Technology-assisted rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis

Rehabilitation interventions delivered via telehealth to support self-management of rheumatic and musculoskeletal diseases: A scoping review protocol

BACKGROUND

Telerehabilitation is a term to describe rehabilitation services delivered via information and communication technology. Such services are an increasingly important component for the management of rheumatic and musculoskeletal diseases (RMDs). Telerehabilitation has the potential to expand the long-term self-management options for individuals with RMDs, improve symptoms, and relieve pressures on health care services. Yet, little is known about the variety of interventions implemented, and how they are being evaluated. Thus, this scoping review aims to identify and describe existing rehabilitation interventions delivered via telehealth for RMDs. Specifically, we aim to identify and summarize the key components of rehabilitation, the technology used, the level of health care professional interaction, and how the effectiveness of interventions is evaluated.

METHODS

We will conduct this review following the latest JBI scoping review methodology and the PRISMA guidelines for Scoping Reviews (PRISMA-ScR). The 'Population-Concept-Context (PCC)' framework will be used, whereby the 'Population' is RMDs (≥18 years); the 'Concept' is rehabilitation; and the 'Context' is telehealth. Developed in collaboration with a subject Librarian, refined PCC key terms will be utilized to search (from 2011-2021) three electronic databases (i.e., Embase, Scopus, Web of Science) for articles published in English. Search results will be exported to the citation management software (EndNote), duplicates removed, and eligibility criteria applied to title/abstract and full-text review. Relevant information pertaining to the PCC framework will be extracted. Data will be summarized qualitatively, and if appropriate, quantitatively via frequency counts of the components comprising the 'Concept' and 'Context' categories of the PCC framework.

DISCUSSION

Findings from the proposed scoping review will identify how telehealth is currently used in the delivery of rehabilitation interventions for RMDs. The findings will develop our understanding of such interventions and provide a platform from which to inform future research directions.

Effectiveness of guided telerehabilitation on functional performance in community-dwelling older adults: A systematic review

OBJECTIVE

To systematically review the effectiveness of guided telerehabilitation on improving functional performance in community-dwelling older adults.

DATA SOURCES

Articles published in PubMed, Cochrane Library and Embase (Ovid) from 01 January 2010 up to 17 October 2023.

REVIEW METHODS

Included studies had (1) a randomised controlled trial design, (2) an average population age of 65 years or older, (3) a home-based setting and (4) evaluated the effectiveness of functional performance outcome measures. The intervention was considered telerehabilitation when guided by a healthcare professional using video, audio and/or text communication technologies with a minimum frequency of once per week. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 statement guideline was followed. Methodological quality was appraised using the revised Cochrane Risk of Bias tool.

RESULTS

A total of 26 randomised controlled trials were included. Telerehabilitation had superior (N = 15), non-superior (N = 16) or non-inferior (N = 11) effectiveness for improving functional performance outcome measures compared to control interventions. No studies found the control intervention to be superior over telerehabilitation. Between study differences in intervention characteristics contributed to significant clinical heterogeneity. Five studies were found to present an overall 'low' risk of bias, 12 studies to present 'some' risk of bias and 9 studies to present an overall 'high' risk of bias.

CONCLUSION

The findings suggest that telerehabilitation could be a promising alternative to in-person rehabilitation for improving functional performance in community-dwelling older adults. Additional well-designed studies with minimised bias are needed for a better understanding of effective telerehabilitation intervention strategies.

Effectiveness of Telemedicine for Musculoskeletal Disorders: Umbrella Review

BACKGROUND

Several systematic reviews (SRs) assessing the use of telemedicine for musculoskeletal conditions have been published in recent years. However, the landscape of evidence on multiple clinical outcomes remains unclear.

OBJECTIVE

We aimed to summarize the available evidence from SRs on telemedicine for musculoskeletal disorders.

METHODS

We conducted an umbrella review of SRs with and without meta-analysis by searching PubMed and EMBASE up to July 25, 2022, for SRs of randomized controlled trials assessing telemedicine. We collected any kind of patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs), and objective measures, including direct and indirect costs. We assessed the methodological quality with the AMSTAR 2 tool (A Measurement Tool to Assess systematic Reviews 2). Findings were reported qualitatively.

RESULTS

Overall, 35 SRs published between 2015 and 2022 were included. Most reviews (n=24, 69%) were rated as critically low quality by AMSTAR 2. The majority of reviews assessed "telerehabilitation" (n=29) in patients with osteoarthritis (n=13) using PROMs (n=142 outcomes mapped with n=60 meta-analyses). A substantive body of evidence from meta-analyses found telemedicine to be beneficial or equal in terms of PROMs compared to conventional care (n=57 meta-analyses). Meta-analyses showed no differences between groups in PREMs (n=4), while objectives measures (ie, "physical function") were mainly in favor of telemedicine or showed no difference (9/13). All SRs showed notably lower costs for telemedicine compared to in-person visits.

CONCLUSIONS

Telemedicine can provide more accessible health care with noninferior results for various clinical outcomes in comparison with conventional care. The assessment of telemedicine is largely represented by PROMs, with some gaps for PREMs, objective measures, and costs.

TRIAL REGISTRATION

PROSPERO CRD42022347366; https://osf.io/pxedm/.

Mobile and Computer-Based Applications for Rehabilitation Monitoring and Self-Management After Knee Arthroplasty: Scoping Review

BACKGROUND

Successful post-knee replacement rehabilitation requires adequate access to health information, social support, and periodic monitoring by a health professional. Mobile health (mHealth) and computer-based technologies are used for rehabilitation and remote monitoring. The extent of technology use and its function in post-knee replacement rehabilitation care in low and middle-income settings are unknown.

OBJECTIVE

To inform future mHealth intervention development, we conducted a scoping review to map the features and functionality of existing technologies and determine users' perspectives on telerehabilitation and technology for self-management.

METHODS

We followed the Joanna Briggs Institute methodology for scoping reviews. We searched the Embase, Medline, PsycINFO via OVID, and Cochrane Central Register of Controlled Trials databases for manuscripts published from 2001 onward. We included original research articles reporting the use of mobile or computer-based technologies by patients, health care providers, researchers, or family members. Studies were divided into the following 3 categories based on the purpose: validation studies, clinical evaluation, and end user feedback. We extracted general information on study design, technology features, proposed function, and perspectives of health care providers and patients. The protocol for this review is accessible in the Open Science Framework.

RESULTS

Of the 5960 articles, 158 that reported from high-income settings contributed to the qualitative summary (64 studies on mHealth or telerehabilitation programs, 28 validation studies, 38 studies describing users' perceptions). The highest numbers of studies were from Europe or the United Kingdom and North America regarding the use of a mobile app with or without wearables and reported mainly in the last decade. No studies were from low and middle-income settings. The primary functions of technology for remote rehabilitation were education to aid recovery and enable regular, appropriate exercises; monitoring progress of pain (n=19), activity (n=20), and exercise adherence (n=30); 1 or 2-way communication with health care professionals to facilitate the continuum of care (n=51); and goal setting (n=23). Assessment of range of motion (n=16) and gait analysis (n=10) were the commonly validated technologies developed to incorporate into a future rehabilitation program. Few studies (n=14) reported end user involvement during the development stage. We summarized the reasons for satisfaction and dissatisfaction among users across various technologies.

CONCLUSIONS

Several existing mobile and computer-based technologies facilitate post-knee replacement rehabilitation care for patients and health care providers. However, they are limited to high-income settings and may not be extrapolated to low-income settings. A systematic needs assessment of patients undergoing knee replacement and health care providers involved in rehabilitation, involving end users at all stages of development and evaluation, with clear reporting of the development and clinical evaluation can make post-knee replacement rehabilitation care in resource-poor settings accessible and cost-effective.

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.

A Device for Prehabilitation of Total Knee Replacement Surgery (Slider): Usability Study

BACKGROUND

Rehabilitation, or "prehabilitation," is essential in preparing for and recovering from knee replacement surgery. The recent demand for these services has surpassed available resources, a situation further strained by the COVID-19 pandemic, which has led to a pivot toward digital solutions such as web- or app-based videos and wearables. These solutions, however, face challenges with user engagement, calibration requirements, and skin contact issues. This study evaluated the practicality of a low-contact, gamified device designed to assist with prehabilitation exercises.

OBJECTIVE

The study aimed to assess the practicality and user-friendliness of a newly designed physiotherapy device (Slider) that enables exercise monitoring without the need for direct contact with the skin.

METHODS

A total of 17 patients awaiting knee replacement surgery at a UK National Health Service (NHS) hospital participated in this study. They used the device over a 2-week period and subsequently provided feedback through a usability and acceptability questionnaire.

RESULTS

The study was completed by all participants, with a majority (13/17, 76%) finding the device intuitive and easy to use. The majority of patients were satisfied with the device's ability to meet their presurgery physiotherapy requirements (16/17, 94%) and expressed a willingness to continue using it (17/17, 100%). No safety issues or adverse effects were reported by the participants.

CONCLUSIONS

The results indicate that the device was found to be a feasible option for patients to conduct presurgery physiotherapy exercises independently, away from a clinical setting. Further research involving a larger and more diverse group of participants is recommended to validate these findings more robustly.

Effects of Electromyographic Biofeedback-Assisted Exercise on Functional Recovery and Quality of Life in Patients after Total Hip Arthroplasty: A Randomized Controlled Trial

The goal of the trial was to examine the effects of adding electromyographic biofeedback (EMG-BF) to the conventional program of physiotherapy after total hip arthroplasty (THA) on functional recovery and quality of life. The trial was designed as a prospective, interventional, single-blinded randomized controlled study. Ninety patients were randomized into an experimental group (EG) (n = 45; mean age 63.9 ± 8.8) and control group (CG) (n = 45; mean age 63.9 ± 9). All patients received 21 days of physiotherapy which consisted of therapeutic exercise (land-based and aquatic), electrotherapy, and education. Electromyographic biofeedback was added to a portion of the land-based exercise in EG. The Hip Disability and Osteoarthritis Outcome Score (HOOS), Numeric Rating Scale (NRS), Short Form Health Survey-36 (SF-36), use of a walking aid, 30 s chair stand test (CST) as well as the Timed Up and Go (TUG) test were used for outcome measurement. A higher proportion of the participants in both groups did not need a walking aid after the intervention (p < 0.05). All participants improved their 30 s CST and TUG results (p < 0.001), as well as their NRS and HOOS scores (p < 0.05). No significant differences between the groups were found. There were no additional benefits from adding EMG-BF to the conventional physiotherapy protocol.

Virtual Reality in Clinical Nursing Practice Over the Past 10 Years: Umbrella Review of Meta-Analyses

Background

Virtual reality (VR) has shown promising levels of effectiveness in nursing education, pain management, and rehabilitation. However, meta-analyses have discussed the effects of VR usage in nursing unilaterally and inconsistently, and the evidence base is diffuse and varied.

Objective

We aimed to synthesize the combined evidence from meta-analyses that assessed the effects of nurses using VR technology on nursing education or patient health outcomes.

Methods

We conducted an umbrella review by searching for meta-analyses about VR intervention in clinical nursing practice on Web of Science, Embase, Cochrane, and PubMed, and in reference lists. Eligible studies were published in English between December 1, 2012, and September 20, 2023. Meta-analyses of ≤2 intervention studies and meta-analyses without 95% CI or heterogeneity data were excluded. Characteristic indicators, population information, VR intervention information, and 95% CIs were extracted. A descriptive analysis of research results was conducted to discern relationships between VR interventions and outcomes. I2 and P values were used to evaluate publication bias. AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2 and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) checklist were used to appraise literature quality.

Results

In total, 768 records were identified; 74 meta-analyses were included for review. The most reported VR study conditions were neuronursing (25/74, 34%), pediatric nursing (13/74, 18%), surgical and wound care (11/74, 15%), oncological nursing (11/74, 15%), and older adult nursing (10/74, 14%). Further, 30% (22/74) of meta-analyses reported publication bias, and 15% (11/74) and 8% (6/74) were rated as "high" based on AMSTAR 2 and the GRADE checklist, respectively. The main outcome indicators among all included meta-analyses were pain (37/214, 17.3%), anxiety (36/214, 16.8%), cognitive function (17/214, 7.9%), balance (16/214, 7.5%), depression (16/214, 7.5%), motor function (12/214, 5.6%), and participation in life (12/214, 5.6%). VR treatment for cognition, pain, anxiety, and depression was effective (all P values were <.05), while the utility of VR for improving motor function, balance, memory, and attention was controversial. Adverse effects included nausea, vomiting, and dizziness (incidence: range 4.76%-50%). The most common VR platforms were Pico VR glasses, head-mounted displays, the Nintendo Wii, and the Xbox Kinect. VR intervention duration ranged from 2 weeks to 12 months (typically ≥4 wk). VR session length and frequency ranged from 5 to 100 minutes and from 1 to 10 times per week, respectively.

Conclusions

VR in nursing has positive effects-relieving patients' pain, anxiety, and depression and improving cognitive function-despite the included studies' limited quality. However, applying VR in nursing to improve patients' motor function, balance, memory, and attention remains controversial. Nursing researchers need to further explore the effects and standard operation protocols of VR in clinical practice, and more high-quality research on VR in nursing is needed.

Multidisciplinary Rehabilitation after Hyaluronic Acid Injections for Elderly with Knee, Hip, Shoulder, and Temporomandibular Joint Osteoarthritis

Osteoarthritis (OA) is a prevalent degenerative joint condition characterized by cartilage deterioration, joint inflammation, and functional limitations, particularly impacting the elderly population. Rehabilitation and hyaluronic acid (HA) injections are common therapeutic approaches routinely used in clinical practice, but their synergistic potential is far from being fully characterized. Thus, the aim of this narrative review was to elucidate the multilevel benefits and synergies of integrating these two approaches in multidisciplinary OA rehabilitation. This narrative review follows the scale for the assessment of narrative review articles (SANRA) criteria and involves a comprehensive literature search from July to August 2023. Two independent reviewers screened studies, including those involving human subjects with OA, rehabilitation strategies, and outcomes following HA injection, published in English. Results: HA injections might improve joint biomechanics, reducing friction, absorbing shocks, and potentially regulating inflammation. Rehabilitation plays a pivotal role in strengthening muscles, increasing the range of motion, and enhancing overall function. Optimizing rehabilitation following HA injection might provide additional benefits in joint health. OA management requires a multidisciplinary approach integrating HA injections, rehabilitation, and personalized care. Challenges in patient adherence and healthcare resources currently exist, but emerging technologies offer opportunities to enhance patient engagement and monitoring optimizing sustainability and outcomes of patients with knee, hip, shoulder, and temporomandibular joint OA.

Robot-assisted rehabilitation of people with breast cancer developing upper limb lymphedema: protocol of a randomized controlled trial with a 6-month follow‑up

Upper limb lymphedema (ULLy) is an external (and/or internal) manifestation of lymphatic system insufficiency and deranged lymph transport for more than 3 months and frequently affects people as a consequence of breast cancer (BC). ULLy is often underestimated despite diminished motor skills, mood, and cognitive-behavioral complaints negatively condition the health-related quality of life (HRQoL) of persons. BC can also metastasize to the jawbone, further impacting on the HRQoL. In time, the implementation of robot-assisted rehabilitation (RR) for neurological diseases has grown to improve HRQoL and pain. This study aims to evaluate the effectiveness of a RR program in the treatment of individuals who develop an ULLy; as a further analysis, the study will assess the effectiveness of the same program in people with jawbone metastases from BC who will also develop ULLy. A randomized, parallel-group superiority-controlled trial will be conducted. 44 participants will be randomly allocated to either the experimental (receiving a RR program) or the control group (regular rehabilitation). Both groups will follow individual-based programs three times a week for 10 weeks. The main outcome measure will be the Lymphedema Quality of Life Questionnaire. Secondary outcomes will be a pain intensity numerical rating scale and the Cranio-Facial Pain Disability Inventory. Evaluations are before and after training and 6 months later. Findings may provide evidence on the effectiveness of a RR program on inducing improvements in the HRQoL and pain of individuals with ULLy due to BC. People with ULLy and jawbone metastases from BC are expected for similar or higher improvements as per the same comparisons above. This trial might contribute towards defining guidelines for good clinical rehabilitation routines and might be used as a basis for health authorities' endorsements.Trial registration OSF REGISTRIES, osf-registrations-jz7ax-v1 . Registered on 26 June 2023.

The efficacy and safety of telerehabilitation for patients following total knee arthroplasty: a overviews of systematic reviews

BACKGROUND

Studies evaluating the effectiveness and safety of telerehabilitation in patients undergoing total knee arthroplasty (TKA) have increased. However, the study quality and results differ, systematic reviews are limited. We aimed to synthesise systematic reviews and meta-analyses to assess the effects of telerehabilitation in patients post-TKA.

MATERIALS AND METHODS

Systematic reviews and meta-analyses regarding the effectiveness and safety of TKA telerehabilitation were retrieved from eight databases from establishment to 18 December 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), Risk of Bias in Systematic Reviews (ROBIS) and GRADE system were used to evaluate results, methods, bias and evidence quality.

RESULTS

Thirteen systematic reviews and meta-analyses were analysed. The AMSTAR 2 showed low methodological quality in seven studies and very low quality in six. Among the key items, item 2 had been registered on website before systematic review in four reviews. Concerning item 4, did not provide a comprehensive search strategy in 4 reviews. For item 7, none of the reviews provided a list of reasons for excluding an article. For item 9, regarding whether appropriate tools were used to assess the risk of bias of each included study, one review was assessed as 'partially yes', one review only included RCTs, and the remainder were assessed as 'yes'. For item 11, one review did not specify the statistical methods used, and three reviews did not conduct a meta-analysis. For item 13, four reviews considered the risk of bias when interpreting or discussing the study results. For item 15, seven reviews did not evaluate publication bias. The PRISMA scores of the 13 reviews ranged from 17.5 to 26.0. The PRISMA indicated that 69.2% had no protocol registration, 38.5% did not provide other materials and evidence certainty, 23.1% did not provide certainty assessment, 30.8% did not report study bias. According to the ROBIS scale, diferrent domains have diferrent risks in all the reviews.

CONCLUSION

Telerehabilitation positively affects walking ability, knee extension and patient costs post-TKA surgery. Regarding the quality of life, patient satisfaction and the WOMAC, telerehabilitation had similar effects to conventional rehabilitation. Owing to the low quality of the studies, these conclusions should be interpreted cautiously, high-quality studies are needed in the future.

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 .

Effect of a telerehabilitation exercise program versus a digital booklet with self-care for patients with chronic non-specific neck pain: a protocol of a randomized controlled trial assessor-blinded, 3 months follow-up

BACKGROUND

Neck pain is the fourth worldwide leading cause of disability and represents 22% of musculoskeletal disorders. Conservative intervention has been strongly recommended to treat chronic neck pain and Telerehabilitation is the alternative for the treatment of musculoskeletal conditions. There is a lack of high-quality research on the effects of telerehabilitation in patients with neck pain and functional disability. Therefore, this study aims to evaluate the effect of a telerehabilitation exercise program versus a digital booklet only with self-care information in individuals with non-specific chronic neck pain.

METHODS

This is a prospectively registered, assessor-blinded, two-arm randomized controlled trial comparing a telerehabilitation exercise program versus a digital booklet with self-care information. Seventy patients will be recruited with non-specific chronic neck pain. Follow-ups will be conducted post-treatment, 6 weeks, and 3 months after randomization. The primary outcome will be disability at post-treatment (6 weeks) measured using neck pain disability. Secondary outcomes will be pain intensity levels, global perceived effect, self-efficacy, quality of life, kinesiophobia, and adherence to treatment. In our hypothesis, patients allocated to the intervention group experience outcomes that are similar to those of those assigned to the self-care digital booklet. Our hypothesis can then be approved or disapproved based on the results of the study.

DISCUSSION

This randomized clinical trial will provide reliable information on the use of telerehabilitation to treat patients with chronic non-specific neck pain.

TRIAL REGISTRATION

The study was prospectively registered at the Brazilian Registry of Clinical Trials (number: RBR-10h7khvk). Registered on 16 September 2022.

Combined Digital Interventions for Pain Reduction in Patients Undergoing Knee Replacement: A Randomized Clinical Trial

Importance

Digital technology represents an opportunity to improve outcomes following total knee replacement (TKR). Digitally delivered interventions have been shown to be similar to face-to-face interventions and to increase participation levels in people with osteoarthritis.

Objective

To assess the effect of a digital technology package in reducing pain compared with usual care following TKR.

Design, Setting, and Participants

This randomized clinical trial recruited 102 adults after they received TKR in 3 rehabilitation hospitals in Sydney, Australia, between June 2020 and July 2021.

Interventions

All participants underwent usual care. In addition to usual care, 51 participants received a digital technology package consisting of an exercise app, fitness tracker, and online health coaching. In the usual care group, 51 participants received a fitness tracker but with all notifications turned off and goals for step count, sleep, and active hours removed. Participants were followed up for 12 months (June 2021 to July 2022).

Main Outcome and Measures

The primary outcome was mean knee pain during the past week assessed using a numerical rating scale (range, 0-10, with 10 indicating worst possible pain) at 3 months. In unadjusted analyses, considered primary and based on multiple imputations, independent t tests were used to compare means between groups. Secondary outcomes, including measures of function, activity participation, and quality of life, were analyzed using a generalized estimating equation model that accounted for repeated measurements.

Results

Of 102 participants (mean [SD] age, 67.9 [7.2] years; 68 [67%] female; and 92 [90%] White) randomly assigned to intervention or usual care groups, 47 (92%) in each group completed the 3-month follow up. At 3 months, participants in the intervention group demonstrated small but not clinically meaningful improvements in pain compared with the usual care group in the unadjusted intention-to-treat analysis (mean difference, -0.84; 95% CI, -1.59 to -0.10; P = .03). Secondary outcomes indicated a statistically significant reduction in pain intensity, (mean difference, -0.94; 95% CI, -1.82 to -0.06), pain disability (mean difference, -5.42; 95% CI, -10.00 to -0.83), and sedentary behavior (mean difference, -9.76; 95% CI, -19.17 to -0.34) favoring the intervention from baseline to 3, 6, and 12 months.

Conclusions and Relevance

In this randomized clinical trial, a combined digital technology program provided small but not clinically meaningful improvements in pain at 3 months and other longer-term favorable outcomes following TKR compared with usual care. Future studies should tailor digital interventions based on participants' abilities and preferences to ensure that the intervention is appropriate and fosters long-term self-management.

Trial Registration

Anzctr.org.au Identifier: ACTRN12618001448235.

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Total Hip Arthroplasty: So Hip It Hurts

Total hip arthroplasty (THA) has become a standard surgical intervention for patients with hip joint disorders [...].

Effects of an online program including mindfulness, exercise therapy and patient education compared to online exercise therapy and patient education for people with Patellofemoral Pain: protocol for a randomized clinical trial

BACKGROUND

Patellofemoral pain (PFP) is a common knee disorder that causes persistent pain, lower self-reported function and quality of life. People with PFP also present with altered psychological factors, which are associated with higher levels of pain and dysfunction. Mindfulness-based interventions (MBI) generally consist of meditative practices developed to provide a holistic approach to chronic conditions. However, the effects of MBI on clinical and psychological outcomes for people with PFP remains understudied.

METHODS

This assessor-blinded, parallel, two-arm randomized clinical trial aims to investigate the effects of adding an 8-week online MBI program to exercise therapy and patient education on clinical and psychological factors for people with PFP. We also aim to investigate whether psychological factors mediate changes in pain and function. Sixty-two participants with PFP will be recruited and randomized into one of two treatment groups (Mindfulness or Control group). Both groups will receive an 8-week intervention involving exercise therapy and education delivered through an online platform. The Mindfulness group will additionally receive a MBI component including formal and informal practices. Outcomes will be assessed online at baseline, intervention endpoint (follow-up 1) and 12 months after intervention completion (follow-up 2). Comparisons between groups will be performed at all time points with linear mixed models. A mediation analysis will be performed using a 3-variable framework.

DISCUSSION

Exercise therapy and patient education are considered the "best management" options for PFP. However, unsatisfactory long-term prognosis remains an issue. It is known that people with PFP present with altered psychological factors, which should be considered during the evaluation and treatment of people with PFP. Adding a MBI to the current best treatment for PFP may improve short and long-term effects by addressing the underlying psychological factors.

TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR-4yhbqwk, registered in April 6, 2021.

Sensor-based telerehabilitation system increases patient adherence after knee surgery

OBJECTIVES

Implementing evidence-based recommendations with the option of patient-individualised and situation-specific adaptations in telerehabilitation may increase adherence with improved clinical outcome.

METHODS

As part of a registry-embedded hybrid design (part 1), digital medical device (DMD)-usage in a home-based setting was analysed in a multinational registry. The DMD combines an inertial motion-sensor system with instructions for exercises and functional tests on smartphones. A prospective, single-blinded, patient-controlled, multicentre intervention study (DRKS00023857) compared implementation capacity of the DMD to standard physiotherapy (part 2). Usage patterns by health care providers (HCP) were assessed (part 3).

RESULTS AND CONCLUSION

Registry raw data (10,311 measurements) were analysed from 604 DMD-users, demonstrating clinically expected rehabilitation progression post knee injuries. DMD-users performed tests for range-of-motion, coordination and strength/speed enabling insight to stage-specific rehabilitation (χ2 = 44.9, p<0.001). Intention-to-treat-analysis (part 2) revealed DMD-users to have significantly higher adherence to the rehabilitation intervention compared to the matched patient-control-group (86% [77-91] vs. 74% [68-82], p<0.05). DMD-users performed recommended exercises at home with higher intensity (p<0.05). HCP used DMD for clinical decision making. No adverse events related to the DMD were reported. Adherence to standard therapy recommendations can be increased using novel high quality DMD with high potential to improve clinical rehabilitation outcome, enabling evidence-based telerehabilitation.

Effectiveness of Game-Based Solutions in Patients with Total Hip and Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials

The aim of this systematic review of randomized controlled trials (RCTs) was to evaluate the effectiveness of game-based solutions in patients with total knee arthroplasty or total hip arthroplasty. The systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies published prior May 2022 were identified from MEDLINE Ovid, Scopus, EBSCO Databases, Web of Science, and PubMed. The Joanna Briggs Institute Critical Appraisal Checklist for RCTs was used to evaluate the quality of the relevant studies published. A narrative synthesis was used to report the results while effect sizes were estimated for different outcomes. A total of 350 records were identified, and 5 RCTs were selected. Most of the game-based solutions were exergames to support rehabilitation. The findings indicate that game-based solutions have potential to induce positive impact on functional and cognitive performance; however, due to the low number of studies and moderate/weak quality of existing research, the area still lacks assertive evidence. Future research should pay attention to the methodological aspects to provide reliable information on the use of game-based solutions in the given context.

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.

The quality of physiotherapy and rehabilitation program and the effect of telerehabilitation on patients with knee osteoarthritis

OBJECTIVE

To compare the effects of telerehabilitation vs home-based exercise programs for knee osteoarthritis (KOA).

METHOD

Patients diagnosed with moderate/mild KOA were enrolled in the study and randomized into two groups. The patients in the telerehabilitation group did their exercises via video conference simultaneously, accompanied by a physiotherapist, while the patients in the control group were given a brochure showing how to do the exercises and explaining how to do each exercise. Patients completed 30-s chair stand test (30 CST), Knee Injury and Osteoarthritis Outcome Score (KOOS), Numeric Rating Scale (NRS), International Physical Activity Questionnaire Short Form (IPAQ-SF), Hospital Anxiety and Depression Scale (HADS), TAMPA Kinesiophobia Scale (TKS), Fatigue Severity Scale (FSS) twice before and after 8-week treatment, and Quality Indicators Questionnaire for Physiotherapy Management of Hip and Knee Osteoarthritis (QUIPA) and Exercise Adherence Rating Scale (EARS) after treatment only. Moreover, the number of painkillers that patients used in the last 15 days was recorded before and after treatment, and patient satisfaction with treatment was questioned after treatment.

RESULTS

Forty-eight patients were included in the study. The mean age of patients was 55.83 ± 6.93 years, and 43 (89.6%) patients were women. No significant differences were determined between groups in terms of baseline characteristics. After the 8-week follow-up, telerehabilitation group demonstrated better 30 CST, IPAQ-SF, KOOS, QUIPA, treatment satisfaction, and total and C subscale of EARS scores increment and greater NRS, HADS, TKS, and FSS score reduction than the control group. It was determined that there was a statistically significant difference between the telerehabilitation and control groups for all of the specified parameters; however, no statistically significant difference was found for the B subscale of EARS.

CONCLUSION

This study indicated that telerehabilitation is superior to self-management. Moreover, through this innovative and population specific web-based approach for KOA, a vast number of patients who have internet access could be reached. Thus, patients with KOA received effective treatment.

Long-Term Clinical Outcomes of a Remote Digital Musculoskeletal Program: An Ad Hoc Analysis from a Longitudinal Study with a Non-Participant Comparison Group

Digital solutions have emerged as an alternative to conventional physiotherapy, particularly for chronic musculoskeletal pain (CMP) management; however, its long-term effects remain largely unexplored. This study focuses on patients reporting CMP, assessing 1-year clinical outcomes after a multimodal digital care program (DCP) versus non-participants, who enrolled in the program but never engaged in a single exercise session or partook of the educational content made available to them. In this longitudinal study ad-hoc analysis, pain and functionality outcomes at 1-year reassessment were studied, focusing on the odds of reaching minimal clinically important difference (MCID) and, overall average reduction in both outcomes. Healthcare utilization was additionally studied within the same period. From 867 individuals allocated to the study, 460 completed the 1-year reassessment (intervention group: 310; comparison group: 150). The intervention group presented sustained and greater pain reduction until 1-year reassessment than the comparison group, reflecting greater odds ratio of achieving the MCID both in pain and functionality (1.90 95% CI: 1.27-2.86, p = 0.002 and 2.02 95% CI: 1.31-3.12, p = 0.001, respectively). A lower healthcare utilization during the 1-year follow-up was observed in the intervention group than in the comparison group. This study suggests that a digital CMP program may have a lasting impact on improved pain and functionality in patients with CMP.

Can you be a manual therapist without using your hands?

BACKGROUND

To align with current best practices, manual therapists have refined their treatment options to include exercise and pain education for people with chronic musculoskeletal pain. In this commentary, we suggest that manual therapists should also add telehealth to their toolbox. Thus, we aim to discuss the use of telehealth by manual therapists caring for patients with musculoskeletal disorders.

MAIN BODY

Telehealth can be delivered to the patient in different modes, such as real-time clinical contact or asynchronously. Platforms vary from websites and smartphone apps to virtual reality systems. Telehealth may be an effective approach, especially for improving pain and function in people with musculoskeletal pain, and it has the potential to reduce the individual and socioeconomic burden of musculoskeletal conditions. However, the certainty of evidence reported in systematic reviews is often low. Factors such as convenience, flexibility, undivided attention from the clinician, user-friendly platforms, goal setting, and use of evidence-based information are all enablers for telehealth use and improving patients' knowledge, self-efficacy, and self-management. Barriers to widening the use of telehealth in musculoskeletal care include the reliability of technology, data privacy issues, difficult to build therapeutic alliance, one-size-fits-all approaches, digital health literacy, and payment models.

CONCLUSION

We suggest that practitioners of manual medicine make telehealth part of their clinical toolbox where it makes sense and where there is evidence that it is beneficial for people who seek their care.

Attributes Underlying Patient Choice for Telerehabilitation Treatment: A Mixed-Methods Systematic Review to Support a Discrete Choice Experiment Study Design

BACKGROUND

Across most healthcare systems, patients are the primary focus. Patient involvements enhance their adherence to treatment, which in return, influences their health. The objective of this study was to determine the characteristics (ie, attributes) and associated levels (ie, values of the characteristics) that are the most important for patients regarding telerehabilitation (TR) healthcare to support a future discrete choice experiment (DCE) study design.

METHODS

A mixed-methods systematic review was conducted from January 2005 to the end of July 2020 and the search strategy was applied to five different databases. The initial selection of articles that met the eligibility criteria was independently made by one researcher, two researchers verified the accuracy of the extracted data, and all researchers discussed about relevant variables to include. Reporting of this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the study. A qualitative synthesis was used to summarize findings.

RESULTS

From a total of 928 articles, 11 (qualitative [n = 5], quantitative [n = 3] and mixed-methods [n = 3] design) were included, and 25 attributes were identified and grouped into 13 categories: Accessibility, Distance, Interaction, Technology experience, Treatment mode, Treatment location, Physician contact mode, Physician contact frequency, Cost, Confidence, Ease of use, Feeling safer, and Training session. The attributes levels varied from two to five. The DCE studies identified showed the main stages to undertake these types of studies.

CONCLUSION

This study could guide the development of interview grid for individual interviews and focus groups to support a DCE study design in the TR field. By understanding the characteristics that enhance patients' preferences, healthcare providers can create or improve TR programs that provide high-quality and accessible care. Future research via a DCE is needed to determine the relative importance of the attributes.

Cutting-Edge Approaches in Arthroplasty: Before, during and after Surgery

Personalised medicine was introduced in arthroplasty a long time ago with the aim of respecting each individual person for their unique personal characteristics in order to further improve outcomes [...].

Robot-assisted rehabilitation for total knee or hip replacement surgery patients: A systematic review and meta-analysis

BACKGROUND

This study was performed to update the current evidence and evaluate the effects of robot-assisted rehabilitation (RAR) in comparison with conventional rehabilitation (CR) in patients following total knee (TKR) or hip replacements (THR).

METHODS

PubMed Central, OVID Medline, Cochrane Collaboration Library, and EMBASE for a comprehensive search for all relevant studies, from database inception to July 2022. The following inclusion criteria were used to determine eligibility for studies: randomized and matched controlled trials recruiting men and women who underwent TKR and THR; and studies examining the effect of RAR on outcome measures of physical function and pain.

RESULTS

A total of 9 studies (230 patients) were included in this review and 4 were included in the meta-analysis. The meta-analysis of 2 studies showed that Hybrid Assistive Limb (HAL) training for 5 days, significantly improved pain measured on a visual analogue scale, compared to CR in patients following TKR (SMD = 1.05, 95% confidence interval [Cl] 0.39-1.71). Heterogeneity for I2 value was lower than moderate (tau^2 = 0.0121; I2 = 5%; P = .30). There were 2 studies that assessed self-selected walking speed. The meta-analysis of these studies showed that HAL training was significantly superior to CR in patients following TKR (SMD = 48.70, 95% Cl -50.53 to 147.94) at 2 months. A high heterogeneity was detected (P < .01; I2 = 97%).

CONCLUSION

The result of this systematic review and meta-analysis suggest that RAR may be an effective treatment in TKR and THR patients. However, high-quality studies are needed to verify the long-term effect on their recovery.

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.

Digital Care Programs for Chronic Hip Pain: A Prospective Longitudinal Cohort Study

Chronic hip pain is a cause of disability worldwide. Digital interventions (DI) may promote access while providing proper management. This single-arm interventional study assesses the clinical outcomes and engagement of a completely remote multimodal DI in patients with chronic hip pain. This home-based DI consisted of exercise (with real-time biofeedback), education, and cognitive-behavioral therapy. Outcomes were calculated between baseline and program end, using latent growth curve analysis. Primary outcome was the Hip Disability and Osteoarthritis Outcome Score (HOOS). Secondary outcomes were pain, intent to undergo surgery, mental health, productivity, patient engagement (exercise sessions frequency), and satisfaction. Treatment response was assessed using a 30% pain change cut-off. A completion rate of 74.2% (396/534), alongside high patient engagement (2.9 exercise sessions/week, SD 1.1) and satisfaction (8.7/10, SD 1.6) were observed. Significant improvements were observed across all HOOS sub-scales (14.7−26.8%, p < 0.05), with 66.8% treatment responders considering pain. Marked improvements were observed in surgery intent (70.1%), mental health (54%), and productivity impairment (60.5%) (all p < 0.001). The high engagement and satisfaction reported after this DI, alongside the clinical outcome improvement, support the potential of remote care in the management of chronic hip conditions.

Movement characteristics during customized exergames after total knee replacement in older adults

Introduction

There is limited understanding of how older adults can reach kinematic goals in rehabilitation while performing exergames and conventional exercises, and how similar or different the kinematics during exergaming are when compared with conventional therapeutic exercise with similar movement. The aim of this study was to describe the movement characteristics performed during exercise in custom-designed exergames and conventional therapeutic exercises among patients who have undergone unilateral total knee replacement (TKR). In addition, the secondary aim was to assess the relation of these exercise methods, and to assess participants' perceived exertion and knee pain during exergaming and exercising.

Materials and methods

Patients up to 4 months after the TKR surgery were invited in a single-visit exercise laboratory session. A 2D motion analysis and force plates were employed to evaluate movement characteristics as the volume, range, and intensity of movement performed during custom-designed knee extension-flexion and weight shifting exergames and conventional therapeutic exercises post TKR. The perceived exertion and knee pain were assessed using the Borg Rating of Perceived Exertion and Visual Analog Scale, respectively.

Results

Evaluation of seven patients with TKR [age median (IQR), 65 (10) years] revealed that the volume and intensity of movement were mostly higher during exergames. Individual goniometer-measured knee range of motion were achieved either with exergames and conventional therapeutic exercises, especially in knee extension exercises. The perceived exertion and knee pain were similar after exergames and conventional therapeutic exercises.

Conclusions

During custom-designed exergaming the patients with TKR achieve the movement characteristics appropriate for post-TKR rehabilitation without increasing the stress and pain experienced even though the movement characteristics might be partly different from conventional therapeutic exercises by the volume and intensity of movement. Physical therapists could consider implementing such exergames in rehabilitation practice for patients with TKR once effectiveness have been approved and they are widely available.

Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear–avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear–avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

Nonlinear and Linear Measures in the Differentiation of Postural Control in Patients after Total Hip or Knee Replacement and Healthy Controls

Primary osteoarthritis treatments such as a total hip (THR) or knee (TKR) replacement lead to postural control changes reinforced by age. Balance tests such as standing with eyes open (EO) or closed (EC) give a possibility to calculate both linear and nonlinear indicators. This study aimed to find the group of linear and/or nonlinear measures that can differentiate healthy people and patients with TKR or THR from each other. This study enrolled 49 THR patients, 53 TKR patients, and 16 healthy controls. The center of pressure (CoP) path length, sample entropy (SampEn), fractal dimension (FD), and the largest Lyapunov exponent (LyE) were calculated separately for AP and ML directions from standing with EO/EC. Cluster analysis did not result in correct allocation to the groups according to all variables. The discriminant model included LyE (ML-EO, ML-EC, AP-EC), FD (AP-EO, ML-EC, AP-EC), CoP-path AP-EC, and SampEn AP-EC. Regression analysis showed that all nonlinear variables depend on the group. The CoP path length is different only in THR patients. It was concluded that standing with EC is a better way to assess the amount of regularity of CoP movement and attention paid to maintain balance. Nonlinear measures better differentiate TKR and THR patients from healthy controls.

Clinical Outcomes After a Digital Musculoskeletal Program for Acute and Subacute Pain: Observational, Longitudinal Study With Comparison Group

Background

Telerehabilitation for musculoskeletal (MSK) conditions may produce similar or better outcomes than usual care, but most telerehabilitation studies address only chronic or postsurgical pain.

Objective

We aimed to examine pain and function at 3, 6, and 12 weeks for individuals with acute and subacute MSK pain who took part in a digital MSK program versus a nonparticipant comparison group.

Methods

We conducted an observational, longitudinal study with a nonparticipant comparison group. The intervention group had video visits with physical therapists who recommended exercise therapies and educational articles delivered via an app. Nonparticipants were those who were registered but unable to participate because their benefit coverage had not yet begun. We collected pain and function outcomes through surveys delivered at 3-, 6-, and 12-week follow-ups. We conducted descriptive analyses, unadjusted regression, and mixed effects regression adjusting for baseline characteristics, time as fixed effects, and a time*group interaction term.

Results

The analysis included data from 675 nonparticipants and 262 intervention group participants. Compared to baseline, the intervention group showed significantly more pain improvement at 3, 6, and 12 weeks versus nonparticipants after adjusting for baseline factors. Specifically, the intervention group’s pain scores decreased by 55.8% at 3 weeks versus baseline, 69.1% at 6 weeks, and 73% at 12 weeks. The intervention group’s adjusted pain scores decreased from 43.7 (95% CI 41.1-46.2) at baseline to 19.3 (95% CI 16.8-21.8) at 3 weeks to 13.5 (95% CI 10.8-16.2) at 6 weeks to 11.8 (95% CI 9-14.6) at 12 weeks. In contrast, nonparticipants’ pain scores decreased by 30.8% at 3 weeks versus baseline, 45.8% at 6 weeks, and 46.7% at 12 weeks. Nonparticipants’ adjusted pain scores decreased from 43.8 (95% CI 42-45.5) at baseline to 30.3 (95% CI 27.1-33.5) at 3 weeks to 23.7 (95% CI 20-27.5) at 6 weeks to 23.3 (95% CI 19.6-27) at 12 weeks. After adjustments, the percentage of participants reporting that pain was better or much better at follow-up was significantly higher by 40.6% at 3 weeks, 31.4% at 6 weeks, and 31.2% at 12 weeks for intervention group participants versus nonparticipants. After adjustments, the percentage of participants with meaningful functional improvement at follow-up was significantly higher by 15.2% at 3 weeks and 24.6% at 12 weeks for intervention group participants versus nonparticipants.

Conclusions

A digital MSK program may help to improve pain and function in the short term among those with acute and subacute MSK pain.

Total Joint Arthroplasty Training (Prehabilitation and Rehabilitation) in Lower Extremity Arthroplasty

Lower extremity total joint arthroplasty (TJA) has an established track record of success and a subset of patients who fail to experience desired improvements. Current TJA success can be attributed to refined surgical techniques, improved preparation of patients for surgery, and enhanced postoperative recovery protocols. One aspect of preoperative patient preparation and enhanced postoperative recovery includes training regimens intended to prepare patients for TJA and facilitate TJA functional recovery (often referred to as using the jargon prehabilitation and rehabilitation). The importance of prehabilitation and rehabilitation is open to debate because of historically insufficient and inconsistent evidence. This review aims to provide direction for future investigative efforts by presenting an overview of current preoperative and postoperative TJA training/exercise programs within the framework of utility, timing, form, setting, and cost.

The effectiveness of telerehabilitation in patients after total knee replacement: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Total knee replacement is a commonly adopted surgical intervention to reduce physical limitations and pain in advanced-stage knee osteoarthritis. However, these patients may experience physical dysfunction to limit their access during conventional rehabilitation after total knee replacement. The use of telemedicine may be the promising solution. This study aims to compare the effectiveness of telerehabilitation with conventional in-person rehabilitation in patients who underwent a total knee replacement.

METHODS

For this systematic review on randomized controlled trials, PubMed, Medline, EMBASE, Cochrane Library, ScienceDirect and CINAHL databases were searched for eligible articles published between 1 January 2003 and 28 February 2022. The eligibility criteria were patients who underwent total knee replacement, randomized controlled trials and publications in English. The main outcome measures were focused on pain and physical function. Reference lists of relevant studies were also manually checked to find additional studies. Two independent reviewers conducted study selection separately. PEDro scale was used to assess the methodological quality of the included randomized controlled trials. A meta-analysis was performed on the collected data. Review Manager (RevMan, version 5.3) was used for all analyses.

RESULTS

A total of 11 studies met the eligibility criteria and included 1825 participants in the systematic review. Overall, the results revealed that the effectiveness of telerehabilitation is comparable to conventional in-person rehabilitation in improving various pain and functional outcomes in patients who underwent a total knee replacement. In the meta-analysis with the fixed-effects model, no significant difference was found in the improvement of pain and physical function in patients with knee osteoarthritis compared with conventional rehabilitation (Standardized Mean Difference (SMD)  -0.15, 95% CI  -0.47 to 0.16, P = 0.34 and SMD -0.04, 95% CI -0.19 to 0.12, P = 0.62, respectively). In addition, the utilization of hospital resources and costs were significantly lower in telerehabilitation when compared with in-person rehabilitation.

CONCLUSION

Telerehabilitation was comparable to conventional in-person rehabilitation in improving clinical outcomes following total knee replacement. However, it might be a more preferable alternative rehabilitation intervention for patients following total knee replacement given the significantly lower cost of telerehabilitation.

A Model for Delivery of Orthopaedic Perioperative Education via Telehealth

With orthopaedic surgery, there is a risk of poor outcomes such as pain, decreased mobility, and decreased function, particularly if patients do not receive adequate preoperative and postoperative orthopaedic education. Healthcare education delivered via telehealth can be individualized to the patient's specific situation and health literacy level and is accessible, convenient, and timely for patients and providers. The purpose of this article is to combine two models of best practice, the EDUCATE model of patient education and Bashshur's Taxonomy of Telehealth, to describe a framework for improving delivery of preoperative and postoperative orthopaedic education. This innovative model presents a patient-centered approach to orthopaedic education that can increase patient comprehension and retention and address health literacy, through consideration of three dimensions essential for effective telehealth programs: functionality, application, and technology. Applications of the model are presented.

Effectiveness of adding virtual reality to physiotherapeutic treatment in patients with total hip arthroplasty. A randomized controlled trial

OBJECTIVE

To determine the clinical effectiveness of adding virtual reality via the Nintendo Wii console and its Wii Balance Board to physiotherapy treatment in patients with total hip arthroplasty.

DESIGN

Randomized controlled trial.

SETTING

Clinical Hospital San Borja Arriaran, Santiago, Chile.

PARTICIPANTS

A total of 73 patients over 50 years of age with total hip arthroplasty were randomly allocated to two groups.

INTERVENTIONS

The control group (n = 37) received 6 weeks of physiotherapy treatment; the intervention group (n = 36) received the same treatment plus virtual reality exercises with the Nintendo Wii console.

OUTCOME MEASURES

The two groups were assessed at baseline and after the 6 weeks of treatment. The primary outcome assessed was the function with the WOMAC questionnaire. The secondary outcomes were the Berg Balance Scale, distance covered with the six-minute walk test, and difference in weight load on the lower extremities.

RESULTS

A total of 73 patients, 37 patients in the control group (20 women; mean age of 70.9 ± 9.16 years) and 36 patients in the intervention group (18 women; mean age of 70.39 ± 9.02 years) were analyzed. At the end of the treatment, the difference between groups for the total WOMAC score was -10.4 points (p = 0.00), 4.7 points (p = 0.00) for the Berg Balance Scale, and 45.2 mt (p = 0.00) for the six-minute walk test All differences were in favor of the intervention group.

CONCLUSIONS

In the short term, the addition of virtual reality via the Nintendo Wii and its Wii Balance Board platform showed statistically significant differences in the function of patients with total hip replacement, but these differences were not minimally clinically important.Trial registration: This research was registered in the Clinical Trials Registry of Australia and New Zealand, with reference ACTRN12618001252202.

[The use of stability training in rehabilitation programs in patients after total knee replacement in the late recovery period]

All over the world, total joint replacement is one of the most common and popular surgical technology. The frequency of knee replacement is steadily increasing. The development of new rehabilitation technologies for patients after total knee replacement is an urgent problem of modern healthcare.

OBJECTIVE

To evaluate the effect of physical training using a stabiloplatform and a standard scheme of medical rehabilitation on the restoration of the walking stereotype, the state of locomotor function and hemodynamic parameters of the affected lower limb in patients after total knee replacement in the late recovery period.

MATERIAL AND METHODS

60 patients were examined three months after total arthroplasty of the joints of the lower limb aged 55 to 80 years, who were divided into two groups comparable in clinical and functional characteristics: the 1^st group - 30 people, who in addition to the standard scheme of medical rehabilitation, were trained using a stabilometric complex with biofeedback for recovery functions of balance and symmetry of movements; the 2^nd group - 30 people, who have undergone a course of medical rehabilitation (physical therapy and medical massage according to the standard method). The state of the microcirculatory bed in the affected limb was assessed using laser Doppler flowmetry, data on static-locomotor disorders (before and after treatment) were analyzed.

RESULTS

The data obtained indicate the advantage of including physical training aimed at restoring impaired locomotor function, balance and symmetry of movements in the standard scheme of medical rehabilitation of patients after total knee replacement of the lower limb. In the course of the study, it was revealed that training with biofeedback helps to improve the overall capillary blood flow in the affected lower limb and normalize the indicators of static-locomotor functions.

CONCLUSION

The inclusion of physical training to restore static balance and symmetry of movements in the standard complex of medical rehabilitation of patients after total knee replacement in the late recovery period significantly improves microcirculation in the affected limb and normalizes motor functions and skills.

[The use of rehabilitation programs for patients in the early recovery period after total knee arthroplasty]

Rehabilitation of patients after total knee arthroplasty is still a challenge for modern medicine. At the same time, there are few publications in the medical literature on rehabilitation programs for patients after total knee arthroplasty. Available scientific studies have proven the effectiveness of low-intensity laser therapy and a pulsed low-frequency electrostatic field (PLFEF) in tissue repair by modulating the inflammatory process and relieving pain.

OBJECTIVE

Scientific substantiation of the feasibility of the combined use of low-intensity laser radiation (LILR) and PLFEF in patients after total knee arthroplasty.

MATERIAL AND METHODS

90 patients aged from 55 to 80 years after total knee arthroplasty were examined. All patients were randomly assigned to three groups. Patients of the 1st group underwent therapeutic exercises with an instructor and low-intensity laser exposure; in the 2nd group, therapeutic exercises with an instructor, low-intensity laser therapy, and PLFEF were performed without a time interval; patients of the 3rd group received only therapeutic exercises with an instructor.

RESULTS

After the course of treatment, a positive dynamics of the state of microcirculation was noted in all patients, which correlated with a significant regression of the pain syndrome and an improvement in the performance of the 10-meter walk test with external support on crutches. However, a more significant decrease in pain intensity after the first procedures and at the end of the course of treatment was found in the group of patients who received complex therapy, which included LILR, PLFEF, and therapeutic exercises.

CONCLUSION

Thus, based on the data of this study, it is possible to recommend the combined use of LILR and PLFEF for the treatment of patients after total knee arthroplasty.

Digital health for quality healthcare: A systematic mapping of review studies

Objective

To systematically catalogue review studies on digital health to establish extent of evidence on quality healthcare and illuminate gaps for new understanding, perspectives and insights for evidence-informed policies and practices.

Methods

We systematically searched PubMed database using sensitive search strings. Two reviewers independently conducted two-phase selection via title and abstract, followed by full-text appraisal. Consensuses were derived for any discrepancies. A standardized data extraction tool was used for reliable data mining.

Results

A total of 54 reviews from year 2014 to 2021 were included with notable increase in trend of publications. Systematic reviews constituted the majority (61.1%, (37.0% with meta-analyses)) followed by scoping reviews (38.9%). Domains of quality being reviewed include effectiveness (75.9%), accessibility (33.3%), patient safety (31.5%), efficiency (25.9%), patient-centred care (20.4%) and equity (16.7%). Mobile apps and computer-based were the commonest (79.6%) modalities. Strategies for effective intervention via digital health included engineering improved health behaviour (50.0%), better clinical assessment (35.1%), treatment compliance (33.3%) and enhanced coordination of care (24.1%). Psychiatry was the discipline with the most topics being reviewed for digital health (20.3%).

Conclusion

Digital health reviews reported findings that were skewed towards improving the effectiveness of intervention via mHealth applications, and predominantly related to mental health and behavioural therapies. There were considerable gaps on review of evidence on digital health for cost efficiency, equitable healthcare and patient-centred care. Future empirical and review studies may investigate the association between fields of practice and tendency to adopt and research the use of digital health to improve care.

[Rehabilitation following total knee replacement]

BACKGROUND

Total knee replacement requires follow-up treatment. This can take place on an outpatient basis as part of health insurance coverage, but also as outpatient or inpatient rehabilitation.

KIND OF REHABILITATION

Outpatient rehabilitation provides comparable results to inpatient rehabilitation, but only for those patients who are suitable for outpatient rehabilitation. Inpatient rehabilitation should be indicated depending on general health status, general physical fitness, housing situation, accessibility of rehabilitation facilities and possibilities of social support in the home environment, as well as age and comorbidities. Physiotherapeutic procedures should focus on exercise therapy. Passive reactive measures complement the therapy. For patients of working age, the activity profile should be considered as part of the rehabilitation process. Patient education, with information on prosthesis-appropriate behavior, represents an important component in follow-up treatment.

PROSPECT

Demographic change requires increasing consideration of orthogeriatric aspects. Fast-track programs will not make follow-up treatment superfluous, but with accelerated processes they represent a new challenge for sectoral cooperation.

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.

The Telemedicine-Based Pediatric Examination of the Back and Lower Limbs: A Narrative Review

The COVID-19 pandemic has accelerated the transition to virtual healthcare while also prompting an abundance of new literature highlighting telemedicine's capabilities and limitations for various medical applications, notably musculoskeletal examinations. Telemedicine provides an opportunity to deliver timely patient- and family-centred care while maintaining physical distancing and improving access to remote communities. This review aims to narrate the current state of the literature on telemedicine applied in the context of a musculoskeletal examination for children aged 3 to 18 years. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. The general examination components relevant to the back and lumbosacral spine, hip, knee, ankle/foot, and gait are described. These components include inspection, palpation, range of motion, motor, and sensory examination as well as special testing. There is general feasibility, validity, and substantial reliability in performing most examination components, and primary diagnoses established virtually were found to be either the same or similar in the vast majority of cases. Despite the current literature focusing mainly on adult populations, we describe how each aspect of the exam can be reliably incorporated into a virtual appointment specific to the pediatric population. Currently available smartphone-based applications that measure joint range of motion were generally found to have high reliability and validity. Caregivers are needed for most of the consultation, especially in younger children, but select physical exam maneuvers can be self-performed by older children and adolescents alone. By providing an overview of the available smartphone tools as well as the reliability and validity of remote assessments, this review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase providers' confidence in incorporating telemedicine into their practice.

Applications of Digital Health Technologies in Knee Osteoarthritis: A Narrative Review (Preprint)

Background

With the increasing adoption of high-speed internet and mobile technologies by older adults, digital health is a promising modality to enhance clinical care for people with knee osteoarthritis (KOA), including those with knee replacement (KR).

Objective

This study aimed to summarize the current use, cost-effectiveness, and patient and clinician perspectives of digital health for intervention delivery in KOA and KR.

Methods

In this narrative review, search terms such as mobile health, smartphone, mobile application, mobile technology, ehealth, text message, internet, knee osteoarthritis, total knee arthroplasty, and knee replacement were used in the PubMed and Embase databases between October 2018 and February 2021. The search was limited to original articles published in the English language within the past 10 years. In total, 91 studies were included.

Results

Digital health technologies such as websites, mobile apps, telephone calls, SMS text messaging, social media, videoconferencing, and custom multi-technology systems have been used to deliver interventions in KOA and KR populations. Overall, there was significant heterogeneity in the types and applications of digital health used in these populations. Digital patient education improved disease-related knowledge, especially when used as an adjunct to traditional methods of patient education for both KOA and KR. Digital health that incorporated person-specific motivational messages, biofeedback, or patient monitoring was more successful at improving physical activity than self-directed digital interventions for both KOA and KR. Many digital exercise interventions were found to be as effective as in-person physical therapy for people with KOA. Many digital exercise interventions for KR incorporated both in-person and web-based treatments (blended format), communication with clinicians, and multi-technology systems and were successful in improving knee range of motion and self-reported symptoms and reducing the length of hospital stays. All digital interventions that incorporated cognitive behavioral therapy or similar psychological interventions showed significant improvements in knee pain, function, and psychological health when compared with no treatment or traditional treatments for both KOA and KR. Although limited in number, studies have indicated that digital health may be cost-effective for these populations, especially when travel costs are considered. Finally, although patients with KOA and KR and clinicians had positive views on digital health, concerns related to privacy and security and concerns related to logistics and training were raised by patients and clinicians, respectively.

Conclusions

For people with KOA and KR, many studies found digital health to be as effective as traditional treatments for patient education, physical activity, and exercise interventions. All digital interventions that incorporated cognitive behavioral therapy or similar psychological treatments were reported to result in significant improvements in patients with KOA and KR when compared with no treatment or traditional treatments. Overall, technologies that were blended and incorporated communication with clinicians, as well as biofeedback or patient monitoring, showed favorable outcomes.

Patient Engagement Approaches in Total Joint Arthroplasty: A Review of Two Decades

Patient engagement is a comprehensive approach to health care where the physician inspires confidence in the patient to be involved in their own care. Most research studies of patient engagement in total joint arthroplasty (TJA) have come in the past 5 years (2015-2020), with no reviews investigating the different patient engagement methods in TJA. The primary purpose of this review is to examine patient engagement methods in TJA. The search identified 31 studies aimed at patient engagement methods in TJA. Based on our review, the conclusions therein strongly suggest that patient engagement methods in TJA demonstrate benefits throughout care delivery through tools focused on promoting involvement in decision making and accessible care delivery (eg, virtual rehabilitation, remote monitoring). Future work should understand the influence of social determinants on patient involvement in care, and overall cost (or savings) of engagement methods to patients and society.

Team Approach: Virtual Care in the Management of Orthopaedic Patients

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Telemedicine and remote care administered through technology are among the fastest growing sectors in health care. The utilization and implementation of virtual-care technologies have further been accelerated with the recent COVID-19 pandemic.

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Remote, technology-based patient care is not a "one-size-fits-all" solution for all medical and surgical conditions, as each condition presents unique hurdles, and no true consensus exists regarding the efficacy of telemedicine across surgical fields.

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When implementing virtual care in orthopaedics, as with standard in-person care, it is important to have a well-defined team structure with a deliberate team selection process. As always, a team with a shared vision for the care they provide as well as a supportive and incentivized environment are integral for the success of the virtual-care mechanism.

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Future studies should assess the impact of primarily virtual, integrated, and multidisciplinary team-based approaches and systems of care on patient outcomes, health-care expenditure, and patient satisfaction in the orthopaedic population.

Telerehabilitation program for older adults on a waiting list for physical therapy after hospital discharge: study protocol for a pragmatic randomized trial protocol

BACKGROUND

Delays in starting physical therapy after hospital discharge worsen deconditioning in older adults. Intervening quickly can minimize the negative effects of deconditioning. Telerehabilitation is a strategy that increases access to rehabilitation, improves clinical outcomes, and reduces costs. This paper presents the protocol for a pragmatic clinical trial that aims to determine the effectiveness and cost-effectiveness of a multi-component intervention offered by telerehabilitation for discharged older adults awaiting physical therapy for any specific medical condition.

METHODS

This is a pragmatic randomized controlled clinical trial with two groups: telerehabilitation and control. Participants (n=230) will be recruited among individuals discharged from hospitals who are in the public healthcare system physical therapy waiting lists. The telerehabilitation group will receive a smartphone app with a personalized program (based on individual's functional ability) of resistance, balance, and daily activity training exercises. The intervention will be implemented at the individuals' homes. This group will be monitored weekly by phone and monthly through a face-to-face meeting until they start physical therapy. The control group will adhere to the public healthcare system's usual flow and will be monitored weekly by telephone until they start physical therapy. The primary outcome will be a physical function (Timed Up and Go and 30-s Chair Stand Test). The measurements will take place in baseline, start, and discharge of outpatient physical therapy. The economic evaluations will be performed from the perspective of society and the Brazilian public healthcare system.

DISCUSSION

The study will produce evidence on the effectiveness and cost-effectiveness of multi-component telerehabilitation intervention for discharged older adult patients awaiting physical therapy, providing input that can aid the implementation of similar proposals in other patient groups.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC), RBR-9243v7 . Registered on 24 August 2020.

Effectiveness of Telerehabilitation in Physical Therapy: A Rapid Overview

OBJECTIVE

The purpose of this article was to summarize the available evidence from systematic reviews on telerehabilitation in physical therapy.

METHODS

We searched Medline/PubMed, EMBASE, and Cochrane Library databases. In addition, the records in PROSPERO and Epistemonikos and PEDro were consulted. Systematic reviews of different conditions, populations, and contexts-where the intervention to be evaluated is telerehabilitation by physical therapy-were included. The outcomes were clinical effectiveness depending on specific condition, functionality, quality of life, satisfaction, adherence, and safety. Data extraction and risk of bias assessment were carried out by a reviewer with non-independent verification by a second reviewer. The findings are reported qualitatively in the tables and figures.

RESULTS

Fifty-three systematic reviews were included, of which 17 were assessed as having low risk of bias. Fifteen reviews were on cardiorespiratory rehabilitation, 14 on musculoskeletal conditions, and 13 on neurorehabilitation. The other 11 reviews addressed other types of conditions and rehabilitation. Thirteen reviews evaluated with low risk of bias showed results in favor of telerehabilitation versus in-person rehabilitation or no rehabilitation, while 17 reported no differences between the groups. Thirty-five reviews with unclear or high risk of bias showed mixed results.

CONCLUSIONS

Despite the contradictory results, telerehabilitation in physical therapy could be comparable with in-person rehabilitation or better than no rehabilitation for conditions such as osteoarthritis, low-back pain, hip and knee replacement, and multiple sclerosis and also in the context of cardiac and pulmonary rehabilitation. It is imperative to conduct better quality clinical trials and systematic reviews.

IMPACT

Providing the best available evidence on the effectiveness of telerehabilitation to professionals, mainly physical therapists, will impact the decision-making process and therefore yield better clinical outcomes for patients, both in these times of the COVID-19 pandemic and in the future. The identification of research gaps will also contribute to the generation of relevant and novel research questions.