (N = 118), 35.5% (N = 42) were at high risk for falling. Balance training was provided to 62.7% (N = 74) during at least one PT session. Of those classified as being at high risk for falling, 33.3% (N = 14) did not receive balance training. The finding of high fall risks in more than one-third of all participants with KOA is consistent with previous reports of a higher risk of falling in this population. Many PT participants did receive some balance training; however, one-third of participants at high risk for falling did not. Balance training for individuals with KOA at high risk for falling may be underutilized.

Level of participation in physical therapy or an internet-based exercise training program: associations with outcomes for patients with knee osteoarthritis

BackgroundTo examine whether number of physical therapy (PT) visits or amount of use of an internet-based exercise training (IBET) program is associated with differential improvement in outcomes for participants with knee osteoarthritis (OA).MethodsA secondary analysis was performed using data from participants in 2 arms of a randomized control trial for individuals with symptomatic knee OA: PT (N = 135) or IBET (N = 124). We examined associations of number of PT visits attended (up to 8) or number of days the IBET website was accessed during the initial 4-month study period with changes in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total, pain and function subscales, as well as a 2-min Step Test, at 4-month and 12-month follow-up.ResultsParticipants with more PT visits experienced greater improvement in WOMAC total score (estimate per additional visit = − 1.18, CI 95% = − 1.91, 0.46, p < 0.001) and function subscore (estimate = − 0.80, CI 95% = − 1.33, − 0.28, p < 0.001) across follow-up periods. For WOMAC pain subscale, the association with number of PT visits varied significantly between 4- and 12-month follow-up, with a stronger relationship at 4-months. There was a non-significant trend for more PT visits to be associated with greater improvement in 2-min Step Test. More frequent use of the IBET website was not associated with greater improvement for any outcome, at either time point.ConclusionIncreased number of PT visits was associated with improved outcomes, and some of this benefit persisted 8 months after PT ended. This provides guidance for PT clinical practice and policies.Trial registrationNCT02312713, posted 9/25/2015.

Level of participation in physical therapy or an internet-based exercise training program: associations with outcomes for patients with knee osteoarthritis

Level of participation in physical therapy or an internet-based exercise training program: associations with outcomes for patients with knee osteoarthritis

Identifying subgroups of patients with differential benefit from physical therapy or internet-based exercise training for knee osteoarthritis

Identifying subgroups of patients with differential benefit from physical therapy or internet-based exercise training for knee osteoarthritis

Associations of number of physical therapy visits and frequency of use of an internet-based exercise training program with knee osteoarthritis outcomes

Associations of number of physical therapy visits and frequency of use of an internet-based exercise training program with knee osteoarthritis outcomes