In Singapore, knee osteoarthritis (OA) is a prevalent musculoskeletal condition, reflecting global trends of an aging population and lifestyle factors. With Singapore's rapidly aging population and the rising prevalence of obesity and sedentary lifestyles, knee OA has become increasingly common. According to recent studies, symptomatic OA of the knee affects around one-fifth (\~300K) of Singaporeans aged 50 years or older. Individuals with advanced knee OA and severe disability often require a total knee replacement (TKR) surgery. While knee replacement surgery is an effective option for severe knee OA, it is costly and there are risks of complications, and should only be considered when all appropriate non-surgical treatment options have been exhausted. Existing research suggests at least a quarter of knee replacements could have been avoided through more optimal conservative treatments. Despite established healthcare systems and treatment pathways, studies in several settings report that the majority of patients with OA do not receive appropriate and optimal medical care. In Singapore, several factors such as cost, extended wait times, cultural factors and travel inconvenience pose barriers to accessing physiotherapy services. These factors hinder patients' ability to access care resulting in suboptimal care, poor outcomes, and needless economic burden. Thus, there is a large unmet need for innovative and flexible strategies to deliver effective conservative management and treatment for knee OA widely and at a relatively low cost. Solutions that empower individuals and allow for self-directed rehabilitation without the need for real-time human supervision could be the key to improve effectiveness, accessibility and reduce the reliance on healthcare manpower. Given the prevalence of mobile phone, mobile applications offer a promising avenue for delivering self-directed rehabilitation programs to adults with knee OA. Previous self-directed rehabilitation programs for patients with knee OA have shown promise, however, the adoption and adherence to these programmes remain low, particularly among older adults who may not be technologically savvy. Developing an application that is tailored to the needs and capabilities of older adults with knee osteoarthritis is crucial to improve engagement and long-term adherence to the programme. The investigators have previously developed a technology-enabled self-directed rehabilitation program for patients who have undergone TKR for primary knee OA. Subsequently, Managing Osteoarthritis of the knee using Therapist-Technology Optimized Rehabilitation (MO-knee-TOR) - a standalone mobile app to facilitate self-directed rehabilitation and complement a "blended" care approach involving an initial face-to-face session with the physiotherapist was developed. MO-knee-TOR was developed for patients with TKR and subsequently evaluated in 2 pilot randomised controlled trials (RCTs). In one of the RCTs, it was found that self-directed rehabilitation post TKR facilitated using the mobile application improved exercise adherence without compromising safety and clinical outcomes. In this current proposal, MO-knee-TOR is adapted for conservative knee OA management through a single-arm pre-post feasibility study with a nested qualitative component.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
DEVICE_FEASIBILITY
Masking
NONE
Enrollment
30
Participants will be instructed on the installation and use of the mobile application on their personal mobile phones during their first outpatient physiotherapy session. Participants will then have to perform the assigned tasks using the mobile application for 12 weeks
Singapore General Hospital
Singapore, Singapore
Feasibility
The feasibility of evaluating the prototype in a larger trial will be assessed using predefined progression criteria including, including recruitment and retention rates, adherence to the program, incidence of adverse events, and improvement in function. Progression will be guided using thresholds categorized as "proceed," "proceed with protocol amendments," or "significant amendments required" based on the criteria defined for each feasibility domain.
Time frame: 12 weeks after using the mobile application
Gait speed
Gait speed will be measured from walking a distance of 4m at comfortable pace and 9m at fast pace with a 2m acceleration and deceleration zone before and after the timed section of 9m.
Time frame: Pre-intervention; 12 weeks after using the mobile application
Knee range-of-motion
A long-arm goniometer will be used to measure active-assisted knee flexion and extension range-of-motion with the participants in supine position
Time frame: Pre-intervention; 12 weeks after using the mobile application
Incidental and planned exercise (IPEQ)
This is a tool developed to measure physical activity, distinguishing between incidental exercise (activities that are not planned but contribute to overall physical activity, like walking to work or taking the stairs) and planned exercise (deliberate, structured exercise like going to the gym or running)
Time frame: 12 weeks after using the mobile application
Health-related quality of life
The EQ5D-5L is a standardised instrument to measure health related quality of life in cost-effectiveness analysis
Time frame: Pre-intervention; 12 weeks after using the mobile application
Muscle strength
Isotonic quadriceps strength will be determined using the one-repetition maximum test, which is the maximum load the patient could lift once in good form. A submaximal warm-up was provided by instructing the patient to perform bilateral knee extension at \< 10 kgs. The range of-motion for the test was set from 90° to 40° of knee flexion to avoid the increased patellofemoral joint stress associated with terminal knee extension
Time frame: Pre-intervention; 12 weeks after using the mobile application
Handgrip strength test
Participants' grip strength will be measured using Jamar hand dynamometer
Time frame: Pre-intervention; 12 weeks after using the mobile application
Weight bearing symmetry
This assesses the ability of the participants to weight bear on their limb. With their feet on 2 portable force plates, participants will stand up from a standard chair, and weight-bearing symmetry is calculated by expressing the peak force produced by the operated leg as a percentage of that produced by the unoperated leg.
Time frame: Pre-intervention; 12 weeks after using the mobile application
5-repetition-sit-to-stand test
A test to assess participants' ability to rise from a chair and return to the sitting position. The time taken for participant to stan up and sit down five times as fast as posible from standard chair (43-47cm) without the use of their hands will be recorded. This test is a measure that is performed as part of standard clinical practice and is also a measure of lower limb strength and dynamic balance.
Time frame: Pre-intervention; 12 weeks after using the mobile application
Physical function
Participants will report their physical function using the Short Modified Arthritis Measure for Function (Short-MAC-F), which assesses difficulty in performing common daily activities related to knee function, including stair negotiation, rising from sitting, walking on a flat surface, getting in and out of a car, and dressing. Each item is rated on a 5-point Likert scale, where 0 indicates "none" and 4 indicates "extreme" difficulty. Higher scores indicate greater functional limitation.
Time frame: Pre-intervention; 12 weeks after using the mobile application
Treatment satisfaction
Participants will rate their satisfaction with the rehabilitation programme using the prototype on a 11 point Likert scale, with 0 indicating "no satisfaction" and 10 indicating "complete satisfaction".
Time frame: 12 weeks after using the mobile application
Exercise Compliance/Adherence
Self-reported compliance will be collected by asking participants how many times they completed their exercises. Compliance will also be determined from the data logs captured by the mobile application.
Time frame: 12 weeks after using the mobile application
Brief Fear of Movement
Participants will report their fear of movement related to knee osteoarthritis using the Brief Fear of Movement Scale (BFOM). The scale consists of multiple statements assessing beliefs about movement, injury, and pain. Each item is rated on a 4-point Likert scale, where 1 indicates "strongly disagree" and 4 indicates "strongly agree."
Time frame: Pre-intervention; 12 weeks after using the mobile application
Psychological distress
Four-dimensional symptom questionnaire (4DSQ) will be used to assess psychological distress, anxiety, depression and
Time frame: Pre-intervention; 12 weeks after using the mobile application
Perceived Need for Knee Replacement Surgery
Participants will rate how necessary they perceive knee replacement surgery for their condition based on knee symptoms over the past week using an 11-point numeric rating scale from 0 to 10 (allowing increments of 0.5), where 0 indicates "not at all necessary" and 10 indicates "totally necessary." Participants will also provide a categorical rating of perceived necessity, ranging from "not at all necessary" to "totally necessary." Higher scores indicate a greater perceived need for knee replacement surgery.
Time frame: Pre-intervention; 12 weeks after using the mobile application
Pain
Participants will rate their knee pain intensity during specific activities using a Visual Analogue Scale (VAS), ranging from 0 to 10, where 0 indicates "no pain" and 11 indicates "worst imaginable pain." Higher scores indicate greater pain intensity.
Time frame: Pre-intervention; 12 weeks after using the mobile application
Participant Experience and Perceptions (Exit Interview)
Participants will attend an exit interview session at study completion to evaluate their experiences and perceptions of using the mobile application and force platforms for self-directed rehabilitation. Qualitative data will be collected through guided interviews, recorded, and analyzed thematically to assess usability, acceptability, and user experience. Findings from these interviews will be used to inform refinements to optimize the application design and overall user experience.
Time frame: 12 weeks after using the mobile application
Physical Function
Participants will provide an overall rating of their knee condition using a global rating scale reflecting their perception of their knee and associated problems. Higher scores indicate greater perceived severity of impairment.
Time frame: Pre-intervention; 12 weeks after using the mobile application
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