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Feasibility of the SOAR (Stop OsteoARthritis) program
Jackie L. Whittaker
a
,
b
,
*
, Linda K. Truong
a
,
b
, Trish Silvester-Lee
b
, Justin M. Losciale
a
,
b
,
Maxi Miciak
c
, Andrea Pajkic
d
, Christina Y. Le
c
, Alison M. Hoens
a
,
b
, Amber D. Mosewich
d
,
Michael A. Hunt
a
, Linda C. Li
a
,
b
, Ewa M. Roos
e
a
Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
b
Arthritis Research Canada, Vancouver, Canada
c
Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
d
Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Canada
e
Department of Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
ARTICLE INFO
Keywords:
Anterior cruciate ligament
Knee trauma
Post-traumatic osteoarthritis
Physiotherapy
ABSTRACT
Objective: Assess the feasibility of a virtually-delivered, physiotherapist-guided knee health program (SOAR) that
targets self-management of knee health and osteoarthritis risk after an activity-related knee injury.
Design: In this quasi-experimental feasibility study, individuals with varied lived experience of knee trauma
completed a 4-week SOAR program. This included: 1) Knee Camp (group education, 1:1 exercise and activity
goal-setting); 2) weekly home-based exercise and activity program with tracking, and; 3) weekly 1:1
physiotherapy-guided action-planning. SOAR program feasibility was assessed with implementation (attrition,
adherence, intervention fidelity), practicality (adverse events, goal completion), acceptability and efficacy
(change in Knee injury and Osteoarthritis Outcome Score subscales, Patient Specific Functional Scale (PSFS),
Godin Leisure-Time Exercise Questionnaire (GLTEQ), Partner in Health Scale (PHS)) outcomes. Descriptive sta-
tistics, disaggregated by gender, were calculated.
Results: Thirty participants (60% women, median (min-max) age 30 years (19–50), time from injury 5.6 years
(1.2–25.2)) were enrolled. No participant attrition or adverse events were reported, and 90% of mandatory
program components were completed. Participants rated their adherence at 80%, and 96% of exercise-therapy
and 95% of activity goals were fully or partially achieved. Both women and men reported significant group
mean (95%CI) improvements in GLTEQ scores (women: 22 METS (6,37), men: 31 METS (8,54)), while women
alone reported improvements in PHS (7(11,-3) and PSFS (1.7 (0.6,2.8) scores.
Conclusion: The SOAR program is feasible for persons at various timepoints post-knee trauma, and gender may be
an important consideration for SOAR implementation and assessment. A randomized controlled trial to assess
intervention efficacy is warranted.
1. Introduction
The Global Burden of Disease Study reports osteoarthritis (OA) as one
of the fastest growing and burdensome conditions worldwide [1], driven
primarily by knee OA [2]. As there is no cure for OA, effective and
accessible prevention interventions that strategically target at-risk pop-
ulations are urgently needed [3].
Knee trauma is associated with a 6-fold elevated risk of radiographic
OA [4], and arthroplasty [5]. This risk varies by injury type with cruciate
ligament, meniscal, fracture, dislocation and collateral ligament injuries
Abbreviations: OA, Osteoarthritis; SOAR, Stop OsteoARthritis; PT, Physiotherapy or Physical Therapy; RCT, Randomized Controlled Trial; ACL, Anterior Cruciate
Ligament; KOOS, Knee injury and Osteoarthritis Outcome Score; GLTEQ, Godin Leisure Time Exercise Questionnaire; PSFS, Patient Specific Functional Scale; PHS,
Partners in Health Scale; CARE, Consultation and Relational Empathy Measure; EARS, Exercise Adherence Rating Scale; RPE, Rating of Percieved Effort; SMART,
Specific, Measurable, Attainable, Relevant, Time-bound; BAP, Brief Action Planning.
* Corresponding author. Department of Physical Therapy, University of British Columbia, Vancouver, Canada.
E-mail addresses: jackie.whittaker@ubc.ca (J.L. Whittaker), linda.truong@ubc.ca (L.K. Truong), trishsl@telus.net (T. Silvester-Lee), jlos18@student.ubc.ca
(J.M. Losciale), maxi@ualberta.ca (M. Miciak), apajkic@ualberta.ca (A. Pajkic), cyle@ualberta.ca (C.Y. Le), alison.hoens@ubc.ca (A.M. Hoens), amber.mosewich@
ualberta.ca (A.D. Mosewich), michael.hunt@ubc.ca (M.A. Hunt), lli@arthritisresearch.ca (L.C. Li), eroos@health.sdu.dk (E.M. Roos).
Contents lists available at ScienceDirect
Osteoarthritis and Cartilage Open
journal homepage: www.elsevier.com/journals/osteoarthritis-and-cartilage-open/2665-9131
https://doi.org/10.1016/j.ocarto.2022.100239
Received 5 November 2021; Accepted 26 January 2022
2665-9131/©2022 The Authors. Published by Elsevier Ltd on behalf of Osteoarthritis Research Society International (OARSI). This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Osteoarthritis and Cartilage Open 4 (2022) 100239
associated with 5-fold or higher risk [4]. Knee trauma is most prevalent
in persons aged 16–35 years, and most commonly activity-related [6].
We have also shown that youth who experienced activity-related knee
trauma up to 10-years previous have more independent OA risk factors
(i.e., quadricep weakness, inactivity, adiposity) [7–9] than uninjured
peers. Despite carrying these modifiable risk factors, people at-risk of OA
after knee trauma are often not aware of the risk, nor do they seek, or
receive care to manage the risk [10,11].
The benefits of exercise for musculoskeletal health is well supported
[12] and exercise-therapy and physical activity are essential to
evidence-based knee trauma [13] and OA [14] management. Exercise
also ameliorates several mechanisms (altered loading [15], inflammation
[16]) and independent risk factors (muscle weakness [17], inactivity,
adiposity [18]) for OA. Despite this, the current standard of care after
discharge from knee trauma treatment (e.g., physiotherapy, surgery) is
no care, and the value of exercise-based activities to modify OA risk
factors after trauma is unclear [19]. Given that knee trauma permanently
elevates OA risk, strategies that enhance self-management, exercise
adherence, and healthy lifestyles, such as informational support and
action-planning, are valuable adjuncts to exercise [20–22].
SOAR (Stop OsteoARthritis) is a virtually-delivered, physiotherapist
(PT)-guided knee health program. SOAR aims to increase the capacity of
persons living with elevated OA risk due to an activity-related knee
injury to self-manage their knee health and knee OA risk. The program
was developed alongside patient and clinician partners, and is based on
past research [7,8,23,24], clinical practice guidelines [17], guidance
from Developing and Evaluating Complex Interventions [25], and is
consistent with patient-centered care [26], shared decision making [27]
and behaviour change theory [28]. Preliminary information about the
feasibility of the SOAR program is required before assessing it in ideal
(efficacy) and then real-life (effectiveness) settings. The primary objec-
tive of this study was to evaluate the feasibility (i.e., program imple-
mentation, practicality, acceptability and preliminary efficacy) of a
4-week SOAR program in preparation for a randomized controlled trial
(RCT). We hypothesized the SOAR program would be feasible for use
with persons living with increased risk of post-traumatic knee
osteoarthritis.
2. Methods
2.1. Study design and ethics
A quasi-experimental feasibility study. Feasibility assessments were
guided by Bowen et al. [29] Reporting follows the Guidelines for
Reporting Non-randomized Pilot and Feasibility studies [30], and
Consensus on Exercise Reporting Template (CERT) [31]. The research
was conducted at the University of British Columbia (UBC) and Arthritis
Research Canada, Vancouver, Canada between October 2020 and March
2021 during the Corona Virus Disease of 2019 (COVID-19) pandemic.
The study was approved by the UBC Clinical Research Ethics Board (REB
#H20-00158) and all participants provided informed consent.
2.2. Participants
Participants were a convenience sample of individuals that had
experienced an activity-related knee injury under the age of 45 years.
Although SOAR targets active youth and young adults, older individuals
with lived experience of a youth knee injury, and subsequent OA were
included to gain their perspective. For this study, activity-related knee
injury referred to a self-reported traumatic knee injury that required both
medical consultation (i.e., physician, PTs, surgeon) and disrupted regular
sport or recreational activity participation (i.e., missed at least one rec-
reational, training or competition session). Injuries were categorized as
including an anterior cruciate ligament (ACL) tear or other. Exclusion
criteria included: inability to communicate in English; residency outside
British Columbia (licensing jurisdiction for study PTs); pregnancy;
inflammatory arthritis or systemic condition diagnosis; lower limb
injury, surgery, or intra-articular injection in the past six-months; no
email address or daily access to a computer with internet; or refusal to
wear an activity tracker for the study duration.
2.3. Recruitment
To ensure the diversity of data, we balanced recruitment on gender
(women and men), age (30 years or >30 years), injury type (ACL tear or
other), and time since injury (5 years or >5 years). Participants were
recruited through patient and clinician partners from community phys-
iotherapy clinics, sport organizations, and social media channels (i.e.,
Twitter, Facebook, Instagram).
2.4. Sample size
Given the aim to assess program feasibility, sample size calculations
were not undertaken. A convenience sample of 30 participants allowed
for calculation of feasibility estimates and sufficient piloting of mea-
surement procedures to inform a future RCT.
2.5. Procedures
Fig. 1 outlines enrollment and study phases. After completing an
online consent form, participants were sent a unique URL to a survey
(REDCap 10.9.4, Vanderbilt University, US) consisting of a study ques-
tionnaire (demographic, socioeconomic, injury, treatment, medical his-
tory) and four self-report instruments (Knee Injury and OA Outcome
Score; KOOS [32], the Patient Specific Functional Scale; PSFS [33], the
Partners in Health Scale; PHS [34], Godin Leisure Time Exercise Ques-
tionnaire; GLTEQ) described below [35]. After survey completion, par-
ticipants were scheduled for the intervention. At the end of the
intervention, participants repeated the four self-report instruments and
an online exit survey that included questions about satisfaction, and
perceived value of SOAR, the Consultation and Relational Empathy
Measure (CARE) [36], and Exercise Adherence Rating Scale (EARS) [37].
Participants were asked to answer all questions in reference to their past
knee injury, or in the case of bilateral knee injuries, the one currently
most symptomatic. Participants were advised to continue with their usual
medication if applicable, during the study.
2.6. Intervention
The intervention was a 4-week virtually-delivered PT-guided knee
health program called SOAR (Stop OsteoARthritis). The program has
three components: 1) one-time Knee Camp; 2) individualized weekly
home-based exercise-therapy, physical activity and tracking, and; 3)
weekly 1:1 PT-guided exercise-therapy and activity action-planning with
optional group exercise class. Before starting, participants received a
Fitbit Inspire™activity tracker (Google, Mountain View, CA, USA),
workbook (educational materials), and resistance loop set (Chimaera,
Amazon, Seattle, WA, USA https://amzn.to/3mn7U7x) providing up to
100 pounds of resistance to enable exercise progression. Four registered
PTs delivered the program.
Knee Camp: This 2-h videoconferencing (Zoom®, San Jose, CA, USA)
session included a 1-h interactive group-based education session, 1:1
knee exam and exercise-therapy and physical activity goal-setting with a
PT, and Fitbit®set-up. The education session covered topics approved by
patient partners, consistent with shared decision making theory [27],
clinical guidelines [13] and current understanding of OA (Table 1, Sup-
plementary File 1 - Education session content). During the knee exam,
PTs and participants co-identified and prioritized functional limitations.
Exercise-therapy and activity goal-setting followed a Brief Action Plan-
ning (BAP) [22] approach (Fig. 1, Supplementary File 1 - BAP overview).
Briefly, PTs guided participants to identify at least one individualized
home-based exercise-therapy and one physical activity SMART (specific,
J.L. Whittaker et al. Osteoarthritis and Cartilage Open 4 (2022) 100239
2
measurable,attainable,relevant, and time-bound) goal with tasks and
adequate dose (target Rating of Perceived Effort; RPE) [38] to address
their unique functional limits (Table 2, Supplementary File 1 - Exemplar
SMART Goals) for week 1. Participants could use the resistance band kit,
body weight, common household materials (i.e., furniture, stairs), or any
exercise equipment that they had access to when developing their dose.
Given that higher confidence levels are associated with increased like-
lihood of success in carrying out a plan [22,47], goals were modified until
participant's confidence to execute them rated 7/10 (0 ¼no confi-
dence, 10 ¼full confidence). Actions to address perceived barriers were
discussed. After agreeing to Fitbit's®privacy policy, participants were
instructed to wear it 24-hrs/day and share their Fitbit®activity ‘Dash-
board’(proprietary Fitbit®software displaying information about daily
step count, floors climbed, distance travelled, calories expended, and
minutes of activity) with the research team through Fitbits®’cloud-based
platform. Finally, participants were orientated to TeleHab®(VALD
Health, Newstead, QLD, Australia), a commercially available exercise
tracking platform.
Weekly Home-based Exercise-Therapy, Physical Activity and Activity
Tracking: At home, participants worked to meet their exercise-therapy
and physical activity goals. Degree of exercise-therapy goal completion,
RPE, and any associated pain was recorded in the TeleHab®application,
and physical activity (Fitbit®) data synchronized with the Fitbit®online
‘Dashboard’.
Weekly PT-guided Exercise-Therapy and Physical Activity Action-Plan-
ning: Each week participants attended a short (~15–30) 1:1 virtual PT
counselling session and had the option of supplementing their program
with a regularly scheduled 1-h virtual PT-guided group exercise class
(Table 3, Supplementary File 1 - Group exercise class menu). At these
sessions, PTs asked and recorded responses to questions related to
adverse events, medication and healthcare use, reviewed Fitbit®wear
(based on a synopsis of weekly Fitbit®data provided by the research
team), and SMART goal completion on a bespoke PT tracking form.
Participants and their PT progressively modified or added SMART
exercise-therapy and physical activity goals (using a BAP approach)
based on the past weeks goal completion, physical activity (Fitbit®
Dashboard), symptoms and obstacles encountered. At group class, par-
ticipants received added instruction and feedback about exercise per-
formance and progression. Participants were able to email their PT
between sessions as needed.
Exercise-therapy and physical activity promote psychological and
physical capability to modify knee health and OA risk factors, with all
other program components supporting their regular performance [28].
Individualized exercise and physical activity tasks leverage automatic
Fig. 1. Flow of participants through the study.
J.L. Whittaker et al. Osteoarthritis and Cartilage Open 4 (2022) 100239
3
motivation and ensure relevant experiences [28]. Knee camp builds
psychological capability with informational support [28], and opportu-
nity for participants and PTs to initiate a therapeutic relationship [39].
Knee camp and weekly group classes provide social opportunity [23,28].
BAP builds reflexive motivation [28] and promotes self-efficacy, health
behavior change, and long-term outcomes [22]. Goal-setting, and exer-
cise and activity tracking facilitate adherence, and promote
accountability and reflexive motivation [28,40]. Regular PT contact
provides participants timely support to navigate obstacles by a health
professional competent in exercise prescription for patient populations
[41] and promotes exercise adherence [40]. Virtual delivery increases
accessibility and physical opportunity [24,28].
2.7. Physiotherapist training
Prior to delivering the intervention, four registered musculoskeletal
PTs completed BAP certification, SOAR program orientation and partic-
ipated in a group debrief after completing a knee assessment and goal
setting session with a simulated patient. BAP skills training and certifi-
cation were conducted in coordination with the Centre for Collaboration,
Motivation and Innovation (Vernon, BC, Canada). Certification (1-h role-
play scenario) followed a 4-h asynchronous online course and three, 1-h
group practice and feedback sessions. During SOAR orientation PTs were
instructed in how use Zoom®, deliver the group education content, guide
a standardized virtual knee exam, enter exercise-goals into TeleHab®,
and complete a weekly PT Tracking form. After reviewing the recorded
practice knee assessment and goal setting session, the principal investi-
gator met with the PTs to review key components of BAP and SOAR
program fidelity.
2.8. Outcomes
Outcomes, methods and timepoints for data collection are summa-
rized in Table 1. Participant characteristics (i.e., age, sex, gender,
ethnicity, socioeconomic status), sport and physical activity participation
in the past year, knee injury history and treatment, as well as medical
history were captured using a study questionnaire. The feasibility of the
SOAR program was assessed with implementation, practicality, accept-
ability and preliminary efficacy outcomes [29].
SOAR Implementation outcomes included participant attrition (% of
participants who withdrew or lost to follow-up), program adherence (%
of knee camp, weekly 1:1 PT counselling sessions and weekly group
classes attended, % of exercise therapy tracking completed, number of
Table 1
Outcomes, method and timeline of collection.
Category Outcome Method T0 T1 End
Participant
Characteristics
Age, sex, gender, ethnicity, employment, education, sport
participation, knee injury and medical history
Self-reported - study questionnaire ✓
Implementation Participant Attrition Drop-out rate –Master list ✓
Program Adherence Mandatory
a
program component completion (%)- Study tracking
form
Weekly
Non-mandatory
b
program component completion (%) - Study
tracking form
Weekly
Exercise therapy tracking app use (%) –TeleHab®Weekly
Fitbit®wear days
c
(number) - Fitbit®Dashboard Weekly
Participant Adherence Self-reported - EARS ✓
Participant reported NRS of action plan completion ✓
PT reported NRS of participant action plan completion ✓
PT Intervention Fidelity Fidelity checklist completion (%) ✓
Therapeutic Alliance Self-reported - CARE ✓
Practicality Adverse Events PT Tracking form Weekly
SMART goal completion Exercise-therapy goal completion (%) - PT tracking form Weekly
Physical activity goal completion (%) - from PT tracking form Weekly
Acceptability Program component acceptability Participant NRS of acceptability - Exit Survey ✓
Efficacy Change in self-reported knee symptoms, function, QoL KOOS ✓✓
Change in self-reported functional restrictions PSFS ✓✓
Change in self-reported perceived self-management PHS ✓✓
Change in self-reported physical activity GLTQ ✓✓
CARE (Consultations and Relational Empathy Scale), EARS (Exercise Adherence Rating Scale), GLTEQ (Godin Leisure Time Exercise Questionnaire), KOOS (Knee Injury
and Osteoarthritis Outcome Score), NRS (Numerical Rating Scale), PHS (Partner in Health Scale), PSFS (Patient Specific Functional Scale), QoL (quality-of-life), SMART
(Specific, Measurable, Achievable, Relevant, Timebound), T0 (Baseline), T1 (4-weeks).
a
Mandatory Program components include knee camp and weekly 1:1 PT counselling sessions.
b
Non-mandatory Program components include the weekly group exercise classes.
c
A Fitbit wear day is 15 h of wear.
Table 2
Participant characteristics.
Characteristic
a
Women
b
n¼
18
Men
b
n¼12 Overall n ¼
30
Age (years) 30.5
(22.9–46.8)
31.7
(19.5–50.8)
30.8
(19.5–50.8)
Ethnicity (White), n (%) 11 (61) 9 (75) 20 (67)
Highest education attained
(Bachelor degree), n (%)
9 (50) 5 (42) 14 (47)
Main pre-injury sport level
(recreational), n (%)
3 (17) 7 (58) 10 (33)
Injury age (years) 22.0
(14.0–44.0)
20.0
(17.0–34.0)
21.4 (14–44)
Index knee injury type (ACL
tear), n (%)
9 (50) 5 (42) 12 (40)
Multi-structure index injury
(yes), n (%)
12 (67) 3 (25) 15 (50)
Index knee injury surgery (yes),
n (%)
c
13 (72) 4 (33) 17 (57)
Index injury physiotherapy
(yes), n (%)
17 (94) 10 (83) 27 (90)
Sport participation in last year
(yes), n (%)
16 (89) 11 (92) 27 (90)
Time from injury to baseline
(years)
5.0
(1.2–18.1)
7.6
(1.4–25.2)
5.6
(1.2–25.2)
a
Assessed at T0 (Baseline) with a self-reported study questionnaire.
b
Values represent median (min-max) unless otherwise noted.
c
14 participants had an Anterior Cruciate Ligament Reconstruction (10
women (8 primary ACL tears and 2 Tibio-femoral dislocations, 4 men (primary
ACL tears)).
J.L. Whittaker et al. Osteoarthritis and Cartilage Open 4 (2022) 100239
4
days with 15 h of Fitbit®wear), participant adherence (EARS, Partic-
ipant Numerical Rating Scale of Action Plan Completion, PT Numerical
Rating Scale of Participant Action Plan Completion), PT intervention fi-
delity (% of a 41-item checklist completed during one randomly recorded
1:1 knee camp and one weekly counselling sessions per PT; Table 4,
Supplementary File 1 –Intervention Fidelity Checklist), and relational
empathy (CARE) which is a key component of therapeutic relationship. A
15-h cut-off to define a ‘Fitbit®wear day’was chosen to understand the
proportion of participants that would wear the device for a duration
equivalent to typical waking hours (16-h) less 1 h for bathing (i.e., the
typical daily period during which participants would have the potential
for being physically active). The EARS is a six-item self-report tool for
measuring adherence to home exercise. Scores range from 0 to 42, with
higher scores indicating better adherence [37]. The CARE is a 10-item
self-report tool that measures empathy in the context of the therapeutic
relationship between a clinician and a patient. Scores range from 10 to
50, with higher scored reflecting more empathy [36].
SOAR Practicality outcomes included the number of self-reported
adverse events (requiring medical treatment or medications, and/or in-
terferes with function for two or more days directly related to SOAR) [42]
over the course of the intervention, and exercise-therapy and physical
activity goal completion (% of goals entirely, partially or not completed)
tracked weekly at the PT counselling sessions. Exercise-therapy and
physical activity goals were coded as ‘completed’,‘partially completed’
or ‘not completed’when the participant reported ‘entirely achieving a
weekly goal’,‘achieving some (but not all) of a weekly goal’,or‘not
achieving any part of a weekly goal’, respectively.
Finally, SOAR acceptability was assessed with an exit survey consisting
of 10 questions that asked participants to rate the value of various aspects
of the SOAR program (i.e., overall program, online delivery, knee camp,
Table 3
SOAR program implementation and practicality outcomes.
Characteristic Target Women
a
n¼18 Men
a
n¼12
Mandatory
d
components attendance (% participants with entire attendance)
b
80% 89 92
Non-mandatory
e
components attenance (% participants with entire, and partial attendance
f
)
b
–22, 44 17, 33
Exercise tracking app use (number of participants, %)
c
–14 (78) 3 (25)
Fitbit daily wear (minutes)
c
–1058 (950–1440) 1107 (1010–1440)
Fitbit daily wear (hours)
c
–18 (16–24) 19 (17–24)
Fitbit wear days
g
(number of days with 15 h)
c
24 days 30 (20–30) 29 (4–30)
Fitbit feasibility (number of participants 24 wear days, %)
c
–10 (56) 7 (58)
Exercise Adherence Rating Scale Score
b
18 (75%) 22 (14–24) 22 (17–24)
Exercise Adherence Rating Scale feasibility (n of participants 18, %)
b
–17 (94) 11 (92)
Participant rating of action plan completion
h
(%)
b
80 94 (81–100) 93 (85–100)
Participant rating of action plan completion
h
feasibility (number of participants 80%)
b
–18 (100) 12 (100)
PT rating of action plan completion
i
(%)
b
80 80 (70–100) 90 (60–100)
PT rating of action plan completion
i
feasibility (number of participants 80%)
b
–17 (94) 9 (75)
Consultation and Relational Empathy Scale Score
b
38 (75%) 50 (35–50) 50 (35–50)
Consultation and Relational Empathy Scale feasibility (n of participants 75%)
b
–17 (94) 11 (92)
Physical activity SMART goal entire or partial completion (% entire, % partial)
c
80 98 (77, 21) 91 (81, 10)
Exercise-therapy SMART goal entire or partial completion (% entire, % partial)
c
80 99 (70, 29) 93 (78, 15)
‘-’No ‘a priori’target set.
a
Values represent median (min-max) unless otherwise noted.
b
Assessed at the end of the study.
c
Assessed weekly throughout the study.
d
Mandatory Program components include knee camp and four weekly 1:1 PT counselling sessions.
e
Non-mandatory Program components include 4 weekly group exercise classes.
f
Partial attendance refers to participants that attended 1, 2 or 3 of the 4 weekly group exercise classes.
g
Days with 15 h Fitbit wear up to a maximum of 30 days (study length).
h
Numercial rating scale (Overall, I completed the exercises and physical activities I planned as part of my weekly goals during the study, 0 ¼strongly disagree, 100 ¼
strongly agree).
i
Numercial rating scale (Overall, the participant I worked with completed the exercises and physical activities as planned as part of their weekly goals during the
study, 0 ¼strongly disagree, 100 ¼strongly agree).
Table 4
SOAR Efficacy Outcomes (intention to treat)
a
.
Outcome Women (n ¼18) Men (n ¼12)
Baseline (T0) Median
(min-max)
End (T1) Median
(min-max)
Change (T1-T0) Mean
(95%CI)
Baseline (T0) Median
(min-max)
End (T1) Median
(min-max)
Change (T1-T0) Mean
(95%CI)
KOOS
Paind
83 (58–100) 86 (47–100) 1.3 (3.5,6.0) 88 (69–97) 86 (75–100) 2.1 (3.3,7.5)
KOOS
Sympd
55 (36–79) 54 (39–75) 1.8 (1.7,5.3) 57 (43–71) 63 (43–68) 1.2 (4.2,6.6)
KOOS
ADLd
98 (79–100) 96 (53–100) 1.6 (8.1,4.8) 98 (81–100) 96 (81–100) 0.6 (3.4,4.6)
KOOS
SR
73 (45–95) 90 (25–100) 8.3 (2.3,19.0) 75 (50–100) 75 (50–100) 3.8 (6.7,14.1)
KOOS
QoL
47 (25–81) 56 (0–88) 6.6 (1.4,14.6) 50 (25–88) 56 (44–88) 6.8 (2.5,16.1)
KOOS
PF
74 (41–91) 78 (27–96) 6.3 (1.3,14.0) 76 (50–91) 71 (57–96) 1.5 (6.2,9.2)
PSFS
b
5(0–7) 6 (2–9) 1.7 (0.6,2.8) 6(3–8) 6 (4–8) 0.4 (1.9,1.1)
PHS 20 (5–37) 8 (0–32) 7 (-11,-3) 20 (0–41) 11 (2–30) 5(13,4)
GLTQ
c
56 (13–118) 71 (37–224) 22 (6,37) 66 (23–92) 90 (35–185) 31 (8,54)
T0 (Baseline), T1 (4-weeks).
Bold: mean change 95% confidence interval does not contain the null value.
a
See Supplementary File 1 for a sensitivity analysis where data from one participant who experienced a time loss knee injury in the first week of the program during a
non-SOAR related event is removed.
b
Average across three goals.
c
Metabolic equivalents.
d
As per Collins et al., 2016,
37
KOOS pain, symptoms and function in daily living have limited validity for this patient group and would not be expected to change.
J.L. Whittaker et al. Osteoarthritis and Cartilage Open 4 (2022) 100239
5
home-based component, weekly group classes, weekly PT counselling,
Zoom®platform, TeleHab®for exercise-tracking, Fitbit for physical ac-
tivity tracking, quality of the relationship with their PT) on a 0–10 nu-
merical rating scale (i.e., 0 ¼not satisfied or valued, 10 ¼very satisfied
or valued).
Preliminary efficacy was assessed as the change in self-reported knee-
related symptoms, function and quality-of-life (KOOS) [32], self-chosen
functional restrictions (PSFS) [33] perceived self-care (PHS) [34], and
physical activity (GLTEQ) [35] over the 4-week program. The KOOS
consists of 53 items, scored on a 5-point Likert scale, organised in six
subscales (i.e., pain, other symptoms, function in daily living, function in
sport and recreation, quality-of-life, patellofemoral symptoms). Subscale
scores are summed, and the total score transformed to a 0–100 scale with
higher scores indicating better outcome. The KOOS has been validated in
various knee injury, surgery and OA populations, and has been shown to
have high test-retest reliability [32,43]. The PSFS prompts participants to
identify three activities important to them and rate their ability to
perform each on a 10-point numerical rating scale. Individual scale scores
are summed and transformed to a 0–100 scale with higher scores indi-
cating better outcomes. The PSFS is valid and reliable for use in persons
with a knee injury [44]. The PHS consists of 11-items across three do-
mains (i.e., self-efficacy, knowledge of health condition and treatment,
and self-management behaviour) scored on a nine-point Likert scale.
Individual items are summed to produce a total score, out of 88 with
lower scores representing greater perceived self-management [34]. The
PHS is valid and reliable across numerous chronic conditions [45].
Finally, the GLTEQ uses the number of 15-min bouts of mild, moderate,
and strenuous physical activity that a person engages in over a typical
week to estimate weekly metabolic equivalents (METS) of physical ac-
tivity. The GLTEQ is a valid measure of leisure time physical activity
[46].
2.9. Patient and clinician partner involvement
Three patient partners (young adult with lived experience of a sport-
related ACL reconstruction, middle-aged adult with lived experience of a
sport-related ACL reconstruction, re-injury, and recent knee OA diag-
nosis, and a middle-aged adult with lived experience of a sport-related
ACL reconstruction, knee OA and knee arthroplasty), and three clini-
cian partner (two PTs with 9-years of clinical experience and one PT with
3-years) were engaged throughout the study. The patient and PT partners
provided guidance on research objectives, appropriateness of outcomes,
funding applications, and the development of the exit survey, SOAR
participant workbook and Knee Camp content. They also participated in
recruitment, and data analysis interpretation.
2.10. Statistical analyses
Descriptive statistics for all participant characteristics, outcomes and
open-ended survey responses were summarized by gender given their
socio-cultural nature. A priori benchmarks were set for key imple-
mentation and practicality outcomes based on past feasibility studies [47,
48] and clinical experience. These included: participant attrition 10%;
80% knee-camp and weekly session attendance; 24 out of 30 Fitbit wear
days (15-h of daily wear); median EARS score of 18 (75% adherence);
80% participant numerical rating of adherence, 80% PT numerical rating
of participant adherence, 75% intervention fidelity; median CARE mea-
sure score of 38 (75% relationship empathy); 80% full or partial SMART
goal completion.
3. Results
Enrollment is outlined in Fig. 2 and participant characteristics are
summarized in Table 2. The majority of participants were in their
twenties (37%) and thirties (33%), White (67%), cis-gendered (100%),
and had participated in organized sport in the last year (90%). Main pre-
injury sports included soccer (20%), volleyball (17%), basketball (10%),
ice hockey (10%), American football (10%), rugby (7%), ultimate frisbee
(7%), biking (3%), boxing (3%), downhill skiing (3%), horse sport (3%),
running (3%), wakeboarding (3%).
No participants were lost to follow-up. One participant suffered a time
loss index knee injury (MRI-confirmed traumatic medial meniscal tear) in
the first week during a non-SOAR related event which required signifi-
cant program modifications, and one was rescheduled and completed the
program at a later start date due to an unexpected non-related minor
medical procedure. No adverse events (event directly related to SOAR
requiring medical treatment or medications, and/or interfered with
function for two or more days) occurred, and all participants completed
the assessment protocol.
Program implementation and practicality outcomes are summarized
in Table 3, and acceptability outcomes in Fig. 3. All participants attended
knee camp and 27 (90%) attended all weekly PT counselling sessions. Of
the three (10%) participants that missed a weekly PT counselling session,
two were due to scheduling difficulties and one requested two weeks to
work on their goals. Although weekly group exercise classes were not
mandatory, 60% of participants attended one or more exercise classes
(43% attended two, 30% attended three, and 20% attended all four
classes). Seventeen (56.7%) participants used the exercise-tracking
application, and Fitbit®data was available for 23 (77%) participants
(five women and two men failed to synchronize their device with the
Fitbit®Dashboard and did not register data). Participants self-reported
high rates of program adherence, with 95% of physical activity and
96% of exercise-therapy SMART goals either entirely or partially
completed across the study period. One participant did not set a week one
physical activity goal deciding to focus on therapeutic exercises only.
The median (range) proportion of intervention fidelity checklist items
completed across the four PTs was 91% (61–98). The most common BAP
element not completed was the approach PTs took to offer an ‘Exercise or
Activity Menu’to participants when they did not know where to start
working on their knee health, or requested ideas. Participants reported
high relational empathy, and 28 (93%) highly valued (9/10) their
relationship with their PT.
Preliminary efficacy outcomes are summarized in Table 4. Both
women and men reported significant increases in self-reported physical
activity, while women reported improvements in perceived self-
management and functional activities identified on the PSFS. When
data from one participant who experienced a time loss knee injury in the
first week of the program during a non-SOAR related event was removed,
women also demonstrated clinically relevant improvements in self-
reported function in sport and recreation function, knee-related qual-
ity-of-life and patellofemoral symptoms (Supplementary File 2).
4. Discussion
This study demonstrates the feasibility of a virtually-delivered, PT-
guided knee health program that targets self-management of knee health
and OA risk after activity-related knee trauma. All a priori feasibility
benchmarks were met or exceeded, including targets for participant
attrition, program and participant adherence, intervention fidelity, and
full or partial completion of weekly SMART goals. No adverse events
were reported, and mean change improvements in self-reported physical
activity (both men and women), perceived self-management (women
only) and function (women only) were demonstrated. Participants also
reported high perceived-value of the program including the online
format, online platform, weekly PT-guided action-planning and group
exercise sessions, and quality of the relationship with their PT. Compo-
nents of the SOAR program that may require modification include aspects
of PT training related to BAP, and method for tracking exercise-therapy
and physical activities. These findings suggest it is appropriate to pro-
ceed with an RCT to determine the ideal length and efficacy of the SOAR
program [51].
Two key aspects of program implementation of specific interest in
J.L. Whittaker et al. Osteoarthritis and Cartilage Open 4 (2022) 100239
6
exercise-based interventions are participant adherence, and intervention
fidelity. Adherence refers to the extent to which a person's behaviour
corresponds with agreed upon approach. Although difficult to measure,
adherence is associated with exercise-therapy effectiveness in persons
with knee conditions [49]. To fully understand participant adherence, we
considered multiple outcomes (i.e., attendance, EARS score, participant
numerical rating of action-plan completion, PT numerical rating of
participant action-plan completion, SMART goal completion). Based on
findings ranging from 80% on the PT numerical rating of participant
action-plan completion to 96% full or partial completion of
exercise-therapy SMART goals there was consistent evidence of high
participant adherence across the program. These results are more
favorable than those reported for other exercise intervention in similar
populations [48], and may be related to the use of action-planning, a
Fig. 3. Summary of participants numerical rating of SOAR program components acceptability.
Fig. 2. Overview of study enrollment. PAR-Q (Physical Activity Readiness Questionnaire), PAR MEDx (Physical Activity Readiness Medical Examination).
J.L. Whittaker et al. Osteoarthritis and Cartilage Open 4 (2022) 100239
7
behavioural change technique positively associated with exercise
adherence [28], and meaningful therapeutic relationships between par-
ticipants and their PT [39].
With respect to intervention fidelity, we used a checklist (including
items indicating meaningful relationship, knee assessment conduct, BAP,
and record keeping) to assess one randomly recorded 1:1 knee camp and
one weekly action-planning session per PT. Although the median inter-
vention fidelity exceeded a priori targets (91%), we identified several
areas with lower fidelity including consistent deviations in BAP when
participants stated that they did not know where to start working on their
knee health or requested ideas. Instead of offering two or three brief ideas
together as a list without pauses, and then asking participants if they had
any ideas come to mind as the last list item, PTs commonly assumed the
‘expert’role, which is a deviation from the spirit of BAP, and chose ex-
ercises for participants. These findings will inform modifications to
future PT training. Specifically, more opportunity to practice and receive
feedback on BAP within the context of SOAR, completion of simulations
of scenarios where a participant requests exercise or physical activity
ideas from the PT, and addition of a requirement to shadow at least one
action-planning session.
A unique aspect of the SOAR program which improves its accessi-
bility, is the online approach and use of commercially available platforms
(i.e., Zoom®, TeleHab®) and activity monitors (Fitbit®). Participants
reported a high degree of acceptability for the Zoom®platform which
was likely influenced by increased familiarity and acceptance of video-
conferencing and online services during to the COVID-19 pandemic.
Despite the value of exercise logs as an active coping strategy after injury
[23], and activity trackers for motivating people to achieve activity goals
[50], the least valued part of the program was using the TeleHab®
application for exercise and physical activity tracking, and the Fitbit®.It
is unclear if the high degree of acceptability of videoconferencing will
persist beyond the COVID-19 pandemic or if there will be a need to move
towards more in-person delivery of the program. Preliminary participant
feedback from 1:1 interviews (which will be reported in-depth else-
where) about barriers to using TeleHab®included lack of relevance
(could remember without tracking), time, and technical issues. Barriers
to Fitbit®use included a perception that it was less accurate than other
commercially available activity trackers, and need for manual synchro-
nization. These findings will inform adaptations for exercise-therapy and
physical activity tracking. Options may include developing a
purpose-built online tracking form with a user-friendly, mobile-device
interface, having research staff set-up participants’Fitbit®accounts,
providing education and reminders for Fitbit®synchronization, or not
requiring it be worn during sleep.
A strength of the study is that we have demonstrated the feasibility of
the SOAR program with persons who have a wide range of time loss,
medical-attention knee injuries and who may be at various stages of re-
covery and different levels of OA risk. Although mean changes in self-
reported physical activity (women and men), perceived self-
management (women only) and function (women only) were demon-
strated, these findings must be interpreted with caution. As the aim of
this study was to assess the feasibility of the SOAR program there was no
control group, the intervention likely not of sufficient length to effect a
true change, and no sample size calculations performed. A limitation of
the intervention is the need for daily access to a computer and the
internet which may have implications for equitable access if SOAR found
to be effective in future studies. It is interesting to note that gender may
play a role in the efficacy of the SOAR program. This is not surprising
given that women and men have different preferences for exercise,
physical activity and sport, and that social support facilitates exercise and
physical activity behaviours by girls and women, more than with boys
and men. These findings suggest that gender will be an important
consideration for SOAR implementation (i.e., tailor for participant
gender) and assessment going forward.
5. Conclusion
A novel exercise-based, PT-guided knee health program that targets
self-management of knee health and osteoarthritis risk after an activity-
related knee injury is feasible, and a RCT to assess its efficacy is war-
ranted. Beyond meeting all feasibility criteria, opportunities for
improving PT training and participant exercise and physical activity
tracking were identified. The importance of considering gender during
implementation and assessment of the program was also highlighted.
This research represents a first, vital step towards mitigating the conse-
quences of activity-related knee injuries and the burden of OA.
Author contributions
All authors were involved in the design of the study. Data collection
and initial analyses was conducted by JLW, LKT, JML. JLW wrote the first
draft of the manusript. All authors contributed to reviewing, editing, and
revising the manuscript and approved the final submitted version. JLW is
the guarantor.
Role of funding sources
Funding to conduct this study came from the BC support Unit, Ca-
nadian MSK Rehab Research Network (CIHR FRN: CFI-148081) and
Arthritis Society. JLW is supported by the Michael Smith Foundation for
Health Research and the Arthritis Society. JML is supported by the
Arthritis Society. LKT is supported by a Canadian Institutes of Health
Research Fellowship.
Declaration of competing interest
JLW is an Associate Editor of the British Journal of Sports Medicine
(BJSM) and Journal of Orthopaedic and Sports Physical Therapy. ER is
Deputy Editor of Osteoarthritis and Cartilage.
Acknowledgements
The authors would like to acknowledge the administrative support of
Shireen Divecha, Kiran Dhiman, and Hussein Mamdani, as well as con-
tributions of Declan Norris PT.
Appendix A. Supplementary data
Supplementary data tothis article can befound online at https://doi.org
/10.1016/j.ocarto.2022.100239.
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