Feasibility of Multimodal Physical Therapy in Hispanic American Older Adults with Moderate Knee Osteoarthritis

Feasibility of Multimodal Physical Therapy in Hispanic American Older Adults with Moderate Knee Osteoarthritis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Feasibility of Multimodal Physical Therapy in Hispanic American Older Adults with Moderate Knee Osteoarthritis Amy Gladin, Shiyun Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6256647/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Little is known about the feasibility of multimodal physical therapy for knee osteoarthritis (OA) among Spanish-speaking older Hispanic American adults with moderate symptomatic knee OA. The primary aim of this pilot study was to explore feasibility, and the secondary aim was to explore clinical changes after the intervention. Hispanic American older adults with moderate knee OA were recruited from an urban health system. Participants attended 10, small group, physical therapy clinic visits over 8 weeks, followed by 4 weekly support phone calls. The intervention was led in Spanish and included progressive lower body strengthening and cycling exercise, manual therapy, and self-management training. Feasibility was explored by using descriptive statistics to document the recruitment, retention, and adherence to exercise and clinic sessions. Eighteen of the 20 participants who enrolled came from sending 500 targeted recruitment letters, median age of 62.5 (range: 51 to 75) years; 85% completed the study. Median exercise adherence was 3.2 (range: 1.8-7) days per week for the 12-week study duration. Preliminary estimates of change in the clinical measures were promising however the study was not powered to detect changes. Multimodal physical therapy was feasible in Spanish-speaking older HA adults with moderate knee OA however recruitment was low. Health sciences/Health care/Geriatrics Health sciences/Health care/Health services/Rehabilitation Hispanic-American knee osteoarthritis feasibility exercise physical therapy strength physical performance Figures Figure 1 BACKGROUND Osteoarthritis (OA) is a leading cause of disability in the US and disproportionately affects older Hispanic American (HA) adults. 1 The population of older adults (age > 65) who are HA is expected to increase fivefold between 2012 and 2050. 2 OA broadly affects 44% of older HA adults and the prevalence of advanced symptomatic knee OA is rising rapidly in the HA population. 3 In older adult HA populations, 36–55% report difficulty walking a half mile and nearly 60% report difficulty climbing stairs and older HA adults with arthritis who speak Spanish are more at risk for developing disability in a longitudinal study. 4 – 6 Reasons for high levels of pain associated with OA in the HA population are complex but may include cultural factors, socioeconomic status, limited access to healthcare and culturally competent care, genetics and increased sensitivity in experimental pain studies. 7 Despite the negative impact of knee OA on the older HA population, there are few studies evaluating interventions targeting knee OA specifically in the HA population. Furthermore, HA people seek total knee replacement at a lower rate than non-Hispanic whites. 8 Therefore, conservative, and culturally appropriate treatment options are needed. 7 , 9 , 10 Clinical guidelines recommend multimodal interventions including land-based exercise and self-management training for the conservative management of knee OA. 11 – 13 While clinical guidelines do not recommend one type of exercise over another, strength training and aerobic exercise are consistently recommended with strong recommendation across clinical guidelines. 11 – 13 Furthermore, conservative multimodal physical therapy core interventions include exercise and self-management training; additionally, there is evidence showing that manual therapy may be beneficial. 13 , 14 To our knowledge, there are no clinical trials exploring the feasibility and clinical outcomes of multimodal physical therapy in Spanish-speaking HA older adults with moderate knee OA. A 6-week, once-weekly community-based self-management training program developed for adults who are HA with mixed types of arthritis has demonstrated effectiveness in improving arthritis-related symptoms. 15 – 18 The self-management program included self-management training and whole-body exercise, but lacked specificity for people with knee OA. The lack of specificity is likely reflected by limited improvements seen in broad measures of disability and physical function. 15 – 17 Adherence and retention after the 6-week in-person self-management training program and, adherence to aerobic and stretching exercise was good; however, specific adherence to strength training exercise was unreported. 15 – 18 Given that clinical guidelines strongly recommend exercise-based interventions for knee osteoarthritis, it is important to know if multiple populations are adherent to exercise interventions. 13 , 14 The primary purpose of this pilot study was to explore the feasibility of participant recruitment, exercise and clinic session adherence, and retention after multimodal physical therapy in Spanish-speaking, older (age 50 or greater) HA adults with moderate knee OA. The secondary aim was to explore the changes in health-related quality of life (HrQol), physical function, and quadriceps strength after the intervention. Results from this study inform a larger planned clinical trial. METHODS This was an uncontrolled, pragmatic, 12-week pre/post-intervention pilot study conducted in an outpatient physical therapy clinic in a large urban integrated health system. The participants were recruited San Francisco Greater Bay area. All written and verbal communication was conducted in Spanish. All participants underwent a 2-step consent process (see below) to ensure adequate understanding of the study risks, as recommended by the Institutional Review Board. The consent process was conducted by bilingual study staff. Informed consent was obtained from all the participants. The inclusion criteria were as follows: identify as Hispanic American, Spanish language preference, speaking Spanish at home, age 50 or greater, radiographic knee OA Kellgren-Lawrence (KL) grade ≥ 2 or at least one compartment rated with moderate OA, knee pain in the previous 30 days, ability to walk inside home without a cane, able to walk ¼ block without a cane, and able to go up one flight of stairs without physical assistance. Exclusion criteria were a history of lower extremity joint arthroplasty, body mass index > 40 kg/m 2 , neurologic dysfunction impacting functional mobility, unstable cardiovascular disease, and uncontrolled psychiatric or behavioral problems preventing the ability to participate in a group exercise program. Human ethics approval and consent was approved by the Kaiser Permanente Northern California Institutional Review Board before participant enrollment. This trial was registered with ClinicalTrials.gov repository, identifier (NCT04219423, first posted 07/01/2020). All interventional procedures were performed in accordance with relevant guidelines and regulations. Spanish cultural competence. All written Spanish communications were translated by a bilingual bi-cultural health educator with 20 years of experience working with the Latino community who holds a bachelor’s degree in linguistics and a master’s degree in public health. The exercise instruction handouts were further reviewed and vetted by a second bilingual bicultural translator, a fellowship-trained physical therapist (PT) with 10 years of experience, who holds bachelor's degree in journalism and doctorate in physical therapy. Both translators had previous experience with the transcreation of content from English to Spanish in multiple medical center settings. The primary health educator translator was from Mexico, the second translator was from Columbia, and both translators vetted exercise instruction word-choice content to ensure cultural appropriateness for people of HA descent. The intervention was led by 5 PTs who were conversant in Spanish with 8 to 30 years of experience, and 80% (n = 4) were board certified in orthopedics and/or fellowship trained in orthopedics or sports medicine. Participants were invited to bring family members to the testing and intervention sessions if they wished. Recruitment. Participants were recruited using three methods: a targeted letter campaign, a referral from health care providers, and study fliers in medical office buildings. The targeted letter campaign included recruitment letters that were sent from a database established by a programmer searching the electronic medical record for Hispanic American, Spanish language preference, knee radiographs within the previous 2 years with KL level 2 or greater or moderate rating of knee OA, age 50 or greater, and lived or worked in San Francisco. The exclusion criteria were also identified and screened from the database. Permission to send a recruitment letter was obtained from the primary care provider before sending a recruitment letter to ensure that no vulnerable participants were inadvertently included. Referral from health care providers was encouraged by study staff attending provider staff meetings to alert providers (primary care, PTs, and orthopedics) about the study. All potential participants were directed to call the study phone line to complete the screening. Once potential participants were screened on the phone, the first consent was initiated, and a one-hour baseline testing session was scheduled. Permission to participate in the intervention was obtained from the primary care provider before the baseline testing session. The second consent was obtained during the baseline testing session in person by bilingual staff and indicated enrollment in the study. Multimodal physical therapy intervention. The multimodal intervention session was 75 minutes in duration and met 2 days per week for 2 weeks, then once per week for 6 weeks, followed by 4 weekly phone calls to determine adherence to the home exercise program (HEP) and provide feedback and support. The total duration of the intervention was 12 weeks which is consistent with previous knee OA exercise trials. 19 – 21 The in-person intervention was led in a small group format with a ratio of one PT for every two participants, and groups never exceeded four participants. The multimodal physical therapy intervention consisted of progressive lower extremity strengthening training targeting the quadriceps and gluteal groups in both legs, progressive stationary bicycle exercise with short bursts of high-velocity training, self-management training, manual therapy, flexibility and stretching exercise and HEP instruction (Table 1 , Supplementary Data File). 22 – 29 Reduced strength in bilateral quadriceps and gluteal groups is common in knee osteoarthritis and strength training and high-velocity exercise training improve physical function in older adults and is safe. 22–25,29−31 All in-clinic intervention sessions began with 10-to-20 minutes of stationary bicycle exercise, 40 minutes of individualized lower extremity strength training, and finished with 10 minutes of lower extremity stretching. The PT prescribed lower extremity strength training and flexibility exercise based on a standardized protocol described in the Supplementary Data File. Participants were provided with a handout of the prescribed HEP in Spanish including photos of the exercises, instructions and dosing parameters to help with adherence. The HEP handout was updated weekly accordingly by the PT. The stationary bicycle high-velocity protocol was progressive in nature and described in detail in the Supplementary Data File. The PT determined which patients received manual therapy based on clinical assessment and all participants received at least 2 manual therapy sessions (details in Supplementary Data File). Weekly safety logs were completed during the 12-week intervention to monitor for pain, new injuries and adherence to HEP. The Principal Investigator, a PT, reviewed the safety logs every week and collaborated with the intervention PTs to make modifications to the exercise if needed. Table 1 Multimodal physical therapy interventions over 12-week study period Weeks 1–2: 75 minutes multimodal physical therapy 2 times per week for 2 weeks, in clinic Bike 10–20 minutes Strengthening 40 minutes Manual Therapy10 min Cooldown 10 minutes 10-minute stationary bike at 50% predicted heart rate max Physical therapist prescribes 5–7 strength exercises from the following list: Quadriceps open chain: Quadricep isometrics, seated or supine knee extension, supine straight leg raises. Gluteal open chain: side lying hip abduction/external rotation (clam), hip abduction, supine bridge. Closed-chain lower extremity: progressive squats, step-up anteriorly or laterally, standing hip abduction, standing hip extension, banded-at-knee side stepping, progressive forward and lateral lunges and calf raises. HEP initiated and updated handouts provided weekly. Assess and treat at least once 5 min Lower extremity stretching: quadricep, hamstring, hip flexor, and calf PT prescribes HEP for flexibility. Ice optional Weeks 3–6: 75 minutes multimodal physical therapy 1-time per week for 4 weeks, in clinic Bike 10–20 minutes Strengthening 40 minutes Manual Therapy10 minutes Cooldown 5 minutes 10-minute warm up. High-velocity training: 3–6 repetitions of 10–30 second fast cadence intervals at moderate intensity on 1-to-2-minute rests PT selects exercises from list above and prescribes resistance. PT customizes intensity and dose of strength exercise based on one-repetition maximum estimations and rate of perceived exertion. PT progresses exercises to therapeutic zone of 60 to 80% one-repetition maximum or perceived exertion. PT prescribes 8 to 12 repetitions, 2 to 3 sets per exercise, 3-days per week for 5–7 strength exercises. Weights and bands issued to patients to perform HEP at home. HEP prescribed and updated handouts provided weekly. Assess and treat at least once 10 minutes Lower extremity stretching. Participants practice flexibility HEP. Ice optional Weeks 8–12: 30-minute weekly phone or video visit adherence check, support and advice n/a Continue 5–7 strength exercises at home at least 3 days per week in a therapeutic zone. Continue recommended flexibility exercises. Advise participants to walk for exercise. Provide support and answer questions about HEP. One-week recall of exercise adherence. n/a n/a Strengthening exercises were adapted from previously published trials that demonstrated the efficacy of exercises. See Supplementary Data File for a detailed description of exercises and intervention protocol. 19 – 21 , 59 Weekly phone follow-up after the 8-week in-clinic intervention. Participants were called weekly during the remaining 4 weeks of the study to review safety logs, determine adherence to HEP, and provide support. 32 The PT verbally reviewed all exercises and recorded the resistance used. Weights for exercises were progressed over the phone if exercises were not in the therapeutic intensity zone described in the Supplementary Data File . 33 , 34 The participants were instructed to participate in aerobic exercise, and support was provided to individualize the instructions. Adherence to aerobic exercise was not observed however advice was provided to participate in an aerobic conditioning program. Primary outcome measures for feasibility: recruitment, adherence, and retention. This was an exploratory feasibility study, a convenience sample of 20 participants who lived or worked in San Francisco were recruited from a large urban integrated health system and measures of feasibility were observed. Recruitment was explored by documenting the number of participants who were screened, the method of recruitment, the number of enrolled participants, and the reasons why participants did not qualify or enroll. Adherence to in-clinic multimodal physical therapy sessions was recorded and weekly exercise adherence was recorded for the 12-week study period using 1-week recall. Participants were instructed to exercise 3 times per week to optimize strength gains during the 12-week study period. 33 , 34 To explore retention, the number of participants who completed the intervention post-testing was recorded. Secondary outcome measures for health-related quality of life and physical performance. Participants were assessed at baseline and after the 12-week intervention period. Baseline testing included a brief physical therapy evaluation and body weight in pounds. A study manual was created for all physical performance measures adapted from previous authors and translated into Spanish by the bilingual health educator. 35 , 36 To ensure fidelity to outcome measurement testing, the PTs stated outcome measure instructions in English, and an interpreter repeated the instructions in Spanish per the study manual. Three PTs (1 board certified in orthopedics) with 7 to 21 years of experience conducted all assessments with a single interpreter for all participants, except for one. Two of the assessing PTs also led the intervention given small study staff. Health-related quality of life. The Spanish Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire measures global HrQol and comprises 24 questions with three subcomponents: pain, stiffness, and physical function. The WOMAC is scored on a 5-point Likert scale (0–4) with a maximum score of 96 points. Higher scores indicated worse symptoms and function. The WOMAC has been translated into Spanish and has an acceptable reliability (Interclass correlation coefficient, ICC = 0.81). 37 Physical performance. The Timed Up and Go (TUG ) test measures the time in seconds to rise from a chair, walk 3 meters turn and return to the chair, and sit down. The TUG test is a measure of gait, dynamic balance, and transfer ability. TUG was measured using two verbal descriptions: ‘walk at your normal speed’ (TUG-normal) and ‘walk as fast and as safely as you can’ (TUG-fast). Between-rater reliability for TUG-normal was ICC = 0.75, and for TUG-fast was ICC = 0.87. 35,38 Two trials for TUG-normal and TUG-fast were recorded, and the mean was used in the analysis. The Six Minute Walk (6MW) test measures in meters the distance walked in 6 minutes. The 6MW is a measure of lower extremity strength and endurance. The test-retest reliability of the 6MW is ICC = 0.94. 39,40 The Five-time sit-to-stand (5TSTS) test measures the time to stand up and sit down from a 19-inch chair 5 times as fast as possible. The 5TSTS is a functional measure of lower-extremity strength and transfer ability. The intra-session intraclass correlation coefficient for the 5TSTS is 0.94. 41 Isometric quadriceps strength. Strength was assessed using a modified hand-held dynamometer method. 36 , 42 Participants sat at the edge of a high-low table with their knees flexed to 90°. A hand-held dynamometer (Chattanooga™ model 01165 Manual Muscle Tester) was placed 1-inch proximal to the distal fibula on the anterior aspect of the tibia, and a gait belt was wrapped around the hand-held dynamometer and secured by a metal support under the table for stability. A second belt was placed over the participant’s hips and wrapped around the tabletop to stabilize the pelvis on the table during testing. Participants were instructed to straighten knee and push hard for to 2–3 practice sessions on 1-minute rests. Participants were verbally encouraged to push as hard as possible for maximal effort during the last 2 test trials, and peak quadriceps strength was recorded in pounds and normalized to body weight. The mean of the 2 maximal efforts was used in the analysis. The modified hand-held dynamometer method has high reliability. 36 , 42 Adverse events. Adverse events were recorded via weekly safety logs, inquiring about new injuries and pain. Weekly safety logs were collected and reviewed in the principal investigator. Statistical analysis. Descriptive statistics were used to describe the recruitment, adherence, and retention of the feasibility outcomes. We calculated the standard error and 95%CI for feasibility proportional outcomes (screened/enrolled and retention) and measures of central tendency are reported for discrete quantitative feasibility variable outcomes (adherence days/week of exercise). 43 For secondary outcomes related to the HrQol and physical performance, all measures were described as means and standard deviations (SD). Changes from the baseline to post-intervention measures were assessed using paired-sample t-tests. The mean changes and 95% confidence intervals (CI) and effect sizes are reported. RESULTS Feasibility of recruitment, adherence, and retention. Potential participants were recruited from May to October 2017 and data collection was completed in March 2018. See Fig. 1 : CONSORT diagram for details. Five hundred targeted recruitment letters were sent, and 27 of 30 who called to be screened came from letters and 18 of 20 who enrolled came from letters. Thirty participants total called to be screened and 20 enrolled, 66.7% (95%CI: 47.2%, 82.7%). Median exercise adherence was 3.17 (range: 1.8-7, IQR = 1.8, mean = 3.65, SD = 1.46) days per week. Participants completed, on average, 121% of the study goal exercise adherence during the 12-week intervention. 33 Participants attended a mean of 7.15 (71.5%) of the 10 total in-clinic sessions. All phone-call follow-up sessions were completed and in cases where a participant was not reachable in one week, a 2-week recall of HEP adherence was recorded. Seventeen participants attended the post-test session, retention was 85% (95%CI: 62.1%,96.8%). The three participants who did not attend post-intervention testing were older (mean age 71), female and had clinically worse performance in all physical performance measures and on WOMAC global and physical performance scales. Participant characteristics. The median age was 62.5 (range: 51 to 75) years, and 55% of the cohort was female (Table 2 ). Eighty-two percent of the cohort had KL classification 1–2 to KL 4. Of the forty knees in the cohort (n = 20), 18 right knees were symptomatic and 11 left knees were symptomatic based on self-report. All symptomatic knees, except for one, met the American College of Rheumatology criteria for clinical diagnosis of knee OA. 44 Table 2 Baseline characteristics Variable Median or N Range or % Age (years) 62.5 51–75 Female 11 55.0 Race Hispanic White 4 20.0 Hispanic Asian 1 5.0 Hispanic other 15 75.0 Body-mass Index (BMI) 29.9 24.1–35.3 Occupation Full-time service 1 5 25.0 Full-time janitor 5 25.0 Full-time construction/maintenance 4 20.0 Full-time retired 2 2.0 Full-time desk job 2 2.0 Part-time 2 2.0 Comorbidities 2 0–1 10 50.0 >2 10 50.0 Knee Range of Motion Passive right flexion 133.5 108–145 Passive left flexion 137 105–145 Self-reported symptomatic knees Right knee 9 45.0 Left knee 2 10.0 Bilateral 9 45.0 Positive on Altman 3 criteria for clinical arthritis Right knee 17 85.0 Left knee 15 75.0 Radiographic severity of OA No radiograph or normal radiograph 7 18.0 KL 4 1–2 or minimal rating 15 37.0 KL 2–4 or moderate/severe rating 18 45.0 1 Service employment = restaurant, retail, caregiver, teachers aid 2 Comorbidities= hypertension, DM2, high cholesterol, hypothyroid, chronic pain, hyperlipidemia, depression 3 Altman criteria: American College of Rheumatology (ACR) clinical classification for knee OA, 3 of the 6 criteria present: age > 50 years, crepitus on active motion, less than 30 minutes of stiffness upon waking, bony enlargement or tenderness, and no palpable warmth of the synovium. 42 4 KL = Kellgren-Lawrence Preliminary estimates of change in clinical measures of HrQol and physical performance. Global HrQol and all three subcomponents of the WOMAC improved post-intervention (Table 3 ). Global HrQol on the WOMAC improved by 15.9 points or 30.1%. Minimum Clinically Important Difference (MCID) and Minimum Detectible change (MDC 95% ) from 2 different English-speaking studies, which showed improvements of 9.1 and 13.4 points, respectively. 45 , 46 WOMAC physical function improved 11.5 points or 35.9% in this study, which also surpassed MCID of 26% reported in a knee OA anti-inflammatory trial. 46 22 Table 3 Secondary outcome measures of health-related quality of life and physical performance Secondary outcome measures Baseline (N = 20) Mean (SD) Post-intervention (N = 17) Mean (SD) Mean Change (N = 17) Mean (95% CI) Effect size Physical Function TUG-regular (sec) 11.9 (3.9) 9.6 (2.1) -2.0 ( -4.2, 0.2) ** 0.513 TUG-fast (sec) 9.4 (2.1) 7.9 (2.3) -1.2 ( -3.6, 1.3) ** 0.571 5TSTS (sec) 14.7 (6.2) 14.5 (3.6) 0.2 ( -3.0, 3.4) 0.032 6MW (meters) 384.6 (103.0) 452.0 (77.4) 50.1( -1.5, 101.6) ** 0.486 Health Related Quality of Life/WOMAC Total score 45.0 (24.6) 27.7 (19.4) -15.9 (-5.3 to -26.5) 0.646 Pain sub-score 9.1 (4.8) 5.8 (3.8) -3.2 (-5.8 to -0.7) 0.667 Physical function sub-score 32.2 (18.1) 19.3 (15.0) -11.5 ( -19.0 to -3.9) 0.635 Stiffness sub-score 3.8 (2.0) 2.5 (1.3) -1.2 ( -2.1 to -0.3) 0.600 Quadriceps Strength Right quadriceps (pounds) 55.8 (29.3) 51.1 (17.3) -4.7 (-15.1, 5.8) 0.160 Left quadriceps (pounds) 56.6 (26.0) 53.3 (19.7) -3.2 (-11.6, 5.2) 0.123 Right quadricep mean change (%) - - 8.34 (-18.85, 35.54) - Left quadricep mean change (%) - - 5.61 ( -17.48, 28.70) - Minimum clinically important difference = MCID and Minimum Clinical Difference = MCD ** denotes clinically significant change MDC 95% TUG regular 1.14 sec, 48 MCID TUG-fast 1.2 sec, 47 5TSTS MDC 90% 2.11 sec 29 , MDC 90% 6MWT 50.2 meters, 38 MDC 95% WOMAC total 13.4 points, 45 MDC percent change in quadriceps strength 21.7% 42 to 49.7% 57 TUG-regular, TUG-fast and 6MWT changed by -2.0 ( -4.2, 0.2) seconds, -2.0 ( -4.2, 0.2) seconds and 50.1( -1.5, 101.6) meters respectively (Table 3 ). The 95% CIs included clinically meaningful changes for the TUG-fast, TUG-regular and 6MW and our small pilot study was not powered for adequate precision to measure these changes (Table 3 ). A 1.2 second decrease has been reported as a major clinical improvement on the TUG-fast, and in another study 1.14 seconds has been reported as MDC 90% for the TUG-regular. 47 , 48 Fifty meter improvement in 6MW has been reported as a substantial improvement in a sample of older adults with mobility impairment and MDC 90% has been reported as 50.2 meters in a hip/knee OA cohort. 38 , 40 Furthermore, effect sizes (0.49–0.57) on these outcomes, suggest there may have been a medium treatment effect on these variables (Table 3 ). Five-time sit-to-stand did not change. Changes in quadriceps strength were not reported in the normalized-to-body-weight format, given missing data for body weight at post-testing sessions. Instead, mean change in quadriceps strength pre/post-intervention was reported and varied between − 66–136% (Table 3 , Table 4 ). Table 4 Percent change before/after intervention in absolute quadriceps strength in all knees Percent change in quadricep strength Combined right and left knees n = 34 Variable percent Mean change 7.0 Standard deviation 14.7 Range -66.3 to 136.3 Quartile 1 -22.3 Median -6.0 Quartile 3 21.6 Interquartile range 44.5 Lower fence -89.7 Upper fence 88.3 Minimum Clinical Difference in quadricep strength 21.7% 42 to 49.7% 57 Adverse events . There were no reportable or unexpected adverse events during the 12-week program. Nineteen non-reportable events occurred during the intervention period. See Additional Data File for details. DISCUSSION We explored feasibility of multimodal physical therapy in an uncontrolled pragmatic trial among Spanish-speaking older adults who are HA and have moderate symptomatic knee OA in terms of recruitment, adherence, and retention. Our results suggest that the intervention is feasible in this population. The study recruitment goal to recruit 20 people was met by utilizing a targeted letter campaign to identify people with moderate radiographic knee OA and other inclusion criteria however recruitment rate was low (500 letters sent, 18 enrolled from letter campaign). Overall, adherence to exercise surpassed the study goal of 3 times per week. Retention was favorable, with 85% of the cohort attending post-testing sessions. There were also promising preliminary estimates of change in HrQol and clinical improvements in TUG and 6MW, however improvements are interpreted with caution given the study was not powered to detect change in clinical measures. A targeted letter campaign searching the medical record for inclusion/exclusion criteria, including radiographic knee OA results, appears to be feasible, as most participants (18 of 20) were enrolled from the targeted letter campaign. The screening to enrollment ratio was acceptable at 67%. However, the recruitment rate was low due to study design limitations (500 recruitment letters were sent to people who met inclusion criteria). It is noteworthy that interest in the study continued beyond the 3-months allocated to recruit and future studies should consider 6-months to recruit participants and may lead to a higher recruitment rate with the targeted letter campaign. In comparison, another study recruiting adults who were HA with knee OA did a medical record search using knee OA and leg pain diagnostic codes and only identified and enrolled five participants from this method for a behavioral telephone intervention. 49 The availability of radiographic data in the medical record search and geographic location in the current study that has a higher proportion of adults who are HA may have contributed to the larger pool of potential participants meeting inclusion criteria. 50 It is unknown why the recruitment rate from the letter campaign was low. It is possible implementation methods (in-clinic versus telehealth intervention) of the current study may contribute to the low recruitment rate. 51 – 54 A future mixed-methods study is planned to explore implementation preferences for knee OA multimodal physical therapy in this population. Adherence to exercise varied from 1.8 to 7 days per week. Participants attended a mean of 71% of the in-clinic sessions and exercised a mean of 3.6 days per week for the 12-week study duration, which was 121% of the study goal. Other trials have reported exercise adherence in the HA population. A self-guided walking intervention, reported higher adherence to a walking program after 6 weeks, 88% of participants walked 3–5 days per week; in our study, 76% of the cohort exercised 3 or more days per week. 55 Reported adherence may be higher in the walking trial due to recall bias given that participants reported adherence to exercise once at the end of the 6-week trial, whereas the current study collected weekly adherence, which is likely to be less vulnerable to recall bias. Adherence to a weekly, 6-week in-person self-management training program (which included generalized exercise) for HA adults with arthritis was 84%, which is higher than our 72% adherence to our 8-week in-person intervention. 15 , 16 Our in-clinic intervention included 10 sessions over the 8-week period, suggesting that a lower number of in-clinic sessions may lead to better in-person adherence. Consistent with previous research in other non-knee OA-specific populations, HA adults adhere to structured exercise and education programs. 15 , 16 , 55 , 56 We retained 85% of our cohort after the 12-week multimodal intervention, which is similar to the walking intervention trial, that reported 82% retention at 6 weeks and the self-management training program, that reported 85% retention after 6 weeks. 15 , 16 , 55 Furthermore, 2 exercise and education trials followed HA participants for longer durations, and retention was 83% in the self-management program at 6 months and 84% an exercise and education intervention trial at 1-year. 16 , 55 Retention of older adults who are HA and have arthritis appears to be feasible in both the short and long term after exercise and educational interventions. Global HrQol change post-intervention changes are similar to the within-group 18.2 point improvement reported after a 6-month behavior change phone intervention study in HA adults with knee OA. 49 It is concerning the patient reported outcome improvements trended positive given the physical performance measures were highly varied. It is possible participants responded favorably on the patient reported outcomes post-intervention due to therapeutic alliance with treating PTs and wanting to please the treating PTs, furthermore the lack of blinding could have contributed to an overestimation of treatment effects. The absolute mean percentage change in quadriceps strength across all knees was highly varied (Table 4 ). The hand-held dynamometer method utilized in this study has high within-subject variability in similar cohorts, with MDC varying from 21.7–49.6% despite high inter- and intra-rater reliability. 42 , 57 All knees in the upper quartile experienced clinically meaningful increases in strength suggesting the intervention has potential to meaningfully improve quadriceps strength among some participants (Table 4 ). Four of the knees in the upper quadrant were possible outliers and spread across 3 people. Each of the 3 people made clinically significant gains in physical performance measures and HrQol suggesting the data points may not be outliers. All percent-change in quadricep strength measures were within the extreme outlier limits. Five of the 8 participants who reported pain during strengthening exercise and required PT modifications to exercise were below the 21.7% MDC quadriceps percent change cut-off suggesting more time may have been needed to accommodate to the intervention. Dose tolerance of quadriceps strengthening varied in our study; some participants maintained a lower intensity during strength exercises for the entire 12-week intervention, while others progressed upwards to the therapeutic level range which may have also contributed to the varied distribution of strength change. 33 Furthermore, our cohort was deconditioned compared to other populations with knee OA. Baseline physical performance was poorer in this study compared to similar non-Hispanic cohorts for the TUG-regular, TUG-fast, 6MWT and 5TSTS (11.9 sec vs 10.9 sec, 9.4 sec vs 7.1 sec 384 m vs 412 m and 14.7 sec vs 10.1 sec) respectively. 39 , 47 , 48 Only 3 of 15 participants tested for one-repetition maximum (a measure of strength described in the Supplementary Data File) on the leg press were able to leg press greater than their body weight. A systematic review found that optimum strength changes in older adults occur at one year. 58 The study team is planning a longer duration trial to allow for accommodation and achieve meaningful changes in strength for this population. This pilot study demonstrated the feasibility of conducting a multimodal physical therapy intervention in a less known and more vulnerable population, namely Spanish-speaking older adults who are HA and have moderate symptomatic knee OA. This study is also pragmatic; it was conducted in a large urban outpatient physical therapy clinic in a group setting, and the multimodal nature of the intervention reflects the clinical practice. This study has several limitations. First, there were no comparison groups in this study. Positive clinical outcomes are suggestive at best; however, the primary aim of this pilot study was to assess feasibility rather than effectiveness. Second, participants' exercise tolerance varied, leading to a broad range of dosing (repetitions, frequency, and intensity) of exercise, which could have impacted the results of clinical measures. The study group is exploring a longer duration trial to allow for accommodation to exercise. Third, there was no structured feedback solicited from participants or interventionists which could help to refine the intervention and better serve this population. Fourth, the 3 participants who did not attend post-testing were older and had worse physical performance and HrQol which could have affected clinical results. The study team is planning a mixed-methods study to explore implementation preferences and clinical effectiveness of multimodal physical therapy in Spanish-speaking older adults who are HA and have moderate symptomatic knee OA. A longer than 12-week duration strengthening intervention is also planned. CONCLUSION Multimodal physical therapy, including individualized progressive lower extremity strengthening, progressive stationary bicycle exercise with short bursts of high-velocity training, self-management training, manual therapy, flexibility and stretching exercises, and HEP instruction, is feasible in a cohort of Spanish-speaking older adults who are HA and have moderate symptomatic knee OA. A 6-month recruitment period is recommended for consideration using a targeted letter campaign. Preliminary estimates of changes in the clinical measures of HrQol and physical performance are promising. Quadriceps strength change post-intervention was highly varied, and consideration for a longer intervention than 12 weeks is warranted. The study team is planning a mixed-methods trial to explore implementation preferences and effectiveness of multimodal physical therapy in Spanish-speaking older adults who are HA and have moderate symptomatic knee OA. Abbreviations Osteoarthritis OA Hispanic American (HA) Health-related quality of life HrQoL Kellgren-Lawrence KL Home exercise program HEP Western Ontario and McMaster Universities Osteoarthritis Index WOMAC Intraclass correlation coefficient ICC Timed up and go TUG Five-times sit to stand 5TSTS Six-minute walk 6MW Minimum clinically important difference MCID Minimum Clinical Difference MCD Declarations Acknowledgements : Sofia Arellano-Padilla MPH, Alexis Anderson PT, DPT, Mary-Edna Harrell PT, FAAOMT, Jillian Cripps PT, DPT, OCS, FAAOMT, Tony Tran PT, DPT, SCS, FAAOMT, Catherine Brunswick PT, DPT, OCS, Joanne M Rhodes PT, DPT, OCS, FAAOMT, Susana Robles, PT, DPT. This study was funded by the Kaiser Permanente Northern California Community Benefits program (RNG021024). This trial was registered with ClinicalTrials.gov repository, identifier (NCT04219423). Registered retrospectively Jan 3, 2020. Authors' contributions: AG is responsible for the study design, execution, study oversite, data analysis and writing the manuscript. SZ was the biostatistician and responsible for statistical analysis and participating in writing the manuscript. Competing interests : Authors and study staff have no conflicts of interest to report. Availability of data and materials : nonidentified data is available via email correspondence with the corresponding author [email protected] Ethics declarations : This study has been approved by the Kaiser Permanente Northern California Institutional Research Board. Consent for publication: All participants participated in a 2-step consent process per recommendations by Kaiser Permanente Northern California Institutional Research Board. Informed consent was obtained from all the participants. References 2014 National Healthcare Quality and Disparities Report chartbook on health care for Hispanics. Agency for Healthcare Research and Quality AHRQ Pub. 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Gladin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYNCCAgbGNgbmA0CWhAyRWgxAWtgSQFp4iNfSwMBjAGIS1sI/7YwB4xcDO9k+6Z7Pr27UWPAwsB8+ugGfFonbOQbMMgbJxm0yZ7dZ5xwDOownLe0GXmtAWiQMmBPbJHK3GeewAbVI8Jjh1SIP0VIP1JLzzDjnHxFaDIBaGD8YHAZpYX6c20aEFsPbaQWHGQyOG7dJpJkx5/ZJ8LAR8ovc7eSND39UVMvOn5H8+HPOtzo5fvbDx/B7n4HD4DA0LtgkwCR+5SDA/oDxB4TF/IGw6lEwCkbBKBiJAADon0RyKA9n0AAAAABJRU5ErkJggg==","orcid":"","institution":"Kaiser Permanente Northern California","correspondingAuthor":true,"prefix":"","firstName":"Amy","middleName":"","lastName":"Gladin","suffix":""},{"id":479417823,"identity":"3485ed1f-5a43-4629-9b52-52f398404dbf","order_by":1,"name":"Shiyun Zhu","email":"","orcid":"","institution":"Kaiser Permanente Northern California Division of Research","correspondingAuthor":false,"prefix":"","firstName":"Shiyun","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2025-03-19 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Osteoarthritis","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eOsteoarthritis (OA) is a leading cause of disability in the US and disproportionately affects older Hispanic American (HA) adults.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The population of older adults (age\u0026thinsp;\u0026gt;\u0026thinsp;65) who are HA is expected to increase fivefold between 2012 and 2050.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e OA broadly affects 44% of older HA adults and the prevalence of advanced symptomatic knee OA is rising rapidly in the HA population.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e In older adult HA populations, 36\u0026ndash;55% report difficulty walking a half mile and nearly 60% report difficulty climbing stairs and older HA adults with arthritis who speak Spanish are more at risk for developing disability in a longitudinal study.\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Reasons for high levels of pain associated with OA in the HA population are complex but may include cultural factors, socioeconomic status, limited access to healthcare and culturally competent care, genetics and increased sensitivity in experimental pain studies.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Despite the negative impact of knee OA on the older HA population, there are few studies evaluating interventions targeting knee OA specifically in the HA population. Furthermore, HA people seek total knee replacement at a lower rate than non-Hispanic whites.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Therefore, conservative, and culturally appropriate treatment options are needed.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClinical guidelines recommend multimodal interventions including land-based exercise and self-management training for the conservative management of knee OA.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e While clinical guidelines do not recommend one type of exercise over another, strength training and aerobic exercise are consistently recommended with strong recommendation across clinical guidelines.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Furthermore, conservative multimodal physical therapy core interventions include exercise and self-management training; additionally, there is evidence showing that manual therapy may be beneficial.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e To our knowledge, there are no clinical trials exploring the feasibility and clinical outcomes of multimodal physical therapy in Spanish-speaking HA older adults with moderate knee OA.\u003c/p\u003e \u003cp\u003eA 6-week, once-weekly community-based self-management training program developed for adults who are HA with mixed types of arthritis has demonstrated effectiveness in improving arthritis-related symptoms.\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e The self-management program included self-management training and whole-body exercise, but lacked specificity for people with knee OA. The lack of specificity is likely reflected by limited improvements seen in broad measures of disability and physical function.\u003csup\u003e\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Adherence and retention after the 6-week in-person self-management training program and, adherence to aerobic and stretching exercise was good; however, specific adherence to strength training exercise was unreported.\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Given that clinical guidelines strongly recommend exercise-based interventions for knee osteoarthritis, it is important to know if multiple populations are adherent to exercise interventions.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe primary purpose of this pilot study was to explore the feasibility of participant recruitment, exercise and clinic session adherence, and retention after multimodal physical therapy in Spanish-speaking, older (age 50 or greater) HA adults with moderate knee OA. The secondary aim was to explore the changes in health-related quality of life (HrQol), physical function, and quadriceps strength after the intervention. Results from this study inform a larger planned clinical trial.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis was an uncontrolled, pragmatic, 12-week pre/post-intervention pilot study conducted in an outpatient physical therapy clinic in a large urban integrated health system. The participants were recruited San Francisco Greater Bay area. All written and verbal communication was conducted in Spanish. All participants underwent a 2-step consent process (see below) to ensure adequate understanding of the study risks, as recommended by the Institutional Review Board. The consent process was conducted by bilingual study staff. Informed consent was obtained from all the participants. The inclusion criteria were as follows: identify as Hispanic American, Spanish language preference, speaking Spanish at home, age 50 or greater, radiographic knee OA Kellgren-Lawrence (KL) grade\u0026thinsp;\u0026ge;\u0026thinsp;2 or at least one compartment rated with moderate OA, knee pain in the previous 30 days, ability to walk inside home without a cane, able to walk \u0026frac14; block without a cane, and able to go up one flight of stairs without physical assistance. Exclusion criteria were a history of lower extremity joint arthroplasty, body mass index\u0026thinsp;\u0026gt;\u0026thinsp;40 kg/m\u003csup\u003e2\u003c/sup\u003e, neurologic dysfunction impacting functional mobility, unstable cardiovascular disease, and uncontrolled psychiatric or behavioral problems preventing the ability to participate in a group exercise program. Human ethics approval and consent was approved by the Kaiser Permanente Northern California Institutional Review Board before participant enrollment. This trial was registered with ClinicalTrials.gov repository, identifier (NCT04219423, first posted 07/01/2020). All interventional procedures were performed in accordance with relevant guidelines and regulations.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSpanish cultural competence.\u003c/b\u003e All written Spanish communications were translated by a bilingual bi-cultural health educator with 20 years of experience working with the Latino community who holds a bachelor\u0026rsquo;s degree in linguistics and a master\u0026rsquo;s degree in public health. The exercise instruction handouts were further reviewed and vetted by a second bilingual bicultural translator, a fellowship-trained physical therapist (PT) with 10 years of experience, who holds bachelor's degree in journalism and doctorate in physical therapy. Both translators had previous experience with the transcreation of content from English to Spanish in multiple medical center settings. The primary health educator translator was from Mexico, the second translator was from Columbia, and both translators vetted exercise instruction word-choice content to ensure cultural appropriateness for people of HA descent. The intervention was led by 5 PTs who were conversant in Spanish with 8 to 30 years of experience, and 80% (n\u0026thinsp;=\u0026thinsp;4) were board certified in orthopedics and/or fellowship trained in orthopedics or sports medicine. Participants were invited to bring family members to the testing and intervention sessions if they wished.\u003c/p\u003e \u003cp\u003e\u003cb\u003eRecruitment.\u003c/b\u003e Participants were recruited using three methods: a targeted letter campaign, a referral from health care providers, and study fliers in medical office buildings. The targeted letter campaign included recruitment letters that were sent from a database established by a programmer searching the electronic medical record for Hispanic American, Spanish language preference, knee radiographs within the previous 2 years with KL level 2 or greater or moderate rating of knee OA, age 50 or greater, and lived or worked in San Francisco. The exclusion criteria were also identified and screened from the database. Permission to send a recruitment letter was obtained from the primary care provider before sending a recruitment letter to ensure that no vulnerable participants were inadvertently included. Referral from health care providers was encouraged by study staff attending provider staff meetings to alert providers (primary care, PTs, and orthopedics) about the study. All potential participants were directed to call the study phone line to complete the screening. Once potential participants were screened on the phone, the first consent was initiated, and a one-hour baseline testing session was scheduled. Permission to participate in the intervention was obtained from the primary care provider before the baseline testing session. The second consent was obtained during the baseline testing session in person by bilingual staff and indicated enrollment in the study.\u003c/p\u003e \u003cp\u003e\u003cb\u003eMultimodal physical therapy intervention.\u003c/b\u003e The multimodal intervention session was 75 minutes in duration and met 2 days per week for 2 weeks, then once per week for 6 weeks, followed by 4 weekly phone calls to determine adherence to the home exercise program (HEP) and provide feedback and support. The total duration of the intervention was 12 weeks which is consistent with previous knee OA exercise trials.\u003csup\u003e\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e The in-person intervention was led in a small group format with a ratio of one PT for every two participants, and groups never exceeded four participants. The multimodal physical therapy intervention consisted of progressive lower extremity strengthening training targeting the quadriceps and gluteal groups in both legs, progressive stationary bicycle exercise with short bursts of high-velocity training, self-management training, manual therapy, flexibility and stretching exercise and HEP instruction (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Supplementary Data File).\u003csup\u003e\u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26 CR27 CR28\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Reduced strength in bilateral quadriceps and gluteal groups is common in knee osteoarthritis and strength training and high-velocity exercise training improve physical function in older adults and is safe. \u003csup\u003e22\u0026ndash;25,29\u0026minus;31\u003c/sup\u003e All in-clinic intervention sessions began with 10-to-20 minutes of stationary bicycle exercise, 40 minutes of individualized lower extremity strength training, and finished with 10 minutes of lower extremity stretching. The PT prescribed lower extremity strength training and flexibility exercise based on a standardized protocol described in the Supplementary Data File. Participants were provided with a handout of the prescribed HEP in Spanish including photos of the exercises, instructions and dosing parameters to help with adherence. The HEP handout was updated weekly accordingly by the PT. The stationary bicycle high-velocity protocol was progressive in nature and described in detail in the Supplementary Data File. The PT determined which patients received manual therapy based on clinical assessment and all participants received at least 2 manual therapy sessions (details in Supplementary Data File). Weekly safety logs were completed during the 12-week intervention to monitor for pain, new injuries and adherence to HEP. The Principal Investigator, a PT, reviewed the safety logs every week and collaborated with the intervention PTs to make modifications to the exercise if needed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultimodal physical therapy interventions over 12-week study period\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eWeeks 1\u0026ndash;2: 75 minutes multimodal physical therapy 2 times per week for 2 weeks, in clinic\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBike\u003c/p\u003e \u003cp\u003e10\u0026ndash;20 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthening\u003c/p\u003e \u003cp\u003e40 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eManual Therapy10 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCooldown\u003c/p\u003e \u003cp\u003e10 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10-minute stationary bike at 50% predicted heart rate max\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical therapist prescribes 5\u0026ndash;7 strength exercises from the following list:\u003c/p\u003e \u003cp\u003eQuadriceps open chain: Quadricep isometrics, seated or supine knee extension, supine straight leg raises.\u003c/p\u003e \u003cp\u003eGluteal open chain: side lying hip abduction/external rotation (clam), hip abduction, supine bridge.\u003c/p\u003e \u003cp\u003eClosed-chain lower extremity: progressive squats, step-up anteriorly or laterally, standing hip abduction, standing hip extension, banded-at-knee side stepping, progressive forward and lateral lunges and calf raises.\u003c/p\u003e \u003cp\u003eHEP initiated and updated handouts provided weekly.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssess and treat at least once\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 min\u003c/p\u003e \u003cp\u003eLower extremity stretching:\u003c/p\u003e \u003cp\u003equadricep, hamstring, hip flexor, and calf\u003c/p\u003e \u003cp\u003ePT prescribes HEP for flexibility.\u003c/p\u003e \u003cp\u003eIce optional\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eWeeks 3\u0026ndash;6: 75 minutes multimodal physical therapy 1-time per week for 4 weeks, in clinic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBike\u003c/p\u003e \u003cp\u003e10\u0026ndash;20 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthening\u003c/p\u003e \u003cp\u003e40 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eManual Therapy10 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCooldown\u003c/p\u003e \u003cp\u003e5 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10-minute warm up.\u003c/p\u003e \u003cp\u003eHigh-velocity training: 3\u0026ndash;6 repetitions of 10\u0026ndash;30 second fast cadence intervals at moderate intensity on 1-to-2-minute rests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePT selects exercises from list above and prescribes resistance. PT customizes intensity and dose of strength exercise based on one-repetition maximum estimations and rate of perceived exertion. PT progresses exercises to therapeutic zone of 60 to 80% one-repetition maximum or perceived exertion. PT prescribes 8 to 12 repetitions, 2 to 3 sets per exercise, 3-days per week for 5\u0026ndash;7 strength exercises. Weights and bands issued to patients to perform HEP at home.\u003c/p\u003e \u003cp\u003eHEP prescribed and updated handouts provided weekly.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssess and treat at least once\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 minutes\u003c/p\u003e \u003cp\u003eLower extremity stretching.\u003c/p\u003e \u003cp\u003eParticipants practice flexibility HEP.\u003c/p\u003e \u003cp\u003eIce optional\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eWeeks 8\u0026ndash;12: 30-minute weekly phone or video visit adherence check, support and advice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinue 5\u0026ndash;7 strength exercises at home at least 3 days per week in a therapeutic zone. Continue recommended flexibility exercises. Advise participants to walk for exercise. Provide support and answer questions about HEP. One-week recall of exercise adherence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eStrengthening exercises were adapted from previously published trials that demonstrated the efficacy of exercises. See Supplementary Data File for a detailed description of exercises and intervention protocol. \u003csup\u003e\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cb\u003eWeekly phone follow-up after the 8-week in-clinic intervention.\u003c/b\u003e Participants were called weekly during the remaining 4 weeks of the study to review safety logs, determine adherence to HEP, and provide support.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e The PT verbally reviewed all exercises and recorded the resistance used. Weights for exercises were progressed over the phone if exercises were not in the therapeutic intensity zone described in the Supplementary Data File .\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e The participants were instructed to participate in aerobic exercise, and support was provided to individualize the instructions. Adherence to aerobic exercise was not observed however advice was provided to participate in an aerobic conditioning program.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePrimary outcome measures for feasibility: recruitment, adherence, and retention.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis was an exploratory feasibility study, a convenience sample of 20 participants who lived or worked in San Francisco were recruited from a large urban integrated health system and measures of feasibility were observed. Recruitment was explored by documenting the number of participants who were screened, the method of recruitment, the number of enrolled participants, and the reasons why participants did not qualify or enroll. Adherence to in-clinic multimodal physical therapy sessions was recorded and weekly exercise adherence was recorded for the 12-week study period using 1-week recall. Participants were instructed to exercise 3 times per week to optimize strength gains during the 12-week study period.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e To explore retention, the number of participants who completed the intervention post-testing was recorded.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSecondary outcome measures for health-related quality of life and physical performance.\u003c/b\u003e Participants were assessed at baseline and after the 12-week intervention period. Baseline testing included a brief physical therapy evaluation and body weight in pounds. A study manual was created for all physical performance measures adapted from previous authors and translated into Spanish by the bilingual health educator.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e To ensure fidelity to outcome measurement testing, the PTs stated outcome measure instructions in English, and an interpreter repeated the instructions in Spanish per the study manual. Three PTs (1 board certified in orthopedics) with 7 to 21 years of experience conducted all assessments with a single interpreter for all participants, except for one. Two of the assessing PTs also led the intervention given small study staff.\u003c/p\u003e \u003cp\u003e \u003cb\u003eHealth-related quality of life.\u003c/b\u003e The Spanish Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire measures global HrQol and comprises 24 questions with three subcomponents: pain, stiffness, and physical function. The WOMAC is scored on a 5-point Likert scale (0\u0026ndash;4) with a maximum score of 96 points. Higher scores indicated worse symptoms and function. The WOMAC has been translated into Spanish and has an acceptable reliability (Interclass correlation coefficient, ICC\u0026thinsp;=\u0026thinsp;0.81).\u003csup\u003e37\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhysical performance.\u003c/b\u003e The Timed Up and Go (TUG\u003cb\u003e)\u003c/b\u003e test measures the time in seconds to rise from a chair, walk 3 meters turn and return to the chair, and sit down. The TUG test is a measure of gait, dynamic balance, and transfer ability. TUG was measured using two verbal descriptions: \u0026lsquo;walk at your normal speed\u0026rsquo; (TUG-normal) and \u0026lsquo;walk as fast and as safely as you can\u0026rsquo; (TUG-fast). Between-rater reliability for TUG-normal was ICC\u0026thinsp;=\u0026thinsp;0.75, and for TUG-fast was ICC\u0026thinsp;=\u0026thinsp;0.87.\u003csup\u003e35,38\u003c/sup\u003e Two trials for TUG-normal and TUG-fast were recorded, and the mean was used in the analysis. The Six Minute Walk (6MW) test measures in meters the distance walked in 6 minutes. The 6MW is a measure of lower extremity strength and endurance. The test-retest reliability of the 6MW is ICC\u0026thinsp;=\u0026thinsp;0.94.\u003csup\u003e39,40\u003c/sup\u003e The Five-time sit-to-stand (5TSTS) test measures the time to stand up and sit down from a 19-inch chair 5 times as fast as possible. The 5TSTS is a functional measure of lower-extremity strength and transfer ability. The intra-session intraclass correlation coefficient for the 5TSTS is 0.94.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eIsometric quadriceps strength.\u003c/b\u003e Strength was assessed using a modified hand-held dynamometer method.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e Participants sat at the edge of a high-low table with their knees flexed to 90\u0026deg;. A hand-held dynamometer (Chattanooga\u0026trade; model 01165 Manual Muscle Tester) was placed 1-inch proximal to the distal fibula on the anterior aspect of the tibia, and a gait belt was wrapped around the hand-held dynamometer and secured by a metal support under the table for stability. A second belt was placed over the participant\u0026rsquo;s hips and wrapped around the tabletop to stabilize the pelvis on the table during testing. Participants were instructed to straighten knee and push hard for to 2\u0026ndash;3 practice sessions on 1-minute rests. Participants were verbally encouraged to push as hard as possible for maximal effort during the last 2 test trials, and peak quadriceps strength was recorded in pounds and normalized to body weight. The mean of the 2 maximal efforts was used in the analysis. The modified hand-held dynamometer method has high reliability.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eAdverse events.\u003c/b\u003e Adverse events were recorded via weekly safety logs, inquiring about new injuries and pain. Weekly safety logs were collected and reviewed in the principal investigator.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical analysis.\u003c/b\u003e Descriptive statistics were used to describe the recruitment, adherence, and retention of the feasibility outcomes. We calculated the standard error and 95%CI for feasibility proportional outcomes (screened/enrolled and retention) and measures of central tendency are reported for discrete quantitative feasibility variable outcomes (adherence days/week of exercise).\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e For secondary outcomes related to the HrQol and physical performance, all measures were described as means and standard deviations (SD). Changes from the baseline to post-intervention measures were assessed using paired-sample t-tests. The mean changes and 95% confidence intervals (CI) and effect sizes are reported.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cb\u003eFeasibility of recruitment, adherence, and retention.\u003c/b\u003e Potential participants were recruited from May to October 2017 and data collection was completed in March 2018. See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: CONSORT diagram for details. Five hundred targeted recruitment letters were sent, and 27 of 30 who called to be screened came from letters and 18 of 20 who enrolled came from letters. Thirty participants total called to be screened and 20 enrolled, 66.7% (95%CI: 47.2%, 82.7%). Median exercise adherence was 3.17 (range: 1.8-7, IQR\u0026thinsp;=\u0026thinsp;1.8, mean\u0026thinsp;=\u0026thinsp;3.65, SD\u0026thinsp;=\u0026thinsp;1.46) days per week. Participants completed, on average, 121% of the study goal exercise adherence during the 12-week intervention.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Participants attended a mean of 7.15 (71.5%) of the 10 total in-clinic sessions. All phone-call follow-up sessions were completed and in cases where a participant was not reachable in one week, a 2-week recall of HEP adherence was recorded. Seventeen participants attended the post-test session, retention was 85% (95%CI: 62.1%,96.8%). The three participants who did not attend post-intervention testing were older (mean age 71), female and had clinically worse performance in all physical performance measures and on WOMAC global and physical performance scales.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eParticipant characteristics.\u003c/b\u003e The median age was 62.5 (range: 51 to 75) years, and 55% of the cohort was female (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Eighty-two percent of the cohort had KL classification 1\u0026ndash;2 to KL 4. Of the forty knees in the cohort (n\u0026thinsp;=\u0026thinsp;20), 18 right knees were symptomatic and 11 left knees were symptomatic based on self-report. All symptomatic knees, except for one, met the American College of Rheumatology criteria for clinical diagnosis of knee OA.\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian or N\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange or %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic White\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic Asian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBody-mass Index (BMI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u0026ndash;35.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time service\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time janitor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time construction/maintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time retired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time desk job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnee Range of Motion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePassive right flexion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108\u0026ndash;145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePassive left flexion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105\u0026ndash;145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-reported symptomatic knees\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight knee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft knee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive on Altman\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e \u003cb\u003ecriteria for clinical arthritis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight knee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft knee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiographic severity of OA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo radiograph or normal radiograph\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKL\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e 1\u0026ndash;2 or minimal rating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKL 2\u0026ndash;4 or moderate/severe rating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003eService employment\u0026thinsp;=\u0026thinsp;restaurant, retail, caregiver, teachers aid\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e2\u003c/sup\u003eComorbidities= hypertension, DM2, high cholesterol, hypothyroid, chronic pain, hyperlipidemia, depression\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003eAltman criteria: American College of Rheumatology (ACR) clinical classification for knee OA, 3 of the 6 criteria present: age\u0026thinsp;\u0026gt;\u0026thinsp;50 years, crepitus on active motion, less than 30 minutes of stiffness upon waking, bony enlargement or tenderness, and no palpable warmth of the synovium.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e KL\u0026thinsp;=\u0026thinsp;Kellgren-Lawrence\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePreliminary estimates of change in clinical measures of HrQol and physical performance.\u003c/b\u003e Global HrQol and all three subcomponents of the WOMAC improved post-intervention (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Global HrQol on the WOMAC improved by 15.9 points or 30.1%. Minimum Clinically Important Difference (MCID) and Minimum Detectible change (MDC\u003csup\u003e95%\u003c/sup\u003e) from 2 different English-speaking studies, which showed improvements of 9.1 and 13.4 points, respectively.\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e,\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e WOMAC physical function improved 11.5 points or 35.9% in this study, which also surpassed MCID of 26% reported in a knee OA anti-inflammatory trial.\u003csup\u003e46 22\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSecondary outcome measures of health-related quality of life and physical performance\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary outcome measures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-intervention\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003cp\u003eChange (N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003eMean (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEffect\u003c/p\u003e \u003cp\u003esize\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePhysical Function\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTUG-regular (sec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.9 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.6 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.0 ( -4.2, 0.2)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTUG-fast (sec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.4 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.9 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.2 ( -3.6, 1.3)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.571\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5TSTS (sec)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.7 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.5 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2 ( -3.0, 3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6MW (meters)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e384.6 (103.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e452.0 (77.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.1( -1.5, 101.6)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth Related Quality of Life/WOMAC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.0 (24.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.7 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-15.9 (-5.3 to -26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.646\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain sub-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.1 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.2 (-5.8 to -0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.667\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical function sub-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.2 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.3 (15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-11.5 ( -19.0 to -3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.635\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStiffness sub-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.2 ( -2.1 to -0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQuadriceps Strength\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight quadriceps (pounds)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.8 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.1 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.7 (-15.1, 5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft quadriceps (pounds)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.6 (26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.3 (19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.2 (-11.6, 5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight quadricep mean change (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.34 (-18.85, 35.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft quadricep mean change (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.61 ( -17.48, 28.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMinimum clinically important difference\u0026thinsp;=\u0026thinsp;MCID and Minimum Clinical Difference\u0026thinsp;=\u0026thinsp;MCD\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e**\u003c/sup\u003edenotes clinically significant change MDC\u003csup\u003e95%\u003c/sup\u003e TUG regular 1.14 sec,\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e MCID TUG-fast 1.2 sec,\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e 5TSTS MDC\u003csup\u003e90%\u003c/sup\u003e 2.11 sec\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, MDC\u003csup\u003e90%\u003c/sup\u003e 6MWT 50.2 meters,\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e MDC\u003csup\u003e95%\u003c/sup\u003e WOMAC total 13.4 points,\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e MDC percent change in quadriceps strength 21.7%\u003csup\u003e42\u003c/sup\u003e to 49.7%\u003csup\u003e57\u003c/sup\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTUG-regular, TUG-fast and 6MWT changed by -2.0 ( -4.2, 0.2) seconds, -2.0 ( -4.2, 0.2) seconds and 50.1( -1.5, 101.6) meters respectively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The 95% CIs included clinically meaningful changes for the TUG-fast, TUG-regular and 6MW and our small pilot study was not powered for adequate precision to measure these changes (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A 1.2 second decrease has been reported as a major clinical improvement on the TUG-fast, and in another study 1.14 seconds has been reported as MDC\u003csup\u003e90%\u003c/sup\u003e for the TUG-regular.\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e Fifty meter improvement in 6MW has been reported as a substantial improvement in a sample of older adults with mobility impairment and MDC\u003csup\u003e90%\u003c/sup\u003e has been reported as 50.2 meters in a hip/knee OA cohort.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e Furthermore, effect sizes (0.49\u0026ndash;0.57) on these outcomes, suggest there may have been a medium treatment effect on these variables (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Five-time sit-to-stand did not change. Changes in quadriceps strength were not reported in the normalized-to-body-weight format, given missing data for body weight at post-testing sessions. Instead, mean change in quadriceps strength pre/post-intervention was reported and varied between \u0026minus;\u0026thinsp;66\u0026ndash;136% (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePercent change before/after intervention in absolute quadriceps strength in all knees\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePercent change in quadricep strength\u003c/p\u003e \u003cp\u003eCombined right and left knees n\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-66.3 to 136.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuartile 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-22.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-6.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuartile 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterquartile range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower fence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-89.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper fence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eMinimum Clinical Difference in quadricep strength 21.7%\u003csup\u003e42\u003c/sup\u003e to 49.7%\u003csup\u003e57\u003c/sup\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAdverse events\u003c/b\u003e. There were no reportable or unexpected adverse events during the 12-week program. Nineteen non-reportable events occurred during the intervention period. See Additional Data File for details.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWe explored feasibility of multimodal physical therapy in an uncontrolled pragmatic trial among Spanish-speaking older adults who are HA and have moderate symptomatic knee OA in terms of recruitment, adherence, and retention. Our results suggest that the intervention is feasible in this population. The study recruitment goal to recruit 20 people was met by utilizing a targeted letter campaign to identify people with moderate radiographic knee OA and other inclusion criteria however recruitment rate was low (500 letters sent, 18 enrolled from letter campaign). Overall, adherence to exercise surpassed the study goal of 3 times per week. Retention was favorable, with 85% of the cohort attending post-testing sessions. There were also promising preliminary estimates of change in HrQol and clinical improvements in TUG and 6MW, however improvements are interpreted with caution given the study was not powered to detect change in clinical measures.\u003c/p\u003e \u003cp\u003eA targeted letter campaign searching the medical record for inclusion/exclusion criteria, including radiographic knee OA results, appears to be feasible, as most participants (18 of 20) were enrolled from the targeted letter campaign. The screening to enrollment ratio was acceptable at 67%. However, the recruitment rate was low due to study design limitations (500 recruitment letters were sent to people who met inclusion criteria). It is noteworthy that interest in the study continued beyond the 3-months allocated to recruit and future studies should consider 6-months to recruit participants and may lead to a higher recruitment rate with the targeted letter campaign. In comparison, another study recruiting adults who were HA with knee OA did a medical record search using knee OA and leg pain diagnostic codes and only identified and enrolled five participants from this method for a behavioral telephone intervention.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e The availability of radiographic data in the medical record search and geographic location in the current study that has a higher proportion of adults who are HA may have contributed to the larger pool of potential participants meeting inclusion criteria.\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e It is unknown why the recruitment rate from the letter campaign was low. It is possible implementation methods (in-clinic versus telehealth intervention) of the current study may contribute to the low recruitment rate.\u003csup\u003e\u003cspan additionalcitationids=\"CR52 CR53\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e A future mixed-methods study is planned to explore implementation preferences for knee OA multimodal physical therapy in this population.\u003c/p\u003e \u003cp\u003eAdherence to exercise varied from 1.8 to 7 days per week. Participants attended a mean of 71% of the in-clinic sessions and exercised a mean of 3.6 days per week for the 12-week study duration, which was 121% of the study goal. Other trials have reported exercise adherence in the HA population. A self-guided walking intervention, reported higher adherence to a walking program after 6 weeks, 88% of participants walked 3\u0026ndash;5 days per week; in our study, 76% of the cohort exercised 3 or more days per week.\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e Reported adherence may be higher in the walking trial due to recall bias given that participants reported adherence to exercise once at the end of the 6-week trial, whereas the current study collected weekly adherence, which is likely to be less vulnerable to recall bias. Adherence to a weekly, 6-week in-person self-management training program (which included generalized exercise) for HA adults with arthritis was 84%, which is higher than our 72% adherence to our 8-week in-person intervention.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Our in-clinic intervention included 10 sessions over the 8-week period, suggesting that a lower number of in-clinic sessions may lead to better in-person adherence. Consistent with previous research in other non-knee OA-specific populations, HA adults adhere to structured exercise and education programs.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe retained 85% of our cohort after the 12-week multimodal intervention, which is similar to the walking intervention trial, that reported 82% retention at 6 weeks and the self-management training program, that reported 85% retention after 6 weeks.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e Furthermore, 2 exercise and education trials followed HA participants for longer durations, and retention was 83% in the self-management program at 6 months and 84% an exercise and education intervention trial at 1-year.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e Retention of older adults who are HA and have arthritis appears to be feasible in both the short and long term after exercise and educational interventions.\u003c/p\u003e \u003cp\u003eGlobal HrQol change post-intervention changes are similar to the within-group 18.2 point improvement reported after a 6-month behavior change phone intervention study in HA adults with knee OA.\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e It is concerning the patient reported outcome improvements trended positive given the physical performance measures were highly varied. It is possible participants responded favorably on the patient reported outcomes post-intervention due to therapeutic alliance with treating PTs and wanting to please the treating PTs, furthermore the lack of blinding could have contributed to an overestimation of treatment effects.\u003c/p\u003e \u003cp\u003eThe absolute mean percentage change in quadriceps strength across all knees was highly varied (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The hand-held dynamometer method utilized in this study has high within-subject variability in similar cohorts, with MDC varying from 21.7\u0026ndash;49.6% despite high inter- and intra-rater reliability.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e,\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e All knees in the upper quartile experienced clinically meaningful increases in strength suggesting the intervention has potential to meaningfully improve quadriceps strength among some participants (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Four of the knees in the upper quadrant were possible outliers and spread across 3 people. Each of the 3 people made clinically significant gains in physical performance measures and HrQol suggesting the data points may not be outliers. All percent-change in quadricep strength measures were within the extreme outlier limits. Five of the 8 participants who reported pain during strengthening exercise and required PT modifications to exercise were below the 21.7% MDC quadriceps percent change cut-off suggesting more time may have been needed to accommodate to the intervention. Dose tolerance of quadriceps strengthening varied in our study; some participants maintained a lower intensity during strength exercises for the entire 12-week intervention, while others progressed upwards to the therapeutic level range which may have also contributed to the varied distribution of strength change.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Furthermore, our cohort was deconditioned compared to other populations with knee OA. Baseline physical performance was poorer in this study compared to similar non-Hispanic cohorts for the TUG-regular, TUG-fast, 6MWT and 5TSTS (11.9 sec vs 10.9 sec, 9.4 sec vs 7.1 sec 384 m vs 412 m and 14.7 sec vs 10.1 sec) respectively.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e Only 3 of 15 participants tested for one-repetition maximum (a measure of strength described in the Supplementary Data File) on the leg press were able to leg press greater than their body weight. A systematic review found that optimum strength changes in older adults occur at one year.\u003csup\u003e\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e The study team is planning a longer duration trial to allow for accommodation and achieve meaningful changes in strength for this population.\u003c/p\u003e \u003cp\u003eThis pilot study demonstrated the feasibility of conducting a multimodal physical therapy intervention in a less known and more vulnerable population, namely Spanish-speaking older adults who are HA and have moderate symptomatic knee OA. This study is also pragmatic; it was conducted in a large urban outpatient physical therapy clinic in a group setting, and the multimodal nature of the intervention reflects the clinical practice.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, there were no comparison groups in this study. Positive clinical outcomes are suggestive at best; however, the primary aim of this pilot study was to assess feasibility rather than effectiveness. Second, participants' exercise tolerance varied, leading to a broad range of dosing (repetitions, frequency, and intensity) of exercise, which could have impacted the results of clinical measures. The study group is exploring a longer duration trial to allow for accommodation to exercise. Third, there was no structured feedback solicited from participants or interventionists which could help to refine the intervention and better serve this population. Fourth, the 3 participants who did not attend post-testing were older and had worse physical performance and HrQol which could have affected clinical results. The study team is planning a mixed-methods study to explore implementation preferences and clinical effectiveness of multimodal physical therapy in Spanish-speaking older adults who are HA and have moderate symptomatic knee OA. A longer than 12-week duration strengthening intervention is also planned.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eMultimodal physical therapy, including individualized progressive lower extremity strengthening, progressive stationary bicycle exercise with short bursts of high-velocity training, self-management training, manual therapy, flexibility and stretching exercises, and HEP instruction, is feasible in a cohort of Spanish-speaking older adults who are HA and have moderate symptomatic knee OA. A 6-month recruitment period is recommended for consideration using a targeted letter campaign. Preliminary estimates of changes in the clinical measures of HrQol and physical performance are promising. Quadriceps strength change post-intervention was highly varied, and consideration for a longer intervention than 12 weeks is warranted. The study team is planning a mixed-methods trial to explore implementation preferences and effectiveness of multimodal physical therapy in Spanish-speaking older adults who are HA and have moderate symptomatic knee OA.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOsteoarthritis OA\u003c/p\u003e \u003cp\u003eHispanic American (HA)\u003c/p\u003e \u003cp\u003eHealth-related quality of life HrQoL\u003c/p\u003e \u003cp\u003eKellgren-Lawrence KL\u003c/p\u003e \u003cp\u003eHome exercise program HEP\u003c/p\u003e \u003cp\u003eWestern Ontario and McMaster Universities Osteoarthritis Index WOMAC\u003c/p\u003e \u003cp\u003eIntraclass correlation coefficient ICC\u003c/p\u003e \u003cp\u003eTimed up and go TUG\u003c/p\u003e \u003cp\u003eFive-times sit to stand 5TSTS\u003c/p\u003e \u003cp\u003eSix-minute walk 6MW\u003c/p\u003e \u003cp\u003eMinimum clinically important difference MCID\u003c/p\u003e \u003cp\u003eMinimum Clinical Difference MCD\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e:\u0026nbsp;Sofia Arellano-Padilla MPH, Alexis Anderson PT, DPT, Mary-Edna Harrell PT, FAAOMT, Jillian Cripps PT, DPT, OCS, FAAOMT, Tony Tran PT, DPT, SCS, FAAOMT, Catherine Brunswick PT, DPT, OCS, Joanne M Rhodes PT, DPT, OCS, FAAOMT, Susana Robles, PT, DPT. This study was funded by the Kaiser Permanente Northern California Community Benefits program (RNG021024). This trial was registered with ClinicalTrials.gov repository, identifier (NCT04219423). Registered retrospectively Jan 3, 2020.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e AG is responsible for the study design, execution, study oversite, data analysis and writing the manuscript. SZ was the biostatistician and responsible for statistical analysis and participating in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: Authors and study staff have no conflicts of interest to report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: nonidentified data is available via email correspondence with the corresponding author [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e:\u0026nbsp;This study has been approved by the Kaiser Permanente Northern California Institutional Research Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e All participants participated in a 2-step consent process per recommendations by Kaiser Permanente Northern California Institutional Research Board. Informed consent was obtained from all the participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e2014 National Healthcare Quality and Disparities Report chartbook on health care for Hispanics. \u003cem\u003eAgency for Healthcare Research and Quality AHRQ\u003c/em\u003e Pub. No. 15-0007-11-EF (September 2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrtman, J. M., Velkoff, V. A. \u0026amp; Hogan, H. An Aging Nation: The Older Population in the United States: Population Estimates and Projections. \u003cem\u003eU.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau, census.gov\u003c/em\u003e Washington DC (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeshpande, B. R. et al. Number of Persons With Symptomatic Knee Osteoarthritis in the US: Impact of Race and Ethnicity, Age, Sex, and Obesity. \u003cem\u003eArthritis Care Res. 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Disord.\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e, 126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1186/1471-2474-11-126\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1186/1471-2474-11-126\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2010).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hispanic-American, knee osteoarthritis, feasibility, exercise, physical therapy, strength, physical performance","lastPublishedDoi":"10.21203/rs.3.rs-6256647/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6256647/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLittle is known about the feasibility of multimodal physical therapy for knee osteoarthritis (OA) among Spanish-speaking older Hispanic American adults with moderate symptomatic knee OA. The primary aim of this pilot study was to explore feasibility, and the secondary aim was to explore clinical changes after the intervention. Hispanic American older adults with moderate knee OA were recruited from an urban health system. Participants attended 10, small group, physical therapy clinic visits over 8 weeks, followed by 4 weekly support phone calls. The intervention was led in Spanish and included progressive lower body strengthening and cycling exercise, manual therapy, and self-management training. Feasibility was explored by using descriptive statistics to document the recruitment, retention, and adherence to exercise and clinic sessions. Eighteen of the 20 participants who enrolled came from sending 500 targeted recruitment letters, median age of 62.5 (range: 51 to 75) years; 85% completed the study. Median exercise adherence was 3.2 (range: 1.8-7) days per week for the 12-week study duration. Preliminary estimates of change in the clinical measures were promising however the study was not powered to detect changes. Multimodal physical therapy was feasible in Spanish-speaking older HA adults with moderate knee OA however recruitment was low.\u003c/p\u003e","manuscriptTitle":"Feasibility of Multimodal Physical Therapy in Hispanic American Older Adults with Moderate Knee Osteoarthritis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-03 05:11:15","doi":"10.21203/rs.3.rs-6256647/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e58f084-388f-4a63-9eed-dc37442594d8","owner":[],"postedDate":"July 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50904958,"name":"Health sciences/Health care/Geriatrics"},{"id":50904959,"name":"Health sciences/Health care/Health services/Rehabilitation"}],"tags":[],"updatedAt":"2025-07-18T03:53:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-03 05:11:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6256647","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6256647","identity":"rs-6256647","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}