Group physical therapy for knee osteoarthritis: protocol for a hybrid type III effectiveness-implementation trial.



Knee osteoarthritis (OA) is a leading cause of chronic pain and disability and one of the most common conditions treated in outpatient physical therapy (PT). Because of the high and growing prevalence of knee OA, there is a need for efficient approaches for delivering exercise-based PT to patients with knee OA. A prior randomized controlled trial (RCT) showed that a 6-session Group Physical Therapy Program for Knee OA (Group PT) yields equivalent or greater improvements in pain and functional outcomes compared with traditional individual PT, while requiring fewer clinician hours per patient to deliver. This manuscript describes the protocol for a hybrid type III effectiveness-implementation trial comparing two implementation packages to support delivery of Group PT.


In this 12-month embedded trial, a minimum of 16 Veterans Affairs Medical Centers (VAMCs) will be randomized to receive one of two implementation support packages for their Group PT programs: a standard, low-touch support based on Replicating Effective Programs (REP) versus enhanced REP (enREP), which adds tailored, high-touch support if sites do not meet Group PT adoption and sustainment benchmarks at 6 and 9 months following launch. Implementation outcomes, including penetration (primary), adoption, and fidelity, will be assessed at 6 and 12 months (primary assessment time point). Additional analyses will include patient-level effectiveness outcomes (pain, function, satisfaction) and staffing and labor costs. A robust qualitative evaluation of site implementation context and experience, as well as site-led adaptations to the Group PT program, will be conducted.


To our knowledge, this study is the first to evaluate the impact of tailored, high-touch implementation support on implementation outcomes when compared to standardized, low-touch support for delivering a PT-based intervention. The Group PT program has strong potential to become a standard offering for PT, improving function and pain-related outcomes for patients with knee OA. Results will provide information regarding the effectiveness and value of this implementation approach and a deeper understanding of how healthcare systems can support wide-scale adoption of Group PT.

Trial registration

This study was registered on March 7, 2022 at (identifier NCT05282927 ).





Published Version (Please cite this version)


Publication Info

Webb, Sara, Connor Drake, Cynthia J Coffman, Caitlin Sullivan, Nina Sperber, Matthew Tucker, Leah L Zullig, Jaime M Hughes, et al. (2023). Group physical therapy for knee osteoarthritis: protocol for a hybrid type III effectiveness-implementation trial. Implementation science communications, 4(1). p. 125. 10.1186/s43058-023-00502-7 Retrieved from

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.



Cynthia Jan Coffman

Professor of Biostatistics & Bioinformatics

Nina Sperber

Associate Professor in Population Health Sciences

My research career has centered on understanding how to improve delivery of new evidence-based practices in health care systems. I work in health services research and development for the VA health care system and have an academic appointment with the Duke University School of Medicine. I create study designs that integrate qualitative and quantitative methods (mixed-methods) and apply Implementation Science and System Science approaches. I currently have a developing body of academic work that uses participatory system dynamics modeling as a strategy to identify system level factors that affect development and implementation of equitable AI tools. For the VA health care system, I direct a cross-functional team that conducts rapid turnaround projects for high priority needs by VHA national, regional, and facility leaders.



Susan Nicole Hastings

Professor of Medicine
Van Houtven

Courtney Harold Van Houtven

Professor in Population Health Sciences

Dr. Courtney Van Houtven is a Professor in The Department of Population Health Science, Duke University School of Medicine and Duke-Margolis Center for Health Policy. She is also a Research Career Scientist in The Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System. Dr. Van Houtven’s aging and economics research interests encompass long-term care financing, intra-household decision-making, unpaid family and friend care, and home- and community-based services. She examines how family caregiving affects health care utilization, expenditures, health and work outcomes of care recipients and caregivers. She is also interested in understanding how best to support family caregivers to optimize caregiver and care recipient outcomes.

Dr. Van Houtven  is co-PI on the QUERI Program Project, “Optimizing Function and Independence”, in which her caregiver skills training program developed as an RCT in VA, now called Caregivers FIRST, has been implemented at 125 VA sites nationally. The team will evaluate how intensification of an implementation strategy changes adoption. She directs the VA-CARES Evaluation Center, which evaluates the VA’s Caregiver Support Program. She leads a mixed methods R01 study as PI from the National Institute on Aging that will assess the value of "home time" for persons living with dementia and their caregivers (RF1 AG072364).

Areas of expertise: Health Services Research and Health Economics

Unless otherwise indicated, scholarly articles published by Duke faculty members are made available here with a CC-BY-NC (Creative Commons Attribution Non-Commercial) license, as enabled by the Duke Open Access Policy. If you wish to use the materials in ways not already permitted under CC-BY-NC, please consult the copyright owner. Other materials are made available here through the author’s grant of a non-exclusive license to make their work openly accessible.