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Question: In people with knee osteoarthritis, how much more effective is stratified exercise therapy that distinguishes three subgroups (high muscle strength subgroup, low muscle strength subgroup, obesity subgroup) in reducing knee pain and improving physical function than usual exercise therapy?, Design: Pragmatic cluster randomised controlled trial in a primary care setting., Participants: A total of 335 people with knee osteoarthritis: 153 in an experimental arm and 182 in a control arm., Intervention: Physiotherapy practices were randomised into an experimental arm providing stratified exercise therapy (supplemented by a dietary intervention from a dietician for the obesity subgroup) or a control arm providing usual, non-stratified exercise therapy., Outcome Measures: Primary outcomes were knee pain severity (numerical rating scale for pain, 0 to 10) and physical function (Knee Injury and Osteoarthritis Outcome Score subscale activities of daily living, 0 to 100). Measurements were performed at baseline, 3 months (primary endpoint) and 6 and 12 months (follow-up). Intention-to-treat, multilevel, regression analysis was performed., Results: Negligible differences were found between the experimental and control groups in knee pain (mean adjusted difference 0.2, 95% CI -0.4 to 0.7) and physical function (-0.8, 95% CI -4.3 to 2.6) at 3 months. Similar effects between groups were also found for each subgroup separately, as well as at other time points and for nearly all secondary outcome measures., Conclusion: This pragmatic trial demonstrated no added value regarding clinical outcomes of the model of stratified exercise therapy compared with usual exercise therapy. This could be attributed to the experimental arm therapists facing difficulty in effectively applying the model (especially in the obesity subgroup) and to elements of stratified exercise therapy possibly being applied in the control arm., Registration: Netherlands National Trial Register NL7463., (Copyright © 2022 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Purpose: Exercise therapy is an effective intervention in a variety of chronic diseases. The prescription of exercise therapy is usually directed toward an index disease. The presence of comorbidity may require adaptations to the exercise program as intended for the index disease. This paper aims to structure the clinical reasoning process of health professionals when prescribing exercise therapy for the individual patient with an index disease and comorbidity. Methods: We adapted the previously published strategy for developing guidelines and protocols on comorbidity-adapted exercise to a version that can be used for individual exercise prescription. Results: Essential steps and considerations involved in prescribing an exercise program to an individual patient with comorbidity are described. A case description is used as an example of how the proposed strategy leads to clinical decisions. Conclusions: The proposed strategy may have a role in educational and professional development. The advanced clinical expertise needed for safe and effective exercise therapy in patients with a complex health status is emphasized.Implications for RehabilitationThe presence of comorbidity may require adaptations to exercise therapy.We describe the essential steps and considerations involved in prescribing an exercise program to an individual patient with an index disease and comorbidity.The proposed strategy can be used to structure the clinical reasoning process of health professionals.

Introduction: E-Exercise is an effective 12-week blended intervention consisting of around five face-to-face physiotherapy sessions and a web-based application for patients with hip/knee osteoarthritis. In order to facilitate effective implementation of e-Exercise, this study aims to identify physiotherapists' experiences and determinants related to the usage of e-Exercise. Methods : An explanatory sequential mixed methods design embedded in a randomized controlled trial comparing e-Exercise with usual physiotherapy in patients with hip/knee osteoarthritis. Usage of e-Exercise was based on recruitment rates of 123 physiotherapists allocated to e-Exercise and objective web-based application usage data. Experiences and determinants related to e-Exercise usage were investigated with a questionnaire and clarified with semi-structured interviews. Results : Of the 123 physiotherapists allocated to e-Exercise, 54 recruited more than one eligible patient, of whom 10 physiotherapists continued using e-Exercise after the study period. Physiotherapists had mixed experiences with e-Exercise. Determinants related to intervention usage were appropriateness, added value, time, workload, professional autonomy, environmental factors, and financial consequences. Physiotherapists recommended to improve the ability to tailor e-Exercise to the individual needs of the patient patients' individual needs. Discussion : Determinants related to the usage of e-Exercise provided valuable information for the implementation of e-Exercise on broader scale. Most importantly, the flexibility of e-Exercise needs to be improved. Next, there is a need for education on how to integrate an online program within physiotherapy.

Objectives: Knee osteoarthritis (OA) is characterized by its heterogeneity, with large differences in clinical characteristics between patients. Therefore, a stratified approach to exercise therapy, whereby patients are allocated to homogeneous subgroups and receive a stratified, subgroup-specific intervention, can be expected to optimize current clinical effects. Recently, we developed and pilot tested a model of stratified exercise therapy based on clinically relevant subgroups of knee OA patients that we previously identified. Based on the promising results, it is timely to evaluate the (cost-)effectiveness of stratified exercise therapy compared with usual, "nonstratified" exercise therapy., Methods: A pragmatic cluster randomized controlled trial including economic and process evaluation, comparing stratified exercise therapy with usual care by physical therapists (PTs) in primary care, in a total of 408 patients with clinically diagnosed knee OA. Eligible physical therapy practices are randomized in a 1:2 ratio to provide the experimental (in 204 patients) or control intervention (in 204 patients), respectively. The experimental intervention is a model of stratified exercise therapy consisting of (a) a stratification algorithm that allocates patients to a "high muscle strength subgroup," "low muscle strength subgroup," or "obesity subgroup" and (b) subgroup-specific, protocolized exercise therapy (with an additional dietary intervention from a dietician for the obesity subgroup only). The control intervention will be usual best practice by PTs (i.e., nonstratified exercise therapy). Our primary outcome measures are knee pain severity (Numeric Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score subscale daily living). Measurements will be performed at baseline, 3-month (primary endpoint), 6-month (questionnaires only), and 12-month follow-up, with an additional cost questionnaire at 9 months. Intention-to-treat, multilevel, regression analysis comparing stratified versus usual care will be performed., Conclusion: This study will demonstrate whether stratified care provided by primary care PTs is effective and cost-effective compared with usual best practice from PTs., (© 2019 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.)

Background: Blended physiotherapy, in which physiotherapy sessions and an online application are integrated, might support patients in taking an active role in the management of their chronic condition and may reduce disease related costs. The aim of this study was to evaluate the cost-effectiveness of a blended physiotherapy intervention (e-Exercise) compared to usual physiotherapy in patients with osteoarthritis of hip and/or knee, from the societal as well as the healthcare perspective., Methods: This economic evaluation was conducted alongside a 12-month cluster randomized controlled trial, in which 108 patients received e-Exercise, consisting of physiotherapy sessions and a web-application, and 99 patients received usual physiotherapy. Clinical outcome measures were quality-adjusted life years (QALYs) according to the EuroQol (EQ-5D-3 L), physical functioning (HOOS/KOOS) and physical activity (Actigraph Accelerometer). Costs were measured using self-reported questionnaires. Missing data were multiply imputed and bootstrapping was used to estimate statistical uncertainty., Results: Intervention costs and medication costs were significantly lower in e-Exercise compared to usual physiotherapy. Total societal costs and total healthcare costs did not significantly differ between groups. No significant differences in effectiveness were found between groups. For physical functioning and physical activity, the maximum probability of e-Exercise being cost-effective compared to usual physiotherapy was moderate (< 0.82) from both perspectives. For QALYs, the probability of e-Exercise being cost-effective compared to usual physiotherapy was 0.68/0.84 at a willingness to pay of 10,000 Euro and 0.70/0.80 at a willingness to pay of 80,000 Euro per gained QALY, from respectively the societal and the healthcare perspective., Conclusions: E-Exercise itself was significantly cheaper compared to usual physiotherapy in patients with hip and/or knee osteoarthritis, but not cost-effective from the societal- as well as healthcare perspective. The decision between both interventions can be based on the preferences of the patient and the physiotherapist., Trial Registration: NTR4224 (25 October 2013).

Background: Integrating physical therapy sessions and an online application (e-Exercise) might support people with hip osteoarthritis (OA), knee OA, or both (hip/knee OA) in taking an active role in the management of their chronic condition and may reduce the number of physical therapy sessions., Objective: The objective of this study was to investigate the short- and long-term effectiveness of e-Exercise compared to usual physical therapy in people with hip/knee OA., Design: The design was a prospective, single-blind, multicenter, superiority, cluster- randomized controlled trial., Setting: The setting included 143 primary care physical therapist practices., Participants: The participants were 208 people who had hip/knee OA and were 40 to 80 years of age., Intervention: e-Exercise is a 3-month intervention in which about 5 face-to-face physical therapy sessions were integrated with an online application consisting of graded activity, exercise, and information modules. Usual physical therapy was conducted according to the Dutch physical therapy guidelines on hip and knee OA., Measurements: Primary outcomes, measured at baseline after 3 and 12 months, were physical functioning and free-living physical activity. Secondary outcome measures were pain, tiredness, quality of life, self-efficacy, and the number of physical therapy sessions., Results: The e-Exercise group (n = 109) received, on average, 5 face-to-face sessions; the usual physical therapy group (n = 99) received 12. No significant differences in primary outcomes between the e-Exercise group and the usual physical therapy group were found. Within-group analyses for both groups showed a significant improvement in physical functioning. After 3 months, participants in the e-Exercise group reported an increase in physical activity; however, no objectively measured differences in physical activity were found. With respect to secondary outcomes, after 12 months, sedentary behavior significantly increased in the e-Exercise group compared with the usual physical therapy group. In both groups, there were significant improvements for pain, tiredness, quality of life, and self-efficacy., Limitations: The response rate at 12 months was 65%., Conclusions: The blended intervention, e-Exercise, was not more effective than usual physical therapy in people with hip/knee OA.

Purpose: Delivery of exercise interventions to patients with early-stage breast cancer undergoing chemotherapy requires complex clinical decisions. The purpose of this study was to develop a framework to support clinical decisions for tailoring exercise interventions to common comorbidities and cancer treatment-induced adverse effects., Method: Tailored exercise prescriptions were developed in four steps, following the i3-S strategy. All steps were based on current best available evidence, complemented with expert opinions. First, common comorbidities and treatment-induced adverse effects were identified. In the subsequent steps, contra-indications and restrictions for exercise were described, along with possible exercise adaptations. In the final step, the obtained information was synthesized into a framework., Results: Prevalent comorbidities were hypertension, heart disease, diabetes mellitus, (osteo)arthritis, chronic obstructive pulmonary disease, and obesity. Adverse effects included conditions induced by pretreatment (e.g., lymphedema as a result of surgery) or by chemotherapy (e.g., reduced blood cell counts). Adaptations to the recommended exercise program were related to exercise tolerance, safety, and hygiene. A framework was proposed to guide clinical decisions during the exercise intervention., Conclusion: Comorbidities and adverse effects of breast cancer treatment require exercise adaptations. The proposed framework provides guidance on tailored exercise prescriptions in patients with breast cancer undergoing chemotherapy. Implications for Rehabilitation Exercise is recommended for patients with breast cancer undergoing chemotherapy, but requires complex clinical decisions of the health professional. We identified the most important comorbidities and adverse effects of breast cancer treatment, and the resultant contra-indications and restrictions to exercise. We incorporated these findings into a clinical decision framework that provides suggestions for exercise adaptations in patients with breast cancer undergoing chemotherapy.

Background: Embedding Web-based interventions within physiotherapy has potential, but knowledge on patient adherence to these interventions is limited., Introduction: This study explores which patient-, intervention-, and environment-related factors are determinants of adherence to the online component of e-Exercise, a 12-week blended intervention for patients with hip and/or knee osteoarthritis., Methods: A convergent mixed methods study was performed, embedded within an ongoing trial. Quantitative data of 109 participants that received e-Exercise were used for negative binomial regression analysis. Adherence was defined as the number of online evaluated weeks. Next, semistructured interviews on factors related to adherence to the online component were analyzed., Results: Nineteen participants with missing outcome data because their program was not started were excluded. Of the 90 analyzed participants, 81.1% were evaluated for at least 8 weeks. Adherence was highest for participants with middle education, 1-5-year osteoarthritis duration, and participants who were physiotherapist recruited. The 10 analyzed interviews revealed that sufficient Internet skills, self-discipline, execution of the exercise plan, the intervention's usability, flexibility, persuasive design, added value, and acceptable required time, and research participation were linked to favorable adherence., Discussion: It is unknown if patients who adhered to the online component also adhered to their exercise plans. The relationship between adherence to the online component and clinical outcomes will be addressed in a future study., Conclusions: The majority of the participants adhered to the online component of e-Exercise, illustrating its applicability. The integration within the physiotherapy setting and intervention's persuasive design appear to have an important role in optimizing patient adherence.

Objective: To study the effectiveness of a 12-month exercise therapy on kinesiophobia and physical activity in patients with spondylolisthesis after lumbar spine fusion., Design: Randomized controlled trial., Subjects: Patients (n = 98) with spondylolisthesis who had undergone lumbar spine fusion., Methods: All patients (mean age 59 years) had received lumbar spine fusion surgery and identical postoperative instructions. Three months postoperatively, they were randomized into an exercise group (n = 48) or usual care group (n = 50). The exercise group received 12-month progressive home-based training with regular booster sessions, and the usual care group a single session of physiotherapy instruction. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK) and physical activity by the International Physical Activity Questionnaire (IPAQ) preoperatively, 3 months after lumbar spine fusion, and at the end of the 12-month intervention., Results: Before the intervention, the median (first quartile; third quartile) of TSK was 32.5 (29.0; 37.0) in the exercise group and 30.0 (25.8; 36.0) in the usual care group, changing to 30.0 (25; 36) in the exercise group and to 30.5 (24; 36.3) in the usual care group (between-group p = 0.17). IPAQ metabolic equivalent minutes per week increased from 1,863 (1,040; 3,042) to 3,190 (1,634; 6,485) in the exercise group and from 2,569 (1,501; 4,075) to 3,590 (1,634; 6,484) in the usual care group (between-group p = 0.92)., Conclusion: Progressive 12-month home-exercise starting 3 months postoperatively was not superior to usual care in decreasing kinesiophobia or increasing physical activity in spondylolisthesis.

Objective: To evaluate the efficacy on physical functioning and safety of tailored exercise therapy in patients with knee osteoarthritis (OA) and comorbidities., Methods: In a randomized controlled trial, 126 participants were included with a clinical diagnosis of knee OA and at least 1 of the following target comorbidities: coronary disease, heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, or obesity (body mass index ≥30 kg/m 2 ), with severity score ≥2 on the Cumulative Illness Rating Scale. The intervention group received a 20-week, individualized, comorbidity-adapted exercise program consisting of aerobic and strength training and training of daily activities. The control group received their current medical care for knee OA and were placed on a waiting list for exercise therapy. Primary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index, subscale physical functioning (WOMAC-pf), and the 6-minute walk test (6MWT). Measurements were performed at baseline, after 20 weeks (directly posttreatment), and at 3 months posttreatment., Results: Statistically significant physical functioning differences over time were found between the intervention and control group (WOMAC: B = -7.43 [95% confidence interval (95% CI) -9.99, -4.87], P < 0.001; and 6MWT: B = 34.16 [95% CI 17.68, 50.64], P < 0.001) in favor of the intervention group. At 3 months followup, the mean improvements in the intervention group were 33% on the WOMAC scale and 15% on the 6MWT. These improvements are of clinical relevance. No serious adverse events occurred during the intervention., Conclusion: This is the first study showing that tailored exercise therapy is efficacious in improving physical functioning and safe in patients with knee OA and severe comorbidities., (© 2016, American College of Rheumatology.)

Purpose: The aim of the study was to investigate the effectiveness of the postoperative 12-month exercise program compared to usual care on disability and health-related quality of life (HRQoL) in patients after lumbar spine fusion surgery (LSF)., Methods: Altogether, 98 patients with isthmic (31) or degenerative (67) spondylolisthesis were randomised to exercise therapy group (EG) (n = 48) or usual care group (UCG) (n = 50) 3 months after LSF. EG patients had home-based progressive strength and aerobic training program for 12 months. UCG patients received only oral and written instructions of exercises. Oswestry Disability Index (ODI) and HRQoL (RAND-36) were evaluated at the time of randomization, at the end of the intervention and 1 year after intervention., Results: The mean ODI score decreased from 24 (12) to 18 (14) in the EG and from 18 (12) to 13 (11) in the UCG during intervention (between-groups p = 0.69). At 1-year follow-up, 25 % of the EG and 28 % of the UCG had an ODI score ≥20. No between-group differences in HRQoL change were found at any time point. The mean (95 % CI) physical functioning dimension of the HRQoL improved by 10.0 (4.6-15.3) in the EG and by 7.8 (2.5-13.0) in the UCG. In addition, the role physical score improved by 20.0 (7.7-32.3) in the EG and by 16.4 (4.4-28.4) in the UCG during the intervention., Conclusions: The exercise intervention did not have an impact on disability or HRQoL beyond the improvement achieved by usual care. However, disability remained at least moderate in considerable proportion of patients.

Objective: Severe pain in patients with knee osteoarthritis (OA) hampers the ability to exercise. A protocol for the standardized optimization of analgesics in combination with exercise therapy was developed. The purpose of this protocol was to reduce pain, thereby allowing the patient to participate in exercise therapy. The objective of the present study was to evaluate the feasibility and outcome of the protocol., Methods: Forty-nine patients with knee OA and severe knee pain (numerical rating scale for pain ≥7) were included. Analgesics were prescribed following an incremental protocol. After 6 weeks, a 12-week exercise therapy program was added. Information about analgesic use and exercise therapy content was recorded. Knee pain and activity limitations were assessed at baseline, after 6 weeks, and after 18 weeks., Results: Statistically significant improvements in pain and activity limitations were found in intent-to-treat analysis after 6 weeks of analgesic use and after the intervention was completed. Mean improvements from baseline were 30% (P < 0.001) for pain and 17% (P < 0.001) for activity limitations after the intervention was completed. Seventy-eight percent of the patients were able to exercise according to the protocol. In these patients, exercise therapy following 6 weeks of analgesic use resulted in a further improvement of activity limitations of 10% (P = 0.004)., Conclusion: The combined intervention of standardized analgesic prescription and exercise therapy allows most patients with knee OA and severe pain to participate in exercise therapy, leading to reduction of pain and activity limitations. These promising results need to be confirmed in a randomized controlled trial., (© 2016, American College of Rheumatology.)

Purpose: Exercise therapy is effective in a wide range of chronic diseases. Comorbid disease necessitates adaptations to exercise therapy. Guidance on how to develop such adaptations is currently not available. We present an innovative strategy for the development of comorbidity-related adaptations to exercise therapy in an index disease., Method: We previously developed comorbidity-related adaptations to exercise therapy in osteoarthritis. We now broaden this approach into a general strategy for the development of comorbidity-related adaptations to exercise therapy in an index disease., Results: The i3-S strategy consists of four steps. The first three steps involve creating an inventory of comorbid disease, an inventory of contraindications and restrictions on exercise therapy, and an inventory of potential adaptations to exercise therapy. In the fourth step, this information is synthesized into guidance on comorbidity-related adaptations to exercise therapy in the index disease. The adaptations concern physiological, behavioural and environmental factors., Conclusion: In view of the general effectiveness of exercise therapy and the high prevalence of comorbidity in older people, there is a great need for comorbidity-related adaptations to exercise therapy. We recommend to use and evaluate the i3-S strategy in future research., Implications for Rehabilitation: Exercise therapy is effective in a wide range of chronic diseases. Comorbid disease necessitates adaptations to exercise therapy. Guidance on how to develop such adaptations is currently not available. We present an innovative strategy for the development of comorbidity-related adaptations to exercise therapy in an index disease. Researchers and clinicians can use this strategy to develop guidance on the adaptation of exercise therapy to comorbidity.

Background: Exercise therapy in patients with hip and/or knee osteoarthritis is effective in reducing pain, increasing physical activity and physical functioning, but costly and a burden for the health care budget. A web-based intervention is cheap in comparison to face-to-face exercise therapy and has the advantage of supporting in home exercises because of the 24/7 accessibility. However, the lack of face-to-face contact with a professional is a disadvantage of web-based interventions and is probably one of the reasons for low adherence rates. In order to combine the best of two worlds, we have developed the intervention e-Exercise. In this blended intervention face-to-face contacts with a physical therapist are partially replaced by a web-based exercise intervention. The aim of this study is to investigate the short- (3 months) and long-term (12 months) (cost)-effectiveness of e-Exercise compared to usual care physical therapy. Our hypothesis is that e-Exercise is more effective and cost-effective in increasing physical functioning and physical activity compared to usual care., Methods/design: This paper presents the protocol of a prospective, single-blinded, multicenter cluster randomized controlled trial. In total, 200 patients with OA of the hip and/or knee will be randomly allocated into either e-Exercise or usual care (physical therapy). E-Exercise is a 12-week intervention, consisting of maximum five face-to-face physical therapy contacts supplemented with a web-based program. The web-based program contains assignments to gradually increase patients' physical activity, strength and stability exercises and information about OA related topics. Primary outcomes are physical activity and physical functioning. Secondary outcomes are health related quality of life, self-perceived effect, pain, tiredness and self-efficacy. All measurements will be performed at baseline, 3 and 12 months after inclusion. Retrospective cost questionnaires will be sent at 3, 6, 9 and 12 months and used for the cost-effectiveness and cost-utility analysis., Discussion: This study is the first randomized controlled trial in the (cost)-effectiveness of a blended exercise intervention for patients with osteoarthritis of the hip and/or knee. The findings will help to improve the treatment of patients with osteoarthritis., Trial Registration: NTR4224.

Background: Exercise therapy is generally recommended for patients with osteoarthritis (OA) of the knee. Comorbidity, which is highly prevalent in OA, may interfere with exercise therapy. To date, there is no evidence-based protocol for the treatment of patients with knee OA and comorbidity. Special protocols adapted to the comorbidity may facilitate the application of exercise therapy in patients with knee OA and one or more comorbidities., Purpose: The purpose of this study was to develop comorbidity-adapted exercise protocols for patients with knee OA and comorbidity., Method: Several steps were undertaken to develop comorbidity-adapted protocols: selection of highly prevalent comorbidities in OA, a literature search to identify restrictions and contraindications for exercise therapy for the various comorbid diseases, consultation of experts on each comorbid disease, and field testing of the protocol in eleven patients with knee OA and comorbidity., Results: Based on literature and expert opinion, comorbidity-adapted protocols were developed for highly prevalent comorbidities in OA. Field testing showed that the protocols provided guidance in clinical decision making in both the diagnostic and the treatment phase. Because of overlap, the number of exercise protocols could be reduced to three: one for physiological adaptations (coronary disease, heart failure, hypertension, diabetes type 2, chronic obstructive pulmonary diseases, obesity), one for behavioral adaptations (chronic a-specific pain, nonspecific low back pain, depression), and one for environmental adaptations (visual or hearing impairments). Evaluation of patient outcome after treatment showed significant (P<0.05) and clinically relevant improvements in activity limitations and pain., Conclusion: Comorbidity-adapted exercise protocols for patients with knee OA were developed, providing guidance in clinical reasoning with regard to diagnostics and treatment. To evaluate the effectiveness of treatment in line with our protocols, a randomized clinical trial should be performed.

Background: Lumbar spine fusion (LSF) effectively decreases pain and disability in specific spinal disorders; however, the disability rate following surgery remains high. This, combined with the fact that in Western countries the number of LSF surgeries is increasing rapidly it is important to develop rehabilitation interventions that improve outcomes., Methods/design: In the present RCT-study we aim to assess the effectiveness of a combined back-specific and aerobic exercise intervention for patients after LSF surgery. One hundred patients will be randomly allocated to a 12-month exercise intervention arm or a usual care arm. The exercise intervention will start three months after surgery and consist of six individual guidance sessions with a physiotherapist and a home-based exercise program. The primary outcome measures are low back pain, lower extremity pain, disability and quality of life. Secondary outcomes are back function and kinesiophobia. Exercise adherence will also be evaluated. The outcome measurements will be assessed at baseline (3 months postoperatively), at the end of the exercise intervention period (15 months postoperatively), and after a 1-year follow-up., Discussion: The present RCT will evaluate the effectiveness of a long-term rehabilitation program after LSF. To our knowledge this will be the first study to evaluate a combination of strength training, control of the neutral lumbar spine position and aerobic training principles in rehabilitation after LSF., Trial Registration: ClinicalTrials.gov Identifier NCT00834015.

Background: Osteoarthritis (OA) is the most common joint disease, causing pain and functional impairments. According to international guidelines, exercise therapy has a short-term effect in reducing pain/functional impairments in knee OA and is therefore also generally recommended for hip OA. Because of its high prevalence and clinical implications, OA is associated with considerable (healthcare) costs. However, studies evaluating cost-effectiveness of common exercise therapy in hip OA are lacking. Therefore, this randomised controlled trial is designed to investigate the cost-effectiveness of exercise therapy in conjunction with the general practitioner's (GP) care, compared to GP care alone, for patients with hip OA., Methods/design: Patients aged ≥ 45 years with OA of the hip, who consulted the GP during the past year for hip complaints and who comply with the American College of Rheumatology criteria, are included. Patients are randomly assigned to either exercise therapy in addition to GP care, or to GP care alone. Exercise therapy consists of (maximally) 12 treatment sessions with a physiotherapist, and home exercises. These are followed by three additional treatment sessions in the 5th, 7th and 9th month after the first treatment session. GP care consists of usual care for hip OA, such as general advice or prescribing pain medication. Primary outcomes are hip pain and hip-related activity limitations (measured with the Hip disability Osteoarthritis Outcome Score [HOOS]), direct costs, and productivity costs (measured with the PROductivity and DISease Questionnaire). These parameters are measured at baseline, at 6 weeks, and at 3, 6, 9 and 12 months follow-up. To detect a 25% clinical difference in the HOOS pain score, with a power of 80% and an alpha 5%, 210 patients are required. Data are analysed according to the intention-to-treat principle. Effectiveness is evaluated using linear regression models with repeated measurements. An incremental cost-effectiveness analysis and an incremental cost-utility analysis will also be performed., Discussion: The results of this trial will provide insight into the cost-effectiveness of adding exercise therapy to GPs' care in the treatment of OA of the hip. This trial is registered in the Dutch trial registry http://www.trialregister.nl: trial number NTR1462.

"Exercise is medicine": exercise therapy reduces pain and activity limitations in osteoarthritis of the knee and is likely to have the same effects in osteoarthritis of the hip. Further research into exercise therapy is needed, since disease-modifying drugs are not available, pain medication can cause side effects, and surgical interventions are preferably applied in an advanced stage of disease. Classical exercise therapy is aimed at improving muscle strength, aerobic capacity, range of joint motion, and training of walking and activities of daily living. New modalities of targeted exercise therapy are currently being developed, aimed at the correction of low levels of activity and to correct instability of the knee. Weight loss, preferably combined with exercise therapy, reduces pain and activity limitations in osteoarthritis patients who are overweight. Modalities of exercise therapy adapted to comorbid conditions are currently being developed.

Objective: To determine the effect of patient exercise adherence within the prescribed physical therapy treatment period and after physical therapy discharge on patient outcomes of pain, physical function, and patient self-perceived effect in individuals with osteoarthritis (OA) of the hip and/or knee., Methods: We performed a prospective observational followup study in which 150 patients with OA of the hip and/or knee receiving exercise therapy were followed for 60 months. Data were obtained from a randomized controlled trial, with assessments at baseline and 3, 15, and 60 months of followup. The association between exercise adherence and patient outcomes of pain, physical function, and self-perceived effect was examined using generalized estimating equations analyses., Results: Adherence to recommended home exercises and being more physically active were significantly associated with better treatment outcomes of pain, self-reported physical function, physical performance, and self-perceived effect. The association between adherence and outcome was consistent over time. Adherence to home activities was only associated with better self-perceived effect., Conclusion: Better adherence to recommended home exercises as well as being more physically active improves the long-term effectiveness of exercise therapy in patients with OA of the hip and/or knee. Both within and after the treatment period, better adherence is associated with better patient outcomes of pain, physical function, and self-perceived effect. Since exercise adherence declines over time, future research should focus on how exercise behavior can be stimulated and maintained in the long term.

Question: Does behavioural graded activity result in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee?, Design: Analysis of secondary outcomes of a cluster-randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis., Participants: Two hundred patients with hip and/or knee osteoarthritis., Intervention: Experimental group received 18 sessions of behavioural graded activity over 12 weeks and up to 7 booster sessions over the next year. The control group received 18 sessions of usual care over 12 weeks according to the Dutch physiotherapy guideline., Outcome Measures: Exercise adherence was measured using a questionnaire and physical activity was measured using the SQUASH questionnaire at baseline, 13, and 65 weeks., Results: Adherence to recommended exercises was significantly higher in the experimental group than in the control group at 13 weeks (OR 4.3, 95% CI 2.1 to 9.0) and at 65 weeks (OR 3.0, 95% CI 1.5 to 6.0). Significantly more of the experimental than the control group met the recommendations for physical activity at 13 weeks (OR 5.3, 95% CI 1.9 to 14.8) and at 65 weeks (OR 2.9, 95% CI 1.2 to 6.7)., Conclusion: Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee, both in the short- and long-term., Trial Registration: NCT00522106.

Objective: To determine the long-term effectiveness (>/=6 months after treatment) of exercise therapy on pain, physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or knee., Methods: We conducted an extensive literature search in PubMed, EMBase, CINAHL, SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Both randomized clinical trials and controlled clinical trials on the long-term effectiveness of exercise therapy were included. The followup assessments were at least 6 months after treatment ended. Methodologic quality was independently assessed by 2 reviewers. Effect estimates were calculated and a best evidence synthesis was performed based on design, methodologic quality, and statistical significance of findings., Results: Five high-quality and 6 low-quality randomized clinical trials were included. Strong evidence was found for no long-term effectiveness on pain and self-reported physical function, moderate evidence for long-term effectiveness on patient global assessment of effectiveness, and conflicting evidence for observed physical function. For exercise programs with additional booster sessions, moderate evidence was found for long-term effectiveness on pain, self-reported physical function, and observed physical function., Conclusion: The positive posttreatment effects of exercise therapy on pain and physical function in patients with OA of the hip and/or knee are not sustained in the long term. Long-term effectiveness was only found for patient global assessment of effectiveness. However, additional booster sessions after the treatment period positively influenced maintenance of beneficial posttreatment effects on pain and physical function in the long term.

Objective: To evaluate whether exercise treatment based on behavioural graded activity comprising booster sessions is a cost-effective treatment for patients with osteoarthritis of the hip and/or knee compared with usual care., Methods: An economic evaluation from a societal perspective was carried out alongside a randomised trial involving 200 patients with osteoarthritis of the hip and/or knee. Outcome measures were pain, physical functioning, self-perceived change and quality of life, assessed at baseline, 13, 39 and 65 weeks. Costs were measured using cost diaries for the entire follow-up period of 65 weeks. Cost and effect differences were estimated using multilevel analysis. Uncertainty around the cost-effectiveness ratios was estimated by bootstrapping and graphically represented on cost-effectiveness planes., Results: 97 patients received behavioural graded activity, and 103 patients received usual care. At 65 weeks, no differences were found between the two groups in improvement with respect to baseline on any of the outcome measures. The mean (95% confidence interval) difference in total costs between the groups was -euro773 (-euro2360 to euro772)--that is, behavioural graded activity resulted in less cost but this difference was non-significant. As effect differences were small, a large incremental cost-effectiveness ratio of euro 51,385 per quality adjusted life year was found for graded activity versus usual care., Conclusions: This study provides no evidence that behavioural graded activity is either more effective or less costly than usual care. Yielding similar results to usual care, behavioural graded activity seems an acceptable method for treating patients with osteoarthritis of the hip and/or knee.

Objective: To determine the effectiveness of a behavioral graded activity program (BGA) compared with usual care (UC; exercise therapy and advice) according to the Dutch guidelines for physiotherapy in patients with osteoarthritis (OA) of the hip and/or knee. The BGA intervention is intended to increase activity in the long term and consists of an exercise program with booster sessions, using operant treatment principles., Methods: We conducted a cluster randomized trial involving 200 patients with hip and/or knee OA. Primary outcome measures were pain (visual analog scale [VAS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), physical function (WOMAC), and patient global assessment, assessed at weeks 0, 13, 39, and 65. Secondary outcome measures comprised tiredness (VAS), patient-oriented physical function (McMaster Toronto Arthritis Patient Preference Disability Questionnaire [MACTAR]), 5-meter walking time, muscle strength, and range of motion. Data were analyzed according to intent-to-treat principle., Results: Both treatments showed short-term and long-term beneficial within-group effects. The mean differences between the 2 groups for pain and functional status were not statistically significant. Significant differences in favor of BGA were found for the MACTAR functional scale and 5-meter walking test at week 65., Conclusion: Because both interventions resulted in beneficial long-term effects, the superiority of BGA over UC has not been demonstrated. Therefore, BGA seems to be an acceptable method to treat patients with hip and/or knee OA, with equivalent results compared with UC.

This study critically reviews the effectiveness of exercise therapy and manual mobilisation in acute ankle sprains and functional instability by conducting a systematic review of randomised controlled trials. Trials were searched electronically and manually from 1966 to March 2005. Randomised controlled trials that evaluated exercise therapy or manual mobilisation of the ankle joint with at least one clinically relevant outcome measure were included. Internal validity of the studies was independently assessed by two reviewers. When applicable, relative risk (RR) or standardised mean differences (SMD) were calculated for individual and pooled data. In total 17 studies were included. In thirteen studies the intervention included exercise therapy and in four studies the effects of manual mobilisation of the ankle joint was evaluated. Average internal validity score of the studies was 3.1 (range 1 to 7) on a 10-point scale. Exercise therapy was effective in reducing the risk of recurrent sprains after acute ankle sprain: RR 0.37 (95% CI 0.18 to 0.74), and with functional instability: RR 0.38 (95% CI 0.23 to 0.62). No effects of exercise therapy were found on postural sway in patients with functional instability: SMD: 0.38 (95% CI -0.15 to 0.91). Four studies demonstrated an initial positive effect of different modes of manual mobilisation on dorsiflexion range of motion. It is likely that exercise therapy, including the use of a wobble board, is effective in the prevention of recurrent ankle sprains. Manual mobilisation has an (initial) effect on dorsiflexion range of motion, but the clinical relevance of these findings for physiotherapy practice may be limited.

Objective: To compare the Osteoarthritis Research Society International (OARSI) response criteria for clinical trials with patient's global assessment in patients with osteoarthritis (OA) of the hip receiving a non-pharmacological intervention, i.e., manual therapy or exercise therapy., Methods: Data of a randomized clinical trial on manual therapy and exercise therapy in patients with OA of the hip (n = 109) were used. Change scores of measures of hip function, range of joint motion and pain were compared between patients who were differently classified by the OARSI response criteria and the patient's global assessment (using a t test, 95% CI). Furthermore, risk ratios (with 95% CI) were calculated for the contrast between treatment outcome, using the OARSI criteria or patient's global assessment., Results: Few patients were classified as improved (i.e., responders) with the OARSI response criteria as compared to patient's global assessment. Significantly worse outcome for hip function and pain was observed in patients who were classified as non-responders (OARSI criteria), but who considered themselves as improved (patient's global assessment). Risk ratios for the contrast between the two treatment programs (manual therapy vs exercise therapy) were similar, when using the OARSI criteria or patient's global assessment., Conclusion: The validity of the OARSI response criteria has been previously demonstrated in OA patients treated with pharmacological interventions. The present study demonstrates the validity of the OARSI response criteria in OA patients treated with a non-pharmacological intervention, i.e., manual therapy and exercise therapy.

Objective: To examine the effect of 2 different recruitment methods on the characteristics of participants with osteoarthritis (OA) of the hip or knee and on the efficacy of an exercise program., Methods: In a clinical trial on the effectiveness of exercise therapy in OA of the hip or knee, 2 groups of patients were recruited: one group through referrals by physiotherapists (PT group, n = 110) and one group invited by newspaper articles (NP group, n = 90). At baseline, demographic, clinical, and psychosocial data were collected and compared between the 2 groups using chi-square and Student's t-tests. After 13 weeks of exercise therapy and followup assessments at weeks 39 and 65, the main outcome measures (pain, physical function, and global perceived effect) were assessed and compared by multiple regression analysis., Results: The NP group reported less pain and tiredness at baseline, although more joints were affected with osteoarthritis. The PT group scored higher on the scale 'powerful-others' of locus of control. After adjusting for baseline differences, the effect of treatment after 13, 39, and 65 weeks was comparable for both groups for all outcome measures., Conclusion: Recruitment method affects clinical characteristics and physical functioning of patients recruited for the study. A mix of recruitment strategies does not seem to affect treatment outcome, on the condition that adjustments are made for baseline differences.

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinson's disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

Objective: To determine the effectiveness of a manual therapy program compared with an exercise therapy program in patients with osteoarthritis (OA) of the hip., Methods: A single-blind, randomized clinical trial of 109 hip OA patients was carried out in the outpatient clinic for physical therapy of a large hospital. The manual therapy program focused on specific manipulations and mobilization of the hip joint. The exercise therapy program focused on active exercises to improve muscle function and joint motion. The treatment period was 5 weeks (9 sessions). The primary outcome was general perceived improvement after treatment. Secondary outcomes included pain, hip function, walking speed, range of motion, and quality of life., Results: Of 109 patients included in the study, 56 were allocated to manual therapy and 53 to exercise therapy. No major differences were found on baseline characteristics between groups. Success rates (primary outcome) after 5 weeks were 81% in the manual therapy group and 50% in the exercise group (odds ratio 1.92, 95% confidence interval 1.30, 2.60). Furthermore, patients in the manual therapy group had significantly better outcomes on pain, stiffness, hip function, and range of motion. Effects of manual therapy on the improvement of pain, hip function, and range of motion endured after 29 weeks., Conclusion: The effect of the manual therapy program on hip function is superior to the exercise therapy program in patients with OA of the hip.

Purpose: The effectiveness of a 12-month home-exercise program on trunk muscle strength after lumbar spine fusion surgery was evaluated. Three months postoperatively, 98 patients were randomized either to the exercise group (EG), with a progressive 12-month home-based exercise program, or to usual care group (UCG), with one guidance session for light home-exercises. Maximal trunk muscle strength was measured by a strain-gauge dynamometer and trunk extensor endurance was measured by Biering-Sørensen's test at baseline and after the intervention. The mean change in extension strength during the intervention was 75 N in EG and 58 N in UCG. Flexion strength improved 50 N in UCG and 45 N in EG. Trunk extension/flexion strength ratio changed from 0.90 to 1.02 in EG and from 0.98 to 1.00 in UCG. In EG, Biering-Sørensen's test improved by 17 s, and in UCG, it improved by 24 s. No statistically significant between-group differences were found in any variables. Median exercise frequency in EG decreased from 2.5×/week during the first two intervention months to 1.7×/week during the last two intervention months. Twelve-month progressive exercise program was equally effective as usual care in improving trunk muscle strength. Home exercise adherence decreased, which may have influenced the strength changes. The 12-month home-based exercise program was equally as effective as usual care after lumbar spine fusion (LSF) in improving trunk muscle strength, however, the back-specific exercises led to better trunk muscle strength balance in exercise group only. The adherence to the home based exercise program is a challenge; therefore, different techniques could be implemented to provide purposeful support for each individual in their long-term exercising. It is important to recognize those who need more individualized rehabilitation in recovery of the spine function, while others may manage with subtle intervention after LSF. [ABSTRACT FROM AUTHOR]

We compliment the authors on a thoroughly well-designed randomized controlled trial in which 2 doses of exercise therapy were compared in patients with knee osteoarthritis. It could therefore be argued that low-dose exercises are generally sufficient for patients with knee osteoarthritis and need to be favored over high-dose exercises for feasibility reasons. Although both groups improved in all outcomes, the results did not support the authors' hypothesis that high-dose exercise is superior to low-dose exercise - similar to results from 2 other recent trials ([2], [3]). [Extracted from the article]

Objective: The objectives of the present study were to: (1) evaluate the effect of an educational course on competence (knowledge and clinical reasoning) of primary care physical therapists (PTs) in treating patients with knee osteoarthritis (KOA) and comorbidity according to the developed strategy; and (2) identify facilitators and barriers for usage. Method: The present research was an observational study with a pretest‐posttest design using mixed methods. PTs were offered a postgraduate course consisting of e‐learning and two workshops (blended education) on the application of a strategy for exercise prescription in patients with KOA and comorbidity. Competences were measured by questionnaire on knowledge (administered before and 2 weeks after the course), and a patient vignette to measure clinical reasoning (administered before the course and after a 6 month period of treating patients). Facilitators and barriers for using the strategy were assessed by a questionnaire and semi‐structured interviews. Results: Thirty‐four PTs were included. Competence (knowledge and clinical reasoning) improved significantly (p < 0.01). Fourteen out of 34 PTs had actually treated patients with KOA and comorbidity, during a 6‐month period. The strategy was found to be feasible in daily practice. The main barriers included the limited number of (self‐) referrals of patients, limited number of reimbursed treatment sessions by insurance companies and a suboptimal collaboration with (referring) physicians. Conclusion: A blended course on exercise therapy for patients with KOA and comorbidity seems to improve PTs' competence through increasing knowledge and clinical reasoning skills. Identified barriers should be solved before large‐scale implementation of exercise therapy can take place in these complex patients. [ABSTRACT FROM AUTHOR]

Objective: We introduced a stepped-care strategy (SCS) for hip and knee osteoarthritis, focusing on delivery of high-quality stepped care. In this study, we aimed to identify factors associated with various steps of the SCS.Methods: We used data from a 2-year observational prospective cohort study, including 313 patients visiting their general practitioner (GP) with a new episode of hip/knee osteoarthritis. We used logistic multilevel analyses to identify factors at the level of the patient, the GP, and the general practice, related to treatment limited to primary care, referral to nonsurgical secondary care, or surgical procedures.Results: Patients whose treatment had been limited to primary care tended to function physically better (odds ratio [OR] 1.03). Furthermore, they less often received exercise therapy (OR 0.46), intraarticular injections (OR 0.08), and radiologic assessments (OR 0.06). Continuation of nonsurgical care after referral was more likely in employed patients (OR 2.90) and patients who had no exercise therapy (OR 0.19) or nonsteroidal antiinflammatory drugs (OR 0.35). Surgically treated patients more often received exercise therapy (OR 7.42). Referral and surgical treatment depended only to a limited extent on the GP or the general practice.Conclusion: After implementation of the SCS in primary care, the performance of exercise therapy, rather than disease severity or psychologic factors, seems to play a key role in the decision whether or not to refer for surgical or nonsurgical treatment in secondary care. To optimize patient-tailored treatment, future research should be adressed to determine the optimal moment of switching from primary to secondary care in patients with hip/knee osteoarthritis. [ABSTRACT FROM AUTHOR]

Background: Exercise interventions in physical therapy (PT) are often not well described in research reports. Omitting details of the intervention hampers the transfer to daily clinical practice. Objective: To develop a framework for describing goals and content of exercise interventions, in order to provide structured and detailed information for use in research reports. Methods: A framework was developed in three steps using a mixed method approach. First, the scientific literature was systematically searched for available methods to describe PT interventions. An inventory of these methods was made and relevant elements were extracted. Second, based on the results of the literature search, a global framework was developed by a focus group of experts in the field of PT. Third, the framework was field tested by describing four different exercise interventions, leading to a final version. Results: In the developed framework intervention goals at the level of body functions and activities/participation were listed using the International Classification of Functioning, Disability and Health. To guide the description of the content of the exercise intervention a list of intervention details was developed, which was derived from an existing classification of PT interventions. Goals and content of exercise interventions were linked. Field testing of the framework led to adequate descriptions of exercise interventions. Conclusion: The developed framework is a promising first step in offering a feasible guide for a structured and detailed description of goals and content of exercise interventions within research reports. [ABSTRACT FROM AUTHOR]

Aim. To explore the treatment experiences in patients of Moroccan and Turkish origin and their rehabilitation therapists regarding an adapted outpatient cardiac rehabilitation programme. Background. Non-native patients who participated in a cardiac rehabilitation programme at a Dutch rehabilitation centre had more difficulties to achieve the treatment aims than native Dutch patients. Therefore, an adapted programme for non-native patients, lacking proficiency in Dutch, has been instigated. The programme contains six adapted treatment modules and additional strategies: adapted education regarding (1) the heart and the vascular system and (2) the use of healthy food, with use the of (audio) visual educational materials, (3) adapted physical exercise module with explicit involvement of the patients' relatives, (4) standard use of professional interpreters, (5) increase in the number and length of consultations and (6) individual treatment instead of a group programme. Design. Qualitative study. Method. Semi-structured, face-to-face interviews were conducted with eight patients of Moroccan and Turkish origin and five native Dutch rehabilitation therapists. By comparison, three native Dutch patients were interviewed regarding the regular programme. Results. The results indicate that the patients' disease symptoms reduced and that patients adopted lifestyle changes. Therapists experienced that the number and length of the consultations, the structural use of interpreters and (audio) visual educational materials contributed to the achievement of the treatment aims. Conclusion. An adapted cardiac rehabilitation programme with separate modules and additional strategies for non-native patients appears to lead to satisfied patients who adopted lifestyle changes. Relevance to clinical practice. The findings of this study are important as the study highlights the practical actions that may be taken by physicians and healthworkers to adjust rehabilitation treatment to the needs of patients of non-native origin. [ABSTRACT FROM AUTHOR]

Exercise therapy is generally recommended in osteoarthritis (OA) of the hip or knee. However, coexisting disorders may bring additional impairments, which may necessitate adaptations to exercise for OA of the hip or knee. For the purpose of developing an adapted protocol for exercise therapy in OA patients with coexisting disorders, information is needed on which specific coexisting disorders in OA are associated with activity limitations and pain. To describe the relationship between specific coexisting disorders, activity limitations, and pain in patients with OA of the hip or knee, a cross-sectional cohort study among 288 older adults (50–85 years of age) with OA of hip or knee was conducted. Subjects were recruited from three rehabilitation centers and two hospitals. Demographic data, clinical data, information about coexisting disorders (i.e., comorbidity and other disorders), activity limitations (WOMAC: physical functioning domain), and pain (visual analogue scale (VAS)) were collected by questionnaire. Statistical analysis included descriptive statistics and multivariate regression analysis. Coexisting disorders associated with activity limitations were chronic back pain or hernia, arthritis of the hand or feet, and other chronic rheumatic diseases (all musculoskeletal disorders); diabetes and chronic cystitis (non-musculoskeletal disorders); hearing impairments in a face-to-face conversation, vision impairments in long distances, and dizziness in combination with falling (all sensory impairments); and overweight and obesity. Coexistent disorders associated with pain were arthritis of the hand or feet, other chronic rheumatic diseases (musculoskeletal disorders), and diabetes (non-musculoskeletal disorder). Specific disorders coexisting next to OA and associated with additional activity limitations and pain were identified. These coexisting disorders need to be addressed in exercise therapy and rehabilitation for patients with OA of the hip or knee. [ABSTRACT FROM AUTHOR]

Our objective was to investigate whether behavioral graded activity (BGA) has particular benefit in specific subgroups of osteoarthritis (OA) patients. Two hundred participants with OA of hip or knee, or both (clinical American College of Rheumatology, ACR, criteria) participated in a randomized clinical trial on the efficacy of BGA compared to treatment according to the Dutch physiotherapy guideline (usual care; UC). Changes in pain (Visual Analog Scale, VAS), physical functioning (Western Ontario and McMaster Universities Osteoarthritis Index, WOMAC, and McMaster Toronto Arthritis Questionnaire, MACTAR), and patient global assessment were compared for specific subgroups. Subgroups were assigned by the median split method and were analyzed using analysis of covariance. Beneficial effects of BGA were found for patients with a relatively low level of physical functioning (p ? 0.03). Furthermore, beneficial effects of BGA in patients with a low level of internal locus of control were marginally significant (p = .05). Patients with a relatively low level of physical functioning benefit more from BGA compared to UC. Compared to UC, BGA is the preferred treatment option in patients with a low level of physical functioning. [ABSTRACT FROM AUTHOR]

• Current evidence showed that exercise therapy is a cost-effective treatment in knee OA. • Our stratified approach of exercise therapy did not appear to be cost-effective compared to usual exercise therapy. • Policy-makers should decide whether stratified exercise therapy can be implemented. A stratified approach to exercise therapy may yield superior clinical and economic outcomes, given the large heterogeneity of individuals with knee osteoarthritis (OA). To evaluate the cost-effectiveness during a 12-month follow-up of a model of stratified exercise therapy compared to usual exercise therapy in patients with knee OA, from a societal and healthcare perspective. An economic evaluation was conducted alongside a cluster-randomized controlled trial in patients with knee OA (n = 335), comparing subgroup-specific exercise therapy for a 'high muscle strength subgroup', 'low muscle strength subgroup', and 'obesity subgroup' supplemented by a dietary intervention for the 'obesity subgroup' (experimental group), with usual ('non-stratified') exercise therapy (control group). Clinical outcomes included quality-adjusted life years – QALYs (EuroQol-5D-5 L), knee pain (Numerical Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score in daily living). Costs were measured by self-reported questionnaires at 3, 6, 9 and 12-month follow-up. Missing data were imputed using multiple imputation. Data were analyzed through linear regression. Bootstrapping techniques were applied to estimate statistical uncertainty. During 12-month follow-up, there were no significant between-group differences in clinical outcomes. The total societal costs of the experimental group were on average lower compared to the control group (mean [95% confidence interval]: € 405 [-1728, 918]), albeit with a high level of uncertainty. We found a negligible difference in QALYs between groups (mean [95% confidence interval]: 0.006 [-0.011, 0.023]). The probability of stratified exercise therapy being cost-effective compared to usual exercise therapy from the societal perspective was around 73%, regardless of the willingness-to-pay threshold. However, this probability decreased substantially to 50% (willingness-to-pay threshold of €20.000/QALY) when using the healthcare perspective. Similar results were found for knee pain and physical functioning. We found no clear evidence that stratified exercise therapy is likely to be cost-effective compared to usual exercise therapy in patients with knee OA. However, results should be interpreted with caution as the study power was lower than intended, due to the Coronavirus disease (COVID-19) pandemic. [ABSTRACT FROM AUTHOR]