Hospital-based Outpatient Physiotherapy Rehabilitation Versus Mobile Health (mHealth)-Based Exercise and Self-management in Patients With Symptomatic Knee Osteoarthritis

Cost and Outcomes of Hospital-based Physiotherapy Versus mHealth-based Self-directed Rehabilitation in Patients With Knee Osteoarthritis: A Randomized, Controlled, Non-inferiority Trial

Symptomatic osteoarthritis (OA) of the knee affects approximately one-fifth (~300K) of Singaporeans aged 50 years or older, with the disease prevalence increasing with age. Patients with advanced knee OA and severe disability often require a total knee replacement (TKR) surgery. With an ageing population and the high prevalence of obesity, the annual number of TKR is projected to rise. Thus, innovative care models are urgently needed to improve patient outcomes, while managing or reducing the economic burden of this common and costly public health problem.

Unmet Need: Conservative treatment through physiotherapy rehabilitation is a key intervention but significant access limitations result in unnecessary TKRs. For patients with knee OA, consensus guidelines are unanimous in recommending education, exercise, and weight management (if required) as first-line intervention. Physiotherapy rehabilitation incorporates these 3 first-line interventions and is a widely advocated and evidence-based component of OA intervention. Despite this, international evidence suggests that these core interventions are often under-utilized, with only 20-40% of community-dwelling older adults with knee OA receiving them. Locally and worldwide, suboptimal care from rehabilitation non-attendance is prevalent and costly: available research suggests that at least a quarter of TKRs could have been avoided with optimal care. Thus, to reduce the economic burden of OA, there is a need to develop innovative and flexible rehabilitation strategies.

mHealth-based program is a likely solution to address this unmet need, but local contextualization is needed. Against this background, a mobile health (mHealth)-based OA self-management program may be a feasible solution to deliver guideline-based interventions, with minimal involvement by healthcare professionals. Whilst several app- or web-based OA self-management programs are available, few have undergone rigorous RCT evaluation, and still fewer provide detailed instructions to enable self-directed exercise (in particular, muscle strengthening exercises) - despite the evidence that exercise is the cornerstone of knee OA management. Furthermore, the reach and adoption of these programs in Singapore is limited as they are designed for English-speaking patients from Western cultures. Hence, whilst there are potential benefits in harnessing technology-enabled programs, these data emphasize the need for local co-design and adaptation to suit the Singapore context and to facilitate adoption.

Thus, we have, through an iterative user-centered design process, developed Managing Osteoarthritis of the Knee using Therapist Technology Optimized Rehabilitation (MOKneeTOR), a blended digital rehabilitation program integrating an initial face-to-face physiotherapy assessment and a mobile health (mHealth)-enabled exercise and self-management program designed to promote first-line interventions (education, exercise, and weight management where indicated) for patients with knee osteoarthritis.

Inclusion Criteria:

• All patients who meet the knee OA clinical criteria (aged ≥45 years, activity-related knee pain, and ≤30 min knee joint stiffness in the morning) will be included,
• an owner of a smartphone,
• an education level of at least 8 years,
• a willingness to be randomized to either MOKneeTOR program or outpatient rehabilitation program,
• an ability to complete baseline assessment.

Exclusion Criteria:

• lower limb joint replacement surgery anticipated within the next 6 months,
• rheumatoid arthritis and other systemic arthritis,
• a previous history of stroke and other major neurological conditions,
• significant back or other non-knee pain,
• pregnant women