{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T14:07:08Z","timestamp":1765807628432,"version":"3.48.0"},"reference-count":43,"publisher":"BMJ","issue":"12","funder":[{"DOI":"10.13039\/501100000925","name":"National Health and Medical Research Council","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100000925","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2017,11,13]]},"published-print":{"date-parts":[[2017,12]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Current guidelines recommend tailored interventions to optimise knee osteoarthritis (OA) management. However, models of care still have a \u2018one size fits all\u2019 approach, which is suboptimal as it ignores patient heterogeneity. This study aims to compare a stepped care strategy with standard care for overweight and obese persons with medial tibiofemoral OA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>\n                      Participants will be randomised into two groups (85 each). The intervention will receive a diet and exercise programme for 18 weeks in the first step of the study. Disease remission will then be assessed using the Patient Acceptable Symptom State (PASS). PASS is defined as the highest level of symptom beyond which patients consider themselves well and takes into account pain intensity, patient\u2019s global assessment of disease activity and degree of functional impairment. In the second step, participants in remission will continue with diet and exercise. If remission is not achieved, participants will be assigned in a hierarchical order to cognitive behavioural therapy, knee brace or muscle strengthening for 12 weeks. The intervention will be decided based on their clinical presentation for symptoms of depression and varus malalignment. Participants without depression or varus malalignment will undertake a muscle strengthening programme. The control group will receive educational material related to OA management. Main inclusion criteria are age \u226550 years, radiographic medial tibiofemoral OA, body mass index (BMI) \u226528\u2009kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      , knee pain \u226540 (Visual Analogue Scale, 0\u2013100), PASS (0\u2013100) &gt;32 for pain and global assessment, and 31 for functional impairment. Outcomes will be measured at 20-week and 32-week visits. The primary outcome is disease remission at 32 weeks. Other outcomes include functional mobility; patient-reported outcomes; BMI; waist-hip ratio; quadriceps strength; symptoms of depression, anxiety and stress; and knee range of motion. The analysis will be performed according to the intention-to-treat principle.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>The local ethics committee approved this protocol (HREC\/14\/HAWKE\/381). Dissemination will occur through presentations at international conferences and publication in peer-reviewed journals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>ACTRN12615000227594.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2017-018495","type":"journal-article","created":{"date-parts":[[2025,12,13]],"date-time":"2025-12-13T04:13:32Z","timestamp":1765599212000},"page":"e018495","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":9,"title":["Stepped care approach for medial tibiofemoral osteoarthritis (STrEAMline): protocol for a randomised controlled trial"],"prefix":"10.1136","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2587-1649","authenticated-orcid":false,"given":"Sarah Rubia","family":"Robbins","sequence":"first","affiliation":[{"name":"Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, Sydney, Australia"},{"name":"Department of Rheumatology, Royal North Shore Hospital and Northern Clinical School, University of Sydney, Sydney, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Luciano Ricardo S","family":"Melo","sequence":"additional","affiliation":[{"name":"Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, Sydney, Australia"},{"name":"Department of Rheumatology, Royal North Shore Hospital and Northern Clinical School, University of Sydney, Sydney, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1390-8109","authenticated-orcid":false,"given":"Hema","family":"Urban","sequence":"additional","affiliation":[{"name":"Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, Sydney, Australia"},{"name":"Department of Rheumatology, Royal North Shore Hospital and Northern Clinical School, University of Sydney, Sydney, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Leticia A","family":"Deveza","sequence":"additional","affiliation":[{"name":"Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, Sydney, Australia"},{"name":"Department of Rheumatology, Royal North Shore Hospital and Northern Clinical School, University of Sydney, Sydney, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rebecca","family":"Asher","sequence":"additional","affiliation":[{"name":"NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Victoria L","family":"Johnson","sequence":"additional","affiliation":[{"name":"Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, Sydney, Australia"},{"name":"Department of Rheumatology, Royal North Shore Hospital and Northern Clinical School, University of Sydney, Sydney, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3197-752X","authenticated-orcid":false,"given":"David J","family":"Hunter","sequence":"additional","affiliation":[{"name":"Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, Sydney, Australia"},{"name":"Department of Rheumatology, Royal North Shore Hospital and Northern Clinical School, University of Sydney, Sydney, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2017,12,26]]},"reference":[{"key":"2025121220131787000_7.12.e018495.1","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2474-13-254"},{"key":"2025121220131787000_7.12.e018495.2","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2013-204763"},{"key":"2025121220131787000_7.12.e018495.3","doi-asserted-by":"publisher","DOI":"10.1038\/nrrheum.2014.44"},{"key":"2025121220131787000_7.12.e018495.4","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1007\/s40266-015-0243-3","article-title":"Can we identify patients with high risk of osteoarthritis progression who will respond to treatment? 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