The feasibility and cost effectiveness of E-Exercise: a combination of a physical therapy treatments and a web-based intervention in patients with knee and hip osteoarthritis

Among the elderly, osteoarthritis (OA) is worldwide one of the leading causes
of pain and disability. Most common affected sites are the hip and knee (Issa,
2013). In the Netherlands, it is estimated that 312.000 persons suffer from
knee OA and 238.000 from hip OA (Poos, 2009) OA is an age-related
disease(Zhang, 2010) and besides pain and disability, characterized by morning
stiffness, reduced range of motion, instability of the joint,(Poos, 2009) loss
of health related quality of life(Salaffi,2005) and mortality (Nüesch, 2010).
Due to the aging population and the increasing number of people with obesity,
expected prevalence of knee and hip OA is 52% in 2040. Healthcare costs related
to OA were about 715 million euro in 2007, which was 14.4% of total healthcare
costs of musculoskeletal diseases in The Netherlands (Poos, 2009) .In order to
regulate these costs while the population with OA is growing, there is a need
for cost-effective interventions.

Because of OA related clinical symptoms people with hip and/or knee OA are less
physically active than the general population (De Groot, 2008, Rosemann 2013).
Where symptoms of OA results in less physical activities, in long term physical
inactivity may lead to physical decline, psychological problems and eventually
functional decline (Dunlop, 2006; Pisters, 2012).Since research showed that
physical activity is beneficial for reducing pain and improvement of physical
functioning (Dunlop2011), physical activity is widely recommended by national
and international (physical therapy) guidelines (Zhang,2008)

Besides physical activity, information and self-management are recommended in
order to improve physical functioning (Zhang, 2008; Peter, 2010. The inclusion
of information is important since a lack of knowledge among OA patients
appeared to be related to depression, anxiety and a passive coping style
(Lorig. 1993). Self-management appeared to reduce disability and health related
costs as in doctor visits and hospitalization (Warsi 2003;Lorig, 1993; Lorig,
1999). The ultimate goal of the physical therapy sessions for patients with OA
is to increase patients* knowledge and amount of physical activity in order to
improve physical functioning. Final aim is that patients maintain a physically
active lifestyle without supervision of physical therapist (Köke, 2011).

With the explosion of internet accessibility, the internet has created new
possibilities to support physical therapists in the treatment of OA patients.
In a review of Pietrzak et al., internet interventions in patients with OA
resulted in improvement of health status, access to care and communication
between patients and health professionals (Pietrzak, 2013). Financially, it is
likely that less face-to-face contact with a professional may result in lower
costs. Besides, a cheaper intervention would make OA treatment accessible for
patients without sufficient insurance (Marcus, 2009). By substitute a part of
the face-to-face contacts with a physical therapist by a website, a combination
of *the best of two worlds* will be generated (Van Gemert, 2013).

To date, there are no studies about the (cost) effectiveness of blended care
initiatives in the field of knee and/or hip osteoarthritis. We therefore have
planned to evaluate E-Exercise, which is an integration of face-to-face
sessions by a physical therapist and a web-based intervention. The web-based
part will be based on the online program Join2Move (Bossen, 2013), since this
program showed to be effective in improvement of physical functioning and
physical activity in patients with knee and/or hip OA.

The aim of this study is to investigate the cost-effectiveness of E-Exercise in
comparison with usual care of a physical therapist. Research question for this
RCT study is: What are the short- (3 months) and long term (12 months) (cost)
effects of E-Exercise in patients with knee and/or hip OA on physical activity
and physical function in comparison with a face-to-face physical therapy
intervention?

We will perform a clustered randomized controlled clinical trial will be
performed. Patients with osteoarthritis of hip or knee will be randomly
assigned to either the E-Exercise intervention or the physical activity program
provided by physical therapists (usual care). Patients who are assigned to the
usual care will be offered to participate in the E-Exercise program after the
study has been finished (after 12 months without guidance of a physical
therapist).The study period of each patient is 12 months. During these 12
months three assessments will be performed, at baseline, after 3 months and 12
months.

The intervention group will receive the 12-week E-Exercise program. E-Exercise
a combination of four to five face-to-face sessions with a physical therapist
and a web-based intervention. The content is written according to the KNGF
guideline Osteoarthritis Hip-Knee (Peter, 2010).Tailored modules are weekly
presented on the website E-Exercise. A module consists of three topics. (i)
Information; various topics will be discussed (e.g. OA, physical activity,
pain, medication, nutrition etc.) through texts and videos.( ii) Graded
Activity; a selected activity will be increased on a weekly basis. Based on a
short term goal, a tailored schedule of modules is generated on a
time-contingent basis. The gradual increase of the selected activity starts
slightly below the baseline value and increases incrementally towards a short
term goal. This part of the intervention is derived from a previous developed
and evaluated behavioral graded activity (BGA) program for patients with knee
and/or hip OA (Veenhof 2006). The gradual increase in activities aims to
improve physical activity levels despite the potential presence of pain. (iii)
Strength and mobility exercises; each module contains specific exercises which
are provided through videos.

When a patient visits, for the first time, the physical therapy practice the
therapists will carry out an anamnesis, physical examination and a clinical
test to confirm clinical knee and/or hip OA. Moreover, the physical therapist
will also assess other in- and exclusion criteria. Eligible and interested
patients will contact the research team to participate in the study. The
following week after the intake is dominated by study related activities.
Participates are requested to read an information letter, sign an informed
consent and complete a baseline measurement. Patients start with E-Exercise
after compliance with these study activities.

In the first week of the program the physical therapist will provide
information about OA and the principles of E-Exercise. Together with the
physical therapist, the patient chooses a central activity (e.g. walking,
cycling or swimming) and four strength/mobility exercises (videos) which are
presented on a website. To determine the physical load ability of the
participants, patients are instructed to perform a 3-day baseline test
(execution of selected activity) and 4 exercises in their home environment.
Results from the baseline test (time, intensity and pain scores) will be
entered on the website. Based on the performance from the baseline self-test,
a range of goals will automatically be generated and presented on the website.
The therapist gives instructions about the selected exercises.

In week 2, the performance of the 3-day self-test will be discussed. The
results from this test have been entered into an online form on the website.
Subsequently, the participant chooses, in consultation with their physical
therapist, one of the proposed goals on the website. Depending on the selected
goal, 12 tailored modules are generated and presented weekly on the website.
The personal goal and upcoming online modules will be discussed and the four
strength/mobility exercises will be again instructed by the physical therapist.
The patients are encouraged the execute the first online module.

From week 3 to week 5, patients are instructed to perform three online modules.
In week 6, a third face-to-face treatment will take place. During this session
patients* progress will be evaluated with respect to the online modules, the
evaluation of the exercise will take place and the upcoming modules will be
discussed. If necessary, the therapist can decide to schedule an additional
face-to-face treatment between week 7-12. This optional session is indicated
for patients who are less capable to perform unsupervised physical exercises.
Indications for this additional session are made by the physical therapist
themselves.

From week 7 to week 12, patients are instructed to perform another seven online
modules. In week 13, the final face-to-face treatments will take place. In this
final treatment the physical therapist will support and reinforce patients to
maintain their active lifestyle.

Since the study has low demands on the participants and selection criteria are
used to exclude participants with a contra-indication for physical activity,
the risks for participation are low.