Using Web-based Tools to Facilitate Tailored Exercise for People With Osteoarthritis

The investigators hypothesize that it is feasible and acceptable to identify people with
knee pain and osteoarthritis (OA) who are interested in individualized exercise programs
through a web-based osteoarthritis treatment diagnosis application; to assess their exercise
barriers, facilitators, motivators and preferences; and engage them in an exercise program
tailored to meet their needs by a Certified Fitness Trainer.

The investigators will accomplish this by:

1. Evaluating the feasibility of identifying patients using a web-based preference
diagnosis tool (PDx) who have knee pain and osteoarthritis and do not meet exercise
guidelines but are interested in tailored exercise programs;

2. Evaluating the feasibility and acceptability of using self-report assessment tools to
identify barriers, facilitators, motivators, and preferences for exercise and to screen
participants for health problems that will limit their ability to exercise safely; and

3. Evaluating the feasibility and potential effectiveness of using the exercise assessment
tool by patients with knee pain and osteoarthritis to select an individualized exercise
program with the help of a Certified Fitness Trainer and to engage in routine physical
exercise.

3. Study Design

Study design: The investigators will use a pre-post pilot study design. The assessments will
be held at either the Dartmouth-Hitchcock Medical Center (One Medical Center Drive, Lebanon
NH 03756), or The Dartmouth Centers for Health and Aging (46 Centerra Parkway, Lebanon, NH
03766). Assessments will be conducted by the principal investigator (PI), and/or a research
assistant (RA). Consent and approval of the Committee for the Protections of Human Subjects
of Dartmouth College will be obtained prior to starting the study. Volunteer non-exercising
and under-exercising participants aged 50-85 will be recruited through flyers and provider
referral. Recruitment will continue until 10 participants answer "yes" to the exercise
question on PDx. Written informed consent will be obtained for all participants.

Aim 1 Methods: Feasibility of identifying patients using a web-based preference diagnosis
tool (PDx) who have knee pain and osteoarthritis and do not exercise at recommended levels
but are interested in tailored exercise programs.

Volunteer participants will be screened by the RA for eligibility for the study.
Demographics of age and sex will be recorded at screening. After obtaining written informed
consent, each eligible participant will complete the Preference Diagnosis (PDx) web-based
software program and respond "yes" or "no" to the question "I am interested in an exercise
program tailored to meet my needs" at the end of the program. PDx is a software application
under development at The Dartmouth Center for Health Care Delivery Science (TDC) that uses
weighted values and patient assessments of perceived unfavorable aspects or "costs", versus
perceived benefits, to develop a profile of preferences around knee OA treatment. An RA
(trained by Catalina Gorla of TDC to administer PDx) will coach participants through using
the PDx program which will be administered on a lap top computer in a private room. All
participants will have their height, weight, and waist circumference measured prior to
starting the application using a standardized protocol. Feasibility will be assessed by the
proportion of potentially eligible participants who endorse the exercise question within a
3-month period until a maximum of 10 is reached.

Aim 2 Methods: Feasibility and acceptability of using a self-report assessment to identify
barriers, facilitators, motivators, and preferences for exercise and to screen participants
for health problems that will limit their ability to exercise safely.

Participants who answer "yes" to the exercise question (the final question of the tool) will
immediately complete a self-report screening tool: Exercise Barriers, Facilitators,
Motivators, and Preferences in Older Adults (appendix A).24 The exercise assessment tool is
currently under iterative development and will incorporate expertise of the Certified
Fitness Trainer. Participants who are age 69 or less will also complete Personal Assessment
of Readiness Questionnaire (PAR-Q) (appendix B).21 As PAR-Q is not validated in adults over
69 years, participants who answer yes to any of the questions (with the excpetion of
question 5) on the PAR-Q and those older than 69 will complete a medical screening prior to
participation in exercise portion of the study. If question 5 (Do you have any bone or joint
problem (for example, back, knee or hip) that could be made worse by a change in your
physical activity?) on the PAR-Q is endorsed, the following questions will be asked:

1. Do you have a bone or joint problem other than osteoarthritis of the knee? If no, then
they will be allowed to participate in the study; If yes, they will be asked:

2. Do you have inflammatory arthritis such as Rheumatoid Arthritis, Psoriatic Arthritis,
Gout, or Infectious Arthritis, such as Lyme disease? If yes, they will be excluded from
participation.

3. If uncertain, they will be referred for medical screening prior to participation.

The RA will assist participants in completing assessments, if needed, and help arrange
medical follow up. Feasibility will be assessed by the proportion of participants who
answered "yes" to the exercise question who complete the Barriers, Facilitators, Motivators
and Preferences screening and the PAR-Q and/or medical screening. Acceptability will be
assessed by qualitative semi-structured one-hour interviews of the 10 participants at 3
months that will be conducted by the RA based upon questions developed by the research team
(Appendix D). Interviews will be transcribed, de-indentified, coded and analyzed for themes
using grounded theory.

Aim 3 Methods: Feasibility and potential effectiveness of using the self-report exercise
assessment by patients with knee pain and OA to select an individualized exercise program
and engage in routine physical exercise with the support of a Certified Fitness Trainer.

Participants will meet with a Certified Fitness Trainer and engage in shared goal setting
and selection of a CDC-recommended exercise program for OA that best fits their needs and
preferences, specifically addressing any identified barriers. The Trainer will use programs
from a vetted list of programs that are appropriate for older adults with knee OA, and
modify as needed. This list will be developed with the Certified Fitness Trainer and the PI.
The Trainer will be available to answer questions and will contact each participant by phone
every two weeks to find out how participants are doing; make adjustments to the program, if
needed; and provide motivation and encouragement. Feasibility will be evaluated by
quantifying the proportion of participants who complete the assessments within a 3-month
period. Potential effectiveness will be evaluated based on pre-post difference in the mean
number of self-reported minutes spent in mild, moderate, or vigorous exercise in the
previous week; the proportion of participants who have adopted any exercise routine, and
change in health goal attainment confidence. Pain as measured on a 10 cm visual analog scale
will be collected as an exploratory measure. (see descriptions of measures below).

Inclusion Criteria:

- Exercise <150 minutes a week of mild-moderate activity or < 75 minutes a week of
vigorous activity;

- Age ≥ 50 and ≤ 85;

- Self-reported uni- or bilateral knee pain in the past 12 months that has been
diagnosed as osteoarthritis and is not due to an acute injury;

- Ability to speak and read English; and

- Have an established relationship with a Primary Care Provider.

Exclusion Criteria:

- Exercise ≥150 minutes a week of mild-moderate activity or ≥ 75 minutes a week of
vigorous activity;

- Age < 50 years or > 85;

- Unable to speak and read English;

- Demonstrate a profound hearing or cognitive impairment;

- Bilateral knee replacements;

- Health reasons that preclude their participation in the study such as, but not
limited to, traumatic knee injury within the past 12 months, rheumatoid or other
inflammatory arthritis, unstable angina, uncompensated heart failure, or their health
care provider's recommendation that they not participate; or

- No established Primary Care Provider.