Effect of an e-health app on adherence to physical activity in people with knee osteoarthritis

Effect of an e-health app on adherence to physical activity in people with 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 Research Article Effect of an e-health app on adherence to physical activity in people with knee osteoarthritis Mathilde Pelletier-Visa, Louise Jeannot, Bruno Pereira, Emmanuel Coudeyre, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6912520/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Context: Physical activity and rehabilitation comprise the main elements of the non-pharmacological management of knee osteoarthritis (KOA). Compliance with home-based muscle-strengthening exercises is weak, thus diminishing the beneficial effects of the care process. Aim : We aimed to estimate the effect of an e-health app providing a self-exercise program, on adherence to physical activity practice in patients with KOA. Materials and methods: We conducted an observational, open labelled, single-center study using a mixed method approach. Results: Of the 32 people with KOA, 26 completed the study process (62.5% of whom were women).Most had unilateral femorotibial compartment involvement (Kellgren & Lawrence stage II or III) and led a sedentary lifestyle. The EARS score decreased between 3 weeks and 3 months (effect size -0.41), with 69% of patients considered non-responders. The KOOSf score also declined (effect size -0.62), with no improvement in pain on the NRS scale. Conclusion: This study showed the beneficial impact of using an e-health application on clinical criteria such as pain and joint function, but not on adherence to prescribed self-exercise. Trial registration: NCT04750304 Date of trial registration : 10/02/2021 knee osteoarthritis mobile applications physical activity smartphones adherence pain function Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Knee osteoarthritis (KOA) is a form of osteoarthritis that affects the knee, leading to the progressive degradation of articular cartilage ( 1 ). Although it is common in older people ( 2 ), factors such as obesity ( 3 ), a history of injury ( 4 ) or abnormal joint alignment can accelerate its onset ( 5 ). The main consequences of this pathology include joint pain, knee stiffness and reduce mobility. Ultimately, these symptoms can impair patients’ quality of life by limiting their daily activities and increase the risk of loss of independence. Advanced cases sometimes require surgery, such as knee replacement ( 6 ). The management of KOA involves both non-pharmacological and pharmacological treatments. Latest guidelines prioritize the use of non-pharmacological treatment, including physical activity (PA), self-management, and weight loss ( 2 ) if necessary. These guidelines are particularly important given the low level of PA performed by people with KOA due to the development of kinesiophobia linked to pain ( 7 ). Today, connected objects have taken a predominant place in our daily life, including older people ( 8 ). Using those tools for patient’s self management is a motivational way to get more adherence from patients. It is a very adaptative and personalized tool compared to conventional rehabilitation ( 9 ). To maximize the effectiveness of physiotherapy sessions, therapists encourage individuals to perform unsupervised muscle-strengthening exercises, outside their hospital or private practice sessions ( 10 , 11 ). However, compliance with self-exercise often declines over time. Methods to motivate and encourage individuals with KOA to continue their home exercise program are being developed, such as mobile e-health applications( 12 – 14 ). These applications provide self-training programs for individuals with KOA, to motivate them to continue performing muscle-strengthening exercises properly at home. However, the use of a mobile application can sometimes be complicated ( 12 ); therefore, it is essential to evaluate its handling and ergonomics to ensure the most comfortable experience for users. Some mHealth apps have already been found effective for musculoskeletal conditions such as low back pain in terms of usability, pain reduction and improved function ( 12 ). To our knowledge, no mHealth tools are currently available in France for the management of KOA. A preliminary qualitative study was conducted with individuals with KOA and physicians to assess perceived barriers and facilitators to the use of an mHealth app for people with KOA (NCT04120727). The results showed that people with osteoarthritis (OA) needed advice and guidance to practice PA safely because of their fear of worsening their symptoms. However, no barriers to the use of digital tools were identified in older people. From this study, we developed our own mHealth app: ARTH-e, designed for use on smartphones and digital tablets. The app includes progressive self-exercise programs with personalized monitoring of progress and pain as well as a self-management section. The main objective of the ARTH-e 2 study was to test the effect of using the ARTH-e application on adherence to physical activity (Exercise Adherence Rating Scale questionnaire) ( 15 ) in individuals with KOA. The secondary objectives of the study were to assess the impact of using the application on knee function (Knee injury and Osteoarthritis Outcome Score questionnaire) and pain (NRS). Materials and methods Study design We conducted an observational, prospective, single center study (Clermont-Ferrand University Hospital). The study was approved by the Sud Est I ethics committee in September 2020. The summary of the research was sent by the Sponsor to the French National Agency for the Safety of Medicines and Health Products (ANSM) before beginning. The protocol was registered on ClinicalTrials.gov (NCT04750304) on the following date: 10/02/2021. The study started in January 2022 and was completed in July 2022. The reporting follows the guidelines and recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)( 16 ). Participant recruitment People with KOA were recruited on a volunteer basis, among those followed in the Physical Medicine and Rehabilitation Department (PMR) of the Clermont-Ferrand University Hospital, France, as part of their pathology (routine care) and among healthcare professionals of the same institution (mailing list). The general process of the study is shown in Fig. 1 . The Clinical Research Associate (CRA) introduced the study to eligible individuals by phone call. After reflecting, people telephoned the CRA if they decided to participate. Then, an inclusion visit was scheduled with the physician and the CRA, during which a medical examination was performed and the inclusion and non-inclusion criteria were checked. Participants received a copy of the information leaflet and the non-opposition form. Then, the CRA installed the application on the smartphone or tablet with the individual. Inclusion criteria We included adults, with no upper age limit, diagnosed with OA in at least one knee according to the American College of Rheumatology (ACR) criteria prior to inclusion by a specialist or non-specialist physician, and symptomatic ( 17 ). They had their own smartphone or tablet running with at least Android 5 or iOS 11. Exclusion criteria We did not include people with comprehension disorders that made interviewing and filling out questionnaires or using the app impossible, people under guardianship, curatorship, or deprived of liberty. ARTH-e app The ARTH-e app was developed by the PMR department in collaboration with the Openium company and can be downloaded from the PlayStore or AppleStore platforms. The interface is simple for easy and intuitive use. The home screen includes a dashboard, predefined exercise programs (14 in all) and randomly suggested programs, as well as a “Did you know?” insert enabling participants to educate themselves about their pathology and thus overcome certain existing preconceived ideas about osteoarthritis. A menu provides 6 items: Home, Did you know? My programs, My follow-up, Information and Legal information (Fig. 2 ). The predefined exercise programs are divided into three levels of difficulty. Each program is built in the same way, and includes 5 categories of exercise performed in the following order: cardiovascular warm-up, joint warm-up, muscle strengthening, proprioception and stretching. The selection and organization of exercises were established through an interdisciplinary collaboration between physicians, physiotherapists, and adapted physical activity instructors. The chosen approach aims to optimize quadriceps and hamstring strengthening, promote joint range of motion gains, and minimize injury risks in patients with knee osteoarthritis. This protocol is based on the recommendations of the French Society of Rheumatology (2019)( 6 , 18 ) and the American Academy of Orthopaedic Surgeons (AAOS, 2021) ( 19 ). Once the user has mastered the application, he or she can create their own program, selecting one or more exercises from each of the above-mentioned categories in a guided fashion (Fig. 2 ). When the participant begins the exercise program, the app provides a list of the equipment required (mat, chair, ball, etc.) so that they can prepare the session. In addition, videos of each exercise were available. The videos provide a demonstration of the correct posture to adopt, enhancing the safety and effectiveness of the exercises. Each program lasts between 25 and 30 minutes and includes breaks. Objective s The main objective of the ARTH-e 2 study was to test an e-health application on a panel of patients in order to assess the benefits of using the application in terms of adherence to physical activity. The secondary objectives of the study were to assess the impact of using the application on knee function and pain (NCT04750304). In view of the difficulties encountered in other research projects in getting to grips with a mobile application ( 12 ), the study also aimed to evaluate the application in terms of both content and form (general user experience, user interface, user expectations), in order to improve its ergonomics and thus limit the obstacles to its use. Outcomes Self-administered questionnaires were used, and outcomes were collected by phone by the CRA at 3 weeks, 6 weeks and 3 months after the beginning of the intervention. The main outcome was the Exercise Adherence Rating Scale (EARS) questionnaire, which we adapted for use in people with knee pain at 3 weeks, 6 weeks and 3 months of use of the app. The EARS questionnaire ( 15 ) was used to assess adherence to self-exercises. It is divided into 6 propositions, which the patient can more or less validate, from 0 (completely agree) to 4 (completely disagree). It was initially developed for low back pain and adapted to the study. The EARS questionnaire has undergone a cross-cultural adaptation and validation in French for patients with knee osteoarthritis by our team, following all recommended adjustments specific to this population compared to the original version. The article is currently in the process of being published. This questionnaire should enable study participants to quantify the time spent performing self-exercises, and thus assess their adherence. A score ranging from 0 to 24 can then be calculated from the participants' answers, with a score of 24/24 corresponding to very good adherence to the prescribed physical activity; a declining score reflects poor adherence to the exercises. Secondary outcomes were clinical outcomes. We assessed pain using a 10-point Numerical Rating Scale (NRS) and disability using the Knee injury and Osteoarthritis Outcome Score (KOOSf) ( 20 ) at 3 weeks, 6 weeks and 3 months of use of the app. The KOOSf questionnaire is an assessment tool designed to measure knee function. This questionnaire is made up of several sub-categories in order to determine different sub-scores. The categories include pain, stiffness, daily life and function, activities and leisure. Each item is rated on a 5-point Likert scale is used (from 0 - “completely agree” to 4 - “strongly disagree”). The higher the total score, the more severe the symptoms experienced by the individual, and the greater the impact of the OA on their quality of life. We also collected indicators of app use (frequency of opening per week, time spent on the app, rating of each exercise). We collected patient-intrinsic data through the Garmin VivoSmart 4 connected wristband, including number of steps, heart rate, movement intensity, heart variability, and energy expenditure in calories. Procedure Participants were seen for the first time at the inclusion visit, during which they were again briefed on the various aspects of the study. After reading the information letter and signing the consent form, they underwent a medical consultation, completed a demographic questionnaire and installed the ARTH-e application on their smartphone. All the participants attended a one-hour self management session with the department's Adapted Physical Activity teacher. This session aimed to guide the participants through the different exercises proposed by the ARTH-e application. Participants were free to use the app during the 3 months of follow-up. We asked all participants whether they would like to benefit from a connected watch as part of the study, and only 16 patients agreed to take part. The sub-population who agreed to wear a Garmin vivosmart 4 connected bracelet for the collection of intrinsic activity data were issued with the bracelet, which allowed collection of the number of daily steps, daily calorie energy expenditure, etc. These participants were allowed to keep the connected bracelet after the study for their personal use. The data collected through the connected bracelets and in the study were anonymized. Two phone calls were then scheduled at 3 and 6 weeks. During these remote interviews, participants were asked to complete the EARS and the KOOSf; they were also asked to estimate their level of pain using a Numeric Rating Scale (NRS). The study was closed with a final phone conversation, three months after the inclusion date, during which the participant was asked to complete the EARS and KOOSf questionnaires again, and to estimate their pain level on the NRS (Fig. 1 ). During the last phone call, participants received a link by email to complete a quality questionnaire about the ARTH-e application, which we will not present in this article. The answers to this quality questionnaire enabled us to improve the app. Statistical analysis Continuous data were reported by the median and interquartile range. The assumption of normality distribution was analyzed using the Shapiro-Wilk test. Mixed model was used to study the effect of time taking into account between and within patient variability (subject as random effect). The results are expressed using effect sizes and 95% confidence intervals. A sensitivity analysis was also conducted on patients with complete data. Thresholds for EARS, KOOSf and pain changes were fixed according to statistical distribution and to the data reported in the literature, i.e. decrease of 5 points, 8 points and 2 points respectively. Analyses were performed using Stata software (version 15; StataCorp, College Station, Texas, USA). A two-sided type I error at 5% was considered for statistical significance. A Sidak’s type I error correction, was applied to take into account two by two multiple comparisons. Results Description Between January 31, 2022 and April 7, 2022, 32 individuals were included in the study. Of these, 26 participants completed all 3 sessions, and 6 were lost to follow-up (Fig. 3 ). The median age of our patients was 63.5 [60.0;68.0] years and 63% of them were female. Most of our patients included in this study were retired (n = 16, i.e. 50.0% of the 32 patients initially recruited, and n = 14, i.e. 53.8% of those who completed the protocol). The majority of working patients had sedentary jobs (respectively n = 9, 64.3% and n = 8, 72.7%). Most had unilateral knee osteoarthritis (63%); 78% had stage II or III femorotibial compartment involvement according to the Kellgren & Lawrence classification ( 21 ). More details are provided in Table 1 . Table 1 Clinical and demographic characteristics of patients with knee osteoarthritis at inclusion n = 32 n = 26 Age, years (median [IQR]) 63.5 [60.0 ; 68.0] 65.5 [60.0 ; 68.0] Sex (M/F), n (%) 12 (37.5%) / 20 (62.5%) 10 (38.5%) /16 (61.4%) BMI, Kg/m² (median [IQR]) 24.11 [21.80 ; 29.82] 24.16 [22.49 ; 29.74] Duration of the evolution of osteoarthritis, months (median [IQR]) 120 [48 ; 180] 120 [48 ; 180] Way of life Asset n (%) 14 (43.7%) 11 (42.3%) Sedentary / Physical /Combined 9 (64.3%) / 2 (14.3%) : 3 (21,4%) 8 (72.7%) / 0 (0.0%) /3 (27.3%) Retired n (%) 16 (50.0%) 14 (53.8%) Invalidity n (%) 2 (6.3%) 1 (3.9%) Radio-clinical damage Unilateral / Bilateral n (%) 20 (62.5%) / 12 (37.5%) 15 (57.7%) / 11 (42.3%) Internal / External femorotibial/ Patellofemoral n (%) 23 (71.9%) / 3 (9.4%) / 13 (40.6%) 17 (65.4%) / 3 (11.5%) / 11 (42.3%) Radiological stage (Kellgrenn and Lawrence) n (%) Stage I / Stage II 0 (0.0%) / 14 (43.7%) 0 (0.0%) / 12 (50.0%) Stage III / Stage IV 11 (34.4%) / 4 (12.5%) 8 (33.3%) / 4 (16.7%) NC 3 (9.4%) 0 (0.0%) Associated pathologies Diabetes n (%) 1 (3.1%) 1 (3.9%) High blood pressure n (%) 6 (18.8%) 6 (23.1%) Dyslipidemia n (%) 2 (14.3%) 2 (7.7%) Others n (%) 8 (25.0%) 7 (26.9%) Physical activities 29 (90.6%) 23 (88.46%) Every day 6 (20.7%) 6 (26.1%) 4 to 6 times a week 5 (17.2%) 5 (21.7%) 1 to 3 times a week 17 (58.6%) 11 (47.8%) Less than once a week 1 (3.4%) 1 (4.4%) Duration of each physical activity session More than 30 minutes 22 (75.9%) 17 (73.9%) 15 to 30 minutes 6 (20.7%) 5 (21.7%) Less than 15 minutes 1 (3.4%) 1 (4.4) Sedentary time , hours (median [IQR]) 5.0 [3.0;8.0] 7.0 [3.5 ; 8.0] Osteoarthritis management 19 (59.4%) Physiotherapy 22 (68.8%) 17 (65.4%) Self-exercices programs 3 (9.4%) 3 (11.5%) Rehabilitation in a specialized center 5 (15.6%) 5 (19.2%) Spa treatment 10 (31.3%) 9 (34.6%) Osteopathy 12 (37.5%) 11 (42.3%) No management 9 (28.1%) 8 (30.8%) Food supplements 7 (21.9%) 6 (23.1%) Homeopathy 0 (0.0%) 0 (0.0%) Tai chi 2 (6.3%) 2 (7.7%) Acupuncture 4 (12.5%) 3 (11.5%) None 13 (40.6%) 10 (38.5%) Technical assistance Knee orthesis 5 (15.63%) 3 (11.5%) Cane 2 (6.25%) 1 (3.9%) Walker 0 (0.0%) 0 (0.0%) The median duration of pain was more than one year. In total, 69% of participants had undergone physiotherapy and 37.5% osteopathy. Most participants (75.9%) performed at least 30 minutes of PA per week, although the majority (58.6%) did not reach the level of PA recommended by the World Health Organization ( 22 ). The median daily sedentary time was 5.0 [3.0; 8.0] hours. Main endpoint EARS scores are presented in Table 2 . For 32 patients initially included, the median EARS score was 21.0 [12.0;22.0] at 3 weeks, to 16.0 [13.0;22.0] at 3 months. The EARS score decreased by -1.0 [-6.0; 1.0] between 3 weeks and 3 months. The change in EARS score between 3 weeks and 3 months was associated with an effect size of -0.37 [-0.73; -0.02]. For 26 patients, the median EARS score decreased from 21.5 [16.0; 22.0] at 3 weeks, to 16.0 [13.0;22.0] at 3 months (Table 2 ) . The change in EARS score was associated with an effect size of -0.41 [-0.79; -0.02]. Table 2 Changes in EARS, KOOS and NRS pain scores at 3 weeks, 6 weeks and 3 months Inclusion 3 weeks 6 weeks 3 months All patients EARS (31/29/26) 3 weeks change 21.0 [12.0 ; 22.0] 18.0 [12.0 ; 22.0] -2.0 [-3.0 ; 2.0], p = 0.224 16.0 [13.0 ; 22.0] -1.0 [-6.0 ; 1.0], p = 0.029 KOOSf (30/28/26) 3 weeks change 14.0 [5.0 ; 20.0] 9.0 [4.0 ; 14.0] -2.0 [-7.0 ; 1.0], p = 0.044 9.0 [2.0 ; 12.0] -4.0 [-11.0 ; 0.0], p = 0.001 NRS Pain (32/31/29/26) Inclusion change 3.0 [1.0; 6.5] 3.0 [2.0; 6.0] 0.0 [-10.0; 20.0], p = 0.125 3.0 [1.0; 5.0] 0.0 [-10.0 ; 10.0], p = 0.391 4.0 [2.0 ; 5.0] 0.0 [-30.0 ; 30.0], p = 0.545 Complete data (n = 26) EARS 3 weeks change / 21.5 [16.0;22.0] 19.5 [16.0;22.0] -1.5 [-3.0;2.0], p = 0.333 16.0 [13.0; 22.0] -1.0 [-6.0;1.0], p = 0.021 KOOSf 3 weeks change / 12.0 [4.0;20.0] 9.0 [5.0;13.0] -1.5 [-5.0;1.0], p = 0.104 8.5 [2.0; 12.0] -3.5 [-11.0; 0.0], p = 0.038 NRS Pain Inclusion change 2.6 [1.0;7.0] 3.0 [2.0;6.0] 0 [-10 ; 10], p = 0.306 2.5 [1.0;5.0] 0 [-10;10], p = 0.748 4.0 [2.0; 5.0] 0 [-30; 30], p = 0.756 Results were expressed as median [IQR]. ‘3-week change’ refers to the variation in scores between the 3-week visit and the follow-up visits at 6 weeks and 3 months. This is calculated for all participants with available data at both time points. 'Inclusion change' refers to the change in scores from baseline and is analysed only in participants with complete data at all assessment time points (n = 26). EARS: Exercise Adherence Rating Scale, KOOS : Knee injury and Osteoarthritis Outcome Score ; NRS : Numeric Rating Scale Concerning the primary endpoint (EARS), 8 participants (31%) were classified as responders, based on an improvement of at least 5 points ( 23 ) between the 3-week and 3-month assessments. Compared with non-responders (n = 18), responders were slightly younger (median age: 63 [58; 67] vs. 66 [60; 69] years), with a higher proportion of women (75% vs. 56%). Body mass index (BMI) was similar between the two groups. Duration of osteoarthritis was significantly longer in responders (132 [120; 180] months vs. 60 [26; 156] months). (Table 3 ). Table 3 Summary of responders and non-responders to the various study endpoints EARS KOOS Pain NRS R (n = 8) NR (n = 18) R (n = 9) NR (n = 17) R (n = 14) NR (n = 12) Age 63 [58; 67] 66 [60; 69] 60 [59 ; 67] 66 [61; 68] 61 [59; 67] 67 [64; 69] Sex (female) 6 (75.0) 10 (56.0) 6 (66.7) 10 (58.8) 9 (64.3) 7 (58.3) BMI (Kg/m²) 24.2 [20.9;30.4] 24.2 [23.0 ;29.7] 22.9 [20.7; 28.9] 24.8 [23.2; 29.7] 25.1 [22.5; 29.8] 23.8 [22.3; 29.2] Unilateral 5 (62.5) 10 (55.6) 5 (55.6) 10 (58.8) 7 (50.0) 8 (66.7) OA duration (months) 132 [120; 180] 60 [26; 156] 126 [54 ; 270] 72 [28 ; 180] 96 [60 ; 222] 120 [24 ; 180] Technical assistance 2 (25.0) 1 (5.6) 2 (22.2) 1 (5.9) 3 (21.4) 0 (0.0) BMI : Body Mass Index ; NR: non-responders ; OA: Osteoarthritis Response (R) was defined according to the Minimal Clinically Important Difference (MCID): a decrease of 5 points for the EARS, 8 points for the KOOS-Function subscale (KOOSf), and 2 points for the pain Numeric Rating Scale (NRS). Secondary endpoint For 32 patients initially included, the median KOOSf score decreased from 14.0 [5.0;20.0] at 3 weeks, to 9.0 [2.0;12.0] at 3 months. The effect size was − 0.59 [-0.95; -0.24]. For 26 patients, the median KOOSf score decreased from 12.0 [4.0; 20.0] at 3 weeks, to 8.5 [2.0;12.0] at 3 months, with an effect size of -0.62 [-1.00; -0.23] (Table 2 ). For our 32 patients, the pain rating scale on the NRS pain increase slightly between inclusion and 3 months (respectively 3.0 [1.0;6.5] and 4.0 [2.0;5.0]. The effect size was 0.11 [-0.24;0.46]. The pain rating on the NRS pain for our 26 patients, did not change between inclusion and 3 months (respectively 2.6 [1.0; 7.0] and 4.0 [2.0;5.0]) with an effect size of 0.06 [-0.32;0.45]. (Table 2 ) . Table 3 summarizes the responders and non-responders to the various study endpoints. For the KOOS-f score, 9 patients (35%) were considered responders (improvement ≥ 8 points). These had a lower Body Mass Index (BMI) (22.9 [20.7; 28.9] vs. 24.8 [23.2; 29.7] kg/m²) and a longer duration of osteoarthritis (126 [54; 270] vs. 72 [28; 180] months) than non-responders. The use of technical assistance was also more frequent among responders (22.2% vs. 5.9%), which may have facilitated performance of the proposed exercises. With regard to the NRS pain scale, 14 patients (54%) were considered responders (improvement ≥ 2 points). The latter were younger (61 [59; 67] vs. 67 [64; 69] years) than the non-responders, with a slightly shorter duration of osteoarthritis (96 [60; 222] vs. 120 [24; 180] months). Figure 4 shows the distribution of responders according to the three judgment criteria: EARS, KOOSf and pain (NRS). It can be seen that only 3 participants (out of 26) responded simultaneously to all three criteria, and 9 patients did not respond to any of the criteria. The aim was to collect their activity and number of daily steps as part of this study. Due to a number of technical problems with this bracelet connected to the ARTH-e application, we were unable to obtain any data. Using data were collected during the three months of follow-up. Patients were using app during a mean of 48 minutes per opening. Level 1 exercise sessions were most completed (248 times), then level 2 sessions (157 times) and level 3 sessions were completed 75 times by 26 patients. Participants could rate each exercise session and the mean rating were 3.7 ± 0.8 on 5.00. Discussion Our study aimed to evaluate the effect of the ARTH-e app on exercise adherence in patients with KOA. Our results showed a significant decrease in the EARS score, with a median decrease of 5.5 points for our 26 patients at 3 months. None of the variables studied (age, gender, BMI, level of education, type of work, type and duration of knee osteoarthritis, radiological stage, and use of a technical aid) showed a statistically significant difference between responders and non-responders. However, a trend towards a difference was observed for duration of osteoarthritis (p = 0.075), suggesting that it may play a role in exercise adherence. This decrease corresponds to the Minimally Detectable Change determined ( 23 ). This decrease in patients' adherence to the exercises prescribed with our application may necessitate a reassessment of engagement strategies or interventions to improve adherence ( 23 ). The effect sizes for EARS score change ranged from − 0.37 to -0.41, indicating a small to moderate decrease. This suggests that patients' commitment to the exercise program tends to decline over the long term. Note that the decrease between 3 weeks and 6 weeks is not statistically significant, indicating a more marked decline beyond this period. Pain shows a general tendency to decrease over time, but none of the variations observed is statistically significant. This may indicate that the application has a limited effect on pain management in this context. A significant decrease in KOOSf is observed between 3 weeks and 3 months (p = 0.038), reflecting an improvement in patient-perceived function. Although the variation between 3 and 6 weeks was not significant, there was a consistent trend towards improved function. Responders to the EARS suggested better adherence in experienced or better-supported patients. For the KOOS-F score, responders had a lower BMI and a longer history of pathology, which may favor better functional improvement. The use of technical aids also seems to play a positive role. On the other hand, for pain (NRS), non-responders were older and had a longer history of osteoarthritis, suggesting less reversibility of chronic pain. Overall, the age of the pathology and technical support appear to be factors favourable to response to intervention. The Venn diagram illustrates the great heterogeneity of responses to the intervention according to the three criteria assessed: EARS, KOOSf and pain. Only three patients showed a simultaneous positive response on all three dimensions, reflecting the rarity of an overall improvement. The majority of participants showed partial responses, suggesting that the benefits of the intervention may be targeted and not concern all the dimensions assessed. Conversely, nine patients did not respond to any of the criteria, indicating a possible lack of efficacy or a mismatch between the program and their profile. These results underline the need for a personalized approach that takes into account the diversity of profiles and needs to optimize the impact of rehabilitation interventions. Although technical issues with the GARMIN Vivosmart bracelet prevented the collection of objective physical activity data, app usage metrics showed that participants used the application for a mean duration of 48 minutes per session. They favored beginner and intermediate exercise levels, which may reflect the perceived difficulty of higher-level sessions or a lack of confidence. This usage behavior emphasizes the importance of adaptability and progressive engagement in digital exercise tools. The findings of our study align with previous research indicating that while digital interventions may not consistently enhance exercise adherence ( 24 – 26 ), they can positively impact functional outcomes ( 27 , 28 ) and pain. The ARTH-e application's inability to improve adherence suggests that technology alone may not address all barriers to sustained exercise engagement. Several factors can influence adherence to exercises: lack of motivation ( 29 ), persistent or fluctuating pain ( 30 ), lack of supervision (feeling isolated and lacking reference points) ( 31 ), or the complexity of exercises without having explanations as to their correct execution. To improve adherence to exercise, several strategies have been put in place: regular follow-up, adaptation of programs( 32 ), encouragement to continue exercising ( 33 ), and raising patients' awareness of the need to exercise to improve their quality of life ( 34 ). Additionally, exploring hybrid models that combine digital tools with in-person support could offer a more comprehensive approach to enhancing exercise adherence and outcomes. This study has several limitations. Its observational design and lack of a control group mean that conclusions about the effectiveness of the ARTH-e application cannot be drawn with confidence. The small sample size (n = 32, of whom 26 completed the follow-up) reduces statistical power and generalisability. Recruiting autonomous, tech-equipped volunteers who are often familiar with rehabilitation may introduce selection bias. Finally, the reliance on self-reported outcomes without objective activity tracking (except in a subgroup) is another limitation. These factors require cautious interpretation and highlight the need for a larger randomised controlled trial. Conclusion In conclusion, this study assessed the change in symptoms in people with KOA over a three-month period. The results showed a significant decrease in the EARS score, reflecting a reduction in exercise adherence, which affected the majority of participants (69%).The KOOS score also showed a significant median reduction at 3 months (p = 0.038). In contrast, the pain score showed no significant variation. These data suggest that the proposed therapeutic interventions have a measurable impact on certain aspects of patients' quality of life, although the improvement in pain remains limited. We plan to launch a prospective, randomized controlled trial, the ARTH-e 3 study, in May 2024. This trial will compare standard care alone with use of the ARTH-e app in addition to standard care (NCT06359171)( 35 ). Abbreviations AAOS American Academy of Orthopaedic Surgeons ACR American College of Rheumatology ANSM Agence Nationale de Sécurité du Médicament et des produits de santé BMI Body Mass Index CRA Clinical Research Associate EARS Exercise Adherence Rating Scale KOA Knee Osteoarthritis KOOS Knee injury and Osteoarthritis Outcome Score NRS Numerical Rating Scale OA Osteoarthritis PA Physical Activity PMR Physical Medicine and Rehabilitation STROBE Strengthening the Reporting of Observational Studies in Epidemiology Declarations Ethics approval and consent to participate The study was approved by the Sud Est I ethics committee in September 2020. The summary of the research was sent by the Sponsor to the French National Agency for the Safety of Medicines and Health Products (ANSM) before beginning. The protocol was registered on ClinicalTrials.gov (NCT04750304). Human Ethics and consent to participate declaration This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. It received approval from the French Ethics Committee “Comité de Protection des Personnes Sud-Est I”. All participants were provided with detailed information regarding the study’s objectives, procedures, potential risks, and benefits. Written informed consent was obtained from each participant prior to inclusion. Participation was voluntary, and subjects were free to withdraw at any time without any consequence to their medical care. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors report there are no competing interests to declare. Funding This work was supported by the Banque Publique d'Investissement (BPI) France under grant DOS0072290/00. Authors’ contributions The guarantor is the name of the corresponding author; whose initials are MPV. The conception and design of the study was made by MPV, EC, BP and CL. The drafting of the original protocol by MPV, EC, BP and CL. The coordination of the study by CL, MPV. The acquisition of data by MPV and LJ. The design of the statistical analysis plan by BP, EC and MPV. The drafting of the present manuscript by MPV, LJ, EC, BP and CL. The final article has been approved by all authors. Acknowledgements The investigating team would firstly like to thank the participants in this study, as well as Candice Rudelle, Clinical Research Associate in the Direction de la Recherche Clinique et de l’Innovation, of theClermont-Ferrand University Hospital. We would also like to thank Paul Gignoux (MD), who carried out the patient inclusion visits, and the company Opénium, with whom we collaborated to create the application. We thank Johanna Robertson, PT, PhD for constructive criticism and language editing. ORCID Louise Jeannot https://orcid.org/0009-0007-9202-3865 Mathilde Pelletier-Visa https://orcid.org/0000-0002-4340-0069 Bruno Pereira https://orcid.org/0000-0003-3778-7161 Charlotte Lanhers https://orcid.org/0000-0002-6584-8411 Emmanuel Coudeyre https://orcid.org/0000-0001-5753-2890 References Giorgino R, Albano D, Fusco S, Peretti GM, Mangiavini L, Messina C. Knee Osteoarthritis: Epidemiology, Pathogenesis, and Mesenchymal Stem Cells: What Else Is New? An Update. Int J Mol Sci. 29 mars 2023;24(7):6405. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. mars 2014;22(3):363‑88. Raud B, Gay C, Guiguet-Auclair C, Bonnin A, Gerbaud L, Pereira B, et al. Level of obesity is directly associated with the clinical and functional consequences of knee osteoarthritis. Sci Rep. 27 févr 2020;10:3601. Whittaker JL, Losciale JM, Juhl CB, Thorlund JB, Lundberg M, Truong LK, et al. Risk factors for knee osteoarthritis after traumatic knee injury: a systematic review and meta-analysis of randomised controlled trials and cohort studies for the OPTIKNEE Consensus. Br J Sports Med. déc 2022;56(24):1406‑21. Li M, Zeng Y, Nie Y, Wu Y, Liu Y, Wu L, et al. Varus-valgus knee laxity is related to a higher risk of knee osteoarthritis incidence and structural progression: data from the osteoarthritis initiative. Clin Rheumatol. 1 avr 2022;41(4):1013‑21. Pers YM. Recommendations from the French Societies of Rheumatology and Physical Medicine and Rehabilitation on the non-pharmacological management of knee osteoarthritis. Annals of Physical and Rehabilitation Medicine. 2024; Gay C, Guiguet-Auclair C, Mourgues C, Gerbaud L, Coudeyre E. Physical activity level and association with behavioral factors in knee osteoarthritis. Annals of Physical and Rehabilitation Medicine. janv 2019;62(1):14‑20. Statista [Internet]. [cité 8 juill 2022]. Smartphone users in France 2018-2024. Disponible sur: https://www.statista.com/statistics/467177/forecast-of-smartphone-users-in-france/ Lambert TE, Harvey LA, Avdalis C, Chen LW, Jeyalingam S, Pratt CA, et al. An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a randomised trial. J Physiother. juill 2017;63(3):161‑7. Thomas DT, R S, Prabhakar AJ, Dineshbhai PV, Eapen C. Hip abductor strengthening in patients diagnosed with knee osteoarthritis – a systematic review and meta-analysis. BMC Musculoskelet Disord. 29 juin 2022;23:622. Pisters MF, Veenhof C, Schellevis FG, Twisk JWR, Dekker J, De Bakker DH. Exercise adherence improving long-term patient outcome in patients with osteoarthritis of the hip and/or knee. Arthritis Care & Research. 2010;62(8):1087‑94. Weber F, Kloek C, Stuhrmann S, Blum Y, Grüneberg C, Veenhof C. Usability and preliminary effectiveness of an app-based physical activity and education program for people with hip or knee osteoarthritis – a pilot randomized controlled trial. Arthritis Res Ther. 2024;26:83. Pelle T, van der Palen J, de Graaf F, van den Hoogen FHJ, Bevers K, van den Ende CHM. Use and usability of the dr. Bart app and its relation with health care utilisation and clinical outcomes in people with knee and/or hip osteoarthritis. BMC Health Serv Res. 10 mai 2021;21:444. Bäcker HC, Wu CH, Schulz MRG, Weber-Spickschen TS, Perka C, Hardt S. App-based rehabilitation program after total knee arthroplasty: a randomized controlled trial. Arch Orthop Trauma Surg. sept 2021;141(9):1575‑82. Mbony-Irankunda D. Adaptation et validation du questionnaire EARS (Exercise Adherence Rating Scale) dans la gonarthrose. 2023; Cuschieri S. The STROBE guidelines. Saudi J Anaesth. avr 2019;13(Suppl 1):S31‑4. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis care & research. 6 janv 2020;72(2):149. Sellam J, Courties A, Eymard F, Ferrero S, Latourte A, Ornetti P, et al. Recommendations of the French Society of Rheumatology on pharmacological treatment of knee osteoarthritis. Joint Bone Spine. déc 2020;87(6):548‑55. Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline [Internet]. [cité 21 févr 2024]. Disponible sur: https://www.aaos.org/globalassets/quality-and-practice-resources/osteoarthritis-of-the-knee/oak3cpg.pdf Collins NJ, Prinsen C a. C, Christensen R, Bartels EM, Terwee CB, Roos EM. Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measurement properties. Osteoarthritis Cartilage. août 2016;24(8):1317‑29. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. déc 1957;16(4):494‑502. Lignes Directrices de l’OMS Sur l’activité Physique et la Sédentarité: En un Coup D’oeil. 1st ed. Geneva: World Health Organization; 2020. 1 p. de Lira MR, de Oliveira AS, França RA, Pereira AC, Godfrey EL, Chaves TC. The Brazilian Portuguese version of the Exercise Adherence Rating Scale (EARS-Br) showed acceptable reliability, validity and responsiveness in chronic low back pain. BMC Musculoskelet Disord. 12 mai 2020;21:294. Svingen J, Rosengren J, Turesson C, Arner M. A smartphone application to facilitate adherence to home-based exercise after flexor tendon repair: A randomised controlled trial. Clin Rehabil. févr 2021;35(2):266‑75. Bennell KL, Marshall CJ, Dobson F, Kasza J, Lonsdale C, Hinman RS. Does a Web-Based Exercise Programming System Improve Home Exercise Adherence for People With Musculoskeletal Conditions?: A Randomized Controlled Trial. American Journal of Physical Medicine & Rehabilitation. oct 2019;98(10):850. Gibbs JC, McArthur C, Milligan J, Clemson L, Lee L, Boscart VM, et al. Measuring the implementation of a group-based Lifestyle-integrated Functional Exercise (Mi-LiFE) intervention delivered in primary care for older adults aged 75 years or older: a pilot feasibility study protocol. Pilot and Feasibility Studies. 31 mai 2015;1(1):20. López-Marcos JJ, Díaz-Arribas MJ, Valera-Calero JA, Navarro-Santana MJ, Izquierdo-García J, Ortiz-Gutiérrez RM, et al. The Added Value of Face-to-Face Supervision to a Therapeutic Exercise-Based App in the Management of Patients with Chronic Low Back Pain: A Randomized Clinical Trial. Sensors (Basel). 16 janv 2024;24(2):567. Dieter V, Janssen P, Krauss I. Efficacy of the mHealth-Based Exercise Intervention re.flex for Patients With Knee Osteoarthritis: Pilot Randomized Controlled Trial. JMIR Mhealth Uhealth. 9 sept 2024;12:e54356. Marks R. Knee osteoarthritis and exercise adherence: a review. Curr Aging Sci. févr 2012;5(1):72‑83. Zhou Z, Hou Y, Lin J, Wang K, Liu Q. Patients’ views toward knee osteoarthritis exercise therapy and factors influencing adherence – a survey in China. The Physician and Sportsmedicine [Internet]. 3 avr 2018 [cité 14 janv 2025]; Disponible sur: https://www.tandfonline.com/doi/abs/10.1080/00913847.2018.1425595 Ledingham A, Cohn ES, Baker KR, Keysor JJ. Exercise adherence: beliefs of adults with knee osteoarthritis over 2 years. Physiotherapy Theory and Practice [Internet]. 1 déc 2020 [cité 14 janv 2025]; Disponible sur: https://www.tandfonline.com/doi/abs/10.1080/09593985.2019.1566943 Krauss I, Katzmarek U, Rieger MA, Sudeck G. Motives for physical exercise participation as a basis for the development of patient-oriented exercise interventions in osteoarthritis: a cross-sectional study. Eur J Phys Rehabil Med. août 2017;53(4):590‑602. Sun RT, Han W, Chang HL, Shaw MJ. Motivating Adherence to Exercise Plans Through a Personalized Mobile Health App: Enhanced Action Design Research Approach. JMIR Mhealth Uhealth. 2 juin 2021;9(6):e19941. Song Y, Reifsnider E, Chen Y, Wang Y, Chen H. The Impact of a Theory-Based mHealth Intervention on Disease Knowledge, Self-efficacy, and Exercise Adherence Among Ankylosing Spondylitis Patients: Randomized Controlled Trial. J Med Internet Res. 20 oct 2022;24(10):e38501. Pelletier-Visa M, Dobija L, Bonhomme A, Lanhers C, Pereira B, Coudeyre E. Effectiveness of the ARTHE-e app for exercise adherence in people with knee osteoarthritis: protocol for a randomised controlled trial. BMJ Open. 18 janv 2025;15(1):e088860. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6912520","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477882609,"identity":"2e3daf7c-bab6-43bf-bd9a-0b86cb75ebd5","order_by":0,"name":"Mathilde Pelletier-Visa","email":"data:image/png;base64,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","orcid":"","institution":"Centre Hospitalier Universitaire de Clermont-Ferrand, INRAE, UNH","correspondingAuthor":true,"prefix":"","firstName":"Mathilde","middleName":"","lastName":"Pelletier-Visa","suffix":""},{"id":477882610,"identity":"014ecd6c-8063-4882-a98c-20eea947af7e","order_by":1,"name":"Louise Jeannot","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Clermont-Ferrand, INRAE, UNH","correspondingAuthor":false,"prefix":"","firstName":"Louise","middleName":"","lastName":"Jeannot","suffix":""},{"id":477882611,"identity":"4cbc198c-c37b-4aee-9b80-cfe3504f9478","order_by":2,"name":"Bruno Pereira","email":"","orcid":"","institution":"CHU Clermont-Ferrand","correspondingAuthor":false,"prefix":"","firstName":"Bruno","middleName":"","lastName":"Pereira","suffix":""},{"id":477882612,"identity":"07979aba-e918-4d67-a867-d0628564c8ce","order_by":3,"name":"Emmanuel Coudeyre","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Clermont-Ferrand, INRAE, UNH","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Coudeyre","suffix":""},{"id":477882613,"identity":"e5ab214e-f9ed-4718-b16f-a3568ddb9642","order_by":4,"name":"Charlotte Lanhers","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Clermont-Ferrand, INRAE, UNH","correspondingAuthor":false,"prefix":"","firstName":"Charlotte","middleName":"","lastName":"Lanhers","suffix":""}],"badges":[],"createdAt":"2025-06-17 09:08:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6912520/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6912520/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85826239,"identity":"aa1efd3f-caed-4d43-8751-ad6c9f489cd3","added_by":"auto","created_at":"2025-07-02 07:12:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50153,"visible":true,"origin":"","legend":"\u003cp\u003eStudy diagram\u003c/p\u003e\n\u003cp\u003eEARS : Exercise Adherence Rating Scale ; KOOS : Knee injury and Osteoarthritis Outcome Score; \u0026nbsp;V : Visit\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6912520/v1/af612694b468b4cd6bb30926.png"},{"id":85826873,"identity":"0f2798fd-e3fc-4dc7-813c-cb19094bf1a8","added_by":"auto","created_at":"2025-07-02 07:20:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":372840,"visible":true,"origin":"","legend":"\u003cp\u003ePresentation of the ARTH-E app interface in French\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6912520/v1/80ac5a74dffad21c40973339.png"},{"id":85826240,"identity":"22dc7dd0-f288-4149-a52c-ad7c940d0cde","added_by":"auto","created_at":"2025-07-02 07:12:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":76126,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram flow\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6912520/v1/e94b61773a119be83a345530.png"},{"id":85826241,"identity":"663089e4-cf4d-4ab1-994b-ad8c90983efe","added_by":"auto","created_at":"2025-07-02 07:12:36","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":28984,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of responders according to the three judgment criteria: EARS, KOOSf and pain (NRS) using the Venn diagram.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6912520/v1/df0c4949269c1b491b128bed.png"},{"id":85829365,"identity":"a917832a-8363-4428-a012-c5b5a5ec1362","added_by":"auto","created_at":"2025-07-02 07:36:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1465335,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6912520/v1/11069489-04df-4202-a912-1f33de8aee15.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of an e-health app on adherence to physical activity in people with knee osteoarthritis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKnee osteoarthritis (KOA) is a form of osteoarthritis that affects the knee, leading to the progressive degradation of articular cartilage (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although it is common in older people (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), factors such as obesity (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), a history of injury (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) or abnormal joint alignment can accelerate its onset (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The main consequences of this pathology include joint pain, knee stiffness and reduce mobility. Ultimately, these symptoms can impair patients\u0026rsquo; quality of life by limiting their daily activities and increase the risk of loss of independence. Advanced cases sometimes require surgery, such as knee replacement (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe management of KOA involves both non-pharmacological and pharmacological treatments. Latest guidelines prioritize the use of non-pharmacological treatment, including physical activity (PA), self-management, and weight loss (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) if necessary. These guidelines are particularly important given the low level of PA performed by people with KOA due to the development of kinesiophobia linked to pain (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Today, connected objects have taken a predominant place in our daily life, including older people (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Using those tools for patient\u0026rsquo;s self management is a motivational way to get more adherence from patients. It is a very adaptative and personalized tool compared to conventional rehabilitation (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). To maximize the effectiveness of physiotherapy sessions, therapists encourage individuals to perform unsupervised muscle-strengthening exercises, outside their hospital or private practice sessions (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, compliance with self-exercise often declines over time. Methods to motivate and encourage individuals with KOA to continue their home exercise program are being developed, such as mobile e-health applications(\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These applications provide self-training programs for individuals with KOA, to motivate them to continue performing muscle-strengthening exercises properly at home. However, the use of a mobile application can sometimes be complicated (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e); therefore, it is essential to evaluate its handling and ergonomics to ensure the most comfortable experience for users.\u003c/p\u003e \u003cp\u003eSome mHealth apps have already been found effective for musculoskeletal conditions such as low back pain in terms of usability, pain reduction and improved function (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). To our knowledge, no mHealth tools are currently available in France for the management of KOA.\u003c/p\u003e \u003cp\u003eA preliminary qualitative study was conducted with individuals with KOA and physicians to assess perceived barriers and facilitators to the use of an mHealth app for people with KOA (NCT04120727). The results showed that people with osteoarthritis (OA) needed advice and guidance to practice PA safely because of their fear of worsening their symptoms. However, no barriers to the use of digital tools were identified in older people. From this study, we developed our own mHealth app: ARTH-e, designed for use on smartphones and digital tablets. The app includes progressive self-exercise programs with personalized monitoring of progress and pain as well as a self-management section.\u003c/p\u003e \u003cp\u003eThe main objective of the ARTH-e 2 study was to test the effect of using the ARTH-e application on adherence to physical activity (Exercise Adherence Rating Scale questionnaire) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) in individuals with KOA. The secondary objectives of the study were to assess the impact of using the application on knee function (Knee injury and Osteoarthritis Outcome Score questionnaire) and pain (NRS).\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eWe conducted an observational, prospective, single center study (Clermont-Ferrand University Hospital). The study was approved by the \u003cem\u003eSud Est I\u003c/em\u003e ethics committee in September 2020. The summary of the research was sent by the Sponsor to the French National Agency for the Safety of Medicines and Health Products (ANSM) before beginning. The protocol was registered on ClinicalTrials.gov (NCT04750304) on the following date: 10/02/2021. The study started in January 2022 and was completed in July 2022. The reporting follows the guidelines and recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)(\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eParticipant recruitment\u003c/h3\u003e\n\u003cp\u003ePeople with KOA were recruited on a volunteer basis, among those followed in the Physical Medicine and Rehabilitation Department (PMR) of the Clermont-Ferrand University Hospital, France, as part of their pathology (routine care) and among healthcare professionals of the same institution (mailing list). The general process of the study is shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eThe Clinical Research Associate (CRA) introduced the study to eligible individuals by phone call. After reflecting, people telephoned the CRA if they decided to participate. Then, an inclusion visit was scheduled with the physician and the CRA, during which a medical examination was performed and the inclusion and non-inclusion criteria were checked. Participants received a copy of the information leaflet and the non-opposition form. Then, the CRA installed the application on the smartphone or tablet with the individual.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eWe included adults, with no upper age limit, diagnosed with OA in at least one knee according to the American College of Rheumatology (ACR) criteria prior to inclusion by a specialist or non-specialist physician, and symptomatic (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e). They had their own smartphone or tablet running with at least Android 5 or iOS 11.\u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eWe did not include people with comprehension disorders that made interviewing and filling out questionnaires or using the app impossible, people under guardianship, curatorship, or deprived of liberty.\u003c/p\u003e\n\u003ch3\u003eARTH-e app\u003c/h3\u003e\n\u003cp\u003eThe ARTH-e app was developed by the PMR department in collaboration with the Openium company and can be downloaded from the PlayStore or AppleStore platforms. The interface is simple for easy and intuitive use. The home screen includes a dashboard, predefined exercise programs (14 in all) and randomly suggested programs, as well as a \u0026ldquo;Did you know?\u0026rdquo; insert enabling participants to educate themselves about their pathology and thus overcome certain existing preconceived ideas about osteoarthritis. A menu provides 6 items: Home, Did you know? My programs, My follow-up, Information and Legal information (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe predefined exercise programs are divided into three levels of difficulty. Each program is built in the same way, and includes 5 categories of exercise performed in the following order: cardiovascular warm-up, joint warm-up, muscle strengthening, proprioception and stretching. The selection and organization of exercises were established through an interdisciplinary collaboration between physicians, physiotherapists, and adapted physical activity instructors. The chosen approach aims to optimize quadriceps and hamstring strengthening, promote joint range of motion gains, and minimize injury risks in patients with knee osteoarthritis. This protocol is based on the recommendations of the French Society of Rheumatology (2019)(\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) and the American Academy of Orthopaedic Surgeons (AAOS, 2021) (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Once the user has mastered the application, he or she can create their own program, selecting one or more exercises from each of the above-mentioned categories in a guided fashion (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eWhen the participant begins the exercise program, the app provides a list of the equipment required (mat, chair, ball, etc.) so that they can prepare the session. In addition, videos of each exercise were available. The videos provide a demonstration of the correct posture to adopt, enhancing the safety and effectiveness of the exercises. Each program lasts between 25 and 30 minutes and includes breaks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main objective of the ARTH-e 2 study was to test an e-health application on a panel of patients in order to assess the benefits of using the application in terms of adherence to physical activity.\u003c/p\u003e\n\u003cp\u003eThe secondary objectives of the study were to assess the impact of using the application on knee function and pain (NCT04750304). In view of the difficulties encountered in other research projects in getting to grips with a mobile application (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e), the study also aimed to evaluate the application in terms of both content and form (general user experience, user interface, user expectations), in order to improve its ergonomics and thus limit the obstacles to its use.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eOutcomes\u003c/h2\u003e\n \u003cp\u003eSelf-administered questionnaires were used, and outcomes were collected by phone by the CRA at 3 weeks, 6 weeks and 3 months after the beginning of the intervention.\u003c/p\u003e\n \u003cp\u003eThe main outcome was the Exercise Adherence Rating Scale (EARS) questionnaire, which we adapted for use in people with knee pain at 3 weeks, 6 weeks and 3 months of use of the app. The EARS questionnaire (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e) was used to assess adherence to self-exercises. It is divided into 6 propositions, which the patient can more or less validate, from 0 (completely agree) to 4 (completely disagree). It was initially developed for low back pain and adapted to the study. The EARS questionnaire has undergone a cross-cultural adaptation and validation in French for patients with knee osteoarthritis by our team, following all recommended adjustments specific to this population compared to the original version. The article is currently in the process of being published. This questionnaire should enable study participants to quantify the time spent performing self-exercises, and thus assess their adherence. A score ranging from 0 to 24 can then be calculated from the participants\u0026apos; answers, with a score of 24/24 corresponding to very good adherence to the prescribed physical activity; a declining score reflects poor adherence to the exercises.\u003c/p\u003e\n \u003cp\u003eSecondary outcomes were clinical outcomes. We assessed pain using a 10-point Numerical Rating Scale (NRS) and disability using the Knee injury and Osteoarthritis Outcome Score (KOOSf) (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e) at 3 weeks, 6 weeks and 3 months of use of the app. The KOOSf questionnaire is an assessment tool designed to measure knee function. This questionnaire is made up of several sub-categories in order to determine different sub-scores. The categories include pain, stiffness, daily life and function, activities and leisure. Each item is rated on a 5-point Likert scale is used (from 0 - \u0026ldquo;completely agree\u0026rdquo; to 4 - \u0026ldquo;strongly disagree\u0026rdquo;). The higher the total score, the more severe the symptoms experienced by the individual, and the greater the impact of the OA on their quality of life.\u003c/p\u003e\n \u003cp\u003eWe also collected indicators of app use (frequency of opening per week, time spent on the app, rating of each exercise). We collected patient-intrinsic data through the Garmin VivoSmart 4 connected wristband, including number of steps, heart rate, movement intensity, heart variability, and energy expenditure in calories.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eParticipants were seen for the first time at the inclusion visit, during which they were again briefed on the various aspects of the study. After reading the information letter and signing the consent form, they underwent a medical consultation, completed a demographic questionnaire and installed the ARTH-e application on their smartphone. All the participants attended a one-hour self management session with the department\u0026apos;s Adapted Physical Activity teacher. This session aimed to guide the participants through the different exercises proposed by the ARTH-e application. Participants were free to use the app during the 3 months of follow-up. We asked all participants whether they would like to benefit from a connected watch as part of the study, and only 16 patients agreed to take part. The sub-population who agreed to wear a Garmin vivosmart 4 connected bracelet for the collection of intrinsic activity data were issued with the bracelet, which allowed collection of the number of daily steps, daily calorie energy expenditure, etc. These participants were allowed to keep the connected bracelet after the study for their personal use. The data collected through the connected bracelets and in the study were anonymized.\u003c/p\u003e\n\u003cp\u003eTwo phone calls were then scheduled at 3 and 6 weeks. During these remote interviews, participants were asked to complete the EARS and the KOOSf; they were also asked to estimate their level of pain using a Numeric Rating Scale (NRS). The study was closed with a final phone conversation, three months after the inclusion date, during which the participant was asked to complete the EARS and KOOSf questionnaires again, and to estimate their pain level on the NRS (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eDuring the last phone call, participants received a link by email to complete a quality questionnaire about the ARTH-e application, which we will not present in this article. The answers to this quality questionnaire enabled us to improve the app.\u003c/p\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eContinuous data were reported by the median and interquartile range. The assumption of normality distribution was analyzed using the Shapiro-Wilk test. Mixed model was used to study the effect of time taking into account between and within patient variability (subject as random effect). The results are expressed using effect sizes and 95% confidence intervals. A sensitivity analysis was also conducted on patients with complete data. Thresholds for EARS, KOOSf and pain changes were fixed according to statistical distribution and to the data reported in the literature, i.e. decrease of 5 points, 8 points and 2 points respectively. Analyses were performed using Stata software (version 15; StataCorp, College Station, Texas, USA). A two-sided type I error at 5% was considered for statistical significance. A Sidak\u0026rsquo;s type I error correction, was applied to take into account two by two multiple comparisons.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDescription\u003c/h2\u003e \u003cp\u003eBetween January 31, 2022 and April 7, 2022, 32 individuals were included in the study. Of these, 26 participants completed all 3 sessions, and 6 were lost to follow-up (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe median age of our patients was 63.5 [60.0;68.0] years and 63% of them were female. Most of our patients included in this study were retired (n\u0026thinsp;=\u0026thinsp;16, i.e. 50.0% of the 32 patients initially recruited, and n\u0026thinsp;=\u0026thinsp;14, i.e. 53.8% of those who completed the protocol). The majority of working patients had sedentary jobs (respectively n\u0026thinsp;=\u0026thinsp;9, 64.3% and n\u0026thinsp;=\u0026thinsp;8, 72.7%). Most had unilateral knee osteoarthritis (63%); 78% had stage II or III femorotibial compartment involvement according to the Kellgren \u0026amp; Lawrence classification (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). More details are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\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\u003eClinical and demographic characteristics of patients with knee osteoarthritis at inclusion\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\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.5 [60.0\u0026nbsp;; 68.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.5 [60.0\u0026nbsp;; 68.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (M/F), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (37.5%) / 20 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (38.5%) /16 (61.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, Kg/m\u0026sup2; (median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.11 [21.80\u0026nbsp;; 29.82]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.16 [22.49\u0026nbsp;; 29.74]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of the evolution of osteoarthritis, months (median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 [48\u0026nbsp;; 180]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 [48\u0026nbsp;; 180]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWay of life\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\u003eAsset n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (43.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSedentary / Physical /Combined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (64.3%) / 2 (14.3%) : 3 (21,4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (72.7%) / 0 (0.0%) /3 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (53.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvalidity n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadio-clinical damage\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\u003eUnilateral / Bilateral n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (62.5%) / 12 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (57.7%) / 11 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal / External femorotibial/ Patellofemoral n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (71.9%) / 3 (9.4%) / 13 (40.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (65.4%) / 3 (11.5%)\u0026nbsp;/ 11 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiological stage\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Kellgrenn and Lawrence) n (%)\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\u003eStage I / Stage II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 \u0026nbsp; (0.0%) / 14 (43.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 \u0026nbsp; (0.0%) / 12 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage III / Stage IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (34.4%) / 4 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (33.3%) / 4 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 \u0026nbsp; (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssociated pathologies\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\u003eDiabetes n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh blood pressure\u0026nbsp; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (26.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical activities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e29 (90.6%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e23 (88.46%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvery day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (26.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 to 6 times a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (21.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 3 times a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (58.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (47.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than once a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of each physical activity session\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\u003eMore than 30 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (75.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (73.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15 to 30 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (21.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 15 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSedentary time\u003c/b\u003e, hours (median [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.0 [3.0;8.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.0 [3.5\u0026nbsp;; 8.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOsteoarthritis management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (59.4%)\u003c/p\u003e \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\u003ePhysiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (68.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (65.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-exercices programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRehabilitation in a specialized center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (19.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpa treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (31.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (34.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOsteopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood supplements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (21.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHomeopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTai chi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcupuncture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (40.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTechnical assistance\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\u003eKnee orthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCane\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe median duration of pain was more than one year. In total, 69% of participants had undergone physiotherapy and 37.5% osteopathy. Most participants (75.9%) performed at least 30 minutes of PA per week, although the majority (58.6%) did not reach the level of PA recommended by the World Health Organization (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The median daily sedentary time was 5.0 [3.0; 8.0] hours.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMain endpoint\u003c/h2\u003e \u003cp\u003eEARS scores are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. For 32 patients initially included, the median EARS score was 21.0 [12.0;22.0] at 3 weeks, to 16.0 [13.0;22.0] at 3 months. The EARS score decreased by -1.0 [-6.0; 1.0] between 3 weeks and 3 months. The change in EARS score between 3 weeks and 3 months was associated with an effect size of -0.37 [-0.73; -0.02]. For 26 patients, the median EARS score decreased from 21.5 [16.0; 22.0] at 3 weeks, to 16.0 [13.0;22.0] at 3 months (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The change in EARS score was associated with an effect size of -0.41 [-0.79; -0.02].\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\u003eChanges in EARS, KOOS and NRS pain scores at 3 weeks, 6 weeks and 3 months\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\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 weeks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 weeks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEARS (31/29/26)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3 weeks change\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 \u003cp\u003e21.0 [12.0\u0026nbsp;; 22.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.0 [12.0\u0026nbsp;; 22.0]\u003c/p\u003e \u003cp\u003e-2.0 [-3.0\u0026nbsp;; 2.0], p\u0026thinsp;=\u0026thinsp;0.224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.0 [13.0\u0026nbsp;; 22.0]\u003c/p\u003e \u003cp\u003e-1.0 [-6.0\u0026nbsp;; 1.0], \u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKOOSf (30/28/26)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3 weeks change\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 \u003cp\u003e14.0 [5.0\u0026nbsp;; 20.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0 [4.0\u0026nbsp;; 14.0]\u003c/p\u003e \u003cp\u003e-2.0 [-7.0\u0026nbsp;; 1.0], \u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.044\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.0 [2.0\u0026nbsp;; 12.0]\u003c/p\u003e \u003cp\u003e-4.0 [-11.0\u0026nbsp;; 0.0], \u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNRS Pain (32/31/29/26)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eInclusion change\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0 [1.0; 6.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0 [2.0; 6.0]\u003c/p\u003e \u003cp\u003e0.0 [-10.0; 20.0], p\u0026thinsp;=\u0026thinsp;0.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.0 [1.0; 5.0]\u003c/p\u003e \u003cp\u003e0.0 [-10.0\u0026nbsp;; 10.0], p\u0026thinsp;=\u0026thinsp;0.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.0 [2.0\u0026nbsp;; 5.0]\u003c/p\u003e \u003cp\u003e0.0 [-30.0\u0026nbsp;; 30.0], p\u0026thinsp;=\u0026thinsp;0.545\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplete data (n\u0026thinsp;=\u0026thinsp;26)\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 \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEARS\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3 weeks change\u003c/b\u003e\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\u003e21.5 [16.0;22.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.5 [16.0;22.0]\u003c/p\u003e \u003cp\u003e-1.5 [-3.0;2.0], p\u0026thinsp;=\u0026thinsp;0.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.0 [13.0; 22.0]\u003c/p\u003e \u003cp\u003e-1.0 [-6.0;1.0], \u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKOOSf\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3 weeks change\u003c/b\u003e\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\u003e12.0 [4.0;20.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0 [5.0;13.0]\u003c/p\u003e \u003cp\u003e-1.5 [-5.0;1.0], p\u0026thinsp;=\u0026thinsp;0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.5 [2.0; 12.0]\u003c/p\u003e \u003cp\u003e-3.5 [-11.0; 0.0], \u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNRS Pain\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eInclusion change\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6 [1.0;7.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0 [2.0;6.0]\u003c/p\u003e \u003cp\u003e0 [-10\u0026nbsp;; 10], p\u0026thinsp;=\u0026thinsp;0.306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.5 [1.0;5.0]\u003c/p\u003e \u003cp\u003e0 [-10;10], p\u0026thinsp;=\u0026thinsp;0.748\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.0 [2.0; 5.0]\u003c/p\u003e \u003cp\u003e0 [-30; 30], p\u0026thinsp;=\u0026thinsp;0.756\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults were expressed as median [IQR].\u003c/p\u003e \u003cp\u003e\u0026lsquo;3-week change\u0026rsquo; refers to the variation in scores between the 3-week visit and the follow-up visits at 6 weeks and 3 months. This is calculated for all participants with available data at both time points. 'Inclusion change' refers to the change in scores from baseline and is analysed only in participants with complete data at all assessment time points (n\u0026thinsp;=\u0026thinsp;26).\u003c/p\u003e \u003cp\u003eEARS: Exercise Adherence Rating Scale, KOOS : Knee injury and Osteoarthritis Outcome Score ; NRS : Numeric Rating Scale\u003c/p\u003e \u003cp\u003eConcerning the primary endpoint (EARS), 8 participants (31%) were classified as responders, based on an improvement of at least 5 points (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) between the 3-week and 3-month assessments. Compared with non-responders (n\u0026thinsp;=\u0026thinsp;18), responders were slightly younger (median age: 63 [58; 67] vs. 66 [60; 69] years), with a higher proportion of women (75% vs. 56%). Body mass index (BMI) was similar between the two groups. Duration of osteoarthritis was significantly longer in responders (132 [120; 180] months vs. 60 [26; 156] months). (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\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\u003eSummary of responders and non-responders to the various study endpoints\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEARS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eKOOS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003ePain NRS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eR\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNR\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;18)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eR\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003eNR\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eR\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eNR\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 [58; 67]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 [60; 69]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60 [59\u0026nbsp;; 67]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e66 [61; 68]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e61 [59; 67]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e67 [64; 69]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e10 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7 (58.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (Kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.2 [20.9;30.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.2 [23.0 ;29.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.9 [20.7; 28.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e24.8 [23.2; 29.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25.1 [22.5; 29.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e23.8 [22.3; 29.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e10 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOA duration (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132 [120; 180]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 [26; 156]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e126 [54\u0026nbsp;; 270]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e72 [28\u0026nbsp;; 180]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e96 [60\u0026nbsp;; 222]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e120 [24\u0026nbsp;; 180]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnical assistance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBMI : Body Mass Index ; NR: non-responders ; OA: Osteoarthritis\u003c/p\u003e \u003cp\u003eResponse (R) was defined according to the Minimal Clinically Important Difference (MCID): a decrease of 5 points for the EARS, 8 points for the KOOS-Function subscale (KOOSf), and 2 points for the pain Numeric Rating Scale (NRS).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSecondary endpoint\u003c/h2\u003e \u003cp\u003eFor 32 patients initially included, the median KOOSf score decreased from 14.0 [5.0;20.0] at 3 weeks, to 9.0 [2.0;12.0] at 3 months. The effect size was \u0026minus;\u0026thinsp;0.59 [-0.95; -0.24]. For 26 patients, the median KOOSf score decreased from 12.0 [4.0; 20.0] at 3 weeks, to 8.5 [2.0;12.0] at 3 months, with an effect size of -0.62 [-1.00; -0.23] (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor our 32 patients, the pain rating scale on the NRS pain increase slightly between inclusion and 3 months (respectively 3.0 [1.0;6.5] and 4.0 [2.0;5.0]. The effect size was 0.11 [-0.24;0.46]. The pain rating on the NRS pain for our 26 patients, did not change between inclusion and 3 months (respectively 2.6 [1.0; 7.0] and 4.0 [2.0;5.0]) with an effect size of 0.06 [-0.32;0.45]. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the responders and non-responders to the various study endpoints. For the KOOS-f score, 9 patients (35%) were considered responders (improvement\u0026thinsp;\u0026ge;\u0026thinsp;8 points). These had a lower Body Mass Index (BMI) (22.9 [20.7; 28.9] vs. 24.8 [23.2; 29.7] kg/m\u0026sup2;) and a longer duration of osteoarthritis (126 [54; 270] vs. 72 [28; 180] months) than non-responders. The use of technical assistance was also more frequent among responders (22.2% vs. 5.9%), which may have facilitated performance of the proposed exercises.\u003c/p\u003e \u003cp\u003eWith regard to the NRS pain scale, 14 patients (54%) were considered responders (improvement\u0026thinsp;\u0026ge;\u0026thinsp;2 points). The latter were younger (61 [59; 67] vs. 67 [64; 69] years) than the non-responders, with a slightly shorter duration of osteoarthritis (96 [60; 222] vs. 120 [24; 180] months).\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the distribution of responders according to the three judgment criteria: EARS, KOOSf and pain (NRS). It can be seen that only 3 participants (out of 26) responded simultaneously to all three criteria, and 9 patients did not respond to any of the criteria.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe aim was to collect their activity and number of daily steps as part of this study. Due to a number of technical problems with this bracelet connected to the ARTH-e application, we were unable to obtain any data. Using data were collected during the three months of follow-up. Patients were using app during a mean of 48 minutes per opening. Level 1 exercise sessions were most completed (248 times), then level 2 sessions (157 times) and level 3 sessions were completed 75 times by 26 patients. Participants could rate each exercise session and the mean rating were 3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 on 5.00.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study aimed to evaluate the effect of the ARTH-e app on exercise adherence in patients with KOA. Our results showed a significant decrease in the EARS score, with a median decrease of 5.5 points for our 26 patients at 3 months. None of the variables studied (age, gender, BMI, level of education, type of work, type and duration of knee osteoarthritis, radiological stage, and use of a technical aid) showed a statistically significant difference between responders and non-responders. However, a trend towards a difference was observed for duration of osteoarthritis (p\u0026thinsp;=\u0026thinsp;0.075), suggesting that it may play a role in exercise adherence. This decrease corresponds to the Minimally Detectable Change determined (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This decrease in patients' adherence to the exercises prescribed with our application may necessitate a reassessment of engagement strategies or interventions to improve adherence (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The effect sizes for EARS score change ranged from \u0026minus;\u0026thinsp;0.37 to -0.41, indicating a small to moderate decrease. This suggests that patients' commitment to the exercise program tends to decline over the long term. Note that the decrease between 3 weeks and 6 weeks is not statistically significant, indicating a more marked decline beyond this period. Pain shows a general tendency to decrease over time, but none of the variations observed is statistically significant. This may indicate that the application has a limited effect on pain management in this context. A significant decrease in KOOSf is observed between 3 weeks and 3 months (p\u0026thinsp;=\u0026thinsp;0.038), reflecting an improvement in patient-perceived function. Although the variation between 3 and 6 weeks was not significant, there was a consistent trend towards improved function. Responders to the EARS suggested better adherence in experienced or better-supported patients. For the KOOS-F score, responders had a lower BMI and a longer history of pathology, which may favor better functional improvement. The use of technical aids also seems to play a positive role. On the other hand, for pain (NRS), non-responders were older and had a longer history of osteoarthritis, suggesting less reversibility of chronic pain. Overall, the age of the pathology and technical support appear to be factors favourable to response to intervention. The Venn diagram illustrates the great heterogeneity of responses to the intervention according to the three criteria assessed: EARS, KOOSf and pain. Only three patients showed a simultaneous positive response on all three dimensions, reflecting the rarity of an overall improvement. The majority of participants showed partial responses, suggesting that the benefits of the intervention may be targeted and not concern all the dimensions assessed. Conversely, nine patients did not respond to any of the criteria, indicating a possible lack of efficacy or a mismatch between the program and their profile. These results underline the need for a personalized approach that takes into account the diversity of profiles and needs to optimize the impact of rehabilitation interventions.\u003c/p\u003e \u003cp\u003eAlthough technical issues with the GARMIN Vivosmart bracelet prevented the collection of objective physical activity data, app usage metrics showed that participants used the application for a mean duration of 48 minutes per session. They favored beginner and intermediate exercise levels, which may reflect the perceived difficulty of higher-level sessions or a lack of confidence. This usage behavior emphasizes the importance of adaptability and progressive engagement in digital exercise tools.\u003c/p\u003e \u003cp\u003eThe findings of our study align with previous research indicating that while digital interventions may not consistently enhance exercise adherence (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), they can positively impact functional outcomes (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and pain. The ARTH-e application's inability to improve adherence suggests that technology alone may not address all barriers to sustained exercise engagement. Several factors can influence adherence to exercises: lack of motivation (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), persistent or fluctuating pain (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), lack of supervision (feeling isolated and lacking reference points) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), or the complexity of exercises without having explanations as to their correct execution. To improve adherence to exercise, several strategies have been put in place: regular follow-up, adaptation of programs(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), encouragement to continue exercising (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and raising patients' awareness of the need to exercise to improve their quality of life (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, exploring hybrid models that combine digital tools with in-person support could offer a more comprehensive approach to enhancing exercise adherence and outcomes.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Its observational design and lack of a control group mean that conclusions about the effectiveness of the ARTH-e application cannot be drawn with confidence. The small sample size (n\u0026thinsp;=\u0026thinsp;32, of whom 26 completed the follow-up) reduces statistical power and generalisability. Recruiting autonomous, tech-equipped volunteers who are often familiar with rehabilitation may introduce selection bias. Finally, the reliance on self-reported outcomes without objective activity tracking (except in a subgroup) is another limitation. These factors require cautious interpretation and highlight the need for a larger randomised controlled trial.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study assessed the change in symptoms in people with KOA over a three-month period. The results showed a significant decrease in the EARS score, reflecting a reduction in exercise adherence, which affected the majority of participants (69%).The KOOS score also showed a significant median reduction at 3 months (p\u0026thinsp;=\u0026thinsp;0.038). In contrast, the pain score showed no significant variation. These data suggest that the proposed therapeutic interventions have a measurable impact on certain aspects of patients' quality of life, although the improvement in pain remains limited. We plan to launch a prospective, randomized controlled trial, the ARTH-e 3 study, in May 2024. This trial will compare standard care alone with use of the ARTH-e app in addition to standard care (NCT06359171)(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAAOS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Academy of Orthopaedic Surgeons\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eACR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican College of Rheumatology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eANSM\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAgence Nationale de S\u0026eacute;curit\u0026eacute; du M\u0026eacute;dicament et des produits de sant\u0026eacute;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCRA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical Research Associate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eEARS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExercise Adherence Rating Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eKOA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKnee Osteoarthritis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eKOOS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKnee injury and Osteoarthritis Outcome Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNRS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNumerical Rating Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOsteoarthritis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysical Activity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePMR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePhysical Medicine and Rehabilitation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSTROBE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the \u003cem\u003eSud Est I\u0026nbsp;\u003c/em\u003eethics committee in September 2020. The summary of the research was sent by the Sponsor to the French National Agency for the Safety of Medicines and Health Products (ANSM) before beginning. The protocol was registered on ClinicalTrials.gov (NCT04750304).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHuman Ethics and consent to participate declaration\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. It received approval from the French Ethics Committee \u0026ldquo;Comit\u0026eacute; de Protection des Personnes Sud-Est I\u0026rdquo;. All participants were provided with detailed information regarding the study\u0026rsquo;s objectives, procedures, potential risks, and benefits. Written informed consent was obtained from each participant prior to inclusion. Participation was voluntary, and subjects were free to withdraw at any time without any consequence to their medical care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report there are no competing interests to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Banque Publique d\u0026apos;Investissement (BPI) France under grant DOS0072290/00.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe guarantor is the name of the corresponding author; whose initials are MPV. The conception and design of the study was made by MPV, EC, BP and CL. The drafting of the original protocol by MPV, EC, BP and CL. The coordination of the study by CL, MPV. The acquisition of data by MPV and LJ. The design of the statistical analysis plan by BP, EC and MPV. The drafting of the present manuscript by MPV, LJ, EC, BP and CL. \u0026nbsp;The final article has been approved by all authors. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe investigating team would firstly like to thank the participants in this study, as well as Candice Rudelle, Clinical Research Associate in the \u003cem\u003eDirection de la Recherche Clinique et de l\u0026rsquo;Innovation,\u0026nbsp;\u003c/em\u003eof theClermont-Ferrand University Hospital. We would also like to thank Paul Gignoux (MD), who carried out the patient inclusion visits, and the company Op\u0026eacute;nium, with whom we collaborated to create the application. We thank Johanna Robertson, PT, PhD for constructive criticism and language editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eORCID \u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLouise Jeannot \u0026nbsp;https://orcid.org/0009-0007-9202-3865\u003c/p\u003e\n\u003cp\u003eMathilde Pelletier-Visa \u0026nbsp; https://orcid.org/0000-0002-4340-0069\u003c/p\u003e\n\u003cp\u003eBruno Pereira \u0026nbsp; \u0026nbsp;https://orcid.org/0000-0003-3778-7161\u003c/p\u003e\n\u003cp\u003eCharlotte Lanhers \u0026nbsp; https://orcid.org/0000-0002-6584-8411\u003c/p\u003e\n\u003cp\u003eEmmanuel Coudeyre \u0026nbsp; \u0026nbsp; https://orcid.org/0000-0001-5753-2890\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGiorgino R, Albano D, Fusco S, Peretti GM, Mangiavini L, Messina C. Knee Osteoarthritis: Epidemiology, Pathogenesis, and Mesenchymal Stem Cells: What Else Is New? An Update. 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Measuring the implementation of a group-based Lifestyle-integrated Functional Exercise (Mi-LiFE) intervention delivered in primary care for older adults aged 75 years or older: a pilot feasibility study protocol. Pilot and Feasibility Studies. 31 mai 2015;1(1):20. \u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez-Marcos JJ, D\u0026iacute;az-Arribas MJ, Valera-Calero JA, Navarro-Santana MJ, Izquierdo-Garc\u0026iacute;a J, Ortiz-Guti\u0026eacute;rrez RM, et al. The Added Value of Face-to-Face Supervision to a Therapeutic Exercise-Based App in the Management of Patients with Chronic Low Back Pain: A Randomized Clinical Trial. Sensors (Basel). 16 janv 2024;24(2):567. \u003c/li\u003e\n\u003cli\u003eDieter V, Janssen P, Krauss I. Efficacy of the mHealth-Based Exercise Intervention re.flex for Patients With Knee Osteoarthritis: Pilot Randomized Controlled Trial. JMIR Mhealth Uhealth. 9 sept 2024;12:e54356. \u003c/li\u003e\n\u003cli\u003eMarks R. Knee osteoarthritis and exercise adherence: a review. Curr Aging Sci. f\u0026eacute;vr 2012;5(1):72‑83. \u003c/li\u003e\n\u003cli\u003eZhou Z, Hou Y, Lin J, Wang K, Liu Q. Patients\u0026rsquo; views toward knee osteoarthritis exercise therapy and factors influencing adherence \u0026ndash; a survey in China. The Physician and Sportsmedicine [Internet]. 3 avr 2018 [cit\u0026eacute; 14 janv 2025]; Disponible sur: https://www.tandfonline.com/doi/abs/10.1080/00913847.2018.1425595\u003c/li\u003e\n\u003cli\u003eLedingham A, Cohn ES, Baker KR, Keysor JJ. Exercise adherence: beliefs of adults with knee osteoarthritis over 2 years. Physiotherapy Theory and Practice [Internet]. 1 d\u0026eacute;c 2020 [cit\u0026eacute; 14 janv 2025]; Disponible sur: https://www.tandfonline.com/doi/abs/10.1080/09593985.2019.1566943\u003c/li\u003e\n\u003cli\u003eKrauss I, Katzmarek U, Rieger MA, Sudeck G. Motives for physical exercise participation as a basis for the development of patient-oriented exercise interventions in osteoarthritis: a cross-sectional study. Eur J Phys Rehabil Med. ao\u0026ucirc;t 2017;53(4):590‑602. \u003c/li\u003e\n\u003cli\u003eSun RT, Han W, Chang HL, Shaw MJ. Motivating Adherence to Exercise Plans Through a Personalized Mobile Health App: Enhanced Action Design Research Approach. JMIR Mhealth Uhealth. 2 juin 2021;9(6):e19941. \u003c/li\u003e\n\u003cli\u003eSong Y, Reifsnider E, Chen Y, Wang Y, Chen H. The Impact of a Theory-Based mHealth Intervention on Disease Knowledge, Self-efficacy, and Exercise Adherence Among Ankylosing Spondylitis Patients: Randomized Controlled Trial. J Med Internet Res. 20 oct 2022;24(10):e38501. \u003c/li\u003e\n\u003cli\u003ePelletier-Visa M, Dobija L, Bonhomme A, Lanhers C, Pereira B, Coudeyre E. Effectiveness of the ARTHE-e app for exercise adherence in people with knee osteoarthritis: protocol for a randomised controlled trial. BMJ Open. 18 janv 2025;15(1):e088860. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"knee osteoarthritis, mobile applications, physical activity, smartphones, adherence, pain, function","lastPublishedDoi":"10.21203/rs.3.rs-6912520/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6912520/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eContext: \u003c/strong\u003ePhysical activity and rehabilitation comprise the main elements of the non-pharmacological management of knee osteoarthritis (KOA). Compliance with home-based muscle-strengthening exercises is weak, thus diminishing the beneficial effects of the care process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: We aimed to estimate the effect of an e-health app providing a self-exercise program, on adherence to physical activity practice in patients with KOA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods:\u003c/strong\u003e We conducted an observational, open labelled, single-center study using a mixed method approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eOf the 32 people with KOA, 26 completed the study process (62.5% of whom were women).Most had unilateral femorotibial compartment involvement (Kellgren \u0026amp; Lawrence stage II or III) and led a sedentary lifestyle. The EARS score decreased between 3 weeks and 3 months (effect size -0.41), with 69% of patients considered non-responders. The KOOSf score also declined (effect size -0.62), with no improvement in pain on the NRS scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This study showed the beneficial impact of using an e-health application on clinical criteria such as pain and joint function, but not on adherence to prescribed self-exercise.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eNCT04750304\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDate of trial registration\u003c/strong\u003e : 10/02/2021\u003c/p\u003e","manuscriptTitle":"Effect of an e-health app on adherence to physical activity in people with knee osteoarthritis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 07:12:32","doi":"10.21203/rs.3.rs-6912520/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"34477617416535531496730194277383112395","date":"2025-12-27T06:29:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-06T23:56:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13119179990181012420966840207835674310","date":"2025-07-17T11:54:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107605527630368017722038854810974029580","date":"2025-06-29T06:34:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-25T16:48:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-20T02:36:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-20T02:35:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Sports Science, Medicine and Rehabilitation","date":"2025-06-17T09:05:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50a42ac8-0858-472f-b717-8921a62a24b3","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-02T07:12:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-02 07:12:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6912520","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6912520","identity":"rs-6912520","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}