Knee osteoarthritis (OA) is a major global health issue. It causes disability, pain, and decreased quality of life. Exercise-based physical therapy (PT) is a crucial non-pharmacological treatment, but it is underutilized due to resource constraints, insufficient integration, and accessibility issues in routine clinical pathways. Group-based PT has demonstrated efficacy in randomized clinical trials. It offers a promising, resource-efficient model that can extend access to reduce clinician hours per patient. Translating this evidence into real-world clinical practice faces challenges in implementing and maintaining new care delivery models.
This study evaluated the effectiveness of 2 levels of implementation support to promote the adoption and long-term sustainability of group PT for veterans with knee OA. It compared foundational support with an enhanced strategy, which involved individualized external facilitation for sites struggling to meet uptake or sustainment benchmarks. A hybrid type 3 effectiveness implementation design was used.
Outpatient rehabilitation clinics within the Veterans Health Administration system were enrolled in either the enhanced or foundational support arms. Data were collected on program adoption rates, sustainability, and fidelity, as well as patient outcomes, including physical function scores and pain levels. The primary outcomes were successful program implementation, assessed by initiation, delivery, and sustainment over time. Secondary outcomes included patient-reported improvement in function and pain.
Results showed that both methods achieved reasonable levels of group PT adoption, which increased implementation support and provided additional benefits at sites that initially struggled to adopt the practice. It demonstrated higher sustainment rates and improved fidelity in program delivery compared to foundational support alone. Patient-level outcomes, such as pain reduction and functional improvements, were largely similar between the groups. This suggested that once the program was successfully implemented, the delivery of group PT yielded consistent clinical benefits regardless of the level of implementation support provided.
Nineteen sites (9 foundational and 10 enhanced support) were enrolled in 3 cohorts, delivering group PT, and 144 patients (76 foundational and 68 enhanced support) over 7 to 12 months. Most patients were male (130 [90.3%]) with a mean age of 67 years (SD 9.2). The estimated mean penetration was 1.0 (95% confidence interval [CI]: 0.2 to 1.7) patients recruited per month for enhanced support and 1.0 (95% CI: 0.1 to 1.9) for the foundational support arm. It has an estimated mean difference in arms of -0.1 (95% CI: -1.1 to 1.0), with a patient recruited (P= 0.92). The mean fidelity difference was 5.0 (95% CI: 4.3 to 5.7) classes per patient in the enhanced support group and 4.1 (95% CI: 3.2 to 4.9) in the foundation support. The mean estimated difference between groups was 0.9 (95% CI: 0 to 1.9) classes per patient (P 0.06).
These findings emphasize that the degree of implementation support required varies across clinical contexts and that tailoring facilitation intensity to site-specific needs can optimize program sustainment.
This study highlights that a foundational implementation method is sufficient for many sites, while increased external facilitation is crucial for overcoming local barriers at less prepared or resource-constrained sites. This results in the value of flexibility and adaptability of implementation methods to scale evidence-based rehabilitation models like group PT for knee OA. The similarity in patient-level outcomes reinforces the effectiveness of group PT as a clinical intervention. It supports broader adoption as an efficient and scalable approach to knee OA management.
This trial provides valuable insights into the clinical value of group-based PT and the practical considerations for implementing and sustaining such models in diverse healthcare settings. It offers a blueprint for improving accessibility, efficiency, and the quality of OA care delivery.
References: Allen KD, Webb S, Coffman CJ, et al. Implementation of Group Physical Therapy for Knee Osteoarthritis: A Cluster Randomized Clinical Trial. JAMA Netw Open. 2025;8(10):e2535038. doi:10.1001/jamanetworkopen.2025.35038
