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Randomized Controlled Trial
. 2025 Oct 1;8(10):e2535038.
doi: 10.1001/jamanetworkopen.2025.35038.

Implementation of Group Physical Therapy for Knee Osteoarthritis: A Cluster Randomized Clinical Trial

Kelli D Allen  1   2   3 , Sara Webb  1 , Cynthia J Coffman  1   4 , Livia Anderson  1 , Graham Cummin  1 , Connor Drake  1   5 , Matthew Tucker  1 , Amy Webster  1 , Nina Sperber  1   5 , Leah L Zullig  1   5 , Jaime M Hughes  1   6   7 , Lindsay A Ballengee  5 , Lauren M Abbate  1   8   9 , Helen Hoenig  1   10   11   12 , Natalie Fullenkamp  1 , Courtney H Van Houtven  5 , Susan N Hastings  1   5   10   11   13
Affiliations
Randomized Controlled Trial

Implementation of Group Physical Therapy for Knee Osteoarthritis: A Cluster Randomized Clinical Trial

Kelli D Allen et al. JAMA Netw Open. .

Abstract

Importance: Group-based physical therapy (PT) for knee osteoarthritis is an effective, efficient strategy for delivering care, but little is known about optimal strategies for implementing new clinical programs like group PT.

Objective: To compare 2 implementation support approaches-foundational support and a combination of foundational support and more intensive enhanced support involving individual external facilitation-for delivering group PT.

Design, setting, and participants: This cluster randomized clinical trial was conducted from January 31, 2022, to March 18, 2024, in outpatient PT departments at Department of Veterans Affairs (VA) Healthcare sites that agreed to deliver group PT to patients with symptomatic knee osteoarthritis. Sites were randomized to receive foundational or enhanced implementation support for delivering 6 sessions of group PT over 12 months that included exercise and educational content.

Interventions: The foundational support approach included self-guided tools and monthly learning collaborative calls. The enhanced support approach added tailored support (eg, external facilitation) for sites that did not meet a priori benchmarks for adoption at 6 months or sustainment at 9 months.

Main outcomes and measures: Site-level implementation outcomes were measured during months 7 to 12 and included penetration (primary outcome, assessed as the mean number of patients enrolled per month) and fidelity (mean number of classes attended per patient, out of a maximum of 6). Generalized linear models were used to examine differences in implementation outcomes between the enhanced and foundational support arms.

Results: Nineteen sites (10 enhanced support, 9 foundational support) enrolling across 3 cohorts delivered group PT to 144 patients (68 enhanced support, 76 foundational support) during months 7 to 12. Patients were predominantly male (130 [90.3%]), with a mean (SD) age of 67 (9.2) years. Mean penetration estimates were 1.0 (95% CI, 0.2-1.7) patients enrolled per month for the enhanced support and 1.0 (95% CI, 0.1-1.9) for the foundational support arm, with an estimated mean difference between arms of -0.1 (95% CI, -1.1 to 1.0) patients enrolled (P = .92). Mean fidelity estimates were 5.0 (95% CI, 4.3-5.7) classes attended per patient in the enhanced support arm and 4.1 (95% CI, 3.2-4.9) in the foundational support arm, with an estimated mean difference between arms of 0.9 (95% CI, 0.0-1.9) classes per patient (P = .06).

Conclusions and relevance: In this cluster randomized clinical trial, an enhanced implementation support approach for delivering group PT did not outperform foundational support. Penetration was modest, illustrating the challenge of fostering referrals.

Trial registration: ClinicalTrials.gov Identifier: NCT05282927.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Allen reported receiving an honorarium from the American College of Rheumatology for serving as editor in chief of Arthritis Care & Research outside the submitted work. Dr Drake reported receiving personal fees from ZealCare as part of compensation for serving as a scientific advisor outside the submitted work. Dr Zullig reported receiving personal fees from Novartis and Eisai for consulting outside the submitted work. Dr Abbate reported receiving grants from the VA Eastern Colorado Health Care System during the conduct of the study. Dr Hoenig reported receiving personal fees from Archives of Physical Medicine and Rehabilitation for serving as deputy editor and from UpToDate for being an author on topics pertaining to geriatric rehabilitation outside the submitted work. Dr Van Houtven reported receiving personal fees from the National Academy of Sciences, Engineering, and Medicine for paid literature review, from USC Schaeffer for serving on the technical expert panel, from the University of Pennsylvania Population Aging Research Center for serving on the advisory board, from the National Institutes of Health for consulting, and from the National Alliance for Caregiving for serving on the advisory board outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Group Physical Therapy (PT) Flow Diagram
aReasons for not enrolling included loss to follow-up, change in clinic priorities, and staffing shortages. bRegardless of randomization, all sites received low-touch supports for the study duration. cA total of 189 patients enrolled during months 1 to 12, but analysis was conducted on the 144 who enrolled during months 7 to 12. dAdoption assessment was defined as delivery of group PT as a clinical service (at least 1 class) and enrollment of at least 5 patients. eSustainment assessment was defined as enrolling 15 or more new patients between months 7 and 9. fThe site that withdrew from the study after the 6-month assessment was still included in the intention-to-treat (ITT) analysis.
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References

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