TRAK MSK is a co-designed digital physiotherapy supported self-management programme. It enables people to develop the knowledge, confidence and skills to self-manage their condition and pain, to improve everyday function and physical activity levels. We explored the feasibility of conducting a definitive trial of the TRAK MSK intervention. We conducted a two-arm multi-site randomised external feasibility trial with an embedded process evaluation. We recruited adults aged 18 and over with self-reported activity related joint pain for at least 3 months, attending physiotherapy clinics. Participants were randomised to either the TRAK MSK intervention or usual NHS physiotherapy care. The TRAK MSK intervention was delivered over 16 weeks and included up to five online coaching consultations with a physiotherapist trained in self-management support, and access to a website designed to support these consultations. Primary feasibility outcomes were recruitment, randomisation and retention at 16 weeks post-randomisation, all of which were pre-defined. Secondary outcomes were feasibility of collecting health services resource use and intervention costs and reported variability of participant rated questionnaires at baseline and follow up. We evaluated acceptability of intervention receipt and trial processes and intervention fidelity with an embedded process evaluation. We consented 87 (59

Older adults, particularly those with multiple long-term conditions (MLTCs) and other intersectional characteristics, are under-represented in clinical trials. This includes digitally enabled trials as older people may be less likely to engage with digital methods. We embedded a ‘Study Within a Project’ (SWAP) in TIPTOE, a UK randomised controlled trial evaluating a self-management support intervention for older adults with knee and/or hip osteoarthritis and MLTCs. Osteoarthritis is a musculoskeletal condition that is more common with age. The aim of the SWAP was to understand the barriers to including older people with MLTCs, rapidly develop strategies to support inclusion, and provide methodological guidance for future trials including those that are digitally enabled and/or decentralised. The mixed-methods SWAP spanned three trial phases: (1) set-up, process mapping to establish recruitment pathways and characteristics of local clinical populations; (2) pilot, interviews with recruiting staff to explore attitudes, skills and confidence when recruiting participants from under-served groups; (3) transition to main trial, interviews with participants to explore their experiences of taking part. Rapid analysis enabled changes to be made to trial processes during the early stages of the trial. Process mapping identified a diversity of populations and accessibility considerations (e.g. language, unfamiliarity with digital technology). Interviews with recruiting staff (n = 12) identified potential recruitment challenges including concerns that older people may be less inclined to participate due to lower digital literacy or lack of understanding about the trial. Interviews with participants (n = 25) found even those with digital access preferred human support and were concerned about being ‘scammed’ when receiving trial communications. Strategies were introduced such as lowering the eligibility age and creating tailored materials and messaging. Recommendations for future trials include ensuring person-centred support for participants, which has resourcing implications. Embedding a SWAP in TIPTOE enabled a greater understanding about recruiting older people who experience intersectional barriers to inclusion. Approaches to support recruitment included providing telephone support for those less confident navigating digital consent and data collection processes and the creation of guidance for sites. The findings could support future trials to better include older people with MLTCs and other under-served groups. ISRCTN 16024745. Registered on October 16, 2023.

Physiotherapist experiences and acceptability of a clinical sensor-based kinematic feedback toolkit for movement feedback rehabilitation for people following Anterior Cruciate Ligament reconstruction. Background: After knee ligament repair many patients do not recover. Tailored physiotherapy treatments developed from accurate kinematic measurement providing individualised movement feedback may improve outcomes. We have developed a sensor-based kinematic feedback toolkit that generates visual quantifiable data giving precise feedback regarding real time multi-planar kinematic data in the clinical setting and we present physiotherapist opinions about this tool. Objective: To gather physiotherapist experience and acceptance of a sensor-based kinematic feedback toolkit for anterior cruciate ligament injury rehabilitation to inform tool development for clinical practice Design and participants: Semi-structured interviews gathered experiences of twelve physiotherapists who used the toolkit for patients undergoing anterior cruciate ligament rehabilitation Findings: Four themes were identified (1) tool kit usability and future design considerations; (2) clinical integration and decision-making; (3) behaviour change; and (4) future use of biomechanical technology in clinical practice. Conclusion: The sensor-based biomechanical feedback toolkit report was perceived to be usable and acceptable. Physiotherapists could identify biomechanical movement compensations in patients that could lead to a more individualised targeted treatment approach. Barriers focused on file sharing, IT integration, and compatibility to access and view the digital report. Recommendations were to determine patient acceptance and implementation of real-time data collection in clinical settings for patients and Physiotherapists.

Knee osteoarthritis (OA) is prevalent in Saudi Arabia and has a significant negative influence on people's daily functioning and quality of life. Although clinical guidelines highlight exercise as a fundamental management strategy, adherence is still low because of logistical and motivational challenges. Virtual reality (VR)-based physiotherapy has emerged as a potential tool to enhance engagement and compliance, yet its acceptance among Saudi end-users is poorly understood. This study aimed to explore the expectations, needs, concerns, and willingness of Saudi end-users to use VR-based physiotherapy systems as an exercise tool for individuals with knee OA. Six people with knee OA and eight musculoskeletal physiotherapists from the Saudi community and related associations were purposefully recruited as part of a qualitative descriptive approach. Semi-structured online interviews and questionnaires measuring technological familiarity were used to collect data, which were supported by a video showcasing VR physiotherapy applications. The transcriptions of the interviews were analysed using inductive thematic analysis. Four major themes emerged: (1) knowledge and impact of knee OA, (2) perceptions of exercise for knee OA, (3) digital health in Saudi Arabia, and (4) perceptions of VR-based physiotherapy. Although participants acknowledged the substantial influence of OA on daily, social, and religious activities, they had a limited awareness of its complexity. Exercise was valued for symptom relief, but adherence was limited by obstacles like pain, lack of motivation, and logistical difficulties. Though issues with privacy, technical support, and technological resistance were observed, both groups showed familiarity with digital health tools and acknowledged their convenience. The majority of participants showed excitement for VR-based physical therapy, emphasising how it can improve engagement, motivation, and care personalisation. Nevertheless, concerns about cost, usability, and therapeutic effect were mentioned. Saudi end-users exhibit a generally positive attitude toward VR-based physiotherapy for knee OA, recognising its potential to address key barriers to exercise adherence. However, usability, cost, and digital literacy issues must be addressed for successful implementation.

Introduction Home-based physiotherapy is a current approach to manage knee osteoarthritis (OA). However, adherence to physiotherapy is poor. Non-immersive virtual reality (VR) has shown promise in improving self-efficacy and adherence in other clinical conditions. A non-immersive VR-based home physiotherapy system named Sensor-based Physiotherapy Intervention with Virtual Reality (SPIN-VR) for knee OA has been developed, integrating physiotherapy exercises into engaging games that adjust in difficulty based on real-time performance. This approach aims to enhance exercise adherence by making physiotherapy more enjoyable and personalised. To evaluate the feasibility of this intervention, a randomised controlled trial is being conducted.Method and analysis This single-centre, open-label, randomised controlled feasibility trial will evaluate the SPIN-VR system over 12 weeks compared with usual care physiotherapy for knee OA. 50 participants will be randomly assigned to either the SPIN-VR or usual care group, with follow-ups at 12 and 24 weeks post randomisation. The primary outcomes will be a description of feasibility of recruitment, patient willingness to be randomised, the completeness of outcome measures and patient adherence to the intervention. Secondary outcomes include evaluations of muscle strength, endurance, aerobic capacity, exercise technique, central pain processing and self-reported pain mechanisms and moderators. Participants in the intervention arm will be interviewed after 12 weeks to capture their experience in using the VR system.Ethics and dissemination This protocol was approved by the Wales Research Ethics Committee 3. Research findings will be disseminated in open-access peer-reviewed journals, to researchers and health professionals through conference presentations, to patients and the public by organising webinars and a seminar.Trial registration number NCT06639867.

OBJECTIVE:To identify research priorities for physical activity and exercise management of knee and hip osteoarthritis (OA). DESIGN:We used a multi-stage process involving an international multi-disciplinary panel of 276 experts (150 consumers, 69 clinicians spanning 5 disciplines, 54 researchers, and 3 funder/consumer organisation representatives) from 26 countries. The process included: 1) compiling a list of unanswered research questions from existing research; 2) assembling the panel and generating additional questions from members via an online survey; 3) consolidating research questions (eg. removing duplicates); 4) scoring questions for priority by the panel on an 11-point numeric rating scale (0='not a priority at all; 10='highest priority') via another online survey; and 5) ranking the top 20 priority questions by the panel via an online discrete choice experiment (1000Minds). RESULTS:A list of 61 research questions was compiled from the literature and the panel generated an additional 346 questions. Following consolidation, 178 questions remained and were scored by 150 of the original panelists (54%), with mean priority scores from 5.0 to 8.4. 153 (55%) panelists completed the discrete choice experiment. The top three research priorities were: 1) investigating the impact of physical activity and exercise on delaying/avoiding joint replacement, 2) developing effective interventions to promote long-term exercise adherence, and 3) stratifying people to the most appropriate form of exercise support. CONCLUSION:We identified research priorities about physical activity and exercise management of knee and hip OA. These will guide the international research agenda with the aim of improving outcomes for people with OA.

Purpose (the aim of the study): TRAK-MSK is a co-produced theory-based digital physiotherapy self-management intervention. It is intended to help people with joint pain have the knowledge, confidence and skills to self-manage their condition so that they are more physically active and experience less pain. Our aim was to evaluate the feasibility and acceptability of conducting a multi-centre randomised controlled trial of TRAK MSK compared to usual care.

BackgroundFour out of five people living with osteoarthritis (OA) also suffer with at least one other long-term health condition. The complex interaction between OA and multiple long-term conditions (MLTCs) can result in difficulties with self-care, restricted mobility, pain, anxiety, depression and reduced quality of life. The aim of the MulTI-domain Self-management in Older People wiTh OstEoarthritis and Multi-Morbidities (TIPTOE) trial is to evaluate the clinical and cost-effectiveness of the Living Well self-management support intervention, co-designed with people living with OA, integrated into usual care, in comparison to usual care alone.MethodsTIPTOE is a multi-centre, two-arm, individually randomised controlled trial where 824 individuals over 65 years old with knee and/or hip joint pain from their OA affected joint and at least one other long-term health condition will be randomised to receive either the Living Well Self-Management support intervention or usual care. Eligible participants can self-refer onto the trial via a website or be referred via NHS services across Wales and England. Those randomised to receive the Living Well support intervention will be offered up to six one-to-one coaching sessions with a TIPTOE-trained healthcare practitioner and a co-designed book. Participants will be encouraged to nominate a support person to assist them throughout the study. All participants will complete a series of self-reported outcome measures at baseline and 6- and 12-month follow-up. The primary outcome is symptoms and quality of life as assessed by the Musculoskeletal Health Questionnaire (MSK-HQ). Routine data will be used to evaluate health resource use. A mixed methods process evaluation will be conducted alongside the trial to inform future implementation should the TIPTOE intervention be found both clinically and cost-effective. An embedded 'Study Within A Project' (SWAP) will explore and address barriers to the inclusion of under-served patient groups (e.g. oldest old, low socioeconomic groups, ethnic groups).DiscussionTIPTOE will evaluate the clinical and cost-effectiveness of a co-designed, living well personalised self-management support intervention for older individuals with knee and/or hip OA and MLTCs. The trial has been designed to maximise inclusivity and access.Trial registrationISRCTN 16024745. Registered on October 16, 2023.

Purpose (the aim of the study): Musculoskeletal disorders of the knee pose a significant health challenge, requiring effective interventions to enhance patient outcomes. However, conventional therapeutic exercises encounter issues related to adherence and motivation. Therefore, virtual reality (VR) has emerged as a promising approach, leveraging immersive experiences to develop rehabilitation. This umbrella review was conducted to comply evidence from the existing systematic reviews on the effectiveness of VR therapeutic exercises while considering technology variations and outcome measures.

BACKGROUND We aimed to identify important components of, and practical resources relevant for inclusion in, a toolkit to aid exercise delivery for people with hip/knee osteoarthritis. METHOD An online international multi-disciplinary survey was conducted across 43 countries (139 clinicians, 44 people with hip/knee osteoarthritis and 135 osteoarthritis researchers). Participants were presented with the seeding statement 'Practical resources to aid the implementation of exercise for people with hip/knee osteoarthritis should…' and asked to provide up to 10 open text responses. Responses underwent refinement and qualitative content analysis to create domains and categories. RESULTS Refinement of 551 open text responses yielded 72 unique statements relevant for analysis. Statements were organised into nine broad domains, suggesting that resources to aid exercise delivery should: (1) be easily accessible; (2) be of high quality; (3) be developed by, and for, stakeholders; (4) include different ways of delivering information; (5) include different types of resources to support exercise and non-exercise components of self-management; (6) include resources on recommended exercises and how to perform/progress them; (7) include tools to support motivation and track progress; (8) include resources to enable tailoring of the programme to the individual and; (9) facilitate access to professional and peer support. CONCLUSION Our findings identified important components of, and practical resources to include within, a toolkit to aid delivery of exercise for people with hip/knee osteoarthritis. These findings have implications for exercise providers and lay the foundation for the development of a toolkit to help ensure exercise provision aligns with current international recommendations.

AIMS:This study gathered expert perspectives in the management of anterior cruciate ligament (ACL) rehabilitation to explore current practice, variations in care and optimal management strategies.MATERIALS AND METHODS:This was a qualitative semi-structured interview study. The participants' experiences were considered in terms of their roles as employees, managers, clinicians and professional gatekeepers. Purposive and snowball sampling were used to recruit physiotherapists and orthopaedic surgeons. Participants were included if they had a proven record in clinical management or research involving ACL patients. Persons were excluded if they could not speak English. Interviews were conducted in person, via skype or over the phone at a time convenient to the participant. Data was analysed using a framework analysis and critical realist approach.RESULTS:Results included 24 interviews that were conducted with 19 physiotherapists and 5 surgeons. Themes of variation in current care and optimal care were explored including subthemes of patient centred practice, evidence based medicine, resources, self-management, multidisciplinary teamwork, training and expertise were explored. Participant's perceptions of current care were that it was a location 'lottery' that significantly varied for patients across the UK.CONCLUSIONS:Stakeholders identified that optimal management should be patient centred and incorporate adequate equipment, specific training for physiotherapists and a closely communicating multidisciplinary team. Research is needed to explore cost effective models of optimal rehabilitation that include return to sport strategies.

This chapter describes the pathology of osteoarthritis (OA) within a continuum of early joint changes to patients requiring joint replacement. Osteoarthritis (OA) is a degenerative disease of the musculoskeletal system inextricably linked with joint pain, swelling, stiffness, muscle weakness and subsequent loss of function and independence. Individuals with OA will normally be managed in a primary care setting first by contact with clinicians such as general practitioners, physiotherapists, podiatrists, occupational therapists or nurses. Pharmacological options in OA can be broadly divided into oral analgesics and topical treatments. Where conservative management has been unable to control a patient's pain to within a bearable level or where the severity of the OA is having significant effects on a patient's mobility, surgical intervention may be suggested by an orthopaedic surgeon. An inextricable feature and chief complaint of OA is pain most noticeable during movement, including daily function and exercise.

Wearable sensors may enable the assessment of movement in a real-world setting, but they are not yet a standard practice in the analysis of movement due to the unknown accuracy and reliability with respect to different functional activities. Here, we established the concurrent validity and test–retest reliability of accelerations and orientations measured using affordable novel sensors during squats, jumps, walking and stair ambulation. In this observational study, participants underwent three data collection sessions during one day. Accelerations and orientations from sacrum, thigh and shank were collected using these sensors and already validated gold-standard sensors as the criterion method. We assessed validity by comparing the similarity of signal waveforms with the Linear Fit Method and by comparing mean differences in range values with the Bland–Altman plots. Reliability was assessed by calculating interclass correlation coefficient and standard error of measurements of the range values. Concurrent validity was from fair to excellent in 91% of the cases for accelerations and in 84.4% for orientations. Test–retest reliability of accelerations was from fair to excellent in 97% of cases when the sensors were attached by a researcher, and in 84.4% of cases when the sensors were attached by participants. Test–retest reliability of orientations was from fair to excellent in 88.9% of cases when the sensors were attached by a researcher, and in 68.9% of cases when the sensors were attached by participants. In conclusion, the new affordable sensors provide accurate measures of accelerations and orientations during multiple functional activities in healthy adults. Reliability of the orientations may depend on the ability to replicate the same position of the sensor under test–retest conditions.

Therapeutic exercise is a recommended first-line treatment for patients with knee and hip osteoarthritis (OA); however, there is little specific advice or practical resources to guide clinicians in its implementation. As the first in a series of projects by the Osteoarthritis Research Society International Rehabilitation Discussion Group to address this gap, we aim in this narrative review to synthesize current literature informing the implementation of therapeutic exercise for patients with knee and hip OA, focusing on evidence from systematic reviews and randomized controlled trials. Therapeutic exercise is safe for patients with knee and hip OA. Numerous types of therapeutic exercise (including aerobic, strengthening, neuromuscular, mind-body exercise) may be utilized at varying doses and in different settings to improve pain and function. Benefits from therapeutic exercise appear greater when dosage recommendations from general exercise guidelines for healthy adults are met. However, interim therapeutic exercise goals may also be useful, given that many barriers to achieving these dosages exist among this patient group. Theoretically-informed strategies to improve adherence to therapeutic exercise, such as patient education, goal-setting, monitoring, and feedback, may help maintain participation and optimize clinical benefits over the longer term. Sedentary behavior is also a risk factor for disability and lower quality of life in patients with knee and hip OA, although limited evidence exists regarding how best to reduce this behavior. Current evidence can be used to inform how to implement best practice therapeutic exercise at a sufficient and appropriate dose for patients with knee and hip OA.

ObjectivesTo evaluate the feasibility of trialling taxonomy for the rehabilitation of knee conditions—ACL (TRAK-ACL), a digital health intervention that provides health information, personalised exercise plans and remote clinical support combined with treatment as usual (TAU), for people following ACL reconstruction.MethodsThe study design was a two-arm parallel randomised controlled trial (RCT). Eligible participants were English-speaking adults who had undergone ACL reconstruction within the last 12 weeks, had access to the internet and could provide informed consent. Recruitment took place at three sites in the UK. TRAK-ACL intervention was an interactive website informed by behaviour change technique combined with TAU. The comparator was TAU. Outcomes were: recruitment and retention; completeness of outcome measures at follow-up; fidelity of intervention delivery and engagement with the intervention. Individuals were randomised using a computer-generated random number sequence. Blinded assessors allocated groups and collected outcome measures.ResultsFifty-nine people were assessed for eligibility at two of the participating sites, and 51 were randomised; 26 were allocated to TRAK-ACL and 25 to TAU. Follow-up data were collected on 44 and 40 participants at 3 and 6 months, respectively. All outcome measures were completed fully at 6 months except the Client Service Receipt Inventory. Two patients in each arm did not receive the treatment they were randomised to. Engagement with TRAK-ACL intervention was a median of 5 logins (IQR 3–13 logins), over 18 weeks (SD 12.2 weeks).ConclusionTRAK-ACL would be suitable for evaluation of effectiveness in a fully powered RCT.