Challenges in rehabilitation and continuum of care provision after knee replacement: a mixed-methods study from a low- and middle-income country

Design and development of a mobile health intervention for rehabilitation support after knee arthroplasty: TeleRehabilitation after knee ArThroplasty (TReAT) project

BACKGROUND

The steep increase in knee arthroplasties in lower- and middle-income countries has increased demand for personalised rehabilitation care. Technology-based rehabilitation programs offer potential to replace or augment conventional face-to-face rehabilitation for providing continuum of care. We aimed to systematically develop a theory, evidence-driven, contextualised, and user-centred mobile health platform for people undergoing knee arthroplasty to facilitate monitoring progress during rehabilitation.

METHODS

We followed the UK Medical Research Council's framework and adopted a behaviour design thinking approach, consisting of five steps; (1) conduct multiple literature reviews and cross-sectional surveys to determine the needs and problems experienced during the rehabilitation phase by healthcare professionals and individuals with replaced knees, (2) identify target behaviours along with barriers and facilitators, integrated within the Capability, Opportunity, Motivation-Behaviour (COM-B) framework, (3) identify intervention functions and components, behaviour change techniques, and features for the mobile application, selected after discussions with orthopaedic surgeons, physiotherapists and behavioural experts, (4) develop a prototype application for end-users, and a web-based platform for healthcare professionals, and (5) pilot test the intervention for end-users' feedback on usability of the application and to identify possible strategies for implementing the intervention package.

RESULTS

Using the COM-B model, education, training, persuasion, enablement, and modelling were chosen as intervention functions for improving adherence to exercise protocol during early-phase of rehabilitation. The application featured five interlinked components; education, training, goal setting and self-management, communication, and a personalized therapy plan utilising 13 behaviour change techniques. An education booklet, exercise videos, text messaging, video consultation, and a digital tool for measuring range of motion were incorporated into the application. Feedback on the interactive prototype and education material was sought from ten patient volunteers and a physiotherapist. Pilot testing in a convenient sample with broad eligibility criteria (n = 30) indicated importance of digital literacy and dedicated time for remote consultation by healthcare provider within the existing clinical work. Overall, the intervention was well received and valued by the end users.

CONCLUSION

This paper demonstrates the development of a contextualised digital behavioural intervention grounded in behavioural theory and evidence from literature to improve end-user's engagement with rehabilitation protocols after knee arthroplasty in lower- and middle-income country context.

TRIAL REGISTRATION

Study registered prospectively (on 16 February 2023) at Clinical Trials Registry of India (CTRI/2023/02/049792).

Effects of a new continuous nursing program on the short-term and long-term low back pain in patients after UBED: a retrospective study based on 282 patients

Background

Unilateral biportal endoscopic discectomy (UBED) is a widely accepted minimally invasive surgery for the treatment of lumbar degenerative diseases. However, some patients continue to have persistent low back pain (LBP) symptoms in the short and long term after surgery, which may be related to improper postoperative nursing and rehabilitation of patients. Further research is needed to determine whether continuous nursing can improve the symptoms of patients after UBED.

Methods

This study retrospectively enrolled 282 lumbar disc herniation (LDH) patients who underwent UBED in our hospital from January 2019 to January 2022. The patients were divided into two groups according to whether they accepted the continuous nursing program: 147 patients in the traditional nursing group and 135 patients in the continuous nursing group. Demographic characteristics, radiological parameters, and follow-up data of the patients were collected. Finally, the risk factors of LBP after UBED were analyzed.

Results

The visual analog scale (VAS) score of LBP in the continuous nursing group was 0.97 ± 1.159 at 3 months and 0.61 ± 0.954 at 12 months after operation, and VAS of leg pain was 0.23 ± 0.421 at 12 months after operation, which were better than those in the traditional nursing group (1.51 ± 1.313, 1.10 ± 1.076, 0.68 ± 0.788, respectively, p < 0.001) The Oswestry disability index (ODI) score of the continuous nursing group was lower than that of the traditional nursing group at 12 months after operation (7.36 ± 6.526 vs. 12.43 ± 6.942, p < 0.001). The rehabilitation completion (7.98 ± 1.857), efficacy satisfaction (9.13 ± 1.101), and re-herniation worry scores (1.97 ± 1.217) in the continuous nursing group were better than those in the traditional nursing group (4.14 ± 3.066, 8.28 ± 1.240, 2.79 ± 1.973, respectively, P < 0.001). The re-herniation rate within 1 year was similar between the two groups (3/135 vs. 2/147, p = 0.673). No incision infection occurred. Multivariate regression analysis showed that risk factors for persistent LBP at 3-month follow-up were degenerative disc [odds ratio (OR): 2.144, CI: 1.306-3.519, p = 0.03], Pfirrmann grade (OR: 3.073, CI: 1.427-6.614, p = 0.04), and surgical time (OR: 0.969, CI: 0.937-1.003, p = 0.74). At the 12-month follow-up, the risk factors for persistent LBP were preoperative VAS of the legs (OR: 1.261, CI: 1.000-1.591, p = 0.05) and Pfirrmann grade (OR: 3.309, CI: 1.460-7.496, p = 0.04).

Conclusion

Continuous nursing programs can improve the symptoms of short-term and long-term persistent LBP in patients after UBED, enhance the completion of rehabilitation training after UBED, alleviate patients' concerns about recurrence, and improve patients' satisfaction.

Low Household Income Increases Hospital Length of Stay and Decreases Home Discharge Rates in Lumbar Fusion

STUDY DESIGN

Retrospective Matched Cohort Study.

OBJECTIVES

Low median household income (MHI) has been correlated with worsened surgical outcomes, but few studies have rigorously controlled for demographic and medical factors at the patient level. This study isolates the relationship between MHI and surgical outcomes in a lumbar fusion cohort using coarsened exact matching.

METHODS

Patients undergoing single-level, posterior lumbar fusion at a single institution were consecutively enrolled and retrospectively analyzed (n = 4263). Zip code was cross-referenced to census data to derive MHI. Univariate regression correlated MHI to outcomes. Patients with low MHI were matched to those with high MHI based on demographic and medical factors. Outcomes evaluated included complications, length of stay, discharge disposition, 30- and 90 day readmissions, emergency department (ED) visits, reoperations, and mortality.

RESULTS

By univariate analysis, MHI was significantly associated with 30- and 90 day readmission, ED visits, reoperation, and non-home discharge, but not mortality. After exact matching (n = 270), low-income patients had higher odds of non-home discharge (OR = 2.5, P = .016) and higher length of stay (mean 100.2 vs 92.6, P = .02). There were no differences in surgical complications, ED visits, readmissions, or reoperations between matched groups.

CONCLUSIONS

Low MHI was significantly associated with adverse short-term outcomes from lumbar fusion. A matched analysis controlling for confounding variables uncovered longer lengths of stay and higher rates of discharge to post-acute care (vs home) in lower MHI patients. Socioeconomic disparities affect health beyond access to care, worsen surgical outcomes, and impose costs on healthcare systems. Targeted interventions must be implemented to mitigate these disparities.