IMPORTANCE: Exercise therapies are advocated in osteoarthritis (OA) clinical guidelines. However, challenges to accessing exercise may be limiting widespread uptake. OBJECTIVE: To evaluate the effects of a self-directed web-based strengthening exercise and physical activity program supported by automated behavior-change text messages on knee pain and function for people with knee OA. DESIGN, SETTING, AND PARTICIPANTS: The participant-blinded and assessor-blinded randomized clinical trial enrolled 206 people who met clinical criteria for knee OA in communities across Australia from July 2018 to August 2019, with follow-up taking place at 24 weeks. INTERVENTIONS: The control group was given access to a custom-built website with information on OA and the importance of exercise and physical activity. The intervention group was given access to the same information plus a prescription for a 24-week self-directed strengthening regimen and guidance to increase physical activity, supported by automated behavior-change text messages encouraging exercise adherence. MAIN OUTCOMES AND MEASURES: Primary outcomes were change in overall knee pain (numeric rating scale 0 to 10) and difficulty with physical function (Western Ontario and McMaster Universities Osteoarthritis Index 0 to 68) over 24 weeks. Secondary outcomes were another knee pain measure, sport and recreation function, quality of life, physical activity, self-efficacy, overall improvement, and treatment satisfaction. RESULTS: Of 206 participants, 180 (87%; mean (SD) age 60 (8.4) years; 109 (61%) women) completed both 24-week primary outcomes. The intervention group showed greater improvements in overall knee pain (mean difference 1.6 units; 95% CI 0.9 to 2.2 units; p < 0.001) and physical function (mean difference 5.2 units; 95% CI 1.9 to 8.5 units; p = 0.002) compared with the control. There was evidence of differences in the proportion of participants exceeding the minimal clinically important improvement in pain (intervention group 72.1% versus control 42.0%; risk difference 0.30 (95% CI 0.16 to 0.44); p < 0.001) and function (intervention group 68% versus control 40.8%; risk difference 0.27 (95% CI 0.13 to 0.41); p < 0.001) favoring the intervention. Between-group differences for all secondary outcomes favored the intervention except for physical activity, self-efficacy for function, and self-efficacy for exercise, for which there was no evidence of differences. CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that a self-directed web-based strengthening exercise regimen and physical activity guidance supported by automated behavior-change text messages to encourage exercise adherence improved knee pain and function at 24 weeks. This unsupervised, free-to-access digital intervention is an effective option to improve patient access to recommended OA exercise and/or to support clinicians in providing exercise management for people with knee OA at scale across the population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry identifier ACTRN12618001167257.

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