Telerehabilitation is non-inferior to usual care following total hip replacement - a randomized controlled non-inferiority trial

Effectiveness of Telerehabilitation Programs in Elderly with Hip or Knee Arthroplasty: A Systematic Review

Background: Lower limb osteoarthritis (OA) often generates musculoskeletal pain causing functional impairment and decreasing mobility, autonomy, and quality of life. Patients with OA are commonly prescribed specific care for total hip arthroplasty or total knee arthroplasty (THA or TKA), when patients present symptoms that are refractory to nondrug treatments. Currently, when patients are discharged from orthopedic surgery, they are either referred to a rehabilitation department, or sent directly home with assistance such as remote monitoring by teleconsultation or a mobile application. In recent years, there has been an evolution in digital health and in particular telerehabilitation. To determine utility and effectiveness, the aim of this systematic review was to highlight and evaluate different telerehabilitation programs using new information and communication technologies. Methods: Five databases, ScienceDirect, PubMed, Web of Sciences, Scopus, and Google scholar, were searched until 30 June 30, 2023. All studies written in English and meeting our inclusion criteria were included. Databases were screened for "Total Hip Arthroplasty," "Total Knee Arthroplasty," "Total Hip Replacement," "Total Knee Replacement," "Rehabilitation," "Physical Activity," "Physiotherapy," "Telerehabilitation," "Telecommunication*," "Senior*," and "Elderly" in accordance with PRISMA-ScR guideline. Results: Fourteen articles were selected according to inclusion criteria. Telerehabilitation was offered in seven different ways (video call, applications smartphones, website, etc.). Assessments included were mainly quality of life questionnaires, perceived effort after exercises, field surveys on the tool experience, and physical tests to assess motor functions. Conclusion: This review highlights the importance and relevance of evaluating the contributions and limits of new health technologies to improve patient monitoring and thus enable better remote clinical care.

Efficacy and safety of continuous nursing in improving functional recovery after total hip or knee arthroplasty in older adults: A systematic review

Objective

This systematic review was conducted to evaluate the efficacy and safety of continuous nursing care for the recovery of joint function in older adults with total hip or knee arthroplasty.

Methods

Randomized controlled trials and cohort studies of continuous nursing in older patients after joint replacement were searched from the database of Cochrane Library, Web of Science, PubMed, and Embase from their establishment to October 25, 2023. After literature screening, two researchers completed data extraction, and the risk of bias was assessed using the Cochrane risk-of-bias tool. The risk analysis included in cohort studies was based on the Newcastle-Ottawa Scale (NOS).

Results

The study included a total of 15 articles, comprising 34,186 knee and hip replacement patients. In this review, the effects of continuous nursing on the recovery of joint function of knee replacement and hip replacement in older adults were classified and discussed. Continuous nursing interventions targeted for total hip replacement could greatly increase the range of joint mobility, enhance muscle strength during hip movements like flexion, extension, and abduction, maintain joint stability, relieve pain, improve daily activities, and lower the risk of complications. For older patients with knee arthroplasty, continuous nursing programs could markedly improve knee motion range, joint flexion, joint stability, daily activities, and pain management. Despite the implementation of interventions, the incidence of complications caused by total knee replacement did not decrease. Out of all the studies reviewed, only one used a theoretical framework for interventions provided to patients during the postoperative period of hip arthroplasty. The overall quality of the included studies was very high.

Conclusion

Continuous nursing can effectively improve the joint function of older patients after joint replacement. However, its effectiveness in terms of clinical outcomes, patient satisfaction, and medical cost of associated continuous nursing needs to be further clarified. In addition, continuous nursing has no significant advantage in the safety of postoperative complications and readmission rates in older adults after knee joint replacement. To enhance the efficacy and safety of continuous nursing effectively, it is crucial to refine the continuous nursing program in the future, thereby elevating the quality of nursing services.

Demystifying the Digital Divide: Disparities in Telerehabilitation Readiness Among Older Adults in the United States

OBJECTIVE

To estimate readiness of older rehabilitation users in the United States to participate in video-based telerehabilitation and assess disparities in readiness among racial and ethnic minoritized populations, socioeconomically disadvantaged populations, and rural-dwelling older adults.

DESIGN

Retrospective cohort study using nationally representative survey data from the National Health and Aging Trends Study from 2015 and 2020. Survey-weighted regression models, accounting for complex survey design, were used to generate estimates of readiness and evaluate disparities across racial and ethnic, socioeconomic, and geographic subgroups. Odds ratios (OR) and 95% confidence intervals (CIs) were estimated for each comparison.

SETTING

Home or community rehabilitation environments.

PARTICIPANTS

A cohort of 5274 home or community-based rehabilitation users aged 70 years or older (N=5274), representing a weighted 33,576,313 older adults in the United States.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Video-based telerehabilitation readiness was defined consistent with prior work; unreadiness was defined as lacking ownership of internet-enabled devices, limited proficiency of use, or living with severe cognitive, visual, or hearing impairment. Telerehabilitation readiness was categorized as "Ready" or "Unready".

RESULTS

Approximately 2 in 3 older rehabilitation users were categorized as ready to participate in video-based rehabilitation. Significantly lower rates of readiness were observed among those living in rural areas (OR=0.75, 95% CI: 0.60-0.94), financially strained individuals (OR=0.37, 95% CI: 0.26-0.53), and among individuals identifying as Black or Hispanic (as compared with non-Hispanic White older adults: Non-Hispanic Black [OR=0.23, 95% CI: 0.18-0.30]; Hispanic [OR=0.17, 95% CI: 0.11, 0.27]).

CONCLUSIONS

Our findings highlight significant disparities in the readiness to uptake video-based telerehabilitation. Policy and practice interventions to address telerehabilitation readiness should focus not only on improving broadband access but also on technology ownership and training to ensure equitable adoption in populations with lower baseline readiness.

The Effectiveness of Telerehabilitation for Functional Recovery After Orthopedic Surgery: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review is to evaluate the effectiveness of physiotherapy treatment provided remotely via the Internet in the postoperative treatment of orthopedic patients and compare it with standard physiotherapy (face-to-face treatment or home-based treatment) in terms of motor performance, pain symptoms, and functional recovery.

Methods

A systematic search of MEDLINE, Physiotherapy Evidence Database; EMBASE, SCOPUS, and CINHAL was conducted. Two independent reviewers performed study selection, data extraction, risk of bias (ROB) assessment using Cochrane ROB 2 tools, and summarize the results by Grading of Recommendations Assessment, Development, and Evaluation.

Results

Eleven randomized controlled trial were selected. Pooled results showed improvement in motor performance in favor of the telerehabilitation group at 4-6 weeks (standardized mean difference -0.24, 95% confidence interval -0.45, -0.02, p = 0.03), and these differences were close to the minimum clinically important difference for Time Up and Go test. For pain and functional recovery, the results showed differences not statistically important. The certainty of evidence ranged from moderate to very low.

Conclusion

For joint replacement patients, treatment conducted via telerehabilitation appears able to provide levels of motor performance better to that achieved through home-based treatment. In contrast, conclusive evidence that telerehabilitation is comparable to standard face-to-face treatment are not available.

AVIP Project (Prosthetic Virtual Friend): Study of clinical-functional outcomes and satisfaction with a mobile application in the perioperative management and follow-up of hip arthroplasty

OBJECTIVE

To analyze the clinical, quality of life, and healthcare quality outcomes obtained in a series of patients undergoing total hip arthroplasty (THA), who were empowered and monitored using the AVIP application. These results will be compared with a control group followed through a standard protocol.

MATERIAL AND METHOD

Randomized clinical trial with parallel groups involving patients with an indication for THA. Clinical variables were measured and compared using the WOMAC and mHHS, pain assessed by the VAS, quality of life with the SF-12 test. Walking capabilities were analyzed using the Functional Gait Assessment Scale, along with satisfaction levels assessed through the SUCE questionnaire, and perceived anxiety levels related to the process.

RESULTS

A total of 68 patients were evaluated, with 31 patients in the AVIP group and 33 in the Control group completing the follow-up. Both groups demonstrated improvement in clinical outcomes based on the WOMAC and mHHS hip tests, a reduction in perceived pain, and an enhancement in quality of life according to the SF-12 test. Patients in the AVIP study group exhibited non-inferiority in clinical outcomes and satisfaction compared to the control group, as well as lower anxiety levels and improved walking capabilities after the first month of follow-up. Notably, 82.25% of the follow-up visits for this group were conducted remotely.

CONCLUSION

The implementation of a mHealth application like AVIP can be safely offered to selected patients undergoing hip arthroplasty, enabling effective monitoring and providing continuous information and training.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Effectiveness and cost-effectiveness of telerehabilitation for musculoskeletal disorders: A systematic review and meta-analysis

BACKGROUND

Internet-based telerehabilitation could be a valuable option for the treatment of musculoskeletal disorders, with the advantage of providing rehabilitation from anywhere. However, there is no solid and updated evidence demonstrating its effectiveness on relevant clinical and cost outcomes.

OBJECTIVE

This systematic review aims to determine the clinical and cost-effectiveness of internet-based telerehabilitation during the recovery of musculoskeletal disorders.

METHODS

Medline, Web of Science, Scopus and Cochrane databases were systematically searched from inception to June 2023. Trials investigating the effects of internet-based telerehabilitation in any musculoskeletal disorder were selected. Nonoriginal articles and grey literature were excluded. Two independent reviewers conducted the study selection and data extraction. Random effect meta-analyses (standardized mean difference) and further sensitivity analyses were performed.

RESULTS

We selected 37 clinical trials (33 randomized and 4 non-randomized) and 5 health economics studies, which included a total of 4,288 participants. Telerehabilitation was more favourable than control treatments in improving all studied clinical outcomes, although the effectiveness varied depending on the type of musculoskeletal disorder. The standard mean differences (SMD) ranged from 0.24 to 0.91. For physical function, the primary outcome, superior effectiveness was found only in people with hip fractures (SMD, 0.87; 95 % CI, 0.34 to 1.41). The effects for joint replacement, osteoarthritis, and spine pain were similar to those of control treatments. However, the favourable outcomes for telerehabilitation became insignificant when compared specifically to face-to-face rehabilitation. Some results displayed publication bias and a lack of robustness, necessitating cautious interpretation. In terms of health economics studies, telerehabilitation was 89.55$ (95 % CI 4.6 to 174.5) cheaper per individual than conventional treatments.

CONCLUSIONS

Telerehabilitation should be considered in the recovery process of musculoskeletal disorders when optimal face-to-face rehabilitation is not feasible. Moreover, telerehabilitation reduces costs and time.

PROSPERO NUMBER

CRD42022322425.

Effects of Digital Physical Health Exercises on Musculoskeletal Diseases: Systematic Review With Best-Evidence Synthesis

BACKGROUND

Musculoskeletal diseases affect 1.71 billion people worldwide, impose a high biopsychosocial burden on patients, and are associated with high economic costs. The use of digital health interventions is a promising cost-saving approach for the treatment of musculoskeletal diseases. As physical exercise is the best clinical practice in the treatment of musculoskeletal diseases, digital health interventions that provide physical exercises could have a highly positive impact on musculoskeletal diseases, but evidence is lacking.

OBJECTIVE

This systematic review aims to evaluate the impact of digital physical health exercises on patients with musculoskeletal diseases concerning the localization of the musculoskeletal disease, patient-reported outcomes, and medical treatment types.

METHODS

We performed systematic literature research using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was conducted using the PubMed, BISp, Cochrane Library, and Web of Science databases. The Scottish Intercollegiate Guidelines Network checklist was used to assess the quality of the included original studies. To determine the evidence and direction of the impact of digital physical health exercises, a best-evidence synthesis was conducted, whereby only studies with at least acceptable methodological quality were included for validity purposes.

RESULTS

A total of 8988 studies were screened, of which 30 (0.33%) randomized controlled trials met the inclusion criteria. Of these, 16 studies (53%) were of acceptable or high quality; they included 1840 patients (1008/1643, 61.35% female; 3 studies including 197 patients did not report gender distribution) with various musculoskeletal diseases. A total of 3 different intervention types (app-based interventions, internet-based exercises, and telerehabilitation) were used to deliver digital physical health exercises. Strong evidence was found for the positive impact of digital physical health exercises on musculoskeletal diseases located in the back. Moderate evidence was found for diseases located in the shoulder and hip, whereas evidence for the entire body was limited. Conflicting evidence was found for diseases located in the knee and hand. For patient-reported outcomes, strong evidence was found for impairment and quality of life. Conflicting evidence was found for pain and function. Regarding the medical treatment type, conflicting evidence was found for operative and conservative therapies.

CONCLUSIONS

Strong to moderate evidence was found for a positive impact on musculoskeletal diseases located in the back, shoulder, and hip and on the patient-reported outcomes of impairment and quality of life. Thus, digital physical health exercises could have a positive effect on a variety of symptoms of musculoskeletal diseases.

Effectiveness of strategies to improve adherence to physical therapy in patients with knee and hip osteoarthritis: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of current strategies oriented to increase adherence to physical therapy in subjects with knee and hip osteoarthritis (OA).

MATERIAL AND METHODS

A systematic review of electronic databases was conducted from inception until March 2023. Studies with experimental interventions using strategies to increase adherence to physical therapy programs in subjects with knee or hip OA were included. A meta-analysis compared the effects of such interventions with usual care for adherence-related measures (primary outcome), and functional and pain outcomes, using standardized mean differences (SMD) with a 95% confidence interval (CI). GRADE was used to determine the strength of the resultant evidence and the external validity of the findings.

RESULTS

Fifteen articles, assessing 1,818 participants, were included. The interventions included cognitive-behavior strategies, telephone calls, internet-based interventions, communication technologies, and booster sessions. A meta-analysis revealed that the experimental interventions increased adherence over usual care with a moderate effect size of SMD = 0.39 (95%CI = 0.08-0.71) and moderate certainty in this evidence.

CONCLUSION

Overall, this review supports that the strategies to promote adherence to physical therapy in individuals with knee and hip OA are effective. However, the positive impact on adherence rates does not always translate into improved clinical outcomes.

Effectiveness of tele-rehabilitation after total hip replacement: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

To identify articles that evaluated the efficacy of tele-rehabilitation after total hip replacement and to provide a reference for clinical decision-making and continuous improvement of rehabilitation exercise intervention strategies for clinical medical staff.

METHODS

Embase, PubMed, Web of Science, Medline, China National Knowledge Network and Google Scholar databases were searched for randomized controlled trials of tele-rehabilitation after total hip replacement from inception to March 4, 2023. The two researchers used the PEDro scale to assess the methodological quality of the included studies. Two researchers used the PEDro scale to assess the methodological quality of the included studies.

RESULTS

Ten studies with 632 participants were analysed.Compared to face-to-face rehabilitation, Internet-based telerehabilitation showed better outcomes in Get-up and go test (SMD -0.54, 95% CI -0.79 to -0.29). telerehabilitation showed no significant difference in outcomes of other functional tests and functional questionnaires.

CONCLUSION

In this systematic review and meta-analysis, internet-based tele-rehabilitation and face-to-face rehabilitation had the same effect on patients after total hip replacement, and compliance was higher in the tele-rehabilitation group, but attention should be devoted to standardizing this form of rehabilitation to avoid adverse events. In addition, the number and quality of included studies in this study are limited, and the outcome indicators and intervention means have not been unified. More high-quality studies are needed to verify these conclusions to better evaluate the effectiveness and advantages of telerehabilitation.Implications for rehabilitationWith the development of science and technology, remote rehabilitation technology will be applied to various fields of rehabilitation, providing personalized and extensive rehabilitation services.The application of tele-rehabilitation technology to postoperative rehabilitation after total hip arthroplasty is feasible and can reduce the workload of healthcare professionals to a certain extent.This review evaluated the randomized controlled trials of telerehabilitation after total hip arthroplasty, and the results showed that the clinical efficacy of telerehabilitation after total hip arthroplasty was not inferior to that of traditional rehabilitation.

Effects of technology-assisted rehabilitation for patients with hip arthroplasty: A meta-analysis

BACKGROUND

To investigate the efficacy of technology-assisted rehabilitation compared to that of usual care programs after total hip arthroplasty (THA) through randomized controlled trials (RCTs).

METHODS

The Medline (PubMed), Cochrane Library, Embase and Web of Science databases were searched for RCTs regarding the efficacy of technology-assisted rehabilitation following THA. Data were analyzed using Stata 12.0 software.

RESULTS

Eleven RCTs involving 1327 patients were included in the meta-analysis. The pooled effect size showed that compared to usual care, telerehabilitation significantly improved the Harris score (standardized mean difference [SMD] 0.74, 95% confidence interval [CI] 0.58 to 0.90) and functional independence measure (FIM) score (SMD 1.26, 95% CI 0.48 to 2.03). In addition, video-based therapy could significantly improve walk test results (SMD 0.43, 95% CI 0.11 to 0.75).

CONCLUSION

The findings suggest that technology-assisted rehabilitation, especially telerehabilitation, have been shown to improve the physical function of patients following THA compared to conventional rehabilitation. More robust studies are needed to validate the long-term efficacy and safety of innovative technology-assisted training strategies.

Rehabilitation Phases, Precautions, and Mobility Goals Following Total Hip Arthroplasty

The prevalence of total hip arthroplasty (THA) for advanced hip osteoarthritis (OA) is both increasing and shifting toward a younger average age. However, THA alone does not typically normalize function in these patients. Postoperative rehabilitation is often recommended to optimize joint motion, strength, and function. To date, there are no peer-reviewed clinical practice guidelines for postoperative rehabilitation following THA. Thus, optimal postoperative rehabilitation requires consideration of the existing literature and clinical expertise. This review article summarizes current recommendations for postoperative management of THA, including phases of rehabilitation, postoperative hip precautions, the effect of rehabilitation setting and mode of delivery on postoperative outcomes, and gait mechanics.

Regional vs global physical therapy interventions to treat chronic pain in survivors of trauma: a randomized controlled trial

BACKGROUND

A history of traumatic life events is associated with chronic pain in later life. Physical therapists utilize a variety of methods to treat pain, however, they have struggled to find effective interventions to improve patient outcomes.

OBJECTIVE

To compare impairment-based, regional (REGION-PT) physical therapy (PT) to a global (GLOBAL-PT) model consisting of pain neuroscience education, graded motor imagery, and exercise for adults with chronic pain and history of trauma.

DESIGN

Randomized Controlled Trial.

METHODS

Adults ≥ 18 years of age with chronic pain and a history of ≥1 trauma identified through the Life Events Checklist received the allocated intervention once a week for six weeks. Treatment effects were assessed using linear mixed models.

RESULTS

Ninety-eight participants completed the trial. There were no difference in outcomes between groups. There were significant interactions between race and intervention. Both interventions were associated with improvements in pain interference for white participants, but non-white participants experienced improvement only with GLOBAL-PT. Regardless of allocation, participants improved in physical function, six of the PROMIS-29 domains, and in pain interference measures.

CONCLUSION

Both interventions are reasonable strategies for individuals with chronic pain and a history of trauma.

Patient satisfaction with telehealth vs in-person hand therapy: A retrospective review of results of an online satisfaction survey

BACKGROUND

The COVID-19 pandemic necessitated a shift from in-person to telehealth visits in many outpatient rehabilitation facilities.

PURPOSE

To determine whether patients reported similar levels of satisfaction receivingtelehealth hand therapy as when receiving in-person hand therapy.

STUDY DESIGN

Retrospective review of patient satisfaction surveys.

METHODS

Satisfaction surveys were reviewed retrospectively among patients who participated in in-person hand therapy between April 21 and October 21, 2019, or after participating in telehealth hand therapy between April 21 and October 21, 2020. Information on gender, age, insurance provider, postoperative status and comments were also collected. Kruskal-Wallis tests were used to compare survey scores between groups. Chi -squared tests were used to compare categorical patient characteristics between groups.

RESULTS

A total of 288 surveys were included: 121 surveys for in-person evaluations, 53 surveys for in-person follow-up visits, 55 surveys for telehealth evaluations and 59 surveys for telehealth follow-up visits. No significant differences in satisfaction were observed between in-person and telehealth visits of either type or when patients were stratified by age (p = 0.78), gender (p = 0.41), insurance payer group (p = 0.099) or postoperative status (p = 0.19).

CONCLUSIONS

Similar rates of satisfaction were observed with both in-person visits and telehealth hand therapy visits. Questions that related to registration and scheduling tended to score lower across all groups, while questions related to technology scored lower in the telehealth groups. Future studies are needed to explore the efficacy and viability of a telehealth platform for hand therapy services.

Postoperative rehabilitation using a digital healthcare system in patients with total knee arthroplasty: a randomized controlled trial

INTRODUCTION

Digital healthcare systems based on augmented reality (AR) show promise for postoperative rehabilitation. We compared the effectiveness of AR-based rehabilitation and conventional rehabilitation after total knee arthroplasty (TKA).

MATERIALS AND METHODS

We randomly allocated 56 participants to digital healthcare rehabilitation group (DR group) and conventional rehabilitation group (CR group). Participants in the CR group performed brochure-based home exercises for 12 weeks, whereas those in the DR group performed AR-based home exercises that showed each motion on a monitor and provided real-time feedback. The primary outcome was change in 4-m gait speed. The secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, health-related quality of life [assessed by the EuroQoL 5-Dimension 5-Level (EQ5D5L) questionnaire], pain [measured using a numeric rating scale (NRS)], Berg Balance Scale (BBS), range of motion (ROM), and muscle strength. Outcomes were measured at baseline (T0) and 3 (T1), 12 (T2), and 24 (T3) weeks after randomization.

RESULTS

There was no significant difference in baseline characteristics of participants between two groups, except age and body mass index. No group difference was observed in 4-m gait speed (0.37 ± 0.19 and 0.42 ± 0.28 for the DR and CR groups, respectively; p = 0.438). The generalized estimating equation model revealed no significant group by time interaction regarding for 4-m gait speed, WOMAC, EQ5D5L, NRS, BBS, ROM, and muscle strength score. All outcomes were significantly improved in both groups (p < 0.001).

CONCLUSION

The use of a digital healthcare system based on AR improved the functional outcomes, pain, and quality of life of patients after TKA. AR-based rehabilitation may be useful treatment as an alternative to conventional rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov (identifier: NCT04513353). Registered on August 9, 2020. http://clinicaltrials.gov/ct2/show/NCT04513353 .

The role of telemedicine in joint replacement surgery? An updated review

The usage of telemedicine and telehealth services has grown tremendously and has become increasingly relevant and essential. Technological advancements in current telehealth services have supported its use as a viable alternative tool to conduct visits for consultations, follow-up, and rehabilitation in total joint arthroplasty. Such technology has been widely implemented, particularly during the coronavirus 2019 (COVID-19) pandemic, to deliver postoperative rehabilitation among patients receiving total joint arthroplasty (TJA), further demonstrating its feasibility with a lower cost yet comparable clinical outcomes when compared with traditional care. There remains ample potential to utilize telemedicine for prehabilitation to optimize the preoperative status and postoperative outcomes of patients with osteoarthritis. In this review, various implementations of telemedicine within total joint arthroplasty and future application of telemedicine to deliver tele-prehabilitation in TJA are discussed.

A randomized controlled trial of postoperative rehabilitation using digital healthcare system after rotator cuff repair

A digital healthcare system based on augmented reality (AR) has promising uses for postoperative rehabilitation. We compare effectiveness of AR-based and conventional rehabilitation in patients after rotator cuff repair (RCR). This study randomly allocates 115 participants who underwent RCR to digital healthcare rehabilitation group (DR group) and conventional rehabilitation group (CR group). The DR group performs AR-based home exercises using UINCARE Home+, whereas the CR group performs brochure-based home exercises. The primary outcome is a change in the Simple Shoulder Test (SST) score between baseline and 12 weeks postoperatively. The secondary outcomes are the Disabilities of the Arm, Shoulder and Hand (DASH) score; Shoulder Pain And Disability Index (SPADI) score; EuroQoL 5-Dimension 5-Level (EQ5D5L) questionnaire score; pain; range of motion (ROM); muscle strength; and handgrip strength. The outcomes are measured at baseline, and at 6, 12, and 24 weeks postoperatively. The change in SST score between baseline and 12 weeks postoperatively is significantly greater in the DR group than in the CR group (p = 0.025). The SPADI, DASH, and EQ5D5L scores demonstrate group×time interactions (p = 0.001, = 0.04, and = 0.016, respectively). However, no significant differences over time are observed between the groups in terms of pain, ROM, muscle strength, and handgrip strength. The outcomes show significant improvement in both groups (all p < 0.001). No adverse events are reported during the interventions. AR-based rehabilitation shows better improvement in terms of shoulder function after RCR compared to conventional rehabilitation. Therefore, as an alternative to the conventional rehabilitation, the digital healthcare system is effective for postoperative rehabilitation.

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Engagement and Utilization of a Complete Remote Digital Care Program for Musculoskeletal Pain Management in Urban and Rural Areas Across the United States: Longitudinal Cohort Study

BACKGROUND

Musculoskeletal (MSK) conditions are the number one cause of disability worldwide. Digital care programs (DCPs) for MSK pain management have arisen as alternative care delivery models to circumvent challenges in accessibility of conventional therapy. Despite the potential of DCPs to reduce inequities in accessing care, the outcomes of such interventions in rural and urban populations have yet to be studied.

OBJECTIVE

The aim of this study was to assess the impact of urban or rural residency on engagement and clinical outcomes after a multimodal DCP for MSK pain.

METHODS

This study consists of an ad hoc analysis of a decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were coded according to their zip codes to a specific rural-urban commuting area code and grouped into rural and urban cohorts. Changes in their engagement and clinical outcomes from baseline to program end were assessed. Latent growth curve analysis was performed to estimate change trajectories adjusting for the following covariates: age, gender, BMI, employment status, and pain acuity. Outcomes included engagement, self-reported pain, and the results of the Generalized Anxiety Disorder 7-item, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment scales. A minimum clinically important difference (MCID) of 30% was considered for pain.

RESULTS

Patients with urban and rural residency across the United States participated in the program (n=9992). A 73.8% (7378/9992) completion rate was observed. Both groups reported high satisfaction scores and similar engagement with exercise sessions, with rural residents showing higher engagement with educational content (P<.001) and higher program completion rates (P=.02). All groups showed a significant improvement in all clinical outcomes, including pain, mental health, and work productivity, without statistically significant intergroup differences. The percentage of patients meeting the MCID was similar in both groups (urban: 67.1%, rural: 68.3%; P=.30).

CONCLUSIONS

This study advocates for the utility of a DCP in improving access to MSK care in urban and rural areas alike, showcasing its potential to promote health equity. High engagement, satisfaction, and completion rates were noted in both groups, as well as significant improvements in clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

Telerehabilitation as a Therapeutic Exercise Tool versus Face-to-Face Physiotherapy: A Systematic Review

Digital physiotherapy, often referred to as "Telerehabilitation", consists of applying rehabilitation using telecommunication technologies. The objective is to evaluate the effectiveness of therapeutic exercise when it is telematically prescribed.

METHODS

We searched PubMed, Embase, Scopus, SportDiscus and PEDro (30 December 2022). The results were obtained by entering a combination of MeSH or Emtree terms with keywords related to telerehabilitation and exercise therapy. RCTs on patients over 18 years and two groups were included, one working with therapeutic exercise through telerehabilitation and one working with conventional physiotherapy group.

RESULTS

a total of 779 works were found. However, after applying the inclusion criteria, only 11 were selected. Telerehabilitation is most frequently used to treat musculoskeletal, cardiac and neurological pathologies. The preferred telerehabilitation tools are videoconferencing systems, telemonitoring and online platforms. Exercise programs ranged from 10 to 30 min and were similar in both intervention and control groups. In all the studies, results proved to be similar for telerehabilitation and face-to-face rehabilitation in both groups when measuring functionality, quality of life and satisfaction.

CONCLUSION

this review generally concludes that intervention through telerehabilitation programs is as feasible and efficient as conventional physiotherapy in terms of functionality level and quality of life. In addition, telerehabilitation shows high levels of patients' satisfaction and adherence, being values equivalent to traditional rehabilitation.

The effectiveness of a mobile application-based programme for rehabilitation after total hip or knee arthroplasty: A randomised controlled trial

BACKGROUND

Total hip arthroplasty and total knee arthroplasty are widely performed worldwide. Patients undergoing total hip or knee arthroplasty are often discharged after a short hospital stay. Using information and communication technologies, such as mobile applications, to provide rehabilitation services remotely may be a strategy to support patients' postoperative recovery.

OBJECTIVE

This study aimed to evaluate the effectiveness of a rehabilitation programme delivered via a mobile application among Chinese patients after total hip or knee arthroplasty.

DESIGN

Randomised controlled trial.

SETTING

A teaching hospital in Shanghai, China.

PARTICIPANTS

Eighty-six patients who received a unilateral primary total hip or knee arthroplasty.

METHODS

The participants were recruited in the hospital and randomised into either the experimental or control group. Once discharged from the hospital, the control group (n = 43) received usual care, and the experimental group (n = 43) received usual care plus a 6-week mobile rehabilitation programme. Outcomes were assessed three times: the day before hospital discharge and 6 and 10 weeks after discharge. Primary outcomes were the changes in scores of self-efficacy and patient-reported physical function from baseline to 6 weeks post-discharge. Secondary outcomes included changes in scores of pain, depression, anxiety, and health-related quality of life. Data were analysed using generalised estimating equations.

RESULTS

At 6 weeks after hospital discharge, the experimental group showed statistically significant improvements compared to the control in scores of self-efficacy (adjusted mean difference = 0.72, 95% CI 0.31 to 1.14, P < .001) and patient-reported physical function (adjusted mean difference = 4.57, 95% CI 1.24 to 7.90, P = .007). The between-group difference in self-efficacy probably reached clinical significance. At week-10 follow-up, the experimental group had statistically significant improvements in scores of self-efficacy (adjusted mean difference = 0.64, 95% CI 0.33 to 0.95, P < .001), health-related quality of life (adjusted mean difference = 0.06, 95% CI 0.01 to 0.10, P = .018), anxiety (adjusted mean difference = -0.51, 95% CI -0.91 to -0.10, P = .015), and depression (adjusted mean difference = -0.37, 95% CI -0.66 to -0.08, P = .012). The between-group difference in self-efficacy and health-related quality of life may be clinically significant.

CONCLUSION

Mobile application-based rehabilitation demonstrated potentially positive effects on patients' self-efficacy, patient-reported physical function, health-related quality of life, and levels of anxiety and depression.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry on 6 July 2021 (ACTRN12621000867897).

A six-week physical therapy exercise program delivered via home-based telerehabilitation is comparable to in-person programs for patients with burn injuries: A randomized, controlled, non-inferiority clinical pilot trial

BACKGROUND

Exercise programmes are essential for burn rehabilitation, however patients often have barriers accessing these services. Home-based telerehabilitation (HBT) may be an alternative. This study aimed to determine if exercise programs delivered via HBT were as effective as in-person (IP) programs with respect to clinical outcomes and participant and therapist satisfaction.

METHODS

A single center, randomized, controlled, non-inferiority pilot trial with blinded assessment was undertaken. Forty-five adults with ≤ 25% total body surface area (TBSA) burns were randomized to receive a 6-week exercise program delivered either by HBT or IP. The primary outcome was burn-specific quality of life (Burn Specific Health Scale - Brief). Secondary outcomes included health-related quality of life, burn scar-specific outcomes, exercise self-efficacy, pain severity, muscle strength and range of motion (ROM). Participant and therapist satisfaction, technical disruptions and adverse events were also recorded.

RESULTS

We found no significant within- or between-group differences for any outcome measures except ROM. Achievement of full ROM was significantly different between groups at Week 12 (IP=100% vs HBT=70%, p = 0.005). Non-inferiority was inconclusive. Participant satisfaction was high (median ≥ 9.8/10), with no significant between-group differences. Therapist satisfaction was high (median ≥ 8.9/10), major technical disruptions low (8%) and no adverse events reported.

CONCLUSION

HBT is a safe, effective option to deliver exercise programs for patients with burn injuries ≤ 25% TBSA with comparable clinical outcomes to in-person programmes. Ongoing research is required to further analyze ROM and investigate the effectiveness of HBT for patients with larger burns.

Transition to a virtual model of physiotherapy and exercise physiology in response to COVID-19 for people in a rural Australia: Is it a viable solution to increase access to allied health for rural populations?

Virtual healthcare has the potential to increase access to allied health for people living in rural areas, but challenges in delivery of such models have been reported. The COVID-19 pandemic provided an opportunity for a rural practice of physiotherapists and exercise physiologists to transition service delivery to a virtual model of care which utilised a combination of phone, video, an exercise app and/or paper handouts. This study aimed to evaluate the uptake and outcomes from virtual delivery of allied health services, and to describe patient and clinician experiences of the virtual model of care. A parallel convergent mixed methods study was conducted. De-identified data from patients who were offered the virtual service between 15 March 2020 and 30 September 2020 were extracted from the database of the rural practice, as were data from patients attending the practice in-person during the same time in 2019 to serve as a historical comparison. De-identified data from a monthly survey tracking clinician experiences of delivering care virtually was also obtained from the practice. Quantitative data were presented descriptively. Between-group differences were compared using independent samples t-tests, and within-group longitudinal changes compared using paired t-tests. Semi-structured interviews were conducted among a purposive sample of patients using the virtual service, and focus groups conducted among clinicians providing this model of care. Qualitative data were recorded and transcribed verbatim, then thematic analysis conducted. During the study period, the practice delivered 4% (n = 242) consultations virtually. Thirty-seven of the 60 patients (62%) using the virtual service were new referrals. Patients attended fewer sessional appointments virtually and a smaller proportion of patients reported high satisfaction with virtual care, compared to those who received in-person care the previous year (p < .05). Clinician confidence in delivering virtual care did not change significantly over time (p>.05), though clinicians not providing virtual care in a given month perceived their lower confidence than those who did provide virtual care (p < .05). Five themes influencing the success of virtual allied health provision emerged from patient interviews and clinician focus groups: adaptation of program elements for virtual delivery, conduct of virtual treatment, clinician flexibility, patient complexity and communication. The theme of communication influenced all the other themes. Virtual healthcare is a potential solution to address lack of access to allied health practitioners in rural areas, but may not suit all patients. Establishing a therapeutic relationship and ensuring people have access to adequate resources prior to virtual care delivery will optimise successful adoption of virtual care models. A hybrid model incorporating limited in-person consultations with virtual consultations appears a more viable option.

Sleep Disturbance in Musculoskeletal Conditions: Impact of a Digital Care Program

Background

Musculoskeletal (MSK) pain is highly prevalent worldwide, resulting in significant disability, and comorbid sleep disturbances. Digital therapy for MSK pain can provide significant improvements in care access, alongside pain and disability reductions. However, studies on the effect of such programs on sleep are lacking.

Purpose

To evaluate the impact on pain-related sleep impairment after a 12-week remote multimodal digital care program (DCP) for MSK conditions.

Patients and Methods

This is an ad-hoc analysis of a decentralized single-arm study into engagement and clinical outcomes after a DCP for MSK rehabilitation. Patients were stratified by baseline sleep disturbance, based on sleep questions in the questionnaires: Oswestry Disability Index, Neck Disability Index, and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire. Additional outcomes were pain, Generalized Anxiety Disorder 7-item scale, Patient Health 9-item questionnaire, Work Productivity, and Activity Impairment, and program engagement.

Results

At baseline, 5749 patients reported sleep disturbance (78.0% of eligible patients). These reported significantly worse clinical outcomes at baseline than patients without sleep disturbance (all p<0.001). Patients with comorbid sleep disturbance showed improvements in sleep, with a significant proportion reporting full recovery at program completion: 56% of patients with upper limb conditions (including 10% of patients with severe sleep disturbance at baseline), and 24% with spine conditions. These patients also reported significant improvements in all clinical outcomes at program completion. Engagement and satisfaction were high, and also higher than in patients without sleep impairment.

Conclusion

This is the first study of its kind investigating the effect of a completely remote DCP for MSK pain on sleep. Patients reporting comorbid sleep disturbance had significant improvement in sleep, alongside pain, mental health and work productivity at program completion. The results suggest that a DCP for MSK pain can improve sleep disturbances in patients with upper limb and spine conditions.

The state of the art in telerehabilitation for musculoskeletal conditions

BACKGROUND

Given the rapid advances in communication technology and the need that emerged from the COVID-19 pandemic, telehealth initiatives have been widely used worldwide. This masterclass aims to provide an overview of telerehabilitation for musculoskeletal conditions, synthesizing the different terminologies used to describe telehealth and telerehabilitation, its effectiveness and how to use it in clinical practice, barriers and facilitators for the implementation in health services, and discuss the need of a curriculum education for the near future.

MAIN BODY

Telerehabilitation refers to the use of information and communication technologies provided by any healthcare professionals for rehabilitation services. Telerehabilitation is a safe and effective option in the management of musculoskeletal conditions in different models of delivery. There are many technologies, with different costs and benefits, synchronous and asynchronous, that can be used for telerehabilitation: telephone, email, mobile health, messaging, web-based systems and videoconferences applications. To ensure a better practice of telerehabilitation, the clinician should certify safety and access, and appropriateness of environment, communication, technology, assessment, and therapeutic prescription. Despite the positive effect of telerehabilitation in musculoskeletal disorders, a suboptimal telerehabilitation implementation may have happened due to the COVID-19 pandemic, especially in countries where telehealth was not a reality, and clinicians lacked training and guidance. This emphasizes the need to identify the necessary curriculum content to guide future clinicians in their skills and knowledge for telerehabilitation. There are some challenges and barriers that must be carefully accounted for to contribute to a health service that is inclusive and relevant to health professionals and end users.

CONCLUSIONS

Telerehabilitation can promote patient engagement in health care and plays an important role in improving health outcomes in patients with musculoskeletal conditions. Digital health technologies can also offer new opportunities to educate patients and facilitate the process of behavior change to a healthy lifestyle. Currently, the main needs in telerehabilitation are the inclusion of it in health curriculums in higher education and the development of cost-effectiveness and implementation trials, especially in low- and middle-income countries where access, investments and digital health literacy are limited.

Rehabilitation for Total Hip Arthroplasty: A Systematic Review

ABSTRACT

We sought to determine the comparative benefits and harms of rehabilitation interventions for patients who have undergone elective, unilateral THA surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We included randomized controlled trials and adequately adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. Large heterogeneity across evaluated rehabilitation programs limited conclusions. Evidence from 15 studies suggests that diverse rehabilitation programs may not differ in terms of risk of harm or outcomes of pain, strength, activities of daily living, or quality of life (all low strength of evidence). Evidence is insufficient for other outcomes. In conclusion, no differences in outcomes were found between different rehabilitation programs after THA. Further evidence is needed to inform decisions on what attributes of rehabilitation programs are most effective for various outcomes.

Staff perspectives on the key elements to successful rapid uptake of telerehabilitation in medium-sized public hospital physiotherapy departments

BACKGROUND AND PURPOSE

During the COVID-19 pandemic, hospital physiotherapy departments transitioned to telerehabilitation to ensure continuity of care for patients. The purpose of this study is to determine the key elements to successful, rapid uptake of telerehabilitation in medium-sized public hospital physiotherapy departments in response to COVID-19.

METHODS

This study used a qualitative design. Physiotherapists who delivered telerehabilitation consultations during the COVID-19 restriction period in two Brisbane public hospital physiotherapy departments were eligible to participate in semi-structured interviews. Data were analysed thematically.

RESULTS

Twenty-five physiotherapists (22-60 years of age; 68% female) with 1-40 years of clinical experience provided insights into their perceptions of the rapid uptake of telerehabilitation in the provision of clinical care. Physiotherapists worked across musculoskeletal outpatient (72%), inpatient, community, paediatrics and pelvic health departments. Qualitative analyses in relation to the physiotherapist perceptions of the key elements of rapid transition to telerehabilitation, revealed four key themes underpinning success: (1) 'it requires a whole team approach', (2) 'technology issues will be encountered and can be overcome', (3) 'optimise the situation while understanding the differences' and (4) 'modifying your approach doesn't imply inferior quality of care'.

CONCLUSION

Rapid implementation of telerehabilitation in a hospital setting is possible, and is facilitated by organisational, administrative and management support, willingness of physiotherapists to adopt, shared learning experience, quality software and connection, availability of equipment and space and optimised systems and processes. Key factors facilitating successful telerehabilitation consultations include effective communication, demonstration, involving a third party to help, and clients who are well prepared and willing to engage.

Service evaluation of telehealth in a physiotherapy musculoskeletal setting: Patient outcomes and results from risk stratification

INTRODUCTION

Due to COVID-19 the ability to see all patients face-to-face (FTF) was removed. Services implemented telehealth to cater for patients requiring musculoskeletal care. A service evaluation was undertaken to assess the effectiveness of a mixed telehealth/FTF approach and identify if stratifying patients could help tailor intervention.

METHODS

Retrospective analysis of data collected from patients who were assessed by Musculoskeletal Physiotherapists in one Scottish health board was undertaken. Patients were divided into low, medium and high risk sub-groups through the Keele STarT MSK tool. Outcome measures for pain and musculoskeletal health were taken at baseline/discharge along with satisfaction/preference. Descriptive and Inferential statistical analysis was conducted to establish whether changes in the outcome measures within and between risk sub-groups were statistically significant.

RESULTS

Pain level difference from baseline to discharge demonstrated clinically and statistically significant improvements across all risk groups (N = 89). Musculoskeletal health demonstrated clinically significant improvements across all risk groups and statistically significant improvements in the medium/high risk groups but not the low risk. Patients with knee osteoarthritis and low back pain in the medium risk group had fewest appointments while patients with chronic shoulder pain had the most. The majority of patients were satisfied with all mediums but preferred FTF or an option between telehealth/FTF in the future.

CONCLUSION

Telehealth is a promising model of care when utilised in combination with FTF for patients with musculoskeletal conditions. Through stratification, identifying specific conditions and shared decision making it may be possible to treat certain patient groups via telehealth.

Effects of tele-exercise rehabilitation intervention on women at high risk of osteoporotic fractures: study protocol for a randomised controlled trial

INTRODUCTION

Premenopausal and postmenopausal osteoporosis and associated fragility fractures are major public health problems. Exercise, especially moderate-to-high-intensity impact exercise, has been recommended as an effective, low-cost non-pharmacological strategy for bone strength improvement; however, evidence on fracture risk is limited. In addition, maintaining regular training is currently a problem. Therefore, this study aims to conduct a randomised controlled trial of moderate-to-high-intensity tele-exercise intervention using a tele-rehabilitation app and quantify its effects on vertical fracture and fall prevention in women at high risk of osteoporotic fractures.

METHODS AND ANALYSIS

In this multicentre, randomised controlled trial, 794 women at high risk of osteoporotic fractures will be recruited and randomised into either the tele-exercise rehabilitation or control group. Participants in the control group will receive routine remote rehabilitation, while those in the intervention group will be provided with a 6-month tele-exercise rehabilitation. The primary outcomes are the percentage of participants with one or more new vertebral fractures and incidence of falls. Intention-to-treat, full analysis set and per-protocol approaches will be used for outcome analyses.

ETHICS AND DISSEMINATION

The study was approved by the biomedical research ethics committee of the West China Hospital of Sichuan University (2021-579). Written informed consent will be obtained from each participant after agreeing to participate in the study. The study findings will be presented at national and international scientific conferences and published in peer-reviewed journals. Results are propagated regardless of the magnitude or direction of the impact. Authorship is assigned according to authorship guidelines as defined by the International Board of Medical Journal Editors, and each author's role is based on journal requirements for publication.

TRIAL REGISTRATION NUMBER

The study was registered with the Chinese Clinical Trial Registry (ChiCTR2200058780) prior to recruitment (May 2022).

Digital Rehabilitation Programs Improve Therapeutic Exercise Adherence for Patients With Musculoskeletal Conditions: A Systematic Review With Meta-Analysis

OBJECTIVE: To investigate the effects of digital rehabilitation for improving adherence to therapeutic exercise in people with musculoskeletal conditions. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: Five databases were searched from their inception to March 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials evaluating digital rehabilitation programs to improve adherence to therapeutic exercise for people with musculoskeletal conditions. DATA SYNTHESIS: We calculated standardized mean differences (SMDs) or mean differences (MDs) and 95% confidence intervals (CIs). Certainty of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Bias was assessed using the Cochrane risk of bias tool. RESULTS: Eleven trials were included in the meta-analysis (n = 1144 participants). At short-term follow-up, digital rehabilitation was no better than nondigital rehabilitation (3 trials, adherence rate of prescribed exercise test SMD 0.50, 95% CI: -0.13, 1.13; 2 trials, self-reported exercise adherence test MD 1.07, 95% CI: 0.58, 1.56; 2 trials, assessor-reported exercise adherence test SMD -0.10, 95% CI: -0.56, 0.36). At intermediate-term follow-up, digital rehabilitation improved exercise adherence compared with nondigital rehabilitation (6 trials, adherence rate of prescribed exercise test SMD 0.53, 95% CI: 0.35, 0.70; 2 trials, self-reported exercise adherence test MD 1.50, 95% CI: 0.76, 2.25; 2 trials, Exercise Adherence Rating Scale test MD 5.86, 95% CI: 0.08, 11.65). At long-term follow-up, there was no clinically important difference between digital and nondigital rehabilitation (2 trials, adherence rate of prescribed exercise test SMD 0.28, 95% CI: -0.14, 0.70; 1 trial, self-reported exercise adherence test MD 0.20, 95% CI: -0.91, 1.31). CONCLUSION: Digital rehabilitation was effective at improving therapeutic exercise adherence in musculoskeletal conditions at mid-term follow-up, but not at short- and long-term follow-up. J Orthop Sports Phys Ther 2022;52(11):726-739. Epub: 12 August 2022. doi:10.2519/jospt.2022.11384.

Racial and Ethnic Differences in Outcomes of a 12-Week Digital Rehabilitation Program for Musculoskeletal Pain: Prospective Longitudinal Cohort Study

BACKGROUND

Musculoskeletal (MSK) pain disproportionately affects people from different ethnic backgrounds through higher burden and less access to care. Digital care programs (DCPs) can improve access and help reduce inequities. However, the outcomes of such programs based on race and ethnicity have yet to be studied.

OBJECTIVE

We aimed to assess the impact of race and ethnicity on engagement and outcomes in a multimodal DCP for MSK pain.

METHODS

This was an ad hoc analysis of an ongoing decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were stratified by self-reported racial and ethnic group, and their engagement and outcome changes between baseline and 12 weeks were compared using latent growth curve analysis. Outcomes included program engagement (number of sessions), self-reported pain scores, likelihood of surgery, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment. A minimum clinically important difference (MCID) of 30% was calculated for pain, and multivariable logistic regression was performed to evaluate race as an independent predictor of meeting the MCID.

RESULTS

A total of 6949 patients completed the program: 65.5% (4554/6949) of them were non-Hispanic White, 10.8% (749/6949) were Black, 9.7% (673/6949) were Asian, 9.2% (636/6949) were Hispanic, and 4.8% (337/6949) were of other racial or ethnic backgrounds. The population studied was diverse and followed the proportions of the US population. All groups reported high engagement and satisfaction, with Hispanic and Black patients ranking first among satisfaction despite lower engagement. Black patients had a higher likelihood to drop out (odds ratio [OR] 1.19, 95% CI 1.01-1.40, P=.04) than non-Hispanic White patients. Hispanic and Black patients reported the highest level of pain, surgical intent, work productivity, and impairment in activities of daily living at baseline. All race groups showed a significant improvement in all outcomes, with Black and Hispanic patients reporting the greatest improvements in clinical outcomes. Hispanic patients also had the highest response rate for pain (75.8%) and a higher OR of meeting the pain MCID (OR 1.74, 95% CI 1.24-2.45, P=.001), when compared with non-Hispanic White patients, independent of age, BMI, sex, therapy type, education level, and employment status. No differences in mental health outcomes were found between race and ethnic groups.

CONCLUSIONS

This study advocates for the utility of a DCP in improving access to MSK care and promoting health equity. Engagement and satisfaction rates were high in all the groups. Black and Hispanic patients had higher MSK burden at baseline and lower engagement but also reported higher improvements, with Hispanic patients presenting a higher likelihood of pain improvement.

Effect of a mHealth exercise intervention compared with supervised exercise therapy in osteoarthritis management: protocol of the DigiOA trial

INTRODUCTION

Soaring prevalence of hip and knee osteoarthritis (OA) inflicts high costs on the healthcare system. A further rise in the OA incidence is expected, generating increased demand of care potentially challenging accessibility and threatening to overwhelm the healthcare system. Innovative solutions that may improve accessibility to recommended OA care for patients in primary care and maintain healthcare sustainability are warranted. Digitalising home exercise therapy may be one such solution. The primary aim of this study is to evaluate the effectiveness of a mobile health app providing digitalised home exercises, compared with supervised exercise therapy in patients with OA. Second, we will evaluate the cost-efficiency of the intervention and explore potential differences in outcome and adherence to exercises in the experimental treatment group.

METHODS AND ANALYSIS

A two-armed non-inferiority randomised controlled trial will be conducted. In total, 156 patients with hip and/or knee OA will be recruited from physiotherapy clinics in primary care in Norway. Following patient education, patients will be randomised to either 6 weeks of standard treatment (2 weekly sessions of supervised exercise therapy) or experimental treatment (home exercises via the Virtual Training (VT) app). Primary outcome is the proportion of Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responders at 6 weeks. Secondary outcomes include physical performance, patient-reported outcomes related to pain, fatigue, disease activity, physical function, mental health, health related quality of life, self-efficacy, utilisation of healthcare services and medication, digital competence and use of apps.

ETHICS AND DISSEMINATION

Patients will sign an informed consent form before participating in the trial. Approval has been granted by the Regional Ethics Committee (201105) and Data Protection Officer at Diakonhjemmet Hospital (00221). Patient research partners will contribute in all parts of the study.

TRIAL REGISTRATION NUMBER

NCT04767854.

Telemedicine Technologies Selection for the Posthospital Patient Care Process after Total Hip Arthroplasty

For many years, the importance of using telematic technologies in medicine has been growing, especially in the period of the coronavirus pandemic, when direct contact and supervision of medical personnel over the patient is difficult. The existing possibilities of modern information and communication technologies (ICTs) are not fully used. The aim of the study is to identify the telemedicine technologies that can be used in future implementation projects of the posthospital patient care process after total hip arthroplasty (THA). The literature search is reported according to PRISMA 2020. The search strategy included databases and gray literature. In total, 28 articles (EMBASE, PubMed, PEDro) and 24 records from gray literature (Google Search and Technology presentations) were included in the research. This multi-source study analyzes the possibilities of using different technologies useful in the patient care process. The conducted research resulted in defining visual and wearable types of telemedicine technologies for the original posthospital patient care process after THA. As the needs of stakeholders in the posthospital patient care process after THA differ, the awareness of appropriate technologies selection, information flow, and its management importance are prerequisites for effective posthospital patient care with the use of telemedicine technologies.

Same Day Joint Replacement Surgery: Patient Selection and Perioperative Management

Joint replacements are increasingly performed as outpatient surgeries. The push toward ambulatory joint arthroplasty is driven in part by the changing current health care economics and reimbursement models. Patients' selection and well-designed perioperative care pathways are critical for the success of these procedures. The rate of complications after outpatient joint arthroplasty is comparable to the rate of complications in the ambulatory setting. Patient education, adequate social support, multimodal analgesia, regional anesthesia are key ingredients to the ambulatory care pathway after joint arthroplasty. Motor sparing nerve blocks are often used in these settings. Implementation of the elements of fast protocols can result in overall improvement of outcome metrics for all patients undergoing joint arthroplasty, including reduced length of stay and increased rate of home discharge.

Rehabilitation Professional and Patient Satisfaction with Telerehabilitation of Musculoskeletal Disorders: A Systematic Review

Telerehabilitation offers an alternative healthcare delivery remotely in a patient's environment at a lower cost, better accessibility, and equivalent quality to the standard approach. Several studies had examined the effectiveness of telerehabilitation inpatients with musculoskeletal disorders, and although there is evidence that it is at least equally effective as the standard care, the patient and rehabilitation professional satisfaction with the delivery method is not conclusive. A systematic review was conducted to study the patients' and rehabilitation professionals' satisfaction with telerehabilitation for musculoskeletal disorders. A search for relevant studies on 29 April 2021 was carried out in Medline/PubMed, Scopus, and Web of Science (WOS). The search terms included “telerehabilitation,” AND “satisfaction” AND “musculoskeletal disorders,” “telehealth,” “telemedicine,” “patient experience,” and “pain”. Fifteen eligible studies with 12,341 patients were included in this systematic review. A report was included if it (a) assessed the satisfaction of patients or professionals or both as one of the outcomes of a telerehabilitation intervention, (b) included adults 18 years and above with musculoskeletal disorders, and (c) is an intervention study using a quantitative approach. The quality of studies was assessed using the critical appraisal checklist tool developed by Joanna Briggs Institute (JBI). Most of the studies reported that patients were satisfied with both telerehabilitation and face-to-face intervention. However, few studies reported that patients were more satisfied with telerehabilitation compared to face-to-face of intervention. Patients in one study had preferred the incorporation of telerehabilitation and face-to-face sessions. Two of three studies had reported overall satisfaction with telerehabilitation by the professionals. Overall, there is evidence that patients and rehabilitation professional are satisfied with telerehabilitation compared to face-to-face consultation.

Acceptability of Telerehabilitation for Magnification Devices for the Visually Impaired Using Various Approaches to Facilitate Accessibility

Purpose

We examined different methods to reduce the burden of accessing technology for videoconferencing during telerehabilitation for magnification devices for the visually impaired.

Methods

During telerehabilitation studies over the past 5 years, vision rehabilitation providers assessed and gave training to visually impaired participants with newly dispensed magnification devices at home who connected to Zoom videoconferencing via loaner tablets or smartphones with assistance from (phase 1; n = 10) investigators by phone, (phase 2; n = 11) local Lions Club volunteers in participants’ homes, or (phase 3; n = 24) remote access control software in a randomized controlled trial with 13 usual care controls who received in-office training. All participants completed the same post-telerehabilitation phone survey.

Results

A significantly greater proportion of phase 3 subjects indicated they strongly or mostly agreed that the technology did not interfere with the session (96%) compared to phase 1 (60%; 95% confidence interval [CI], 1.2–12.5; P = 0.03) or phase 2 (55%; 95% CI, 1.8–188; P = 0.01). The majority indicated telerehabilitation was as accurate as in person (68%), they were comfortable with telerehabilitation (91%) and interested in a future session (83%), and their magnifier use improved (79%), with no significant differences in these responses between phases (all P > 0.10), including comparisons of participants randomized to telerehabilitation or in-office training in phase 3 who reported similar overall satisfaction levels (P = 0.84).

Conclusions

Participants across all phases reported high levels of acceptance for telerehabilitation, with least interference from technology using remote access control in phase 3.

Translational Relevance

With accommodations for accessibility to videoconferencing technology, telerehabilitation for magnification devices can be a feasible, acceptable, and valuable option in countries with resources to support the technology.

Mobile rehabilitation support versus usual care in patients after total hip or knee arthroplasty: study protocol for a randomised controlled trial

Background

The global increase in total hip or knee arthroplasty has led to concern about the provision of postoperative rehabilitation. Telerehabilitation may be a strategy to meet the patients’ requirements for rehabilitation after arthroplasty. This study aims to investigate the effectiveness of a telerehabilitation programme delivered via the mobile application WeChat in patients after total hip or knee arthroplasty on the following outcomes: self-efficacy, physical function, pain, depression, anxiety and health-related quality of life.

Methods

This is a single-centre, single-blinded, parallel-group, superiority randomised controlled trial conducted in Shanghai, China. Eighty-four eligible participants who undergo primary total hip or knee arthroplasty will be recruited preoperatively in a university teaching hospital and randomly assigned to the experimental or control group with their informed consent. Once discharged, the control group (n = 42) will receive the usual care provided by the hospital. The experimental group (n = 42) will receive usual care and a 6-week mobile application rehabilitation programme that consists of physical exercises and techniques for enhancing participants’ self-efficacy for rehabilitation. Baseline assessments will be conducted on the day before hospital discharge, and outcome assessments will be conducted 6 and 10 weeks postoperatively. The primary outcomes are changes in self-efficacy and physical function 6 weeks postoperatively, and the secondary outcomes include pain, depression, anxiety and health-related quality of life. The approach of a generalised estimating equation will be used to analyse the effect of the intervention on outcomes at a significance level of 0.05.

Discussion

This study is the first of its kind conducted in China to incorporate self-efficacy and learning theories as a framework to guide the development of a mobile application rehabilitation programme after arthroplasty. This study will contribute to the knowledge about the effectiveness of mobile application-based rehabilitation among patients after total hip or knee arthroplasty. If the findings are positive, they will support the implementation of mobile application-based rehabilitation in practice, which may potentially increase the accessibility of rehabilitation services as well as patient adherence to rehabilitation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12621000867897. Retrospectively registered on July 6, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06269-x.

Current state of remote physiotherapy in Finland: cross-sectional web-based questionnaire study

Background

The ongoing COVID-19 pandemic has required social, health, and rehabilitation organizations to implement remote physiotherapy (RP) as a part of physiotherapists’ daily practice. RP may improve access to physiotherapy as it delivers physiotherapy services to rehabilitees through information and communications technology. Even if RP has already been introduced in this century, physiotherapists’ opinion, amount of use, and form in daily practice have not been studied extensively.

Objective

This study aims to investigate physiotherapists’ opinions of the current state of RP in Finland.

Methods

A quantitative, cross-sectional, web-based questionnaire was sent to working-aged members of the Finnish Association of Physiotherapists (n=5905) in March 2021 and to physiotherapists in a private physiotherapy organization (n=620) in May 2021. The questionnaire included questions on the suitability of RP in different diseases and the current state and implementation of RP in work among physiotherapists.

Results

Of the 6525 physiotherapists, a total of 9.9% (n=662; n=504, 76.1% female; mean age 46.1, SD 12 years) answered the questionnaire. The mean suitability “score” (0=not suitable at all to 10=fully suitable) of RP in different disease groups varied from 3.3 (neurological diseases) to 6.1 (lung diseases). Between early 2020 (ie, just before the COVID-19 pandemic) and spring 2021, the proportion of physiotherapists who used RP increased from 33.8% (21/62) to 75.4% (46/61; P<.001) in the public sector and from 19.7% (42/213) to 76.6% (163/213; P<.001) in the private sector. However, only 11.7% (32/274) of physiotherapists reported that they spent >20% of their practice time for RP in 2021. The real-time method was the most common RP method in both groups (public sector 46/66, 69.7% vs private sector 157/219, 71.7%; P=.47). The three most commonly used technical equipments were computers/tablets (229/290, 79%), smartphones (149/290, 51.4%), and phones (voice call 51/290, 17.6%). The proportion of physiotherapists who used computers/tablets in RP was higher in the private sector than in the public sector (183/221, 82.8% vs 46/68, 67.6%; P=.01). In contrast, a higher proportion of physiotherapists in the public sector than in the private sector used phones (18/68, 26.5% vs 33/221, 14.9%; P=.04).

Conclusions

During the COVID-19 pandemic, physiotherapists increased their use of RP in their everyday practice, although practice time in RP was still low. When planning RP for rehabilitees, it should be considered that the suitability of RP in different diseases seems to vary in the opinion of physiotherapists. Furthermore, our results brought up important new information for developing social, health, and rehabilitation education for information and communications technologies.

Virtual health care & telehealth: Current therapy practice patterns

STUDY DESIGN

Survey Study.

PURPOSE

To investigate recent practice changes with respect to the provision of virtual visits by hand therapists due to the COVID-19 pandemic by asking about changes in the frequency of virtual visits, the assessments and treatments currently provided virtually, and the opinions of therapists on the future on virtual visits in hand therapy practice.

METHODS

The survey was distributed to the American Society of Hand Therapists (ASHT), the Australian Hand Therapy Association (AHTA), the Canadian Society of Hand Therapists (CSHT), and the European Federation for the Societies of Hand Therapy (EFSHT).

RESULTS

Of the 819 responses, there were 573 therapists (70%) who reported that they currently use virtual visits in their practice. Only 38 therapists (4.6%) were providing virtual visits prior to COVID-19, representing a 15-fold increase in virtual visits since the beginning of the pandemic. Only 26% (n = 213) reported that they used patient-reported outcome measures (PROM) in conjunction with their virtual visits. Approximately 78% (n = 638) said that they thought there is a sustainable future for this method of care in hand therapy practice.

DISCUSSION

This survey has helped identify the changing landscape in the provision of rehabilitation and established some of the common assessments and interventions currently utilized by hand therapists in the virtual environment. Next, steps for research are to investigate the reliability and validity of some of the assessments and interventions used, to establish whether virtual care will provide good outcomes for patients, and ultimately understand the optimal combination of conventional therapy and virtual care.

[Effectiveness of physical therapy after total hip arthroplasty at the third stage of rehabilitation using a telemedicine program]

OBJECTIVE

To assess the quality of life and efficacy of telemedicine technologies for rehabilitation after total hip replacement.

MATERIAL AND METHODS

The study included 60 patients aged 40-75 years after total hip replacement. All patients were divided into two groups by simple randomization. All patients underwent a 7-day course of complex in-hospital postoperative rehabilitation. At discharge, patients of the main group received an access to telemedicine program for 3-month physical exercises (3 times a week for 30 minutes). In the control group, patients received routine recommendations for rehabilitation procedures and orthopedic recommendations.

RESULTS

A course of rehabilitation with telemedicine technologies after total hip replacement was accompanied by significant clinical effect according to EQ5D, SF-36 and STAI questionnaires.

CONCLUSION. T

Elemedicine technologies in postoperative rehabilitation after total hip replacement are accompanied by QoL improvement. It is an effective form of medical rehabilitation.

Balance and proprioception impairment, assessment tools, and rehabilitation training in patients with total hip arthroplasty: a systematic review

BACKGROUND

Osteoarthritis and subsequent total hip arthroplasty (THA) lead to damages to hip joint mechanoceptors, which in turns lead to impairments in proprioception. One of the abilities mainly affected by an altered joint proprioception is balance. The aim of this work was to investigate the balance and proprioception impairments, current assessment tools, and rehabilitation training after THA.

METHODS

A systematic literature revision was conducted on PubMed, Web of Science and Cochrane databases. Articles reporting balance and proprioception impairments, current assessment tools, or rehabilitation interventions were included. Methodological quality was assessed using the Downs and Black checklist. A total of 41 articles were included, 33 discussing balance and proprioception assessment, and 8 dealing with training. Data related to type of surgical approach, type and timing of assessment protocols, assessment instrumentation, and type, volume and duration of the rehabilitation training were extracted from each study.

RESULTS

Thirty-one studies were of high quality, 2 of moderate quality and 8 of low-quality. Literature review showed an improvement in balance following THA in comparison with the pre-operative performance, although balance abnormalities persist up to 5 years after surgery, with THA patients showing an increased risk for falls. Balance training is effective in all the rehabilitation phases if specifically structured for balance enhancement and consistent in training volume. It remains unclear which assessments are more appropriate for the different rehabilitation phases, and if differences exist between the different surgical procedures used for THA. Only two studies assessed proprioception.

CONCLUSION

Balance and proprioception show impairments up to 5 years after THA, increasing the risk of falls. However, patients with THA may benefit of an adequate balance training. Further research is needed to investigate the gaps in balance and proprioception assessment and training following THA surgery.

Patients' needs regarding rehabilitation services delivered via mobile applications after arthroplasty: A qualitative study

AIMS AND OBJECTIVES

To obtain an in-depth understanding of the specific needs of patients for rehabilitation services delivered via mobile applications after total hip or knee arthroplasty.

BACKGROUND

Due to increased demand for arthroplasty, the provision of face-to-face rehabilitation services for patients is becoming challenging. New approaches using digital technologies are being developed, such as mobile applications to deliver rehabilitation services. However, the perspectives of patients on the delivery of these services via mobile applications after total hip or knee arthroplasty have not been explored extensively.

DESIGN

A qualitative descriptive study.

METHODS

Twenty patients who had been discharged from the hospital after a total hip or knee arthroplasty were interviewed via telephone about their needs regarding the future use of mobile applications to conduct arthroplasty rehabilitation. Interview records were transcribed verbatim and analysed using inductive content analysis. Reporting of the findings complies with the COREQ checklist for qualitative studies.

RESULTS

Four categories emerged from the data collected from the participants: (1) assisting rehabilitation self-management, (2) facilitating peer support, (3) facilitating contact with healthcare professionals and (4) supporting emotional well-being.

CONCLUSIONS

The study provided an in-depth understanding of the specific needs of patients for rehabilitation services delivered via mobile applications after total hip or knee arthroplasty. The findings of the study could be used in the development or revision of mobile application rehabilitation programmes to better support the rehabilitation of patients. Future studies are needed to evaluate the effectiveness of such programmes, especially including the self-efficacy of patients as an outcome measure.

RELEVANCE TO CLINICAL PRACTICE

From the perspective of patients who have undergone arthroplasty, a mobile application rehabilitation programme should encourage patients in rehabilitation self-management, assist them to contact healthcare professionals and other patients and support their postoperative emotional well-being. The study findings will assist nurses with the preparation and delivery of telerehabilitation programmes after arthroplasty.

Process of Posthospital Care Involving Telemedicine Solutions for Patients after Total Hip Arthroplasty

The importance of telemedicine technologies around the world has been growing for many years, and it turned out to be a particularly important issue for conducting some medical procedures during the SARS-CoV-2 pandemic. It is necessary to create interdisciplinary teams to design and implement improved procedures using telemedicine tools. The aim of the article is to develop original, improved posthospital patient care process after total hip arthroplasty (THA) with the use of telemedicine technologies. In the study, a literature review and empirical research were used. The conducted research resulted in the designing an original posthospital patient care process after THA that uses telematics technologies. Due to the use of analyzed telemedicine technologies, the designed patient care process brings a possibility to increase the patient's safety by monitoring life parameters, allowing for regular, remote contact with specialists and to be supervised remotely. All this may contribute to shortening the convalescence time, reducing the risk of complications, as well as reducing treatment costs. The designed model is ready for further clinical research with the participation of medical staff, patients after THA and patient caregivers.

An investigation into the use of mHealth in musculoskeletal physiotherapy: Scoping Review (Preprint)

Background

Musculoskeletal physiotherapy provides conservative management for a range of conditions. Currently, there is a lack of engagement with exercise programs because of the lack of supervision and low self-efficacy. The use of mobile health (mHealth) interventions could be a possible solution to this problem, helping promote self-management at home. However, there is little evidence for musculoskeletal physiotherapy on the most effective forms of mHealth.

Objective

The aim of this review is to investigate the literature focusing on the use of mHealth in musculoskeletal physiotherapy and summarize the evidence.

Methods

A scoping review of 6 peer-reviewed databases was conducted in March 2021. No date limits were applied, and only articles written in the English language were selected. A reviewer screened all the articles, followed by 2 additional researchers screening a random sample before data extraction.

Results

Of the 1393 studies, 28 (2.01%) were identified. Intervention characteristics comprised stretching and strengthening exercises, primarily for degenerative joint pain and spinal conditions (5/28, 18%). The most reported use of mHealth included telephone and videoconferencing calls to provide a home exercise program or being used as an adjunct to physiotherapy musculoskeletal assessment (14/28, 50%). Although patient satisfaction with mHealth was reported to be high, reasons for disengagement included a lack of high-quality information and poor internet speeds. Barriers to clinical uptake included insufficient training with the intervention and a lack of time to become familiar.

Conclusions

mHealth has some benefits regarding treatment adherence and can potentially be as effective as normal physiotherapy care while being more cost-effective. The current use of mHealth is most effective when ongoing feedback from a health care professional is available.

Expanding Role of Technology in Rehabilitation After Lower-Extremity Joint Replacement: A Systematic Review

BACKGROUND

The effectiveness of telehealth programs in the administration of rehabilitation and the monitoring of postoperative progress after joint replacement is not well studied. The purpose of the present study was to systematically review the currently available evidence on the use of smart-device technology and telehealth programs to guide and monitor postoperative rehabilitation following total joint arthroplasty and to assess their impact on outcomes following surgery.

METHODS

A literature search of the MEDLINE database was performed using keywords "mobile," "app," "telehealth," "virtual," "arthroplasty," "outcomes," "joint replacement," "web based," "telemedicine," "TKA," "THA," "activity tracker," "fitness tracker," "monitor," "rehab," "online," and "stepcounter" in all possible combinations. All English studies with a level of evidence of I to III that were published from January 1, 2010, to December 19, 2020 were considered for inclusion. Quantitative and qualitative analysis was performed on the data collected.

RESULTS

A total of 28 articles meeting the inclusion criteria were identified and reviewed. With regard to objective functional outcome measures, such as strength, range of motion, or results of the Timed Up and Go (TUG) test, the virtual physical therapy group had equivalent or slightly superior outcomes compared with in-person physical therapy. There was similar improvement overall in patient-reported outcome measures (PROMs) and patient satisfaction between virtual and in-person physical therapy. Virtual physical therapy resulted in cost savings ranging from $206 to $4,100 per patient compared with in-person physical therapy.

CONCLUSIONS

Telerehabilitation following lower-extremity joint replacement is less expensive compared with in-person physical therapy, with equivalent outcomes and patient satisfaction. Telerehabilitation and electronic health adjuncts can be used to substitute for traditional rehabilitation and augment postoperative care following total joint arthroplasty, respectively. Telerehabilitation that provides outcomes equivalent to in-person physical therapy not only increases convenience for patients but also decreases the cost burden on the health-care system.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of eHealth Tools for Hip and Knee Arthroplasty: A Systematic Review

Objective: This study aimed to compare the effectiveness and costs of eHealth tools with usual care in delivering health-related education to patients' undergoing total hip or knee arthroplasty due to osteoarthritis.

Data Sources: Six electronic databases were searched to identify randomized controlled trials and experimental designs (randomized or not) examining the effect of eHealth tools on pre- or post-operative care. Only manuscripts written in English were included. In the current study, no specific primary or secondary outcomes were selected. Any study that investigated the impacts of eHealth tools on hip or knee arthroplasty outcomes were included.

Review Methods: Two researchers reviewed all titles and abstracts independently and in duplicate. Two researchers also conducted full-text screening and data extraction from the 26 selected articles.

Results: The data were descriptively reported, and themes could emerge from each outcome. Two researchers separately assessed the Risk of Bias for each paper using the Cochrane risk of bias assessment tool. The majority of studies evaluated the impact of eHealth tools on physical (n = 23) and psychosocial outcomes (n = 19). Cost-related outcomes were measured in 7 studies. eHealth tools were found to be equivocal to usual care, with few studies reporting statistically significant differences in physical or psychosocial outcome measures. However, cost-related outcomes showed that using eHealth tools is more cost-effective than usual care.

Conclusions: This review demonstrated that eHealth tools might be as effective as usual care, and possibly more cost-effective, a crucial implication for many overly burdened health care systems.

Addressing COVID-19 challenges in a randomised controlled trial on exercise interventions in a high-risk population

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic is a threat to ongoing clinical trials necessitating regular face-to-face, in-person meetings, particularly in participants with a high risk of complications. Guidance on how to handle and safely continue such trials is lacking. Chronically ill elderly individuals require-in addition to protection from infection-regular physical exercise and social contact to remain healthy. Solutions on how to handle these conflicting necessities are needed. The ENTAIER-randomised controlled trial was investigating the influence of mindful movements on fall risk, fear of falling, mobility, balance, life quality, and other outcomes. The study population was planned to comprise of 550 chronically ill elderly individuals with a high risk of falling. The movements were regularly performed in coached groups over 6 months. After the trial began, COVID-19 lockdowns stopped all in-person meetings, and it was expected that the limitations of this pandemic would continue for a long term. Therefore, the exercise programme, which involved complex movements and was typically conducted face-to-face in groups, had to be substituted by a telemedicine programme within a short timeframe. The objectives, therefore, were to identify challenges and tasks that could to be resolved and steps that could to be taken to achieve high-quality, efficacy, safety, and enable human encounter and motivation.

METHODS

We proceeded with four steps: 1) A literature review on the quality and feasibility issues of telemedicine in general, and specifically, in exercise training in elderly individuals. 2) Participation in two international telemedicine task forces on integrative medicine, particularly, mind-body medicine. 3) Interviews with study therapists, (for practical purposes, eurythmy therapists and Tai Chi teachers are summarized here as therapists) personnel, and international experts on providing mindful movement exercises and other physiotherapies via live telecommunication technology, and with scientists and patient representatives. 4) Final evaluation by the core trial team and subsequent planning and implementation of changes in the trial organisation.

RESULTS

Various tasks and challenges were identified: for the technical equipment for therapists and patients; for the ability of therapists and trial participants to adequately manage the technology and telemedicine intervention; the reservations and concerns about the technology among therapists and participants; safety and data protection in using the technology; and study design. The two major options found on how to continue the trial in the COVID-19 situation were a complete switch to telemedicine and a partial switch in the form of risk management implemented into the former design.

CONCLUSIONS

The management of an ongoing clinical trial in a national or international crisis with a minimum of available time and extra financial resources, alongside with two checklists on steps and procedures for trial continuation and telemedicine implementation, may be informative for other researchers or healthcare providers faced with similar challenges and making similar decisions in the current situation or similar future scenarios. TRAIL REGISTRATION: www.drks.de . DRKS00016609. Registered July 30, 2019.

Transition to Telehealth Physical Therapy After Hip Arthroscopy for Femoroacetabular Impingement: A Pilot Study With Retrospective Matched-Cohort Analysis

Background

Telehealth use has increased significantly of late. However, outside of total hip and knee arthroplasty, there is minimal evidence regarding its efficacy in orthopaedics and postoperative rehabilitation.

Purpose

To determine the efficacy and cost-effectiveness of a transition to postoperative telehealth physical therapy in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI).

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 51 patients undergoing postoperative physical therapy after hip arthroscopy for FAI. The intervention group consisted of patients undergoing initial in-person visits followed by a transition to telehealth physical therapy for 3 months postoperatively (group 1; n = 17). Comparison groups included patients undergoing in-person physical therapy with the same physical therapy team as the telehealth group (group 2; n = 17) and patients undergoing in-person therapy with a different therapy team at the same facility (group 3; n = 17). All groups were matched 1-to-1 by patient age and sex. All patients completed the short version of the International Hip Outcome Tool (iHOT-12) both preoperatively and at 3 months postoperatively. At 3 months postoperatively, it was determined whether patients met the minimally clinically important difference (MCID; ≥13 points) or substantial clinical benefit (SCB; ≥28 points) or whether they reached a Patient Acceptable Symptomatic State (PASS; ≥64 points). Billed charges were recorded as a measure of cost.

Results

The overall mean age of the study patients ranged from 33 to 34 years. Among the 3 groups, there was no significant difference in the preoperative, postoperative, or pre- to postoperative change in iHOT-12 scores or in the percentage of patients meeting MCID, SCB, or PASS at 3 months. Group 1 had significantly lower mean costs ($1015.67) compared with group 2 ($1555.62; P = .011) or group 3 ($1896.38; P < .001).

Conclusion

In this pilot study, telehealth physical therapy after hip arthroscopy was found to lead to similar short-term outcomes and was cost-effective compared with in-person physical therapy.