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Trial registered on ANZCTR
Registration number
ACTRN12624001226594
Ethics application status
Approved
Date submitted
18/09/2024
Date registered
9/10/2024
Date last updated
9/10/2024
Date data sharing statement initially provided
9/10/2024
Type of registration
Prospectively registered
Titles & IDs
Public title
Home strengthening exercise for knee osteoarthritis: the MULTI-ONE randomised controlled trial
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Scientific title
MULTIple or ONE home strengthening exercise(s) for knee osteoarthritis: the MULTI-ONE randomised controlled trial (RCT)
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Secondary ID [1]
312857
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None
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Universal Trial Number (UTN)
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Trial acronym
MULTI-ONE
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Linked study record
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Health condition
Health condition(s) or problem(s) studied:
Knee osteoarthritis
334993
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Condition category
Condition code
Musculoskeletal
331508
331508
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0
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Osteoarthritis
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Physical Medicine / Rehabilitation
331901
331901
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0
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Physiotherapy
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Intervention/exposure
Study type
Interventional
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Description of intervention(s) / exposure
Active exercise groups
Participants will be randomly assigned a physiotherapist (stratified by group allocation - ‘one’ or ‘five’ exercise arm using random permuted block sizes) and research staff will book three consultation appointments (1, 2 and 6 weeks post-randomisation, 30 minutes each) on behalf of the participant.
The consultations with the physiotherapist will occur via telehealth (Zoom video- conferencing), for prescription, monitoring and progression of a home strength program that participants will be asked to undertake for 12 weeks, but encouraged to continue beyond that time up until 9 months. Physiotherapists will be permitted to use their clinical judgement to prescribe exercise(s) from a pre-determined list of allowed exercises that reflects the typical home strength exercises prescribed in the literature for knee OA and by physiotherapists in Australia. Physiotherapists will be asked to prescribe the exercise(s) that they think will be most beneficial in relieving pain and improving function for a given participant. Exercises will be selected from a list including quadriceps exercises (including weightbearing such as squats and non-weightbearing exercises such as seated knee extensions), hamstrings exercises (such as hamstring curls or seated knee flexion), hip exercises (such as crab walking or bridges) and calf exercises (such as calf raises). Participants will be asked to perform prescribed exercises at home (3 sets of 12 repetitions for each exercise), three times/week.
The only difference across trial arms is in the number of exercises that will be prescribed (one versus five as per the randomisation schedule). The physiotherapist will individualise the technique of each exercise (e.g. depth of knee bend, amount of body weight, hold time, colour of exercise band etc) to encourage the participant to work at an intensity of 5-7 out of ten (hard to very hard) on the modified Borg Rating of Perceived Exertion CR-10 scale for strength training. At subsequent consultations, physiotherapists may replace a prescribed exercise(s) for a different exercise(s) if required (eg because an exercise is too easy, too hard, aggravates the knee etc) as long as they adhere to the allocated number of exercises (ie a participant’s program contains only the allocated number of exercises of either one or five) and choose only from the defined list of exercises.
Consultations will occur via the video-conferencing facility of Zoom, a commercial cloud-based system accessible from any internet-connected computer, laptop or mobile device. Physiotherapists will consult from their clinic with participants based at home or wherever is suitable (e.g. work). Physiotherapists will be provided access to a website containing a video library of exercises to allow them to provide real-time demonstration of exercises to participants. This will be shared with the participants via a share-screen feature on Zoom so that the participant is able to view a demonstration of the exercise during the consultations. Participants will not have access to the online video library outside of the consultations. During each consultation, physiotherapists will email participant’s exercise handouts for how to perform each of their prescribed exercises (the research team will provide the physiotherapists with standardised digital instructions for each exercise on the allowed list of exercises to facilitate this).
Semi-structured electronic consultation notes will be recorded by the physiotherapist for each consultation and submitted to research staff at the completion of each consultation. Notes will be scrutinised by research staff for physiotherapist fidelity to exercise protocols.
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Intervention code [1]
329436
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Rehabilitation
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Comparator / control treatment
Control group (usual care)
Participants allocated to this group will continue with their usual care/management approaches for their knee problem. They will not have any consultations with a trial physiotherapist and so will not be prescribed any home strength exercises.
Usual care for knee osteoarthritis in Australia may entail self-management strategies such as use of heat or medications (such as analgesics or anti-inflammatories) to manage pain as required. Participants may also use other medications as prescribed by their doctor.
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Control group
Active
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Outcomes
Primary outcome [1]
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Self-reported severity of knee pain during walking over the past week
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Assessment method [1]
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An 11-point numerical rating scale
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Timepoint [1]
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Baseline, 3 months (primary timepoint) & 9 months after randomisation
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Secondary outcome [1]
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Self-reported knee pain
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Assessment method [1]
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Western Ontario & McMaster Osteoarthritis Index (WOMAC) pain sub-scale
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Timepoint [1]
439401
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Baseline, 3 months & 9 months after randomisation
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Secondary outcome [2]
439402
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Self-reported physical function
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Assessment method [2]
439402
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Western Ontario & McMaster Osteoarthritis Index (WOMAC) physical function sub-scale
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Timepoint [2]
439402
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Baseline, 3 months & 9 months after randomisation
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Secondary outcome [3]
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Quality of life
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Assessment method [3]
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Assessment of Quality of Life II Instrument (6D version)
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Timepoint [3]
439403
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Baseline, 3 months & 9 months after randomisation
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Secondary outcome [4]
439404
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Self-efficacy
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Assessment method [4]
439404
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Using the 8-item Arthritis Self-Efficacy Scale
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Timepoint [4]
439404
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Baseline, 3 months & 9 months after randomisation
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Secondary outcome [5]
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Exercise self efficacy
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Assessment method [5]
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Self-efficacy for Exercise Scale
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Timepoint [5]
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Baseline, 3 months & 9 months after randomisation
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Secondary outcome [6]
439406
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Fear of movement
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Assessment method [6]
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Brief Fear of Movement Scale for Osteoarthritis
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Timepoint [6]
439406
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Baseline, 3 months & 9 months after randomisation
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Secondary outcome [7]
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Global rating of change in the knee overall
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Assessment method [7]
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Scored using a 7-point global rating of change Likert scale with response options ranging from “much worse” to “much better” when compared to baseline.
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Timepoint [7]
439407
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3 months & 9 months after randomisation
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Secondary outcome [8]
439408
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Quadriceps strength
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Assessment method [8]
439408
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The 30 second chair stand test administered over Zoom
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Timepoint [8]
439408
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Baseline, 3 months & 9 months after randomisation
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Secondary outcome [9]
439409
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Calf strength
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Assessment method [9]
439409
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The double leg calf raise test administered over Zoom
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Timepoint [9]
439409
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Baseline, 3 months & 9 months after randomisation
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Secondary outcome [10]
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Willingness to undergo knee joint replacement surgery
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Assessment method [10]
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Participants will answer the question “Are you willing to have a knee joint replacement in the near future?” Response options of:
Not willing or Willing
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Timepoint [10]
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Baseline, 3 months & 9 months after randomisation
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Eligibility
Key inclusion criteria
i) meet National Institute for Health and Care Excellence clinical criteria for Osteoarthritis (OA)
a. age 45 years or over;
b. activity-related knee joint pain;
c. no morning knee stiffness or morning knee stiffness duration of 30 mins or less;
ii) report history of knee pain of 3 months or longer;
iii) report knee pain on most days of the past month;
iv) report knee pain on walking over past week of 4 or more on 11-point (0-10 range) numerical rating scale (NRS);
v) report difficulty walking or climbing stairs;
vi) have an email address for receiving exercise instruction sheets;
vii) have access to a computer/laptop/tablet/smartphone with webcam and internet connection for Zoom consultations and;
viii) willing to participate in video consultations for physiotherapy appointments.
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Minimum age
45
Years
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Maximum age
No limit
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Sex
Both males and females
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Can healthy volunteers participate?
No
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Key exclusion criteria
i) inability to speak or read English;
ii) on waiting list for/planning knee/hip surgery in next 9 months;
iii) previous arthroplasty on affected knee;
iv) undergone knee surgery in the past 6 months;
v) is undertaking/has undertaken regular strengthening exercise (at least once per week) for knee problems at any stage in the past 6 months;
vi) intending to/planning to commence regular strengthening exercise (at least once per week) for knee problems in the next 3 months;
vii) self-reports any inflammatory arthritis (e.g., rheumatoid arthritis);
viii) self-reports any neurological condition that impacts their lower limb function or;
ix) self-reports any unstable/uncontrolled cardiovascular condition that could make exercise unsafe.
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Study design
Purpose of the study
Treatment
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Allocation to intervention
Randomised controlled trial
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Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
The person who will determine if a potential participant is eligible for inclusion in the trial will be unaware, when this decision is made, to which group the participant will be allocated. The randomisation schedule will be concealed in a password protected computer database. A member of our research team will maintain and access the schedule and reveal allocation to the Trial Coordinator as each participant requires randomisation.
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Methods used to generate the sequence in which subjects will be randomised (sequence generation)
The randomisation schedule will be prepared by the biostatistician (permuted random block sizes) with physiotherapist allocation stratified by group
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Masking / blinding
Blinded (masking used)
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Who is / are masked / blinded?
The people analysing the results/data
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Intervention assignment
Parallel
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Other design features
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Phase
Not Applicable
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Type of endpoint/s
Efficacy
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Statistical methods / analysis
A biostatistician will develop a detailed Statistical Analysis Plan while blinded to intervention allocation. This will be written and published on the CHESM website prior to data analysis commencing.
Sample Size Calculation
A total sample size of 144 (48 per arm) is required. Sample size calculations were performed accounting for differential clustering between the ‘usual care’ and the ‘one’ or ‘five’ exercise arms where clustering in the exercise arm is due to the treating physiotherapist, assuming that the correlation between two repeated measurements is the same for both control and intervention arms. Assuming there will be 10 physiotherapists treating approximately 4 patients each, with an intra-cluster correlation of 0.05, 40 participants per arm are required to detect a minimal clinically important difference (MCID) of 1.8 NRS units in change in pain from baseline to 3 months with 80% power. This assumes a between-participant standard deviation of 2.4 and pre-post correlation of 0.41, with a two-sided alpha of 0.05 (split equally as 0.167 between the three pairwise comparisons). Accounting for 15% loss to follow-up, 48 participants per arm are required. This sample size of 144 participants provides greater than 80% power to detect a MCID of 1.8 NRS units in change in pain at 3 months from baseline between ‘one’ versus ‘five’ exercise arms with a two-sided alpha of 0.167, assuming a between-participant standard deviation of 1.9 and pre-post correlation of 0.36.
Statistical Analysis Plan
Analysis will be undertaken while biostatisticians are masked to intervention name. Main comparative analyses between groups will be performed using intention-to-treat. A constrained longitudinal data analysis (cLDA) model will be fitted to examine differences in change in walking pain (primary outcome) between the three intervention arms. The response will consist of all walking pain scores (baseline, 3 months, 9 months) and the model will include factors representing intervention arm, time (categorical), and an intervention arm-by-time interaction with random effects for participant and accounting for clustering by physiotherapist as appropriate, with the restriction of a common baseline mean across intervention arms. The primary hypotheses will be evaluated by obtaining the estimated differences in mean change in pain score between each pair of intervention arms (five exercises versus control; one exercise versus control; five exercises versus one exercise) from baseline to 3 months (primary time point), two-sided multiplicity-adjusted 95% confidence intervals and p-values. These models provide valid inference in the presence of missing data if the data are missing at random. An analysis will be conducted using the delta-adjustment method under the pattern-mixture modelling framework in the context of multiple imputation to assess sensitivity to missingness not at random.
A similar approach will be used for continuous secondary outcomes. Binary secondary outcomes will each be compared between groups using risk differences and risk ratios calculated from a logistic regression model fit using generalized estimating equations to account for clustering, including a term for week and an interaction between week and treatment group. Assumptions will be assessed using standard diagnostic plots and methods. Since these are all secondary analyses, p-values for these assessments will not be adjusted for multiple comparisons. We will conduct exploratory analyses to evaluate moderation of treatment effects on the primary outcome by pre-specified potential moderators. This will be assessed by including appropriate interaction terms between the moderators and the intervention arms.
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Recruitment
Recruitment status
Not yet recruiting
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Date of first participant enrolment
Anticipated
4/11/2024
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Actual
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Date of last participant enrolment
Anticipated
31/03/2026
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Actual
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Date of last data collection
Anticipated
31/12/2026
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Actual
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Sample size
Target
144
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Accrual to date
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Final
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Recruitment in Australia
Recruitment state(s)
ACT,NSW,NT,QLD,SA,TAS,WA,VIC
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Funding & Sponsors
Funding source category [1]
317300
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Government body
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Name [1]
317300
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National Health and Medical Research Council (NHMRC) Investigator Grant
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Address [1]
317300
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Country [1]
317300
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Australia
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Primary sponsor type
University
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Name
The University of Melbourne
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Address
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Country
Australia
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Secondary sponsor category [1]
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None
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Name [1]
319677
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Address [1]
319677
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Country [1]
319677
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Ethics approval
Ethics application status
Approved
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Ethics committee name [1]
316033
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University of Melbourne Central Human Research Ethics Committee
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Ethics committee address [1]
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https://research.unimelb.edu.au/work-with-us/ethics-and-integrity/our-ethics-committees
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Ethics committee country [1]
316033
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Australia
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Date submitted for ethics approval [1]
316033
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19/07/2024
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Approval date [1]
316033
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12/09/2024
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Ethics approval number [1]
316033
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2024-29890-58015-3
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Summary
Brief summary
Participants will be randomly allocated in a 1:1:1 ratio to receive either i) control (usual care); ii) a prescribed home program with one strength exercise or; iii) a prescribed home program with multiple (five) exercises. The control group will not receive any intervention and will continue with their usual care. Participants in the exercise groups will have three video-conferencing consultations with a physiotherapist (week 1-, 2- and 6-weeks post-randomisation, 30 minutes each) for prescription, monitoring and progression of their exercise program, which will be performed independently at home for 3 months. Participants in the exercise groups will be encouraged to continue with exercises beyond the intervention period. Primary time-point for re-assessment will be 3 months, with a secondary time-point of 9 months, after randomisation. The primary outcome measure will be change in average walking pain over the past week on NRS. Secondary outcome measures will include WOMAC pain and function subscales, quality-of-life; arthritis and exercise self-efficacy; fear of movement; global rating of change; muscle strength; willingness for joint replacement.
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Trial website
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Trial related presentations / publications
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Public notes
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Contacts
Principal investigator
Name
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Prof Rana Hinman
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Address
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Centre for Health, Exercise and Sports Medicine Department of Physiotherapy Level 7, Alan Gilbert Building The University of Melbourne, Victoria 3010 Australia
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Country
136570
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Australia
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Phone
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+61 3 8344 3223
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Fax
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Email
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[email protected]
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Contact person for public queries
Name
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Penny Campbell
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Address
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Centre for Health, Exercise and Sports Medicine Department of Physiotherapy Level 7, Alan Gilbert Building The University of Melbourne, Victoria 3010 Australia
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Country
136571
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Australia
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Phone
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+61 3 9035 5401
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Fax
136571
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Email
136571
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[email protected]
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Contact person for scientific queries
Name
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Rana Hinman
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Address
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Centre for Health, Exercise and Sports Medicine Department of Physiotherapy Level 7, Alan Gilbert Building The University of Melbourne, Victoria 3010 Australia
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Country
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Australia
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Phone
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+61 3 8344 3223
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Fax
136572
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Email
136572
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[email protected]
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Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
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What data in particular will be shared?
All data presented in the published results paper, available in XLSX format.
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When will data be available (start and end dates)?
A period of 15 years from publication
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Available to whom?
Data will be made available as required for specific, approved analyses by researchers. Data will be provided from locked, cleaned, and de- identified study database. Requests will be reviewed by the Principal Investigator prior to approval.
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Available for what types of analyses?
The investigators endorse the concept of data sharing to advance medical science. All requests for data sharing will be reviewed by the Principal Investigator to ensure no conflict with any planned sub analyses and to ensure that the data are shared in an ethical and protected manner.
Analyses aimed to improve treatment of knee osteoarthritis for non-commercial purposes are eligible.
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How or where can data be obtained?
By emailing the Principal Investigator at
[email protected]
. Data will be made available after review and approval by the Principal Investigator. Before any analysis, a signed Confidentiality Agreement and/or Data Sharing Agreement is required.
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What supporting documents are/will be available?
No Supporting Document Provided
Doc. No.
Type
Citation
Link
Email
Other Details
Attachment
24206
Data dictionary
The Data Dictionary will be supplied with the de-i...
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Results publications and other study-related documents
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No additional documents have been identified.
Download to PDF