Improving Resilience and Longevity for Workers Through Exercise
Phase: NA
Conditions: Osteoarthritis, Knee, Osteoarthritis, Hip
Sponsor: McMaster University

 
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1
Improving Resilience and Longevity for Workers Through Exercise 
Protocol 
 
The Canadian workforce is aging.  The most prevalent age group is 50-54 years and most of these 
Canadians will aim to continue working over the next 10 years 1.  However, the impact of arthritis on 
aging Canadians compromises their ability to continue working 2.  By 2031, over 2 million Canadians 
aged 45 to 64 years will have arthritis.  Among those with arthritis, one of three is expected to be out of 
work 3.  This unemployment rate is worse than for any other chronic health condition 3.   
We aim to boost the ability of older adults with the most common arthritis, osteoarthritis (OA), 
to engage in the workforce for as long as they desire.  Osteoarthritis targets older adults and currently 
affects 4.4 million Canadians, a number expected to grow to 10 million in the next two decades 4.  The 
disease causes degeneration of all joint tissues, most commonly in the knee and hip 5.  Further, OA 
affects the Canadian labour force:  30% of those with OA will experience difficulty at work 4.  Pain and 
immobility caused by OA result in frequent absences from work and, ultimately, lost productivity 6.   
Identifying strategies to promote productivity among older workers with knee and hip OA will 
be of great public health significance in the coming decades.  However, we face two challenges.  First, 
obesity among sedentary workers is a risk for worsening knee and hip OA.  A five unit increase in body 
mass index is associated with a 35% increased risk of developing OA 7.  Second, large occupational 
loads on the knee and hip worsen OA.  Pooled data from 66 studies (n=526,343) revealed that, 
compared to workers who stand, those required to frequently squat, kneel, and carry have over a 60% 
increased risk of worsening chronic pain 8.  Therefore to promote productivity, we must address obesity 
while minimizing exposure to large loads.  Unfortunately, few studies have investigated strategies to 
improve productivity among aging workers with OA 9.  A systematic review showed that exercise has 
the most promise in achieving this goal because it reduces pain and sick time, and improves mental 
health 9.  By comparison, ergonomic interventions (e.g., mechanical patient lifts, ergonomic work-
stations), and education yield a minimal effect on pain, sick time, or longevity in the workplace 9.  Not 
surprisingly, there is a call for studies examining exercise for the aging worker with knee and hip OA 9. 
 
RESEARCH PURPOSE AND SCOPE 
The purpose of this study is to examine the impact of an OA-specific aerobic and strengthening 
exercise program, delivered within the workplace, on mobility, pain, physical capacity, and resilience 
among workers with knee or hip OA as well as those with no joint pain.  We hypothesize that exercise 
designed for OA, delivered at work, will improve all of these outcomes.   
 
METHODOLOGY 
 
Participants 
Participants will be women and men employed in administrative roles at Ford Motor Company in 
Oakville.  All eligible participants will be welcome to participate.  
 
Inclusion and Exclusion Criteria: We will recruit 40 participants from Ford.  Inclusion criteria include 
part- or full-time employment in an administrative role at Ford.  Men and women will be welcome.  
The exclusion criteria include a self-reported history of patellofemoral symptoms because the exercise 
program delivered to the intervention group places large loads on this joint.  Participants with a 
previous osteoporotic fragility fracture will be excluded.  Those with osteoporosis but no fragility 
fracture will be eligible.  Exclusion criteria include active non-arthritic joint disease (e.g., gout); 
conditions that might be exacerbated (e.g., unstable angina); neurological conditions such as a stroke; 
leg trauma within 3 months; and cancer.  Participants will be screened for the American College of 

 
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Rheumatology (ACR) criteria for clinical knee or hip OA.  However, participants not meeting this 
criterion will still be eligible to participate.   
 
Recruitment & Sample Size: Participants will be recruited through the research coordinator at 
McMaster.  Administrative personnel at Ford who are not in a supervisory role (i.e., Fitness Centre 
Manager) will disseminate recruitment posters and an email/verbal script.  Both will request that 
interested employees directly contact the research coordinator.  These materials will explicitly state that 
the decision to participate, or not participate, will not be shared with Ford administration. 
Our primary outcome is change in self-reported mobility on the Lower Extremity Functional 
Scale (LEFS).  Self-reported mobility is critically important from the patient’s perspective 13 and is 
likely to see the largest effect of exercise 14.  The minimal clinically important difference (MCID) of 
the LEFS is 5 points 15, 16.  Rehabilitation produces changes of ≥10 LEFS points, with an effect size of 
0.517. Given a Type I error=0.05 on change, n=27 will yield 81% power. 
 
Randomization: An independent research assistant will conduct randomization and concealed 
allocation. Participants will be randomized to receive either the exercise intervention, or no 
intervention. After baseline, the independent research assistant will provide each participant with one 
sequentially numbered, sealed, opaque envelope that identifies the intervention they will receive. 
 
Interventions 
Exercise Program: A 12-week exercise intervention will be offered in the workplace.   Ford employees 
will complete their exercise program at Ford in the on-site exercise facility.  20 of the 40 participants 
will be randomized to the exercise intervention. 
A 12-week supervised exercise program designed for OA knees and hips will emphasize 
strengthening leg muscles with minimal loads.  Each exercise program will be 30 minutes and offered 
at 7:00am (Mon, Tues, Wed, Thurs, Fri). These timeslots will enable participants to exercise at the start 
of their workday.  Participants will be asked to attend 3 or more supervised exercise sessions weekly 18.  
Strengthening will focus on “body weight” strategies that we have used previously, such as squats and 
lunges.  A certified yoga instructor will offer exercise modifications and education about anatomy, OA, 
and proper lower limb alignment.  Over 12 weeks, the exercises will be progressed.  These exercises 
yield nominal loads while increasing leg strength 19. Our previous randomized controlled trial of this 
intervention (n=31), delivered within the community, yielded improvements in pain, mobility and self-
reported physical function without adverse events. 
 
Control Program: 20 of the 40 participants will be randomized to the control group. These participants 
will be asked to refrain from changing any interventions or activity existing at baseline over the 12-
week intervention period. Afterwards, these participants will be offered the same exercise program free 
of charge.  
 
Outcome Measures 
Outcome measures will be collected at baseline and immediately after the 12-week exercise program. 
Primary Outcome:  The primary outcome is the change between baseline and follow-up on the LEFS 16, 
20, 21.  The LEFS consists of 20 items on an adjectival scale that assess difficulty during mobility tasks 
ranging from transfers to running.  This range avoids ceiling and floor effects.  It is reliable and valid in 
OA and has superior sensitivity to change compared to similar measures 17, 21, 22.    
 
 
 
 

 
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Secondary Outcomes 
 Pain:  
o  The Intermittent and Constant Osteoarthritis Pain (ICOAP) self-report questionnaire 
consists of two subscales: constant and intermittent pain 23.  Data from the ICOAP 
demonstrate excellent test-retest reliability, internal consistency, and criterion validity in 
knee and hip OA 24.  The ICOAP shows responsiveness following physiotherapy 25.   
o As well, we will collect the Knee/Hip injury and Osteoarthritis Outcome Score (K/HOOS) 
26.  The K/HOOS is a patient-administered, 42 item questionnaire.  Study participants are 
asked to answer questions on a 5-point Likert scale, which takes approximately 10 minutes 
to complete.  The K/HOOS consists of 5 subscales:  pain, other symptoms, activities of 
daily living (ADL), function in sport and recreation and knee-related quality of life 
(QOL).  The questionnaire results in a normalized score out of 100 for each subscale, where 
100 indicates no symptoms and 0 indicates extreme symptoms. The questionnaire relies on 
subject’s recall from the previous week 26.   
o Participants will also complete the Disabilities of the Arm, Shoulder, and Hand (DASH) 
questionnaire. This 30-item questionnaire addresses upper extremity physical function and 
symptoms 27.  
 
 Physical Capacity:   
o The strength (peak torque) developed during extension and flexion of the hip and knee 
during maximum voluntary isometric contractions (MVICs) will be measured using a hand-
held dynamometer.  The peak value for each of knee and hip extension and flexion will be 
extracted.  The reliability scores for these data are excellent 28.   
o Peak grip strength will also be captured using a hand-held dynamometer because grip 
strength is related to disability, morbidity and mortality 29.   
o In addition, participants will be asked to complete a treadmill walking submaximal fitness 
test. Maximal oxygen uptake (VO2max) is the best measure of cardiovascular fitness and is 
a good indicator of health status 30. This test requires exposure to no more than 85% of 
maximum heart rate.  It is ideal for assessing fitness of people not accustomed to maximal 
intensity exercise and has produced valid, reliable data in older women 31.   
 
 Mobility:  The mobility performance measures selected reflect the core set of mobility measures 
recommended by the Osteoarthritis Research Symposium International (OARSI) 32.  
o Six-Minute Walk Test (6MWT) - The 6MWT is used to quantify walking ability.  The 
6MWT is an inexpensive clinical tool that involves recording the distance that participants 
cover while walking indoors at their own pace for 6 minutes.  Participants are free to stop or 
use a mobility aid to complete the walking task, making this measure clinically useful.  The 
6MWT measurement will be recorded indoors in a well-lit, tiled rectangular hallway.  The 
score recorded is the total distance traveled in 6 minutes.  Instructions for the 6MWT will 
correspond with the published protocol 33.  The 6MWT yields highly reliable (intraclass 
correlation coefficient=.96) and valid data 34. 
o Stair Climbing - Participants will be asked to ascend and descend a 9-step staircase as 
quickly as possible, without compromising their safety.  The hand rail can be used as 
needed.  The participants will be asked to start at the base of the stairs at a distance from the 
first step of their choosing.  The participants will be instructed not to run or jog, and not to 
skip any steps.  Time to ascend and descend will be recorded separately, to the nearest 10th 
of a second, using a stopwatch.  Participants will be asked to repeat this procedure two 
times, where scores from only the ascent and descent on the second attempt are recorded.  

 
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Data from our laboratory demonstrate excellent test-retest reliability of the stair ascent and 
descent tasks among 29 adults (ICC=0.881, 0.843 respectively). 
o 30-Second Chair Stand Test - The 30 second chair stand task quantifies the number of sit-
to-stand movements that can be completed within 30 seconds, starting from a seated 
position in an armless chair of a standard height (45 cm).  After an opportunity to practice 
the task, participants will be asked to perform this task at a comfortable pace.  Knee 
extensor strength is a strong predictor of performance on repeated chair stand tests 35.  In 
addition, lower extremity muscle power was predicted from performance of the 30 second 
chair stand in 14 older adults 36.  
 
 Resilience:  To reflect the ability to adapt to stress and adversity, we selected measures of 
resilience, work ability, and depression.  
o The Resilience Scale (RS) is a 25-item questionnaire that captures information about 
personal competence and acceptance of life and self 38.  This questionnaire produces data 
that are reliable and show good concurrent validity 38.   
o The Work Ability Index (WAI) is a widely-used self-report questionnaire that consists of 
seven dimensions including current work ability relative to life-time best, work ability 
related to job demands, number of current physician-diagnosed health conditions, estimated 
work impairment due to the conditions, sick leave over the past year, own prognosis, and 
mental resources 39.  The WAI produces reliable data 39.   
o Depressive symptoms will be assessed with the Center for Epidemiologic Studies–
Depression (CES-D) Scale, a 20-item scale with emphasis on affect (mood, guilt, 
worthlessness, helplessness, appetite) 40.  Data from the CES-D are valid and reliable in 
adult and arthritic populations 40-42.  
o Self-efficacy will be measured using the Arthritis Self-Efficacy Scale (ASES). The ASES 
measures arthritis-specific beliefs regarding perception of performance on certain tasks to 
cope with the disease 43. The ASES produces both reliable and valid data in knee OA 44. 
 
 
Statistical Analyses:  Descriptive statistics will be calculated.  A repeated measures analysis of variance 
will be used to compare the impact of the exercise program on change scores for each outcome 
measure between the exercise and control groups.  Independent analyses will be performed for 
participants that demonstrated clinical criteria for hip and knee OA.   
 
 
 
 

 
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Letter of Information and Consent 
 
Improving Resilience and Longevity for Workers Through Exercise 
Principal Investigator:  
Dr. Monica Maly (PT, PhD) 
 
 
 
 
Associate Professor (Part-time), Rehabilitation Sciences 
 
 
 
 
McMaster University 
 
 
 
 
Associate Professor, Kinesiology 
 
 
 
 
University of Waterloo 
 
 
 
 
(519) 888-4567 x 37916 
 
Co-investigators:  
Dr. Peter Keir, Kinesiology (BSc, PhD) 
 
 
 
 
Dr. Jim Potvin, Kinesiology (BSc, PhD) 
 
 
 
 
Dr. Jaclyn Hurley, Rehabilitation Sciences (BSc, PhD) 
 
 
 
 
Emily Wiebenga, Kinesiology (BSc) 
 
 
 
 
Brittany Bulbrook, Kinesiology (BSc) 
McMaster University 
 
 
Funding Source: 
 
This study is funded by the Labarge Optimal Aging Initiative Opportunities Fund and the 
Centre of Research Expertise for the Prevention of Musculoskeletal Disorders 
(CREMSD). 
 
Introduction 
You are invited to participate in a study that will compare 12 weeks of specialized exercise 
designed for arthritic knees and hips versus no exercise on your resilience in the 
workplace, mobility, fitness, strength, physical function and pain.  
 
Before agreeing to participate, it is important that you read and understand the proposed 
study procedures.  The information provided describes the purpose, procedures, benefits, 

 
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discomforts, risks and precautions associated with this study.  It also describes your right 
to refuse to participate or withdraw from the study at any time.  In deciding whether you 
wish to participate, you should understand enough about the risks and benefits to be able 
to make an informed decision.  This is part of the informed consent process.  Make sure 
all of your questions have been answered to your satisfaction before signing this 
document. 
 
Background and Purpose 
By 2031, over 2 million Canadians aged 45 to 64 years will have arthritis.  Among those 
with arthritis, one of three is expected to be out of work.  This unemployment rate is worse 
than for any other chronic health condition.  Osteoarthritis, the most common type of 
arthritis in Canada, affects one in ten Canadians.  This condition is associated with pain, 
problems with mobility, and additional health complications including – but not limited 
to – chronic inactivity, heart disease, diabetes, and depression. Keeping individuals with 
knee osteoarthritis physically active is critically important.   
Exercise is effective at reducing pain while improving physical function.  However we do 
not know if exercise can boost resilience in the workplace, to allow people with 
osteoarthritis to work as long as they desire.  Previous research shows that exercise holds 
the most promise for helping people enjoy their work because it reduces sick time, reduces 
pain, and improves productivity.  However, little work has examined the effect of exercise 
for people with arthritis in the workplace.  The purpose of the study is to investigate 
whether leg strengthening exercises improve resilience in the workplace, mobility, 
fitness, strength, physical function and pain in comparison to no exercise in those 
with knee and/or hip osteoarthritis.  A secondary purpose is to evaluate whether 
exercise improves each of these clinical outcomes among workers with no joint pain.   
Men and women administrative employees at Ford Oakville are welcome to participate in 
this study. 40 participants will be recruited to in this study. We cannot include anyone 
who has the following: 
 Medical restrictions to physical activity 
 Fractures from osteoporosis 
 Other forms of arthritis (e.g. psoriatic, rheumatoid) 
 Active non-arthritic disease (e.g. gout, patellofemoral symptoms) 
 Current use of intra-articular injections or knee/hip surgery 
 History of stroke or heart disease 
 Use of walking aids such as a cane 
 Inability to safely climb 2 flights of stairs 
 Leg injury in the last 3 months 
 Ankle problems 
 Radiation (e.g. cancer treatment) 
 Pregnancy 
 

 
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Procedure 
If you meet the above criteria and are interested in participating, we welcome you to join 
our study!  You will be asked to provide us with your phone number or email address so 
that we can contact you to answer any questions that may arise and to book an initial 
appointment.  Also, we will ask you to provide us with the name and contact information 
for your family physician, and permission to contact your family physician if a health 
concern arises during your participation in the study.  
 
As a participant in this study, you will be randomly assigned to one of two study arms 
(exercise program, or no exercise program). Those assigned to the exercise program will 
be asked to attend supervised exercise classes at least 3 times weekly, for 12 weeks.  The 
exercise classes will be offered in the exercise facility at the Ford Oakville Plant. Class 
times are Monday, Tuesday, Wednesday, Thursday and Friday from 7-8am. You may also 
attend any other exercise class instructed and approved by the Fitness Centre Manager, 
should those time slots better fit your schedule. Those assigned to the no exercise program 
will be asked to maintain their existing activity level for the 12-week period. 
Unfortunately, we cannot let you choose which study arm you will participate in. 
However, if you are randomized to the no exercise program, you will be eligible to receive 
the same exercise program upon completing the second, follow-up data collection.   
 
We will ask you to attend 2 visits (one before and one after the 12 week intervention 
period), also in the exercise facility at Ford Oakville.  These visits will take approximately 
2 hours each to complete.  
 
Measurements at the Start of the Study   
1. Complete this form  
2. Body size measurements  
3. Resting heart rate and blood pressure 
4. Mobility performance measurements 
a. 6-minute walk 
b. Stair climb 
c. 30-second chair stand 
5. Treadmill walking fitness test 
6. Strength assessment of muscles of the knee, hip and hand 
7. Questionnaires 
This visit will take approximately 2 hours to complete. 
Study Arms: 
Exercise Program 
 12-weeks of exercise.  Each class is 1 hour. 
 Weekly attendance at 3 of 4 available time slots offered each week. 
 Classes will be offered on-site in the exercise facility at the Ford Oakville Plant 

 
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 Classes include a warm-up, series of exercises with a focus on lower extremity 
strength, balance and flexibility, cool down 
 All exercise sessions will be supervised by a Certified Yoga Instructor.  All 
equipment are available for your use.  The facility also has bathroom/change room 
facilities including showers. 
 
No Exercise Program 
 We ask that you refrain from changing your physical activity over 12 weeks 
 We ask that you maintain any strategies you use to manage with your knee and/or 
hip pain over 12 weeks. 
 Upon completing the second, follow-up data collection, you will be eligible to 
receive the same exercise program as the exercise group. 
 
Measurements at the End of the Study  
1. Body size measurements  
2. Resting heart rate and blood pressure 
3. Mobility performance measurements 
a. 6-minute walk 
b. Stair climb 
c. 30-second chair stand 
4. Treadmill walking fitness test 
5. Strength assessment of muscles of the knee, hip and hand 
6. Questionnaires 
This visit will take approximately 2 hours to complete. 
You must complete these measurements at the end of the study to be eligible to receive 
the $50 stipend. 
Total time commitment if you choose to participate in the study 
Activity 
Time per session 
Number 
of 
sessions 
Total time 
Measurement visit 2 h 
2 
4 h 
Classes 
1 h 
36 
36 h 
Total: 
 
 
40 hours 
Risks & Benefits 
There are risks associated with exercise in this study, including the following:  fatigue, 
soreness, heart complications in those with poor heart health, increased risk of fracture 
especially in those with osteoporosis, and worsening of knee pain in those with 
patellofemoral syndrome.  With regards to the potential muscle soreness, we will teach 
you gentle stretches and how to use an ice pack to reduce the soreness.  If you experience 
any serious discomfort following an exercise session or laboratory visit, please contact 
Dr. Monica Maly at (519) 888-4567 x 37916. 
 

 
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You may gain the physical and mental benefits associated exercise.  Your participation 
will help improve our understanding of how exercise, a non-invasive treatment option, 
affects osteoarthritis of the knee or hip and whether exercise can improve your resilience 
at work.   
 
Confidentiality 
All information obtained during the study will be held in strict confidence.  You will be 
identified in the study by a code only.  No names or identifying information will be used 
in any publication or presentation to Ford, or otherwise.  No information identifying you 
will be available outside the investigation.  However, summary information about the 
group changes as a result of the study will be shared with Ford to give the company the 
information necessary to consider implementing a similar program in the future. The 
information we collect will be secured in a locked filing cabinet in the MacMobilize 
Laboratory at McMaster University to which only the researchers will have direct access.  
This research space is also locked.  Following completion of the study, the information 
we collect will be destroyed.  Representatives of the McMaster University Health Sciences 
Research Board may require access to your study-related records or may follow up with 
you to monitor the conduct of the research. 
 
Participation 
Your participation in this study is voluntary.  If you decide to participate, you can decide 
to stop at any time, even after signing the consent form or part-way through the study.  If 
you drop out of the study, your data will only be used with your explicit consent.  You 
can withdraw from the study at any time, for any reason, without any negative 
consequences.  You will receive a $50 stipend upon completion of the study.  There will 
be rewards for best attendance during the 12 weeks. Your decision to participate, or not, 
will not be communicated to Ford. 
 
Questions 
If you have any general questions, please call the MacMobilize Research Laboratory at 
(905) 525-9140 x 20748.  If you have any questions about your rights as a research 
participant or the conduct of the study, you may contact Dr. Monica Maly, the principal 
investigator at (519) 888-4567 x 37916.  This letter is yours to keep for future reference. 
 
This study has been reviewed by Hamilton Integrated Research Ethics Board (HIREB). If 
you have questions regarding your rights as a research participant, you may contact the 
office of HIREB chair at 905-521-2100 ext. 42013. 
 
 
 
 
 

 
Version Date: February 3, 2017 
13
Improving Resilience and Longevity for Workers Through Exercise 
Consent 
I have read the Letter of Information, have had the nature of the study explained to me 
and I agree to participate.  All questions have been answered to my satisfaction.  I will 
receive a signed copy of this form. 
 
 
_______________________ 
____________________  
_______________ 
Participant Name (please print) Participant Signature 
 
 
Date 
 
 
 
 
 
 
I confirm that I have explained the nature and purpose of this study to the participant 
named above.  I have answered all questions. 
 
 
_______________________ 
____________________  
_______________ 
Person Obtaining Consent 
 
Signature 
 
 
 
Date 
 
 
 
 
________________________ ____________________  
_______________ 
Principal Investigator  
 
 
Signature 
 
 
 
Date