Progressive Resistance Training Compared to Neuromuscular Exercise in Patients With Hip Osteoarthritis

Study Overview
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Brief Summary
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The primary aim of this randomized controlled trial is to investigate the effectiveness of 12 weeks of progressive resistance training (PRT) compared to neuromuscular exercise (NEMEX) on functional performance in patients with hip OA measured by the 30-seconds chair stand test. Secondary aims are to investigate; the determinants of improvement in physical function following PRT or NEMEX; the effectiveness of booster sessions in prolonging the effects of the initial interventions (12 months), the cost-effectiveness of booster sessions (12 months). We will test the hypothesis that PRT is superior to NEMEX in improving physical function measured with the 30s sit-to-stand test at 12 week follow-up.

Detailed Description
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This randomized controlled trial will be a multicenter trial involving hospitals and physiotherapy clinics across Denmark. Part 1: For the initial 12-week exercise intervention, participants will be randomized into two groups: PRT or NEMEX. Part 2: After the initial intervention, participants in each group will be randomized to booster sessions (PRT+B and NEMEX+B) or to receive no further treatment (PRT-B and NEMEX-B). Booster sessions will be provided at 4, 6, 8 and 10 months after baseline. Outcomes will be measured at baseline, after 12 weeks of intervention, and at 6-, 9- and 12-months follow-up. The exercise interventions will be performed at the collaborating hospitals and physiotherapy clinics across Denmark. All sessions will be conducted in group sessions with one physiotherapist supervising the exercises. The duration and frequency of the interventions will be 12 weeks with 2 supervised sessions each week. If participants experience pain during exercise exceeding 5 out of 10 on a Visual Analogue Scale (VAS), the physiotherapist will modify the exercise, decreasing the exercise intensity (load) or modifying the range of motion. All unilateral exercises will be performed for both sides. The NEMEX intervention will follow the NEMEX program as described by Ageberg et al. The sessions consist of a 10-minute submaximal warm up on an exercise bike followed by 50 minutes of NEMEX training with exercises focused on stability, postural function, postural orientation, lower extremity muscle strength, and functional exercises. The PRT intervention will follow the same protocol for training frequency and duration as the NEMEX intervention. The sessions consist of a 10-minute submaximal warm up on an exercise bike followed by 50 minutes of PRT with exercises targeting the muscles of the hip and knee joints; leg press, hip extension, hip abduction, hip flexion and knee extension.

Official Title
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Progressive Resistance Training Compared to Neuromuscular Exercise in Patients With Hip Osteoarthritis, and the Additive Effect of Booster Sessions: A Multicenter Randomized Controlled Trial

Conditions
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Hip Osteoarthritis

Intervention / Treatment
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* Other: Progressive Resistance Training and no booster sessions
* Other: Progressive Resistance Training and booster sessions
* Other: Neuromuscular exercise and no booster sessions
* Other: Neuromuscular exercise and booster sessions


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Clinically diagnosed OA of the hip joint according to the National Institute for Health and Care Excellence criteria Have experienced pain of at least 3 out of 10 on the visual analog scale in the index hip within the last two weeks Age ≥ 45 years No surgery in the lower extremities six months prior to inclusion No comorbidity that prevents exercising Adequacy in written and spoken Danish Not being a candidate for total hip arthroplasty Exclusion Criteria: BMI score > 40 Pregnancy Resistance training or neuromuscular training for the lower extremities for more than 12 sessions in the last 6 months or 6 sessions in the last 3 months (resistance training is defined by the American College of Sports Medicine guidelines while neuromuscular training is defined by exercises involving multiple joints and muscle groups performed in functional weight-bearing positions with emphasis on the quality and efficiency of movement, as well as alignment of the trunk and lower limb joints) Planned vacation for more than 14 days within the 12-week intervention period without the possibility of expanding the intervention accordingly

Ages Eligible for Study
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Minimum Age: 45 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Group 1:<br>PRT | Other: Progressive Resistance Training and no booster sessions<br>* An initial 12-week exercise intervention, consisting of 1-hour group sessions of progressive resistance training supervised by a physiotherapist 2 times per week. The sessions consist of a 10-minute submaximal warm up on an exercise bike followed by 50 minutes of PRT with exercises targeting the muscles of the hip and knee joints; leg press, hip extension, hip abduction, hip flexion and knee extension. The progression will be in line with guidelines provided by the American College of Sports Medicine. The intensity will follow repetition maximum (RM) targets, from 12 RM for the first week towards 8 RM for the last weeks. After the 12 weeks, this group consists of patients who are randomized to receive no further treatment. For the following 9 months, these patients are given a membership to a fitness center where they are encouraged to continue the same exercise regime.<br>|
| Experimental: Group 2:<br>PRT + Booster sessions | Other: Progressive Resistance Training and booster sessions<br>* An initial 12-week exercise intervention, consisting of 1-hour group sessions of progressive resistance training supervised by a physiotherapist 2 times per week. The sessions consist of a 10-minute submaximal warm up on an exercise bike followed by 50 minutes of PRT with exercises targeting the muscles of the hip and knee joints; leg press, hip extension, hip abduction, hip flexion and knee extension. The progression will be in line with guidelines provided by the American College of Sports Medicine. The intensity will follow repetition maximum (RM) targets, from 12 RM for the first week towards 8 RM for the last weeks. After the 12 weeks, this group consists of patients who are randomized to receive 4 booster sessions (at 1, 3, 5 and 7 months after termination of the initial 12 week intervention). Additionally, for the following 9 months, these patients are given a membership to a fitness center where they are encouraged to continue the same exercise regime without supervision.<br>|
| Active Comparator: Group 3:<br>NEMEX | Other: Neuromuscular exercise and no booster sessions<br>* An initial 12-week exercise intervention, consisting of 1-hour group sessions of progressive resistance training supervised by a physiotherapist 2 times per week. The sessions consist of a 10-minute submaximal warm up on an exercise bike followed by 50 minutes of NEMEX training with exercises focused on stability, postural function, postural orientation, lower extremity muscle strength, and functional exercises. Progression is made when an exercise is performed with good sensorimotor control and good quality of the performance and with minimal exertion and adequate control of the movement. After the 12 weeks, this group consists of patients who are randomized to receive no further treatment. For the following 9 months, these patients are given equipment and encouraged to continue the same exercise regime at home without supervision.<br>|
| Experimental: Group 4:<br>NEMEX + Booster sessions | Other: Neuromuscular exercise and booster sessions<br>* An initial 12-week exercise intervention, consisting of 1-hour group sessions of progressive resistance training supervised by a physiotherapist 2 times per week. The sessions consist of a 10-minute submaximal warm up on an exercise bike followed by 50 minutes of NEMEX training with exercises focused on stability, postural function, postural orientation, lower extremity muscle strength, and functional exercises. Progression is made when an exercise is performed with good sensorimotor control and good quality of the performance and with minimal exertion and adequate control of the movement. After the 12 weeks, this group consists of patients who are randomized to receive 4 booster sessions (at 1, 3, 5 and 7 months after termination of the initial 12 week intervention). Additionally, for the following 9 months, these patients are given equipment and encouraged to continue the same exercise regime at home.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in functional performance measured by the 30-seconds chair stand test | The 30-second chair stand test is a valid and responsive measure of lower-extremity muscle strength evaluating sit-to-stand function, which is limited in people with lower extremity OA. | Measured at baseline, 12 week and 12 month follow-up. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in 40m fast-paced walk test | Time (in seconds) taken to complete a 40 m course at fast walking pace. | Measured at baseline, 12 week and 12 month follow-up. | 
| Change in 9 step stair climb test | Time (in seconds) taken to negotiate 9 steps on a standard step-height stair-way (up and down). | Measured at baseline, 12 week and 12 month follow-up. | 
| Change in leg extension muscle power (watt/kg bodyweight) | Leg extensor muscle power (force times acceleration) will be measured using the Nottingham Power Rig (NPR). The NPR measures the power output in total watt and watt pr. bodyweight in kilograms from a seated push on a flat pedal which is transmitted by a lever and chain to spin a flywheel. The NPR is a safe and reliable method to measure explosive knee extensor muscle power and has been validated as a clinically important measure of muscle function in elderly individuals. | Measured at baseline, 12 week and 12 month follow-up. | 
| Change in the HOOS pain subscale | The HOOS pain subscale is a 10-item patient-reported outcome measure designed to assess other hip symptoms in patients with hip osteoarthritis. The total score ranges from 0 to 100, with higher scores indicating better symptoms status. | Measured at baseline, 12 week and 12 month follow-up. | 
| Change in the HOOS activities of daily living (ADL) function subscale | The HOOS ADL function subscale is a 17-item patient-reported outcome measure designed to assess ADL function in patients with hip osteoarthritis. The total score ranges from 0 to 100, with higher scores indicating better ADL function status. | Measured at baseline, 12 week and 12 month follow-up. | 
| Change in the HOOS quality-of-life subscale | The HOOS quality-of-life subscale is a four-item patient-reported outcome measure designed to assess hip-related quality-of-life in patients with hip osteoarthritis. The total score ranges from 0 to 100, with higher scores indicating better quality-of-life status. | Measured at baseline, 12 week and 12 month follow-up. | 
| Change in the HOOS sports and recreation subscale | The HOOS sports and recreation subscale is a four-item patient-reported outcome measure designed to assess sports and recreation function in patients with hip osteoarthritis. The total score ranges from 0 to 100, with higher scores indicating better sports and recreation status. | Measured at baseline, 12 week and 12 month follow-up. | 
| Global Perceived Effect (GPE) | The GPE of the interventions will be assessed for three domains on a 7-point Likert scale | Measured at 12 week and 12 month follow-up. | 
| Change in muscle strength | Muscle strength is measured in a standardized one-repetition maximum test for the leg press exercise. | Measured at baseline, 12 week and 12 month follow-up. | 
| Change in the HOOS symptoms subscale | The HOOS symptoms subscale is a five-item patient-reported outcome measure designed to assess hip symptoms in patients with hip osteoarthritis. The total score ranges from 0 to 100, with higher scores indicating better symptoms status. | Measured at baseline, 12 week and 12 month follow-up. | 
| Adherence to the 12 week initial intervention | High adherence is defined as ≥ 80% attendance to the supervised interventions. | Registered throughout the 12 week initial intervention. | 
| Adherence to the 9 months of self-administered training | High adherence is defined by ≥ 80% of the assigned exercise programs performed at home or at the fitness center. | Registered throughout the 9 months follow-up period. | 
| AE (Adverse Events) & Serious Adverse Events (SAE) | Continous registration of health issues and injuries. Physiotherapists in charge of the training sessions will monitor potential AE and SAE. Also, during the follow-up visits at week 12 and 12 months, the participants will be asked about potential AE's and SAE's using open-probe questions. | Registered throughout the 12 month study period. | 
| Drop-outs | Number og drop-out from the training interventions. | Registered throughout the 12 month study period. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Progressive Resistance Training, Neuromuscular Exercise, Physical Therapy, Physical Rehabilitation