Effectiveness Of The Core Activation And Rehabilitation Exercises For Knee Osteoarthritis - Program (CARE -KOA<sup>&copy;</sup>) Among Patients Diagnosed With Knee Osteoarthritis.

Dias Tina Thomas; Charu Eapen; Atmananda S Hegde; Ajit R. Mahale; Prajwal Prabhudev Mane; Saurabh Mehta

doi:10.12688/f1000research.163321.1

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Research Article

Effectiveness Of The Core Activation And Rehabilitation Exercises For Knee Osteoarthritis - Program (CARE -KOA^©) Among Patients Diagnosed With Knee Osteoarthritis.

[version 1; peer review: 2 approved with reservations]

Dias Tina Thomas¹, Charu Eapen¹, Atmananda S Hegde², Ajit R. Mahale³, Prajwal Prabhudev Mane², Saurabh Mehta⁴

Dias Tina Thomas¹, Charu Eapen¹, [...] Atmananda S Hegde², Ajit R. Mahale³, Prajwal Prabhudev Mane², Saurabh Mehta⁴

PUBLISHED 15 May 2025

Author details Author details

¹ Department of Physiotherapy, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
² Department of Orthopedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
³ Department of Radiology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India
⁴ College of Clinical and Rehabilitation Health Sciences, East Tennessee State University, Johnson City, TN, USA

Dias Tina Thomas
Roles: Data Curation, Investigation, Writing – Original Draft Preparation

Charu Eapen
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Atmananda S Hegde
Roles: Supervision, Writing – Original Draft Preparation

Ajit R. Mahale
Roles: Formal Analysis, Writing – Review & Editing

Prajwal Prabhudev Mane
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Saurabh Mehta
Roles: Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Manipal Academy of Higher Education gateway.

Abstract

Background

Knee osteoarthritis (KOA) is a prevalent condition. Recent research on people with KOA has addressed kinetic chain and core muscle contribution in disease progression.

Objective

This study aims to assess the efficacy of including the CARE -KOA© regimen and evaluate its effect on pain, patient-reported functional outcomes, physical function tests, knee strength, and core endurance.

Methods/Design

15 patients above 45 were recruited and underwent a 4-week CARE -KOA© program with 12 supervised sessions over four weeks. Pre- and Post-exercise assessment included evaluating the primary outcome pain using the VAS scale and the patient-reported outcome using the KOOS scale. The secondary outcomes, knee muscle strength, core endurance, and the physical function tests, i.e., the stair climb test, the sit-to-stand test, the 40m fast-paced walking test, and the timed up-and-go test, were also evaluated. The data collected in the study was analyzed using the statistical software JAMOVI. p < 0.05 was significant.

Results

Notably, all the parameters examined exhibited a statistically significant difference between their pre-intervention and post-intervention values, except the knee muscle strength in the flexors of the affected knee and extensors of the unaffected knee.

Conclusion

Patients who completed a 4-week supervised CARE -KOA© program alongside routine rehabilitation experienced reduced pain and improved outcomes. This approach aims to address biomechanical issues and positively impacts pain mechanisms.

Study Trial Registration

CTRI/2023/07/05480 on 05/07/2024 https://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=69416.70327

Copy right registration: L – 158197/2024

Keywords

Knee Osteoarthritis, Core muscle, Strength training, Rehabilitation, Exercise Therapy.

Corresponding author: Charu Eapen

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2025 Thomas DT et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Thomas DT, Eapen C, Hegde AS et al. Effectiveness Of The Core Activation And Rehabilitation Exercises For Knee Osteoarthritis - Program (CARE -KOA^©) Among Patients Diagnosed With Knee Osteoarthritis. [version 1; peer review: 2 approved with reservations]. F1000Research 2025, 14:496 (https://doi.org/10.12688/f1000research.163321.1) First published: 15 May 2025, 14:496 (https://doi.org/10.12688/f1000research.163321.1) Latest published: 21 Jul 2025, 14:496 (https://doi.org/10.12688/f1000research.163321.4)

Introduction

Knee osteoarthritis (KOA) is a widely prevalent condition resulting in persistent disability. The combined prevalence of KOA was 16% for individuals aged 15 and above, escalating to 22.9% in the demographic aged 40 and beyond worldwide.¹ In India, up to 28.7% of people who have knee pain and signs of KOA document being unable to perform everyday tasks.^2,3

Conservative treatment for KOA emphasizes decreasing the compressive forces on the joint. It might be accomplished by strengthening the lower extremity's muscle strength, particularly the quadriceps muscle, which not only influences the initiation and progression of the disease but also plays an integral part in functional limitations in those with KOA.^4–7

When compared to routine rehabilitation alone, 12 weeks of generalized core exercise with a routine rehabilitation program was superior and more efficient in reducing pain in patients who had KOA.⁸ It has been demonstrated that various periarticular muscle exercise regimens and pharmaceutical treatments effectively minimize discomfort and improve physical function. The muscles that stabilize the knee joint are known to atrophy and lose strength because of KOA.⁹

Core exercise can enhance trunk, pelvic, hip, and knee stability and coordination by stimulating the periarticular muscles of the knee and the lumbopelvic hip complex.¹⁰ Initial implications of the proximal contributions and the kinetic chains have recently been investigated in individuals with KOA, and a link between KOA and poor core has been seen as a plausible avenue attributing to the progression of the disease.¹⁰

As a result, this study explored the effectiveness of incorporating the CARE -KOA© program and evaluated its efficacy on pain, patient-reported functional outcomes, physical function tests, knee strength, and core endurance in patients diagnosed with KOA, alongside, exploring the feasibility of conducting a future randomized controlled trial, to assess the long-term effect and adherence of the patient population to the program.

Study Trial Registration: CTRI/2023/07/05480 on 05/07/2024 https://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=69416.70327

Methods

Study design

A prospective, single group, pre – and post-study that was presented and approved by the Kasturba Medical College Mangaluru Institutional Ethics Committee (IECKMCMLR05/2023/206) on 18/5/2023 and recruitment was carried out from June 18 2023. The study was then registered with the Clinical Trials Registry India (CTRI) (CTRI/2023/07/054805). The study was chosen to test the effectiveness of using the CARE -KOA© and to evaluate its effects on the desired outcomes in patients diagnosed with KOA. The reporting of this study was in line with the Consolidated Standards of Reporting Trials (CONSORT). Our interest in this early investigation was to maximize the exploration of study methods and performance outcomes in patients diagnosed with KOA. 4- weeks was selected as the program length for this study. Informed consent was signed by all the participants included in the study, and all ethical standards defined by the Helsinki declaration were abided by.

Participant and setting

The study was carried out in the hospital settings of Kasturba Medical College Mangalore.

Patients with a medical diagnosis of KOA, referred by the orthopaedic surgeon to the Physical Therapy Department, were included. The diagnosis was made by an orthopaedic surgeon specializing in knee conditions, based on the patient’s medical history (knee pain with crepitus during active motion, morning stiffness or bony enlargement, age, and a physical examination to rule out other causes of knee pain), along with radiographic imaging showing a K-L grade of 1-3.

Patients with severe KOA, in whom knee replacement is indicated, and those with a history of hip OA, lower limb joint replacement, inflammatory arthritis, spine surgery, lower limb surgery, or corticoid injection within the past three months, were excluded.

Procedure

The purpose of the study was explained to the patients before enrolment and a written informed consent was obtained. Pain using the Visual Analog Scale (VAS), Patient-reported Outcomes using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Physical function test i.e., 30 seconds to stand test (30STS), 40 m fast-paced walking test (40MFPW), the stair climb test (SCT) and the timed up and go test (TUG), along with knee muscle strength, core muscle strength, and endurance was recorded by a qualified assessor who was blinded to the intervention and had adequate knowledge of the assessment tool, following a standardized procedure that has been previously described and published in the literature.¹¹

Demographic and baseline data were noted on the day the patient was referred for physiotherapy and then at four weeks post-intervention. Exercises were progressed based on the CARE -KOA© program and each exercise session lasted for an hour and included a 10-minute warmup session.

Sample size determination and statistical analysis

A target sample size of n = 15 participants was achieved based on a pragmatic approach in the context of the study. Once eligibility was assessed and participants signed the informed consent form, they underwent the first evaluation and started with the four-week exercise routine.

The JAMOVI software was utilized to conduct statistical analysis, baseline data analysis, and non-parametric testing (Wilcoxon signed rank test) for within-group analysis. p < 0.05 was statistically significant.

Participant flow

The patient enrolment in the study is depicted in Figure 1 flow diagram (Figure 1). Fifteen participants were included after screening 35 patients with KOA.

Figure 1. CONSORT flow diagram.

Results

15 participants over the age of 50 years were recruited ( Table 1) shows the descriptive data of the included participants.

Table 1. Descriptive data for participants (n = 15).

Variable	Median	IQR
Age (year)	54	50.0-56.5
Height (cm)	159	155-166
Weight (kg)	72	69.0-77.0
BMI	26.1	25.1-31.2

After four weeks of intervention, the patients reported less pain both at rest and during activity, along with significant improvements in functional and patient-reported outcomes as shown in Table 2. The muscle strength of the flexors in the unaffected knee and the extensors of the affected knee demonstrated statistically significant gains ( Table 2); however, muscle strength in the flexors of the affected knee and the extensors of the unaffected knee (p = 0.104 and p = 0.433, respectively) did not show a statistically significant difference.

Table 2. Comparison of pre- and post-intervention results on functional and clinical outcomes.

Measure	Baseline Mean ± SD	Post Mean ± SD	p-value	Effect Size (Cohen's d)
Pain at Rest (VR) (cm)	1.53 ± 1.30	0.40 ± 0.74	0.0006*	1.07
Pain During Activity (VA) (cm)	6.33 ± 1.29	3.87 ± 1.51	0.000001*	1.76
KOOS Pain (KP)	51.93 ± 12.72	62.27 ± 12.31	0.00003*	-0.83
KOOS Symptoms (KS)	55.93 ± 10.89	64.33 ± 8.82	0.0006*	-0.85
KOOS ADL (KADL)	51.60 ± 11.29	64.00 ± 9.43	0.0000009*	-1.19
KOOS QOL (KQOL)	41.27 ± 9.04	50.47 ± 9.80	0.00017*	-0.98
30-Second Sit-to-Stand (30STS) (reps)	8.13 ± 3.04	9.00 ± 2.59	0.050*	-0.31
40-Meter Fast-paced walking test (40-MFPW) (m/sec)	1.00 ± 0.28	0.96 ± 0.25	0.044*	-0.15
Stair Climb Test (SCT) (sec)	33.67 ± 10.10	30.73 ± 7.03	0.031*	0.34
Timed Up and Go Test (TUG) (sec)	33.33 ± 18.68	31.07 ± 17.36	0.006*	0.13
Endurance Test (ET) (sec)	17.73 ± 8.16	19.67 ± 9.80	0.027*	0.21
Muscle Strength - Flexors Unaffected (MSFUA) (kg)	4.80 ± 1.93	5.20 ± 1.90	0.028*	-0.21
Muscle Strength - Extensors Affected (MSEA) (kg)	5.07 ± 2.37	5.53 ± 2.59	0.013*	-0.19
Muscle Strength - Flexors Affected (MSFA) (kg)	4.00 ± 1.93	4.27 ± 2.05	0.104	-0.13
Muscle Strength - Extensors Unaffected (MSEUA) (kg)	6.53 ± 3.62	6.67 ± 3.70	0.433	-0.04

* p<0.05 was statistically significant.

Discussion

The findings of this study provide increasing evidence that integrating the CARE-KOA© program into rehabilitation significantly enhances functional outcomes and reduces pain. This preliminary study indicates a notable reduction in pain and an improvement in various functional outcomes, highlighting the potential of core activation exercises in modulating pain mechanisms beyond conventional rehabilitation strategies.

A statistically and clinically significant reduction in pain at rest and during activity (d = 1.07 and d-1.76) as measured by VAS highlights the efficiency of the CARE-KOA© program in modulating pain mechanisms. Pain in KOA is multifactorial and influenced by joint degeneration, altered loading patterns, and neuromuscular imbalances. The core musculature, particularly the transverse abdominus and multifidus, contribute to trunk stability and pelvic alignment, preventing excessive strain on the knee joint.^10,12

One of the most significant results of this research is the clinically meaningful improvement in patient-reported outcomes, specifically pain reduction (KOOS Pain, d = -0.83), symptomatic relief (KOOS Symptoms, d = -0.85), functional capacity (KOOS-ADL, d = -1.19), and overall quality of life (KOOS-QOL, d = -0.98). These findings underscore the critical role of kinetic chain activation in addressing biomechanical deficits associated with knee osteoarthritis (KOA).

Unlike traditional rehabilitation methods that mainly focus on strengthening the quadriceps, this study emphasizes the importance of targeting core muscle activation to enhance knee joint stability, improve load distribution, and optimize movement efficiency. The improvement in pain reduction and functional capacity can be attributed to enhanced stability resulting from the involvement of core stabilizers in the exercise regimen, which likely plays a pivotal role in offloading knee joint stress, thereby reducing pain and improving function. Furthermore, the observed changes are consistent with prior research indicating that kinetic chain impairments in KOA extend beyond the knee, affecting proximal joint coordination and motor function control.^10,14

Physical function tests demonstrated meaningful improvements across the parameters assessed. The SCT and the core endurance test showed a moderate effect size, (d = 0.34) indicating that patients experienced significant functional gains in core endurance and stair negotiation. Similarly, the 30 STS and the 40MFPW showed improvements with a small effect size (d = -0.31 and d = -0.15), indicating improved mobility and walking efficiency. Additionally, the TUG (d = 0.13) showed significant improvements, reflecting better reaction time and movement efficiency. These gains indicate improved endurance, balance, and mobility, all of which are necessary for performing everyday tasks that retain independence and improve dynamic balance.¹³ The core endurance test (ET, d = 0.21) demonstrated a small effect size, highlighting the role of core endurance in functional performance. Our findings align with previous studies highlighting exercises lead to improvements in mobility and functional performance, ultimately helping those affected to maintain their independence, reduce risk to all, and enhance overall quality of life.¹⁴

The intervention’s comprehensive strategy, which emphasized strengthening core muscles, likely contributed to improved overall stability, movement mechanics, and functional capabilities For the trunk and pelvis to remain stable and to preserve joint loading patterns and lower limb biomechanics, the core muscles must provide dynamic stability.^10,12 Strengthening exercises for the core muscles can help distribute forces more evenly across all joints, reducing the mechanical strain on the injured knee and relieving discomfort. Additionally, improved trunk stability and alignment may have improved joint biomechanics and reduced pain and discomfort during weight bearing.¹²

Notably, while improvements were seen in most indicators, there were no appreciable gains in the strength of the knee flexors and extensors of the affected and unaffected knee respectively. This might be explained by the relatively brief intervention period of exercises and the nature of the muscles to adapt to load over some time, implying that longer duration and frequency of exercises are required to observe plausible strength changes.^15,16

The exercise regime incorporated in our study was in line with the previous studies^14,17 where a more holistic core exercise program was incorporated, whereas the current study targeted the TA and multifidus, which are considered the prime stabilizer muscles of the core.¹⁸ The patients tolerated the exercises well; no adverse events were noted during the 4-week intervention. To provide a more comprehensive knowledge of the intervention's benefits, our study also examined various outcomes, such as patient-reported measures, physical function tests, knee strength, and core endurance.

Long-term follow-up examinations are necessary to assess whether outcomes may be sustained beyond the short duration of the intervention. The study establishes the foundation for further research by offering insightful information on the possible advantages of including the CARE -KOA© program in treating KOA.

Given the improvements in pain management, patient-reported outcomes, and functional performance, a complete strategy incorporating focused core exercises appears promising for treating KOA patients. A limitation noted in this study was the exclusion of patients who could not attend follow-up appointments. This highlights that access to the physiotherapy department and the ability to participate in follow-ups were essential criteria for participation in the exercise program. This ensured adherence to the program.

Our findings suggest that the CARE-KOA© program may benefit individuals with KOA by emphasizing proximal stability and biomechanical efficiency. By integrating core activation strategies into routine rehabilitation, clinicians can offer an evidence-based intervention that enhances the mobility, independence, and overall quality of life of individuals with KOA.

Conclusion

Patients who underwent a 4-week CARE-KOA© supervised rehabilitation program experienced notable improvements in multiple dimensions of KOA management. Specifically, there were significant reductions in reported pain levels and enhancements in the quality of life as evaluated by the KOOS and physical function test. Additionally, core endurance, which is crucial for maintaining stability and reducing strain on the knee, was also significantly increased.

However, while the short-term benefits are evident, further research with extended follow-up periods is essential to evaluate this intervention's sustainability and long-term impact, alongside implementing the CARE -KOA© program against routine rehabilitation in controlled trials and longer follow-up periods. This would help us understand whether the observed improvements are maintained over time and could provide insights into optimizing rehabilitation strategies for chronic knee osteoarthritis.

Ethics and consent

Ethical Approval and Consent to Participate – The independent institutional ethical committee has approved the study and has the ethical number (IECKMCMLR05/2023/206). The study was then registered with the Clinical Trials Registry India (CTRI) (CTRI/2023/07/054805). Kasturba Medical College Mangaluru Institutional Ethics Committee (IECKMCMLR05/2023/206) on 18/5/2023 and recruitment was carried out from June 18 2023.

Consent for publication - All participants included in the study signed a written informed consent form, which was approved by the institutional ethics committee.

Data availability

Repository name: OSF

The project contains the following underlying data: CARE-KOA PROTOCOLCARE -KOA (10.17605/OSF.IO/5E34P)

The data in this study has been registered on the OSF database¹⁹ https://doi.org/10.17605/OSF.IO/R4MQD

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Extended data

Repository name: OSF

https://doi.org/10.17605/OSF.IO/R4MQD

References

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2. Vos T, Allen C, Arora M, et al.: Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016 Oct 8; 388(10053): 1545–1602. PubMed Abstract | Publisher Full Text | Free Full Text
3. Pal CP, Singh P, Chaturvedi S, et al.: Epidemiology of knee osteoarthritis in India and related factors. Indian J. Orthop. 2016 Sep 1 [cited 2022 May 4]; 50(5): 518–522. PubMed Abstract | Publisher Full Text | Free Full Text
4. Astephen JL, Deluzio KJ, Caldwell GE, et al.: Biomechanical changes at the hip, knee, and ankle joints during gait are associated with knee osteoarthritis severity. J. Orthop. Res. 2008 Mar; 26(3): 332–341. PubMed Abstract | Publisher Full Text
5. Varady NH, Grodzinsky AJ: Osteoarthritis year in review 2015: Mechanics. Vol. 24, Osteoarthritis and Cartilage. W.B. Saunders Ltd; 2016; 27–35.
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7. Hunt MA, Wrigley TV, Hinman RS, et al.: Individuals with severe knee osteoarthritis (OA) exhibit altered proximal walking mechanics compared with individuals with less severe OA and those without knee pain. Arthritis Care Res (Hoboken). 2010; 62(10): 1426–1432. PubMed Abstract | Publisher Full Text
8. Hernandez D, Dimaro M, Navarro E, et al.: Efficacy of core exercises in patients with osteoarthritis of the knee: A randomized controlled clinical trial. J. Bodyw. Mov. Ther. 2019; 23(4): 881–887. PubMed Abstract | Publisher Full Text
9. Alnahdi AH, Zeni JA, Snyder-Mackler L: Muscle Impairments in Patients With Knee Osteoarthritis. Sports Health. 2012 Jul; 4(4): 284–292. PubMed Abstract | Publisher Full Text | Free Full Text
10. Flowers DW, Brewer W, Mitchell K, et al.: Why are we neglecting the core muscles in patients with knee osteoarthritis? A narrative review of the literature.2021 [cited 2022 Sep 28]; 26(4): 276–283. Publisher Full Text Reference Source
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13. Hansen P, Nygaard H, Ryg J, et al.: Applying both the 30-s and the 5-repetition sit-to-stand tests captures dissimilar groups and a broader spectrum of physical abilities in mobility-limited older individuals: results from the BIOFRAIL study. Eur. Geriatr. Med. 2024 Dec 7 [cited 2025 Mar 14]; 16: 703–707. PubMed Abstract | Publisher Full Text | Free Full Text
14. Hernandez D, Dimaro M, Navarro E, et al.: Efficacy of core exercises in patients with osteoarthritis of the knee: A randomized controlled clinical trial. J. Bodyw. Mov. Ther. 2019 Oct 1 [cited 2022 Sep 22]; 23(4): 881–887. PubMed Abstract | Publisher Full Text
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Comments on this article Comments (0)

Version 4

VERSION 4 PUBLISHED 15 May 2025

Author details Author details

Dias Tina Thomas
Roles: Data Curation, Investigation, Writing – Original Draft Preparation

Charu Eapen
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Atmananda S Hegde
Roles: Supervision, Writing – Original Draft Preparation

Ajit R. Mahale
Roles: Formal Analysis, Writing – Review & Editing

Prajwal Prabhudev Mane
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Saurabh Mehta
Roles: Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (4)

version 4

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Published: 21 Jul 2025, 14:496

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Published: 11 Jun 2025, 14:496

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version 1

Published: 15 May 2025, 14:496

https://doi.org/10.12688/f1000research.163321.1

© 2025 Thomas DT et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Thomas DT, Eapen C, Hegde AS et al. Effectiveness Of The Core Activation And Rehabilitation Exercises For Knee Osteoarthritis - Program (CARE -KOA^©) Among Patients Diagnosed With Knee Osteoarthritis. [version 1; peer review: 2 approved with reservations]. F1000Research 2025, 14:496 (https://doi.org/10.12688/f1000research.163321.1)

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Reviewer Report 14 Jun 2025

Peeyoosha Gurudut, Department of Orthopedic Physiotherapy, KLEU Institute of Physiotherapy, Belagavi, Karnataka, India

Approved with Reservations

https://doi.org/10.5256/f1000research.179648.r387321

1. Abstract: Background needs more details on CARE protocol and gap in literature; Methods does not mention the study design. Results need to be more detailed with p values and effect sizes. Additionally results mentions affected and unaffected knees interpretation which is not explained in the methodology or table. Conclusion comments on biomechanical issues. which outcomes or tests assess the biomechanical problems is not clear.
2. Introduction: there is no clear introduction or overview given about this CARE protocol which is copyrighted. or developer or previous studies and how this protocol is different from the conventional protocols. The rationale needs to be stronger that connects specifically to CARE as this is the highlight of your study
3. Methodology: Considering your CARE protocol being highlight, this is very briefly explained. Intervention details of CARE protocol is entirely missing. this grossly affects reproducibility by other authors. no images are added or tables. no progression of the protocol. Who is the developer? can add these as annexure or table form and add few images. with references wherever needed/. Were both sides treated?
4. Methodology: Even the outcome measures have not been explained in the detail.
5. Advise to authors to follow TiDiER checklist and CERT checklist to report the interventions and assessments. can easily find them on web browsers.
6. results: Gender wise distribution is missing. Even grades of KOA distribution is not added. side affected and occupation etc can be added in demographic details.
7. Affected and unaffected side details are not there in the table if at all compared which is mentioned in the abstract and text form.
8. Results: more details need to be given in text of results for better readability and understanding.
Discussion: Most discussions only discuss results. The mechanism of the CARE protocol, how is it comparable to the conventional exercise protocol, and how is it better than other protocols need to be discussed.
Conclusion: This is not in line of the objective stated.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Musculoskeletal Physical therapy, Manual Therapy, Biomechanics or kinesiology, Kinesiotherapy, WOmen's health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 11 Sep 2025

Tina Dias, Kasturba Medical College Hospital, India

11 Sep 2025

Author Response

We thank you for your review.
1. Abstract: Background needs more details on CARE protocol and gap in literature; Methods does not mention the study design. Results need to be ... Continue reading We thank you for your review.
1. Abstract: Background needs more details on CARE protocol and gap in literature; Methods does not mention the study design. Results need to be more detailed with p values and effect sizes. Additionally results mentions affected and unaffected knees interpretation which is not explained in the methodology or table. Conclusion comments on biomechanical issues. which outcomes or tests assess the biomechanical problems is not clear.
The abstract has been revised to include a brief description of the CARE-KOA© protocol and the gap in literature regarding core-focused interventions. The study design (prospective, single-group, pre-post intervention) is now specified. Results now include p-values and effect sizes for each outcome. The interpretation of affected/unaffected knees is clarified in the results and methodology. The conclusion now specifies which outcomes (core endurance, physical function tests) assess biomechanical issues

2. Introduction: there is no clear introduction or overview given about this CARE protocol which is copyrighted. or developer or previous studies and how this protocol is different from the conventional protocols. The rationale needs to be stronger that connects specifically to CARE as this is the highlight of your study
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

3. Methodology: Considering your CARE protocol being highlight, this is very briefly explained. Intervention details of the CARE protocol is entirely missing. this grossly affects reproducibility by other authors. no images are added or tables. no progression of the protocol. Who is the developer? can add these as an annexure or table form and add few images. with references wherever needed/. Were both sides treated?
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

4. Methodology: Even the outcome measures have not been explained in the detail.
Each outcome measure (VAS, KOOS, 30STS, 40MFPW, SCT, TUG, core endurance, muscle strength) is now described in detail, including how and when they were measured.

5. Advise to authors to follow TiDiER checklist and CERT checklist to report the interventions and assessments. can easily find them on web browsers.
The manuscript now states that the study was reported in accordance with the TiDiER and CERT checklists. A supplementary table or annexure listing checklist compliance is included.

6. Results: Gender wise distribution is missing. Even grades of KOA distribution is not added. side affected and occupation etc can be added in demographic details.
The demographic table and text now include gender, KOA grade, affected side, and occupation.

7. Affected and unaffected side details are not there in the table if at all compared which is mentioned in the abstract and text form.
The strength was taken for both the affected and unaffected side .The results table and text now clearly indicate which outcomes pertain to the affected or unaffected knee.

8. Results: more details need to be given in text of results for better readability and understanding.The results text has been expanded to provide a detailed narrative of the main findings, highlighting key p-values, effect sizes, and clinical relevance.

Discussion: Most discussions only discuss results. The mechanism of the CARE protocol, how is it comparable to the conventional exercise protocol, and how is it better than other protocols need to be discussed.
The discussion now explains the mechanism of the CARE-KOA© protocol, compares it to conventional protocols, and discusses its advantages. Discussion section, revised for clarity and detail.

Conclusion: This is not in line of the objective stated.
The conclusion has been revised to directly address each stated objective, summarize key findings, and discuss implications.
We thank you for your review.
1. Abstract: Background needs more details on CARE protocol and gap in literature; Methods does not mention the study design. Results need to be more detailed with p values and effect sizes. Additionally results mentions affected and unaffected knees interpretation which is not explained in the methodology or table. Conclusion comments on biomechanical issues. which outcomes or tests assess the biomechanical problems is not clear.
The abstract has been revised to include a brief description of the CARE-KOA© protocol and the gap in literature regarding core-focused interventions. The study design (prospective, single-group, pre-post intervention) is now specified. Results now include p-values and effect sizes for each outcome. The interpretation of affected/unaffected knees is clarified in the results and methodology. The conclusion now specifies which outcomes (core endurance, physical function tests) assess biomechanical issues

2. Introduction: there is no clear introduction or overview given about this CARE protocol which is copyrighted. or developer or previous studies and how this protocol is different from the conventional protocols. The rationale needs to be stronger that connects specifically to CARE as this is the highlight of your study
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

3. Methodology: Considering your CARE protocol being highlight, this is very briefly explained. Intervention details of the CARE protocol is entirely missing. this grossly affects reproducibility by other authors. no images are added or tables. no progression of the protocol. Who is the developer? can add these as an annexure or table form and add few images. with references wherever needed/. Were both sides treated?
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

4. Methodology: Even the outcome measures have not been explained in the detail.
Each outcome measure (VAS, KOOS, 30STS, 40MFPW, SCT, TUG, core endurance, muscle strength) is now described in detail, including how and when they were measured.

5. Advise to authors to follow TiDiER checklist and CERT checklist to report the interventions and assessments. can easily find them on web browsers.
The manuscript now states that the study was reported in accordance with the TiDiER and CERT checklists. A supplementary table or annexure listing checklist compliance is included.

6. Results: Gender wise distribution is missing. Even grades of KOA distribution is not added. side affected and occupation etc can be added in demographic details.
The demographic table and text now include gender, KOA grade, affected side, and occupation.

7. Affected and unaffected side details are not there in the table if at all compared which is mentioned in the abstract and text form.
The strength was taken for both the affected and unaffected side .The results table and text now clearly indicate which outcomes pertain to the affected or unaffected knee.

8. Results: more details need to be given in text of results for better readability and understanding.The results text has been expanded to provide a detailed narrative of the main findings, highlighting key p-values, effect sizes, and clinical relevance.

Discussion: Most discussions only discuss results. The mechanism of the CARE protocol, how is it comparable to the conventional exercise protocol, and how is it better than other protocols need to be discussed.
The discussion now explains the mechanism of the CARE-KOA© protocol, compares it to conventional protocols, and discusses its advantages. Discussion section, revised for clarity and detail.

Conclusion: This is not in line of the objective stated.
The conclusion has been revised to directly address each stated objective, summarize key findings, and discuss implications.
Competing Interests: No competing intrest Close
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COMMENTS ON THIS REPORT

Author Response 11 Sep 2025

Tina Dias, Kasturba Medical College Hospital, India

11 Sep 2025

Author Response

We thank you for your review.
1. Abstract: Background needs more details on CARE protocol and gap in literature; Methods does not mention the study design. Results need to be ... Continue reading We thank you for your review.
1. Abstract: Background needs more details on CARE protocol and gap in literature; Methods does not mention the study design. Results need to be more detailed with p values and effect sizes. Additionally results mentions affected and unaffected knees interpretation which is not explained in the methodology or table. Conclusion comments on biomechanical issues. which outcomes or tests assess the biomechanical problems is not clear.
The abstract has been revised to include a brief description of the CARE-KOA© protocol and the gap in literature regarding core-focused interventions. The study design (prospective, single-group, pre-post intervention) is now specified. Results now include p-values and effect sizes for each outcome. The interpretation of affected/unaffected knees is clarified in the results and methodology. The conclusion now specifies which outcomes (core endurance, physical function tests) assess biomechanical issues

2. Introduction: there is no clear introduction or overview given about this CARE protocol which is copyrighted. or developer or previous studies and how this protocol is different from the conventional protocols. The rationale needs to be stronger that connects specifically to CARE as this is the highlight of your study
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

3. Methodology: Considering your CARE protocol being highlight, this is very briefly explained. Intervention details of the CARE protocol is entirely missing. this grossly affects reproducibility by other authors. no images are added or tables. no progression of the protocol. Who is the developer? can add these as an annexure or table form and add few images. with references wherever needed/. Were both sides treated?
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

4. Methodology: Even the outcome measures have not been explained in the detail.
Each outcome measure (VAS, KOOS, 30STS, 40MFPW, SCT, TUG, core endurance, muscle strength) is now described in detail, including how and when they were measured.

5. Advise to authors to follow TiDiER checklist and CERT checklist to report the interventions and assessments. can easily find them on web browsers.
The manuscript now states that the study was reported in accordance with the TiDiER and CERT checklists. A supplementary table or annexure listing checklist compliance is included.

6. Results: Gender wise distribution is missing. Even grades of KOA distribution is not added. side affected and occupation etc can be added in demographic details.
The demographic table and text now include gender, KOA grade, affected side, and occupation.

7. Affected and unaffected side details are not there in the table if at all compared which is mentioned in the abstract and text form.
The strength was taken for both the affected and unaffected side .The results table and text now clearly indicate which outcomes pertain to the affected or unaffected knee.

8. Results: more details need to be given in text of results for better readability and understanding.The results text has been expanded to provide a detailed narrative of the main findings, highlighting key p-values, effect sizes, and clinical relevance.

Discussion: Most discussions only discuss results. The mechanism of the CARE protocol, how is it comparable to the conventional exercise protocol, and how is it better than other protocols need to be discussed.
The discussion now explains the mechanism of the CARE-KOA© protocol, compares it to conventional protocols, and discusses its advantages. Discussion section, revised for clarity and detail.

Conclusion: This is not in line of the objective stated.
The conclusion has been revised to directly address each stated objective, summarize key findings, and discuss implications.
We thank you for your review.
1. Abstract: Background needs more details on CARE protocol and gap in literature; Methods does not mention the study design. Results need to be more detailed with p values and effect sizes. Additionally results mentions affected and unaffected knees interpretation which is not explained in the methodology or table. Conclusion comments on biomechanical issues. which outcomes or tests assess the biomechanical problems is not clear.
The abstract has been revised to include a brief description of the CARE-KOA© protocol and the gap in literature regarding core-focused interventions. The study design (prospective, single-group, pre-post intervention) is now specified. Results now include p-values and effect sizes for each outcome. The interpretation of affected/unaffected knees is clarified in the results and methodology. The conclusion now specifies which outcomes (core endurance, physical function tests) assess biomechanical issues

2. Introduction: there is no clear introduction or overview given about this CARE protocol which is copyrighted. or developer or previous studies and how this protocol is different from the conventional protocols. The rationale needs to be stronger that connects specifically to CARE as this is the highlight of your study
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

3. Methodology: Considering your CARE protocol being highlight, this is very briefly explained. Intervention details of the CARE protocol is entirely missing. this grossly affects reproducibility by other authors. no images are added or tables. no progression of the protocol. Who is the developer? can add these as an annexure or table form and add few images. with references wherever needed/. Were both sides treated?
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

4. Methodology: Even the outcome measures have not been explained in the detail.
Each outcome measure (VAS, KOOS, 30STS, 40MFPW, SCT, TUG, core endurance, muscle strength) is now described in detail, including how and when they were measured.

5. Advise to authors to follow TiDiER checklist and CERT checklist to report the interventions and assessments. can easily find them on web browsers.
The manuscript now states that the study was reported in accordance with the TiDiER and CERT checklists. A supplementary table or annexure listing checklist compliance is included.

6. Results: Gender wise distribution is missing. Even grades of KOA distribution is not added. side affected and occupation etc can be added in demographic details.
The demographic table and text now include gender, KOA grade, affected side, and occupation.

7. Affected and unaffected side details are not there in the table if at all compared which is mentioned in the abstract and text form.
The strength was taken for both the affected and unaffected side .The results table and text now clearly indicate which outcomes pertain to the affected or unaffected knee.

8. Results: more details need to be given in text of results for better readability and understanding.The results text has been expanded to provide a detailed narrative of the main findings, highlighting key p-values, effect sizes, and clinical relevance.

Discussion: Most discussions only discuss results. The mechanism of the CARE protocol, how is it comparable to the conventional exercise protocol, and how is it better than other protocols need to be discussed.
The discussion now explains the mechanism of the CARE-KOA© protocol, compares it to conventional protocols, and discusses its advantages. Discussion section, revised for clarity and detail.

Conclusion: This is not in line of the objective stated.
The conclusion has been revised to directly address each stated objective, summarize key findings, and discuss implications.
Competing Interests: No competing intrest Close
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Reviewer Report 05 Jun 2025

Varun Naik, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Approved with Reservations

https://doi.org/10.5256/f1000research.179648.r387317

1. The widely cited ( refer to 1 ) on exercise for knee OA is missing.
2. No references from OARSI (Osteoarthritis Research Society International) guidelines are cited.
3. Procedure of of intervention should be clearly mentioned for replication ... Continue reading

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Fransen M, McConnell S, Harmer A, Van der Esch M, et al.: Exercise for osteoarthritis of the knee: a Cochrane systematic review. British Journal of Sports Medicine. 2015; 49 (24): 1554-1557 Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Physiotherapy Interventions

CITE

Report a concern

Author Response 11 Sep 2025

Tina Dias, Kasturba Medical College Hospital, India

11 Sep 2025

Author Response

Dear reviewer,
Thank you for the detailed review and comments. I have addressed the comments and provided clarifications where required
1. The widely cited (refer to 1) on exercise for ... Continue reading Dear reviewer,
Thank you for the detailed review and comments. I have addressed the comments and provided clarifications where required
1. The widely cited (refer to 1) on exercise for knee OA was missing.
Response:
Thank you for your observation. I incorporated the widely cited systematic review by Fransen et al. (BJSM, 2015) in both the Introduction and Discussion sections to strengthen the evidence base for exercise as a core intervention in knee osteoarthritis. This reference was cited when discussing the efficacy of exercise therapy in reducing pain and improving function in KOA, ensuring the manuscript reflected the most current and robust literature on this topic.

2. No references from OARSI (Osteoarthritis Research Society International) guidelines were cited.
Response:
Thank you for highlighting this important omission. I added a citation to the latest OARSI guidelines (Bannuru et al., Osteoarthritis Cartilage, 2019) in the Introduction and Discussion. This clarified that the intervention protocol aligned with internationally recognized recommendations for non-surgical management of knee OA, thereby reinforcing the clinical relevance and appropriateness of the exercise program used in this study.

3. Procedure of intervention should be clearly mentioned for replication of the intervention.
Response:
Thank you for your suggestion. I provided the detailed intervention as a supplementary file and uploaded it to the OSF repository to ensure full transparency and enable replication of the intervention by other researchers.

4. Conclusion not meeting the objectives of the study
Response:
Thank you for your feedback. I revised the Conclusion to explicitly address all stated objectives, summarizing the effects of the CARE-KOA program on pain, patient-reported outcomes, physical function, knee strength, and core endurance. The revised conclusion clearly stated how the findings supported the integration of core activation exercises into knee OA rehabilitation and included a statement on the need for further research with larger samples and longer follow-up to confirm these results.
Dear reviewer,
Thank you for the detailed review and comments. I have addressed the comments and provided clarifications where required
1. The widely cited (refer to 1) on exercise for knee OA was missing.
Response:
Thank you for your observation. I incorporated the widely cited systematic review by Fransen et al. (BJSM, 2015) in both the Introduction and Discussion sections to strengthen the evidence base for exercise as a core intervention in knee osteoarthritis. This reference was cited when discussing the efficacy of exercise therapy in reducing pain and improving function in KOA, ensuring the manuscript reflected the most current and robust literature on this topic.

2. No references from OARSI (Osteoarthritis Research Society International) guidelines were cited.
Response:
Thank you for highlighting this important omission. I added a citation to the latest OARSI guidelines (Bannuru et al., Osteoarthritis Cartilage, 2019) in the Introduction and Discussion. This clarified that the intervention protocol aligned with internationally recognized recommendations for non-surgical management of knee OA, thereby reinforcing the clinical relevance and appropriateness of the exercise program used in this study.

3. Procedure of intervention should be clearly mentioned for replication of the intervention.
Response:
Thank you for your suggestion. I provided the detailed intervention as a supplementary file and uploaded it to the OSF repository to ensure full transparency and enable replication of the intervention by other researchers.

4. Conclusion not meeting the objectives of the study
Response:
Thank you for your feedback. I revised the Conclusion to explicitly address all stated objectives, summarizing the effects of the CARE-KOA program on pain, patient-reported outcomes, physical function, knee strength, and core endurance. The revised conclusion clearly stated how the findings supported the integration of core activation exercises into knee OA rehabilitation and included a statement on the need for further research with larger samples and longer follow-up to confirm these results.
Competing Interests: No competing interests were disclosed. Close
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Respond or Comment

COMMENTS ON THIS REPORT

Author Response 11 Sep 2025

Tina Dias, Kasturba Medical College Hospital, India

11 Sep 2025

Author Response

Dear reviewer,
Thank you for the detailed review and comments. I have addressed the comments and provided clarifications where required
1. The widely cited (refer to 1) on exercise for ... Continue reading Dear reviewer,
Thank you for the detailed review and comments. I have addressed the comments and provided clarifications where required
1. The widely cited (refer to 1) on exercise for knee OA was missing.
Response:
Thank you for your observation. I incorporated the widely cited systematic review by Fransen et al. (BJSM, 2015) in both the Introduction and Discussion sections to strengthen the evidence base for exercise as a core intervention in knee osteoarthritis. This reference was cited when discussing the efficacy of exercise therapy in reducing pain and improving function in KOA, ensuring the manuscript reflected the most current and robust literature on this topic.

2. No references from OARSI (Osteoarthritis Research Society International) guidelines were cited.
Response:
Thank you for highlighting this important omission. I added a citation to the latest OARSI guidelines (Bannuru et al., Osteoarthritis Cartilage, 2019) in the Introduction and Discussion. This clarified that the intervention protocol aligned with internationally recognized recommendations for non-surgical management of knee OA, thereby reinforcing the clinical relevance and appropriateness of the exercise program used in this study.

3. Procedure of intervention should be clearly mentioned for replication of the intervention.
Response:
Thank you for your suggestion. I provided the detailed intervention as a supplementary file and uploaded it to the OSF repository to ensure full transparency and enable replication of the intervention by other researchers.

4. Conclusion not meeting the objectives of the study
Response:
Thank you for your feedback. I revised the Conclusion to explicitly address all stated objectives, summarizing the effects of the CARE-KOA program on pain, patient-reported outcomes, physical function, knee strength, and core endurance. The revised conclusion clearly stated how the findings supported the integration of core activation exercises into knee OA rehabilitation and included a statement on the need for further research with larger samples and longer follow-up to confirm these results.
Dear reviewer,
Thank you for the detailed review and comments. I have addressed the comments and provided clarifications where required
1. The widely cited (refer to 1) on exercise for knee OA was missing.
Response:
Thank you for your observation. I incorporated the widely cited systematic review by Fransen et al. (BJSM, 2015) in both the Introduction and Discussion sections to strengthen the evidence base for exercise as a core intervention in knee osteoarthritis. This reference was cited when discussing the efficacy of exercise therapy in reducing pain and improving function in KOA, ensuring the manuscript reflected the most current and robust literature on this topic.

2. No references from OARSI (Osteoarthritis Research Society International) guidelines were cited.
Response:
Thank you for highlighting this important omission. I added a citation to the latest OARSI guidelines (Bannuru et al., Osteoarthritis Cartilage, 2019) in the Introduction and Discussion. This clarified that the intervention protocol aligned with internationally recognized recommendations for non-surgical management of knee OA, thereby reinforcing the clinical relevance and appropriateness of the exercise program used in this study.

3. Procedure of intervention should be clearly mentioned for replication of the intervention.
Response:
Thank you for your suggestion. I provided the detailed intervention as a supplementary file and uploaded it to the OSF repository to ensure full transparency and enable replication of the intervention by other researchers.

4. Conclusion not meeting the objectives of the study
Response:
Thank you for your feedback. I revised the Conclusion to explicitly address all stated objectives, summarizing the effects of the CARE-KOA program on pain, patient-reported outcomes, physical function, knee strength, and core endurance. The revised conclusion clearly stated how the findings supported the integration of core activation exercises into knee OA rehabilitation and included a statement on the need for further research with larger samples and longer follow-up to confirm these results.
Competing Interests: No competing interests were disclosed. Close
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Version 4

VERSION 4 PUBLISHED 15 May 2025

Open Peer Review

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Version 4 (revision) 21 Jul 25	read	read
Version 3 (revision) 19 Jun 25		read
Version 2 (revision) 11 Jun 25
Version 1 15 May 25	read	read

Varun Naik, KAHER Institute of Physiotherapy, Belagavi, India
Peeyoosha Gurudut, KLEU Institute of Physiotherapy, Belagavi, India

Aarti Welling, KLE Academy of Higher Education & Research, Belagavi, India

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2 Views

11 Aug 2025 | for Version 4

Peeyoosha Gurudut, Department of Orthopedic Physiotherapy, KLEU Institute of Physiotherapy, Belagavi, Karnataka, India

Aarti Welling, Department of Orthopedic Physiotherapy, KLE Institute of Physiotherapy, KLE Academy of Higher Education & Research, Belagavi, Karnataka, India

2 Views Cite this report Responses(0)

Approved

I am glad to see the authors have incorporated all the changes and justified to all my comments. All the best with the journey.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Musculoskeletal, Physical therapy, Biomechanics, Kinesiotherapy, Physical treatments, aging, women

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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2 Views

11 Aug 2025 | for Version 4

Varun Naik, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

2 Views Cite this report Responses(0)

Approved

Previous revisions are corrected.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Knee Rehabilitation

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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9 Views

08 Jul 2025 | for Version 3

Peeyoosha Gurudut, Department of Orthopedic Physiotherapy, KLEU Institute of Physiotherapy, Belagavi, Karnataka, India

9 Views Cite this report Responses(1)

Approved With Reservations

Who performed measurements and assessment? how many times each measure was assessed? how many trials. was the assessor blinded? qualification of assessor? what are psychometric properties of the outcomes as in ICC value validity or reliability of tests.. References for the outcomes are missing too. need to be added.

A tabular format for CARE-KOA protocol is needed for clarity on FITT-PV. Who gave intervention? authors seem to not have referred to CERT guidelines or checklist. Its emphasized for better readership and reproducibility of the copyright material. In the present format I cannot apply CARE protocol on my patients.

I still don't see images or figures for the protocol

Justify including affected and unaffected sides. were they compared? If not then why unaffected side was assessed?

Other changes have been incorporated by the authors.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Musculoskeletal, Physical therapy, Biomechanics, Kinesiotherapy, Physical treatments, aging, women

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Author Response

10 Sep 2025

Tina Dias, Kasturba Medical College Hospital, India

1. Assessment and Measurement Procedures
Who performed the measurements and assessment?
All assessments were conducted by a trained assessor who was blinded to the intervention status of participants, following standardized protocols as described in prior literature.
How many times was each measure assessed?
Each outcome measure was assessed twice: at baseline (pre-intervention) and after the 4-week intervention (post-intervention).
How many trials per measure?
For muscle strength measurements, three trials were performed per muscle group, and the best value was recorded.
Was the assessor blinded?
Yes, the assessor was blinded to the intervention status of the participants.
Qualification of assessor?
Assessments and interventions were performed by a physiotherapist trained in the CARE-KOA protocol, with adequate knowledge of musculoskeletal rehabilitation and core activation strategies.
2. Psychometric Properties and References
All the psychometric properties and references have been added
3. CARE-KOA Protocol: FITT-PV Table
The table using the FITT protocol has been added
5. Images and Figures
Images and the tabular format of the protocol have been added to the manuscript.
6. Affected vs. Unaffected Side Assessment
Justification for Assessing Both Sides: Both affected and unaffected limbs were assessed for isometric strength to: Establish a baseline comparison within each participant for compensatory changes or asymmetries, which are clinically relevant in KOA rehabilitation.
Were sides compared?
Yes, results for both sides were reported, but only the affected side was targeted for intervention. The unaffected side served as an internal control to monitor changes due to the intervention or natural progression

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Competing Interests

No competing interests were disclosed.

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10 Views

14 Jun 2025 | for Version 1

Peeyoosha Gurudut, Department of Orthopedic Physiotherapy, KLEU Institute of Physiotherapy, Belagavi, Karnataka, India

10 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Musculoskeletal Physical therapy, Manual Therapy, Biomechanics or kinesiology, Kinesiotherapy, WOmen's health

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Author Response

11 Sep 2025

Tina Dias, Kasturba Medical College Hospital, India

We thank you for your review.
1. Abstract: Background needs more details on CARE protocol and gap in literature; Methods does not mention the study design. Results need to be more detailed with p values and effect sizes. Additionally results mentions affected and unaffected knees interpretation which is not explained in the methodology or table. Conclusion comments on biomechanical issues. which outcomes or tests assess the biomechanical problems is not clear.
The abstract has been revised to include a brief description of the CARE-KOA© protocol and the gap in literature regarding core-focused interventions. The study design (prospective, single-group, pre-post intervention) is now specified. Results now include p-values and effect sizes for each outcome. The interpretation of affected/unaffected knees is clarified in the results and methodology. The conclusion now specifies which outcomes (core endurance, physical function tests) assess biomechanical issues

2. Introduction: there is no clear introduction or overview given about this CARE protocol which is copyrighted. or developer or previous studies and how this protocol is different from the conventional protocols. The rationale needs to be stronger that connects specifically to CARE as this is the highlight of your study
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

3. Methodology: Considering your CARE protocol being highlight, this is very briefly explained. Intervention details of the CARE protocol is entirely missing. this grossly affects reproducibility by other authors. no images are added or tables. no progression of the protocol. Who is the developer? can add these as an annexure or table form and add few images. with references wherever needed/. Were both sides treated?
The methodology now includes a detailed description of the CARE-KOA© intervention, with a table and images in the annexure/supplementary materials. The protocol progression, session structure, and developer are clearly stated. It is clarified that only the affected knee was treated.

4. Methodology: Even the outcome measures have not been explained in the detail.
Each outcome measure (VAS, KOOS, 30STS, 40MFPW, SCT, TUG, core endurance, muscle strength) is now described in detail, including how and when they were measured.

5. Advise to authors to follow TiDiER checklist and CERT checklist to report the interventions and assessments. can easily find them on web browsers.
The manuscript now states that the study was reported in accordance with the TiDiER and CERT checklists. A supplementary table or annexure listing checklist compliance is included.

6. Results: Gender wise distribution is missing. Even grades of KOA distribution is not added. side affected and occupation etc can be added in demographic details.
The demographic table and text now include gender, KOA grade, affected side, and occupation.

7. Affected and unaffected side details are not there in the table if at all compared which is mentioned in the abstract and text form.
The strength was taken for both the affected and unaffected side .The results table and text now clearly indicate which outcomes pertain to the affected or unaffected knee.

8. Results: more details need to be given in text of results for better readability and understanding.The results text has been expanded to provide a detailed narrative of the main findings, highlighting key p-values, effect sizes, and clinical relevance.

Discussion: Most discussions only discuss results. The mechanism of the CARE protocol, how is it comparable to the conventional exercise protocol, and how is it better than other protocols need to be discussed.
The discussion now explains the mechanism of the CARE-KOA© protocol, compares it to conventional protocols, and discusses its advantages. Discussion section, revised for clarity and detail.

Conclusion: This is not in line of the objective stated.
The conclusion has been revised to directly address each stated objective, summarize key findings, and discuss implications.

View more View less

Competing Interests

No competing intrest

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Reviewer Report

13 Views

05 Jun 2025 | for Version 1

Varun Naik, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

13 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Partly

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Physiotherapy Interventions

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Responses (1)

Author Response

11 Sep 2025

Tina Dias, Kasturba Medical College Hospital, India

Dear reviewer,
Thank you for the detailed review and comments. I have addressed the comments and provided clarifications where required
1. The widely cited (refer to 1) on exercise for knee OA was missing.
Response:
Thank you for your observation. I incorporated the widely cited systematic review by Fransen et al. (BJSM, 2015) in both the Introduction and Discussion sections to strengthen the evidence base for exercise as a core intervention in knee osteoarthritis. This reference was cited when discussing the efficacy of exercise therapy in reducing pain and improving function in KOA, ensuring the manuscript reflected the most current and robust literature on this topic.

2. No references from OARSI (Osteoarthritis Research Society International) guidelines were cited.
Response:
Thank you for highlighting this important omission. I added a citation to the latest OARSI guidelines (Bannuru et al., Osteoarthritis Cartilage, 2019) in the Introduction and Discussion. This clarified that the intervention protocol aligned with internationally recognized recommendations for non-surgical management of knee OA, thereby reinforcing the clinical relevance and appropriateness of the exercise program used in this study.

3. Procedure of intervention should be clearly mentioned for replication of the intervention.
Response:
Thank you for your suggestion. I provided the detailed intervention as a supplementary file and uploaded it to the OSF repository to ensure full transparency and enable replication of the intervention by other researchers.

4. Conclusion not meeting the objectives of the study
Response:
Thank you for your feedback. I revised the Conclusion to explicitly address all stated objectives, summarizing the effects of the CARE-KOA program on pain, patient-reported outcomes, physical function, knee strength, and core endurance. The revised conclusion clearly stated how the findings supported the integration of core activation exercises into knee OA rehabilitation and included a statement on the need for further research with larger samples and longer follow-up to confirm these results.

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Effectiveness Of The Core Activation And Rehabilitation Exercises For Knee Osteoarthritis - Program (CARE -KOA©) Among Patients Diagnosed With Knee Osteoarthritis.

Abstract

Background

Objective

Methods/Design

Results

Conclusion

Study Trial Registration

Keywords

Introduction

Methods

Study design

Participant and setting

Procedure

Sample size determination and statistical analysis

Participant flow

Figure 1. CONSORT flow diagram.

Results

Table 1. Descriptive data for participants (n = 15).

Table 2. Comparison of pre- and post-intervention results on functional and clinical outcomes.

Discussion

Conclusion

Ethics and consent

Data availability

Extended data

References

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Effectiveness Of The Core Activation And Rehabilitation Exercises For Knee Osteoarthritis - Program (CARE -KOA^©) Among Patients Diagnosed With Knee Osteoarthritis.