The Technology, Exercise Programming, and Activity Prescription for Enhanced Mobility (TEAM) Study
The Technology, Exercise Programming, and Activity Prescription for Enhanced Mobility (TEAM) Study
Many individuals with osteoarthritis (OA) (up to 45%) are referred to an orthopaedic surgeon
 for a joint replacement prematurely or will not be candidates for surgery. These individuals
 need appropriate (non-operative) care to help reduce their pain and enhance their mobility.
 We are studying the use of innovative technology to help physicians give physical activity
 advice for patients to become more active and provide free online resources to help patients
 understand OA self-management and exercise, especially when they have barriers to accessing
 formal care. Individuals with OA that are referred to a specialized clinic will receive one
 of three interventions: usual care (handout on resources), a physical activity prescription
 by a doctor, or the prescription and a link to a free web-based platform (website) on
 non-operative management of OA with patient education and exercise videos. Our goal is to
 help with non-operative management strategies to improve quality of life, reduce pain,
 improve mobility, and possibly delay or prevent a joint replacement.

 Osteoarthritis is a condition where people feel joint pain or stiffness. Joints are the body
 parts where two bones join together with softer material (cartilage) between them. In
 osteoarthritis, this cartilage wears down. It is the biggest cause for disability worldwide.
 Helping people with osteoarthritis starts with education, physical activity, and
 physiotherapy. Doctors can also prescribe braces, injections or medications. For severe
 osteoarthritis when nothing else helps, surgery can be done to replace the joint.

 Doctors often refer patients for surgery too soon. Skipping steps of care may mean
 unnecessary surgery and longer wait times. The Musculoskeletal Rapid Access Clinic (now
 called Clinic) in London was set up to solve these problems. They screen patients before
 referring them to a surgeon, and do not refer almost half of patients. Our goal is to support
 these patients with new ways to make their non-surgical treatment better.

 The first way is through physical activity 'prescription'. It works well for other chronic
 conditions and patients say it helps. We don't know how well it works for people with
 osteoarthritis. Most doctors have little time, training or experience for prescribing
 physical activity. Technology can make it easier for doctors and patients. We have designed a
 tool to help doctors prescribe physical activity and a smartphone app to track patient
 activity. We have also created a free website. This includes patient education, exercise
 videos, and virtual physiotherapy. This can be important for individuals who can't access
 in-person care.
Osteoarthritis (OA) is the leading cause of disability worldwide and affects more than 4.4
 million Canadians. Current evidence-based guidelines for OA management recommend weight
 management, patient education, physical activity, physiotherapy (PT), bracing,
 viscosupplementation, and anti-inflammatory/pain medications prior to joint replacement
 surgery. Unfortunately, current practice trends are not consistent with these guidelines, as
 nearly half of patients with OA referred to orthopedic surgeons do not require total joint
 arthroplasty (TJA) at the time of initial consultation. Through the Southwest Musculoskeletal
 Rapid Access Clinic (RAC), approximately ten referrals (20%) are rejected each day due to OA
 criteria not met, and a further 20% are assessed as non-operative.

 We aim to identify individuals with 'mild to moderate' OA and optimize their first-line
 non-operative management, starting with physical activity and education.

 Physical activity prescriptions are effective in increasing patient levels of physical
 activity, and 93% of patients surveyed want advice on physical activity from their
 physicians; but it is underused.

 Physicians cite lack of time and inadequate training as barriers. Electronic screening of
 physical activity behaviours can save time for physicians, and the use of digital health
 tools can improve physical activity levels.

 Patient education and physiotherapist-led group exercise therapy programs have shown to delay
 progression of knee OA symptoms and improve pain and function; however, two of the most
 significant barriers to accessing exercise programming is the cost (~approximate $425-475 per
 6-8-week session) and accessibility to attend the exercise session (proximity to facility,
 remote/rural communities, etc.).

 The Need for a Solution that targets both Providers and Patients Screening for baseline
 physical activity levels and including educational components significantly increase
 intervention effectiveness.

 We have previously tested the feasibility of implementing an e-health tool to support
 physical activity counselling by physicians during patients' periodic health review. We will
 adapt and implement this tool, Physical Activity and App Prescription (PARx) to screen and
 provide tailored resources for physical activity in the setting of OA. We will use tablet
 computers and email, directly linked with the electronic medical record (EMR), to engage
 patients in contemplating their own physical activity levels, start conversations with their
 healthcare providers (in this case, primary care physicians with additional training in sport
 and exercise medicine), and support customized, patient-centered health care. After patients
 enter their information, they will receive evidence-based behavioural change supports to help
 them meet their goals.

 The automated algorithm assesses current activity level, risk factors/comorbidities and
 readiness for change. Based on the answers provided, patients are risk-stratified and
 tailored resources will be provided to the patient and to their clinician in the form of
 decision support tools embedded in the EMR. This will include the novel implementation of an
 exercise tracking platform via the smartphone app (myrecovery.ai).

 The web-based platform Joint Management (JM) is a free, readily accessible evidenced-based
 resource focusing on non-operative management strategies for mild to moderate hip and knee
 OA. The platform will include exercise programming (videos, pictures, and descriptions of the
 exercises) and patient education (benefits of exercise, lifestyle modifications, nutrition,
 injections, etc.), to assist the patient engage in self-management. JM will also include the
 option for (paid) virtual access to PTs, who can provide individualized support,
 recommendations and exercise programming via the platform.

 RATIONALE:

 Creating customized physical activity plans with automated reminders and other supports
 addresses the problem of self-efficacy in providers by developing an evidence-based automated
 method, while also addressing the issue of patient adherence by using tailored behaviour
 change techniques, through assessing readiness for change, and helping patients create new
 habits.

 The motivation for JM is to create a free, online evidence-based OA education and exercise
 programming resource for those that are not able to afford or access community-based exercise
 programs. The virtual PT option will help optimize patient's experience with the web-based
 platform, offering support and personalized recommendations regarding management of their
 condition and exercise programming tailored to their specific abilities, preferences, and
 needs.

 Why this is Innovative:

 The evidence for using patient-reported measures and functional outcomes to guide quality
 improvement for personalized OA care in a systematic manner is in an early stage, meaning
 that this project can not only impact healthcare delivery and translate new knowledge into
 medical practice but help position Western University as a leader in this area. The novel
 technologies (PARx and JM) are innovative tools informed by patient priorities and
 co-designed with our patient partners, specifically geared towards 1) developing new and more
 personalized treatment approaches, 2) developing more effective self-management tools, and 3)
 reducing disparities in vulnerable and hard-to-reach populations. To this end, we will share
 our findings broadly with our patient partners and reach out to these harder-to-reach groups
 in particular.

 EXPECTED OUTCOMES:

 Health Outcomes: We expect to increase patients' physical activity and improve outcomes for
 individuals with mild to moderate OA. We aim to optimize non-operative management of OA
 symptoms and therefore possibly delay and/or prevent the need for TJA.

 Academic Outcomes: We expect to develop a model of physical activity prescription and patient
 education that can be scaled up for implementation in primary care.

 Societal Outcomes: Both novel technologies have the potential to be implemented across
 Canada, targeting modifying disease progression and, ideally, delaying or preventing TJA.

 Innovative Technology 1: Physical Activity (PA) and App Prescription (Rx) (PARx) Physical
 Activity and App Prescription (PARx): Tablet/email software (REDCap) is used to collect
 physical activity data from patient input and prompt intervention by providers. The automated
 algorithm assesses current activity level, risk factors/comorbidities and readiness for
 change. Based upon their answers, patients will be risk-stratified and tailored resources
 will be provided to them in the form of a personalized prescription and free smartphone app
 (myrecovery.ai) to track activity levels.

 Innovative Technology 2: Joint Management (JM) Joint Management (JM): This is a free online
 evidence-based OA education and exercise programming resource for those that are not able to
 afford or access community-based exercise programs, with a virtual physiotherapy (PT) option
 to offer support and personalized recommendations.

 OBJECTIVES:

 The objective of the proposed study is to 1) determine if PARx and JM will improve pain,
 increase physical activity levels, and improve functional outcomes in patients with mild to
 moderate hip or knee OA

 RESEARCH QUESTIONS:

 1. Does the use of novel technology (PARx) affect patient reported outcomes in individuals
 with mild to moderate hip or knee OA?

 2. Does PARx influence activity levels in individuals with mild to moderate hip or knee OA?

 3. Does the use of novel technology (PARx and JM) affect patient reported and functional
 outcomes in individuals with mild to moderate hip or knee OA?

 4. What are the experiences and perceptions of patients and physicians during this process?

 SPECIFIC AIMS:

 Measure and compare A1) patient reported outcomes (pain, joint stiffness, disability, quality
 of life, disease knowledge, self-efficacy, depression, and fatigue), A2) physical activity
 levels, and A3) functional outcomes with those that have access (PARx and JM) and those that
 do not have access (usual care) to the technology. Determine A4) participant and physician
 experiences.

 HYPOTHESES:

 We hypothesize that access to technology-facilitated physical activity prescription (PARx)
 and access to the web-based platform (JM) will H1) improve patient reported outcomes (pain,
 joint stiffness, disability, quality of life, disease knowledge, self-efficacy, depression,
 and fatigue), H2) increase PA levels, and H3) improve functional outcomes in individuals with
 mild to moderate hip or knee OA compared to usual care. We hypothesize that access to JM will
 result in a greater improvement than PARx alone.
Inclusion Criteria:

 -  40-74 years of age

 -  Screened by the Southwest Musculoskeletal RAC as "mild to moderate OA" using clinical
 and radiographic criteria

 Exclusion Criteria:

 -  Concomitant end-stage OA (awaiting/prior TJA)

 -  Inflammatory arthritis (rheumatoid, psoriatic, or disease-modifying anti-rheumatic
 drug exposure)

 -  Unstable medical conditions that would preclude physical activity prescription (e.g.
 unstable angina, uncontrolled Type 2 Diabetes)

 -  Not able/willing to follow up for the study period

 -  Does not have access to the internet

 -  Cannot communicate in English.