Medium-Term Outcomes of Digital Versus Conventional Home-Based Rehabilitation After Total Knee Arthroplasty: Prospective, Parallel-Group Feasibility Study

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).

Patient Engagement in a Mobile App-Based Rehabilitation Program for Total Hip or Knee Arthroplasty: Secondary Data Analysis of a Randomized Controlled Trial

BACKGROUND

Health care professionals use mobile apps to support patients' rehabilitation after total hip or knee arthroplasty. Understanding patient engagement in such mobile health interventions can help tailor these interventions to better support patients.

OBJECTIVE

This study aimed to investigate patient engagement in a mobile app-based arthroplasty rehabilitation program and to investigate the association between patient engagement and their characteristics.

METHODS

Data were extracted from a pool of 42 participants in the experimental arm of a randomized controlled trial that used a mobile app (WeChat [Tencent Holdings Limited])-based program to support patients' rehabilitation after total hip or knee arthroplasty. The primary outcomes were the number of days the participants accessed the program and completed recommended rehabilitation tasks. Secondary outcomes included data on the participants' posts on a discussion forum, messages sent by the participants, access to the program components, and reading and sharing the program content. Generalized linear models were used to analyze the association between patient engagement and personal characteristics.

RESULTS

The participants reported in a rehabilitation diary accessing the program on a mean of 5.2 (SD 2) days per week and completing recommended rehabilitation tasks on a mean of 6.5 (SD 0.8) days per week. The majority (31/42, 74%) posted on the discussion forum, with a mean of 18.1 (SD 21.2) posts. Most participants (37/42, 88%) sent messages to health care professionals, with a mean of 14 (SD 15.9) messages. The program components were visited for a total of 525 times. The program content was read 898 times and shared 82 times in total. Generalized linear models showed that both primary outcomes, the number of days the participants accessed the program (B=6.46, 95% CI 1.98-15.35; χ21=11.1, P=.001) and the number of days they completed rehabilitation tasks (B=2.65, 95% CI 0.45-5.48; χ21=5.7, P=.02), were positively associated with having a high school education or above. In addition, the number of posts on the discussion forum was positively associated with living with family, having a high school education or above, undergoing total knee arthroplasty, having comorbidities, and the score of self-efficacy but was negatively associated with age. The number of messages sent by the participants was positively associated with having a high school education or above, having comorbidities, and the score of self-efficacy.

CONCLUSIONS

Patient engagement in mobile arthroplasty rehabilitation is associated with their education level, cohabitation status, age, type of surgery, presence of comorbidities, and sense of self-efficacy. Program developers can consider these characteristics and use strategies, such as family involvement, in the design of mobile arthroplasty rehabilitation programs to enhance patient engagement in such interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621000867897; https://tinyurl.com/mtdw25fp.

Physical therapists' perceptions and attitudes towards artificial intelligence in healthcare and rehabilitation: A qualitative study

BACKGROUND

Artificial intelligence (AI) is being introduced to rehabilitation practices, and it can optimize the patient's outcome through their ability to design personalized care strategies and interventions.

OBJECTIVES

To understand the attitudes and perceptions of physical therapy professionals on the use of AI in rehabilitation in regard to treatment planning, diagnosis, outcome prediction, and advantages and disadvantages.

DESIGN AND METHODS

This paper followed an exploratory, qualitative research design. Semi-structured, one-to-one interviews were conducted with participants of different experience levels and specialties in physical therapy. Results were evaluated using thematic analysis.

RESULTS

Four themes were identified: (i) perceptions of AI and its applications in healthcare services, (ii) impact on the workforce (iii) considerations around implementing AI within rehabilitation and (iv) AI, and the fast-approaching future. Participants shared views on the potential impact of AI on rehabilitation practices, such as aiding the decision-making process, saving time and effort of both the therapist and patients. Participants have stressed on potential pitfalls that still need to be considered, such as patient data privacy, potential loss of patient-healthcare practitioner relationship, ethical concerns regarding overreliance on these applications and how that might hinder effective patient care.

CONCLUSION

The findings add to the literature about physical therapists' understanding regarding the use of AI in patient care. Several concerns were raised to the adoption of AI, including concerns about patient privacy, and ethical concerns. Based on the study findings, researchers emphasize the importance of establishing guidelines when incorporating AI in rehabilitation to improve the therapist's knowledge and skills.

Effectiveness of In-Home, Augmented Reality-Based Telerehabilitation After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Background

New digital technology-based rehabilitation may be a viable option for patients after anterior cruciate ligament reconstruction (ACLR), with advantages such as easy access to treatment and learning as well as cost-effectiveness.

Purpose

To investigate the effects of an augmented reality (AR)-based, telerehabilitation system in patients after ACLR compared with a brochure-based rehabilitation program in terms of patient-reported outcomes and functional performance measures.

Study Design

Randomized controlled trial; Level of evidence, 2.

Methods

This was a multicenter, assessor-blinded study. Enrolled participants were allocated randomly to either the intervention group, who underwent AR-based telerehabilitation system, or to the control group, who underwent a brochure-based rehabilitation program with a self-log. Both groups performed the same postoperative rehabilitation exercise protocol. Subjective knee function was assessed using the International Knee Documentation Committee (IKDC) as the primary outcome; secondary outcomes were a numeric rating scale for pain, the EuroQol 5-Dimension 5-Level, isometric knee strength, range of motion, and the single-leg hop test. The intervention group also completed a satisfaction survey. Follow-up was conducted at 2, 6, 12, and 24 weeks postoperatively.

Results

A total of 28 patients were enrolled in each group; 1 patient in the control group was lost to follow-up. Patients in both groups demonstrated improvement on all outcomes over time. There were no significant between-group differences in the IKDC score from baseline to 12 weeks postoperatively. The intervention group saw a greater increase in the relative isometric strength of the quadriceps on the involved limb at 6, 12, and 24 weeks postoperatively (P < .05 for all). No significant group differences were observed in the remaining secondary outcomes.

Conclusion

Study findings indicated that patients who underwent AR-based telerehabilitation in the early rehabilitation phase after ACLR demonstrated similar improvements as those who followed a brochure-based rehabilitation program and had a quicker recovery of knee extensor strength.

Registration

NCT04513327 (ClinicalTrials.gov identifier).

Position paper on how technology for human motion analysis and relevant clinical applications have evolved over the past decades: Striking a balance between accuracy and convenience

BACKGROUND

Over the past decades, tremendous technological advances have emerged in human motion analysis (HMA).

RESEARCH QUESTION

How has technology for analysing human motion evolved over the past decades, and what clinical applications has it enabled?

METHODS

The literature on HMA has been extensively reviewed, focusing on three main approaches: Fully-Instrumented Gait Analysis (FGA), Wearable Sensor Analysis (WSA), and Deep-Learning Video Analysis (DVA), considering both technical and clinical aspects.

RESULTS

FGA techniques relying on data collected using stereophotogrammetric systems, force plates, and electromyographic sensors have been dramatically improved providing highly accurate estimates of the biomechanics of motion. WSA techniques have been developed with the advances in data collection at home and in community settings. DVA techniques have emerged through artificial intelligence, which has marked the last decade. Some authors have considered WSA and DVA techniques as alternatives to "traditional" HMA techniques. They have suggested that WSA and DVA techniques are destined to replace FGA.

SIGNIFICANCE

We argue that FGA, WSA, and DVA complement each other and hence should be accounted as "synergistic" in the context of modern HMA and its clinical applications. We point out that DVA techniques are especially attractive as screening techniques, WSA methods enable data collection in the home and community for extensive periods of time, and FGA does maintain superior accuracy and should be the preferred technique when a complete and highly accurate biomechanical data is required. Accordingly, we envision that future clinical applications of HMA would favour screening patients using DVA in the outpatient setting. If deemed clinically appropriate, then WSA would be used to collect data in the home and community to derive relevant information. If accurate kinetic data is needed, then patients should be referred to specialized centres where an FGA system is available, together with medical imaging and thorough clinical assessments.

Impact of 25 Years of Mobile Health Tools for Pain Management in Patients With Chronic Musculoskeletal Pain: Systematic Review

BACKGROUND

Mobile technologies are increasingly being used in health care and public health practice for patient communication, monitoring, and education. Mobile health (mHealth) tools have also been used to facilitate adherence to chronic musculoskeletal pain (CMP) management, which is critical to achieving improved pain outcomes, quality of life, and cost-effective health care.

OBJECTIVE

The aim of this systematic review was to evaluate the 25-year trend of the literature on the adherence, usability, feasibility, and acceptability of mHealth interventions in CMP management among patients and health care providers.

METHODS

We searched the PubMed, Cochrane CENTRAL, MEDLINE, EMBASE, and Web of Science databases for studies assessing the role of mHealth in CMP management from January 1999 to December 2023. Outcomes of interest included the effect of mHealth interventions on patient adherence; pain-specific clinical outcomes after the intervention; and the usability, feasibility, and acceptability of mHealth tools and platforms in chronic pain management among target end users.

RESULTS

A total of 89 articles (26,429 participants) were included in the systematic review. Mobile apps were the most commonly used mHealth tools (78/89, 88%) among the included studies, followed by mobile app plus monitor (5/89, 6%), mobile app plus wearable sensor (4/89, 4%), and web-based mobile app plus monitor (1/89, 1%). Usability, feasibility, and acceptability or patient preferences for mHealth interventions were assessed in 26% (23/89) of the studies and observed to be generally high. Overall, 30% (27/89) of the studies used a randomized controlled trial (RCT), cohort, or pilot design to assess the impact of the mHealth intervention on patients' adherence, with significant improvements (all P<.05) observed in 93% (25/27) of these studies. Significant (judged at P<.05) between-group differences were reported in 27 of the 29 (93%) RCTs that measured the effect of mHealth on CMP-specific clinical outcomes.

CONCLUSIONS

There is great potential for mHealth tools to better facilitate adherence to CMP management, and the current evidence supporting their effectiveness is generally high. Further research should focus on the cost-effectiveness of mHealth interventions for better incorporating these tools into health care practices.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42024524634; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=524634.

Application of digital technology in rehabilitation of total knee arthroplasty: A systematic review

Purpose

Total Knee Arthroplasty (TKA) aids in reducing pain and improving knee mobility, function, and quality of life in osteoarthritis knee (OA Knee). Techology-based rehabiliation has proved to be promising post-TKA. The objective of this systematic review was to summarize the digital technology after TKA.

Methods

The PRISMA Checklist was used for the present systematic review. Randomized and non-randomized studies were included. Joanna Briggs Critical Appraisal Checklist was used to assess risk of bias by two independent reviewers. The data was summarized narratively for the digital technologies utilized.

Results

177 studies were screened from the databases, and 14 studies were included. The risk of bias assessment showed low to moderate-quality evidence. The technologies were divided into 2 broad categories-mobile-based and web-based- although the individual studies had unique technologies utilizing sensors, motion trackers, and game-based and video-based.

Conclusion

Various digital technologies focus on providing exercise intervention post-TKA. Clinicians can use face-to-face and technology-based approaches for TKA rehabilitation for a comprehensive subjective and objective assessment post-TKA based on low to moderate quality studies.

A home-based tele-rehabilitation exercise system for patients after knee replacement surgery

BACKGROUND

Knee arthritis is a destructive disorder that affects the knee joints and causes pain and reduced mobility. Drug treatments, weight loss, and exercise control the symptoms of the disease, but these methods only delay the disease process and eventually, knee joint replacement surgery will be needed. After surgery, with the help of a proper physiotherapy program, full recovery takes an average of 6-12 months. However, currently, there is no similar tool to facilitate this process in Iran.

OBJECTIVE

The purpose of this research is to design and develop the prototype of a rehabilitation system for patients after knee replacement surgery, which provides patients with information and appropriate physiotherapy programs.

METHODS

This study was development-applied and was done in three stages. In the first stage, the needs and content of education and therapeutic exercises were prepared in the form of a checklist, and then the necessity of each item was checked in the evaluation sessions. In the second stage, the prototype of the system was developed using Adobe XD software and based on the requirements approved from the previous stage. In the third stage, the usability of the program was analyzed from the point of view of experts using the exploratory evaluation method with Nielsen's 13 principles of usability.

RESULTS

At first, the system requirements were extracted and prepared in two checklists of content (51 exercises) and capabilities (60 items). Then after a survey of experts based on the Delphi technique, content information (43 exercises) and functional and non-functional requirements (53 items) were obtained. A survey of experts helped to finalize the information elements, categorize them, and prepare the final version of the checklists. Based on this, the system requirements were classified into 11 categories, and the training content was classified into 3 training periods. Finally, the design and development of the system was done. This system has admin, physician, and patient user interfaces. The result of usability showed that this system is efficient and there are only a few problems in the feature of helping users to detect and recover from errors.

CONCLUSION

It seems necessary to develop a system based on the principles of usability by therapists and rehabilitation specialists to train and monitor the remote rehabilitation process of patients after knee joint replacement at home. And the importance of involving stakeholders in the design and development of remote rehabilitation systems is not hidden from anyone. Kara system has all of the above.

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.

Feasibility of 3D Body Tracking from Monocular 2D Video Feeds in Musculoskeletal Telerehabilitation

Musculoskeletal conditions affect millions of people globally; however, conventional treatments pose challenges concerning price, accessibility, and convenience. Many telerehabilitation solutions offer an engaging alternative but rely on complex hardware for body tracking. This work explores the feasibility of a model for 3D Human Pose Estimation (HPE) from monocular 2D videos (MediaPipe Pose) in a physiotherapy context, by comparing its performance to ground truth measurements. MediaPipe Pose was investigated in eight exercises typically performed in musculoskeletal physiotherapy sessions, where the Range of Motion (ROM) of the human joints was the evaluated parameter. This model showed the best performance for shoulder abduction, shoulder press, elbow flexion, and squat exercises. Results have shown a MAPE ranging between 14.9% and 25.0%, Pearson's coefficient ranging between 0.963 and 0.996, and cosine similarity ranging between 0.987 and 0.999. Some exercises (e.g., seated knee extension and shoulder flexion) posed challenges due to unusual poses, occlusions, and depth ambiguities, possibly related to a lack of training data. This study demonstrates the potential of HPE from monocular 2D videos, as a markerless, affordable, and accessible solution for musculoskeletal telerehabilitation approaches. Future work should focus on exploring variations of the 3D HPE models trained on physiotherapy-related datasets, such as the Fit3D dataset, and post-preprocessing techniques to enhance the model's performance.

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 .

Quick Transition to One Day Length of Stay after Hip and Knee Arthroplasty Using a Digital Follow-Up Tool during COVID-19: A Retrospective Comparative Study

The COVID-19 pandemic highlighted the need for efficient use of hospital infrastructure. The hypothesis was that a rapid shift to outpatient surgery after hip or knee arthroplasty could be implemented without compromising quality of care. The aim of this study was to assess the safety, pain management and patient-reported outcomes before and after the implementation of an accelerated discharge program using a digital follow-up tool. A retrospective cohort design was used to compare 97 patients who received primary total hip or knee arthroplasty during the pandemic (early discharge) to comparable 194 pre-pandemic patients (normal discharge). Both cohorts had the same inclusion criteria and were closely monitored using the digital follow-up tool. The accelerated discharge program reduced length of stay from a median of 3 days (before the pandemic) to a median of 1 day (during the pandemic) (p < 0.001). The complication rate of 2% was the same for both groups (p > 0.05). Patient-reported outcomes for matched samples of hip (n = 100) and knee (n = 82) arthroplasty patients were similar before, at 6 weeks and 3 months after surgery for both groups (p > 0.05). There were no differences in pain and medication consumption for the first 6 weeks (p > 0.05). This study demonstrates that reducing length of stay from three to one night after total knee or hip arthroplasty, with the help of a digital follow-up tool, results in a stable rate of complications, readmission, and comparable clinical outcomes, while reducing the socio-economic burden on the health system.

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

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

Postoperative Rehabilitation after Anterior Cruciate Ligament Reconstruction through Telerehabilitation with Artificial Intelligence Brace during COVID-19 Pandemic

BACKGROUND

Due to the rapid spread of the coronavirus disease-19 (COVID-19), most of the patients expressed a reluctance to undergo postoperative rehabilitation at a rehabilitation clinic. Therefore, in this scenario it was necessary to reshape the crucial role of postoperative rehabilitation of these patients. We conducted a telerehabilitation program based on an artificial intelligence brace (AI brace) which can monitor the progress of rehabilitation through an app and an internet server. Our hypothesis was that home-based telerehabilitation might provide clinical outcomes comparable to face-to-face, hospital-based rehabilitation programs in terms of effectiveness.

METHODS

A retrospective cohort study enrolled patients who received anterior cruciate ligament reconstruction (ACLR) between January and September 2020. Patients were divided into two groups: the tele-AI group received telerehabilitation with an AI brace while the FTF group had face-to-face, hospital-based rehabilitation. Clinical knee functional scores and Tegner Activity Scale (TAS) were assessed and analyzed until 12 months after the operation.

RESULTS

The tele-AI group had higher IKDC scores at 3 months (p = 0.0443) and 6 months (p = 0.0052) after surgery and higher KOOS scores at 1 month (p = 0.0365) and 6 months (p = 0.0375) after surgery. However, no significant difference between the two groups was detected at the end of the follow-up. The tele-AI group had higher TAS than FTF group after 1 year.

CONCLUSIONS

Telerehabilitation after ACLR seems to provide a superior short-term outcome compared to hospital-based rehabilitation during the COVID-19 pandemic.

The Effectiveness of Digital Apps Providing Personalized Exercise Videos: Systematic Review With Meta-Analysis

BACKGROUND

Among available digital apps, those providing personalized video exercises may be helpful for individuals undergoing functional rehabilitation.

OBJECTIVE

We aimed to assess the effectiveness of apps providing personalized video exercises to support rehabilitation for people with short- and long-term disabling conditions, on functional capacity, confidence in exercise performance, health care consumption, health-related quality of life, adherence, and adverse events.

METHODS

In this systematic review, we searched MEDLINE, CENTRAL, and Embase databases up to March 2022. All randomized controlled trials evaluating the effect of apps providing personalized video exercises to support rehabilitation for any condition requiring physical rehabilitation were included. Selection, extraction, and risk of bias assessment were performed by 2 independent reviewers. The primary outcome was functional capacity at the end of the intervention. The secondary outcomes included confidence in exercise performance, care consumption, health-related quality of life, adherence, and adverse events. A meta-analysis was performed where possible; the magnitude of the effect was assessed with the standardized mean difference (SMD).

RESULTS

From 1641 identified references, 10 papers (n=1050 participants, 93% adults) were included: 7 papers (n=906 participants) concerned musculoskeletal disorders and 3 (n=144 participants) concerned neurological disorders. Two (n=332 participants) were employee based. The apps were mostly commercial (7/10); the videos were mostly elaborated on by a physiotherapist (8/10). The duration of app use was 3-48 weeks. All included studies had a high overall risk of bias. Low-quality evidence suggested that the use of apps providing personalized video exercises led to a significant small to moderate improvement in physical function (SMD 0.35, 95% CI 0.19-0.51; Phet=.86; I2=0%) and confidence in exercise performance (SMD 0.67; 95% CI 0.37-0.96; Phet=.22; I2=33%). Because of the very low quality of the evidence, the effects on quality of life and exercise adherence were uncertain. Apps did not influence the rate of adverse events.

CONCLUSIONS

Apps providing personalized video exercises to support exercise performance significantly improved physical function and confidence in exercise performance. However, the level of evidence was low; more robust studies are needed to confirm these results.

TRIAL REGISTRATION

PROSPERO CRD42022323670; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=323670.

Randomized-controlled trial assessing a digital care program versus conventional physiotherapy for chronic low back pain

Low back pain (LBP) is the world's leading cause of years lived with disability. Digital exercise-based interventions have shown great potential in the management of musculoskeletal conditions, promoting access and easing the economic burden. However, evidence of their effectiveness for chronic LBP (CLBP) management compared to in-person physiotherapy has yet to be unequivocally established. This randomized controlled trial (RCT) aims to compare the clinical outcomes of patients with CLBP following a digital intervention versus evidence-based in-person physiotherapy. Our results demonstrate that patient satisfaction and adherence were high and similar between groups, although a significantly lower dropout rate is observed in the digital group (11/70, 15.7% versus 24/70, 34.3% in the conventional group; P = 0.019). Both groups experience significant improvements in disability (primary outcome), with no differences between groups in change from baseline (median difference: -0.55, 95% CI: -2.42 to 5.81, P = 0.412) or program-end scores (-1.05, 95% CI: -4.14 to 6.37; P = 0.671). Likewise, no significant differences between groups are found for secondary outcomes (namely pain, anxiety, depression, and overall productivity impairment). This RCT demonstrates that a remote digital intervention for CLBP can promote the same levels of recovery as evidence-based in-person physiotherapy, being a potential avenue to ease the burden of CLBP.

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

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

Digital Rehabilitation after Knee Arthroplasty: A Multi-Center Prospective Longitudinal Cohort Study

Rehabilitation for total knee replacement (TKA) often involves in-person therapy sessions, which can be time consuming and costly. Digital rehabilitation has the potential to address these limitations, but most of these systems offer standardized protocols without considering the patient's pain, participation, and speed of recovery. Furthermore, most digital systems lack human support in case of need. The aim of this study was to investigate the engagement, safety, and clinical effectiveness of a personalized and adaptative app-based human-supported digital monitoring and rehabilitation program. In this prospective multi-center longitudinal cohort study, 127 patients were included. Undesired events were managed through a smart alert system. Doctors were triggered when there was a suspicion of problems. The drop-out rate, complications and readmissions, PROMS, and satisfaction were collected through the app. There was only 2% readmission. Doctor actions through the platform potentially avoided 57 consultations (85% of alerts). The adherence to the program was 77%, and 89% of the patients would recommend the use of the program. Personalized human-backed-up digital solutions can help to improve the rehabilitation journey of patients after TKA, lower healthcare-related costs by lowering the complication and readmission rate, and improve patient reported outcomes.

Patients' Perceptions of Remote Monitoring and App-based Rehabilitation Programs: A Comparison of Total Hip and Knee Arthroplasty

BACKGROUND

Remote monitoring rehabilitation programs are new technologies growing in popularity for patients undergoing lower extremity total joint arthroplasty. The purpose of this study was to assess the patients' perceptions of these technologies.

METHODS

Patients who underwent total hip (THA), knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) from September 2020 to February 2022 and participated in a clinical study utilizing remote monitoring and an app-based rehabilitation program were given a questionnaire three months postoperatively to assess their perceptions of these technologies. There were 166 patients who completed the survey (42 THA; 106 TKA; 18 UKA).

RESULTS

There were 92% of patients who found the technology easy to use. A majority of patients felt the technologies motivated them. The TKA/UKA patients felt more strongly that these technologies allowed the surgeon to monitor their recovery closely (81.9% v. 65.9%; P=0.009). There were 85% of THA patients and 94.5% of TKA/UKA patients recommended these technologies. The THA patients felt more strongly that digital rehabilitation could completely replace in-person physical therapy compared to TKA/UKA patients (85.4% v. 41.3%; P<0.001). A majority (83%) of patients recommended a combination of inpatient and technology-assisted rehabilitation (THA 90.2%; 84.4% TKA/UKA).

CONCLUSIONS

The THA and TKA/UKA patients found remote monitoring rehabilitation easy to use, increased motivation, and recommend it to other patients undergoing lower extremity arthroplasty. They recommend a combination of technology and in-person rehabilitation postoperatively. The THA patients felt these technologies could replace in-person rehabilitation programs.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Randomised controlled trial.

SETTING

A teaching hospital in Shanghai, China.

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Evaluation of a smartphone application for self-rehabilitation after anterior cruciate ligament reconstruction during a COVID-19 lockdown

BACKGROUND

Rehabilitation after surgery is a crucial process that governs the final functional outcome. The self-rehabilitation smartphone application Doct'up (Healing SAS, Lyon, France) is designed for patients who have had anterior cruciate ligament (ACL) reconstruction surgery. In France in the spring of 2020, the lockdown mandated due to the COVID-19 pandemic prevented patients from seeing their physiotherapists for 2 months. The objective of this study was to compare the clinical outcomes in two groups of patients who underwent ACL reconstruction surgery: in one group, surgery performed before the lockdown was followed by standard in-person physiotherapy while, in the other, surgery was done just before the lockdown and rehabilitation was performed by the patients themselves using the phone application.

HYPOTHESIS

Using a self-rehabilitation smartphone app limits the negative effects of not receiving physiotherapist rehabilitation after ACL reconstruction.

MATERIAL AND METHODS

We performed a case-control study involving the retrospective analysis of prospectively collected data from two groups of patients who had undergone ACL reconstruction surgery. Patients in the App group had surgery just before the 2-month COVID-19-related lockdown that started in France on March 17, 2020,and used only the smartphone app for rehabilitation. The standard-care group was composed of matched controls who had surgery 1 year before the cases and received rehabilitation therapy during in-person physiotherapist visits. The ACL reconstruction technique was the same in the two groups. The primary outcome measure was extension lag 6 weeks after surgery. The secondary outcome measures were extension lag 3 weeks and 6 months after surgery, quadriceps muscle activation, knee extension locking 3 and 6 weeks after surgery, and the 6-month rate of surgical revision for cyclops syndrome.

RESULTS

We included 32 cases managed using only self-rehabilitation guided by the phone app, and we identified 101 matched controls managed using standard care. We found no significant between-group difference in extension lag after 6 weeks: 9.4% (28/32) vs. 4.6% (87/101), p=0.39. After 3 weeks, the App group had a higher proportions of patients with quadriceps activation (94% [30/32] vs. 73% [74/101], p=0.015) and extension control using canes (78.1% [25/32] vs. 40.6% [41/101], p=0.0002). None of the other measured outcomes differed significantly between the two groups (extension lag after 3 weeks: 12.5% [4/32] vs. 13.8% 14/101]; extension lag after 6 months: 3.2% [1/32] vs. 1% [1/101]; quadriceps activation after 6 weeks: 97% [31/32] vs. 99% [100/101]; extension locking with canes after 6 weeks: 96.9% [31/32] vs. 93.1% [94/101]; extension locking without canes after 3 weeks: 53.2% [17/32] vs. 47.5% [48/101]; extension locking without canes after 6 weeks: 93.7% [30/32] vs. 82.2% [83/101]; and surgery for cyclops syndrome (3.1% [1/32] vs. 1% [1/101]).

DISCUSSION

The use of a self-rehabilitation phone app after ACL reconstruction during a COVID-19 lockdown limited the adverse effects of not receiving in-person physiotherapy. The 6-month outcomes were similar to those seen with standard rehabilitation. The study results demonstrate the usefulness of self-rehabilitation after ACL reconstruction surgery. Self-rehabilitation guided by a phone app could be used as a complement to the protocols generally applied by physiotherapists.

LEVEL OF EVIDENCE

IV, single-centre retrospective case-control study.

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

Background

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

“Wearable Sensors to Guide Remote Rehabilitation Following Knee Arthroplasty Surgery”

Background

Total knee arthroplasty requires effective rehabilitation to achieve optimal results, but institutions often rely on unsupervised home exercises due to cost constraints. Wearable sensors have become increasingly popular as a potential method of monitoring patients remotely to ensure efficacy and compliance. This review assesses the current evidence for their use in remotely monitored rehabilitation following knee arthroplasty.

Methods

A systematic review of the literature from 1st January 2000 to 17th February 2022 was undertaken. Devices were categorised as joint-specific or physical activity sensors. Studies were classified as those providing remotely supervised rehabilitation as an additional or as an alternative intervention.

Results

Remotely supervised rehabilitation using wearable sensors demonstrated similar outcomes when provided as an alternative to standard care in most studies. One group found improved outcomes for knee-specific sensors compared with standard care. There were improved physical activity and healthcare resource use outcomes described in the literature where sensors were used in addition to standard care.

Discussion

This review found evidence for the use of wearable sensors in remotely supervised rehabilitation following knee arthroplasty surgery. This included methodological heterogeneity, differing definitions of standard care, and variable follow-up periods. Robust randomised control trial data with a longer follow-up period are needed.

Telerehabilitation has similar clinical and patient-reported outcomes compared to traditional rehabilitation following total knee arthroplasty

PURPOSE

Telehealth rehabilitation (telerehab) is an increasingly popular cost-saving alternative to traditional rehabilitation after total joint arthroplasty. We compared the safety and efficacy of an institutional telerehab program to conventional "face-to-face" rehabilitation in a sample of patients undergoing total knee arthroplasty (TKA).

METHODS

A retrospective matched cohort study was performed. Medicare patients who utilized telerehab following unilateral TKA were matched in a 1:3 ratio to those utilizing conventional rehabilitation. Patients were matched on sex, body mass index (BMI, ± 5 kg/m2), preoperative extension (± 10 degrees), preoperative flexion (± 10 degrees), and Risk Assessment and Prediction Tool (RAPT) score (± 2 points). Ninety-day unplanned healthcare encounters, 120-day manipulations under anesthesia (MUAs), and 6-week and 3-month changes in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), pain visual analog scale (VAS), Veterans RAND 12 (VR-12), and Lower-Extremity Activity Scale (LEAS) were compared between groups.

RESULTS

Eighty-two telerehab patients and 244 conventional rehab patients were included. After matching, there were no differences in 90-day unplanned healthcare encounters or 120-day MUA rates between groups. There were no differences in 6-week or 3-month changes in KOOS-JR, VAS pain, or VR-12 mental or physical sub-scores between groups. Telerehab patients had a greater improvement in LEAS score at 3 months compared to the conventional group (mean difference 1.9, P = 0.03).

CONCLUSION

In a matched cohort study of 326 TKA patients, telerehab patients had similar rates of unplanned healthcare encounters and MUAs and similar patient-reported outcomes compared to conventional PT patients, suggesting that telerehab can be an equally effective alternative to conventional PT following TKA.

LEVEL OF EVIDENCE

III.

Facilitators and Barriers of Artificial Intelligence Applications in Rehabilitation: A Mixed-Method Approach

Artificial intelligence (AI) has been used in physical therapy diagnosis and management for various impairments. Physical therapists (PTs) need to be able to utilize the latest innovative treatment techniques to improve the quality of care. The study aimed to describe PTs' views on AI and investigate multiple factors as indicators of AI knowledge, attitude, and adoption among PTs. Moreover, the study aimed to identify the barriers to using AI in rehabilitation. Two hundred and thirty-six PTs participated voluntarily in the study. A concurrent mixed-method design was used to document PTs' opinions regarding AI deployment in rehabilitation. A self-administered survey consisting of several aspects, including demographic, knowledge, uses, advantages, impacts, and barriers limiting AI utilization in rehabilitation, was used. A total of 63.3% of PTs reported that they had not experienced any kind of AI applications at work. The major factors predicting a higher level of AI knowledge among PTs were being a non-academic worker (OR = 1.77 [95% CI; 1.01 to 3.12], p = 0.04), being a senior PT (OR = 2.44, [95%CI: 1.40 to 4.22], p = 0.002), and having a Master/Doctorate degree (OR = 1.97, [95%CI: 1.11 to 3.50], p = 0.02). However, the cost and resources of AI were the major reported barriers to adopting AI-based technologies. The study highlighted a remarkable dearth of AI knowledge among PTs. AI and advanced knowledge in technology need to be urgently transferred to PTs.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Digital rehabilitation for hand and wrist pain: a single-arm prospective longitudinal cohort study

Supplemental Digital Content is Available in the Text.

This study supports that a fully remote digital care program is feasible and able to promote high patient engagement in the telerehabilitation of patients with wrist and hand pain.

Introduction:

Wrist and hand represent the third most common body part in work-related injuries, being associated with long-term absenteeism. Telerehabilitation can promote access to treatment, patient adherence, and engagement, while reducing health care–related costs.

Objective:

Report the results of a fully remote digital care program (DCP) for wrist and hand pain (WP).

Methods:

A single-arm interventional study was conducted on individuals with WP applying for a DCP. Primary outcome was the mean change in the Numerical Pain Rating Scale after 8 weeks (considering a minimum clinically important change of 30%). Secondary outcomes were: disability (Quick Disabilities of the Arm, Shoulder, and Hand questionnaire), analgesic intake, surgery intention, mental health (patient health questionnaire [PHQ-9] and generalized anxiety disorder [GAD-7]), fear-avoidance beliefs (FABQ-PA), work productivity and activity impairment, and engagement.

Results:

From 189 individuals starting the DCP, 149 (78.8%) completed the intervention. A significant pain improvement was observed (51.3% reduction (2.26, 95% CI 1.73; 2.78)) and 70.4% of participants surpassing minimum clinically important change. This change correlated with improvements in disability (52.1%), FABQ-PA (32.2%), and activities impairment recovery (65.4%). Improvements were also observed in other domains: surgery intent (76.1%), mental health (67.0% in anxiety and 72.7% in depression), and overall productivity losses (68.2%). Analgesic intake decreased from 22.5% to 7.1%. Mean patient satisfaction score was 8.5/10.0 (SD 1.8).

Conclusions:

These findings support the feasibility and utility of a fully remote DCP for patients with WP. Clinically significant improvements were observed in all health-related and productivity-related outcomes, alongside very high patient adherence rates and satisfaction. This study strengthens that management of WP is possible through a remote DCP, decreasing access barriers and potentially easing health care expenditure.

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.

A Review of Functional Outcomes after the App-Based Rehabilitation of Patients with TKA and THA

Following the outbreak of SARS-CoV-2, several elective surgeries were cancelled, and rehabilitation units were closed. This has led to difficulties for patients seeking access to rehabilitation in order to achieve the best possible outcome. New applications with or without sensors were developed to address this need, but the outcome has not been examined in detail yet. The aim of this study was to perform a systematic literature review on smart phone applications for patients suffering from hip and knee osteoarthritis after arthroplasty. The MEDLINE/PubMed and Google databases were queried using the search term “[APP] AND [ORTHOPEDIC]” according to PRISMA guidelines. All prospective studies investigating rehabilitation applications reporting the functional outcome in hip and knee osteoarthritis after arthroplasty were included. The initial search yielded 420 entries, but only 9 publications met the inclusion criteria, accounting for 1067 patients. In total, 518 patients were in the intervention group, and 549 patients were in the control group. The average follow-up was 9.5 ± 8.1 months (range: 3 to 23.4 months). Overall, significantly lower A-VAS values were observed for the interventional group in the short term (p = 0.002). There were no other significant differences observed between the two groups. Smart phone applications provide an alternative to in-person sessions that may improve access for patients after total joint arthroplasty. Our study found there are significant improvements in the short term by using this approach. In combination with a blue-tooth-enabled sensor for isometric exercises, patients can even receive real-time feedback after total knee arthroplasty.

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.

Impacts of Digital Care Programs for Musculoskeletal Conditions on Depression and Work Productivity: Longitudinal Cohort Study

BACKGROUND

Comorbidity between musculoskeletal (MSK) pain and depression is highly common, and is associated with a greater symptom burden and greater loss of work productivity than either condition alone. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement.

OBJECTIVE

The aim of this study was to assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels.

METHODS

Ad hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP was performed. Three subgroups with different baseline depression severity levels were established based on responses to the Patient Health Questionnaire (PHQ-9): cluster 1 (score<5: minimal depression), cluster 2 (scores 5-10: mild depression), and cluster 3 (score≥10: moderate depression). The mean changes in depression, anxiety, fear-avoidance beliefs, work productivity, and activity impairment and adherence between baseline and end of program (8-12 weeks) were assessed across subgroups by latent growth curve analysis.

RESULTS

From a total of 7785 eligible participants, 6137 (78.83%) were included in cluster 1, 1158 (14.87%) in cluster 2, and 490 (6.29%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not in cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (score of 5 and 10, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from -16.82, 95% CI -20.32 to -13.42 in cluster 1 to -20.10, 95% CI -32.64 to -7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74).

CONCLUSIONS

A multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain.

TRIAL REGISTRATION

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

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

Background

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

Methods

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

Discussion

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

Trial registration

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

Supplementary Information

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

Digital Rehabilitation for Acute Low Back Pain: A Prospective Longitudinal Cohort Study

Background

Low back pain (LBP) has a lifetime prevalence of 70–80%. Access to timely and personalized, evidence-based care is key to prevent chronic progression. Digital solutions may ease accessibility to treatment while reducing healthcare-related costs.

Purpose

We aim to report the results of a fully remote digital care program (DCP) for acute LBP.

Patients and Methods

This was an interventional, single-arm, cohort study of patients with acute LBP who received a DCP. Primary outcome was the mean change in disability (Oswestry Disability Index – ODI) after 12 weeks. Secondary outcomes included change in pain (NPRS), analgesic consumption, surgery likelihood, depression (PHQ-9), anxiety (GAD-7), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.

Results

A total of 406 patients were enrolled in the program and of those, 332 (81.8%) completed the intervention. A significant disability reduction of 55.1% (14.93, 95% CI 13.95; 15.91) was observed, corresponding to a 76.1% responder rate (30% cut-off). Disability reduction was accompanied by significant improvements in pain (61.0%), depression (55.4%), anxiety (59.5%), productivity (65.6%), fear-avoidance beliefs (46.3%), intent to pursue surgery (59.1%), and analgesic consumption (from 35.7% at baseline to 10.8% at program end). DCP-related patient satisfaction score was 8.7/10.0 (SD 1.4).

Conclusion

This study demonstrated the utility of a multimodal DCP for patients with acute LBP. Very high adherence rates and patient satisfaction were observed, alongside significant reductions in all assessed outcomes, consistent with the growing body of evidence supporting the management of acute LBP with DCPs.

Asynchronous and Tailored Digital Rehabilitation of Chronic Shoulder Pain: A Prospective Longitudinal Cohort Study

Background

Chronic shoulder pain (SP) is responsible for significant morbidity, decreased quality of life and impaired work ability, resulting in high socioeconomic burden. Successful SP management is dependent on adherence and compliance with effective evidence-based interventions. Digital solutions may improve accessibility to such treatments, increasing convenience, while reducing healthcare-related costs.

Purpose

Present the results of a fully remote digital care program (DCP) for chronic SP.

Patients and Methods

Interventional, single-arm, cohort study of individuals with chronic SP applying for a digital care program. Primary outcome was the mean change between baseline and 12 weeks on the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Secondary outcomes were change in pain (NPRS), analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.

Results

From 296 patients at program start, 234 (79.1%) completed the intervention. Changes in QuickDASH between baseline and end-of-program were both statistically (p < 0.001) and clinically significant, with a mean reduction of 51.6% (mean −13.45 points, 95% CI: 11.99; 14.92). Marked reductions were also observed in all secondary outcomes: 54.8% in NPRS, 44.1% ceased analgesics consumption, 55.5% in surgery intent, 37.7% in FABQ-PA, 50.3% in anxiety, 63.6% in depression and 66.5% in WPAI overall. Higher engagement was associated with higher improvements in disability. Mean patient satisfaction score was 8.7/10.0 (SD 1.6).

Conclusion

This is the first real-world cohort study reporting the results of a multimodal remote digital approach for chronic SP rehabilitation. High completion and engagement rates were observed, which were associated with clinically significant improvement in all health-related outcomes, as well as marked productivity recovery. These promising results support the potential of digital modalities to address the global burden of chronic musculoskeletal pain.

Telerehabilitation of acute musculoskeletal multi-disorders: prospective, single-arm, interventional study

Background

Acute musculoskeletal (MSK) pain is very common and associated with impaired productivity and high economic burden. Access to timely and personalized, evidence-based care is key to improve outcomes while reducing healthcare expenditure. Digital interventions can facilitate access and ensure care scalability.

Objective

Present the feasibility and results of a fully remote digital care program (DCP) for acute MSK conditions affecting several body areas.

Methods

Interventional single-arm study of individuals applying for digital care programs for acute MSK pain. Primary outcome was the mean change between baseline and end-of-program in self-reported Numerical Pain Rating Scale (NPRS) score and secondary outcomes were change in analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI-GH) and engagement.

Results

Three hundred forty-three patients started the program, of which 300 (87.5%) completed the program. Latent growth curve analysis (LGCA) revealed that changes in NPRS between baseline and end-of-program were both statistically (p < 0.001) and clinically significant: 64.3% reduction (mean − 2.9 points). Marked improvements were also noted in all secondary outcomes: 82% reduction in medication intake, 63% reduction in surgery intent, 40% in fear-avoidance beliefs, 54% in anxiety, 58% in depression and 79% recovery in overall productivity. All outcomes had steeper improvements in the first 4 weeks, which paralleled higher engagement in this period (3.6 vs 3.2 overall weekly sessions, p < 0.001). Mean patient satisfaction score was 8.7/10 (SD 1.26).

Strengths and limitations

This is the first longitudinal study demonstrating the feasibility of a DCP for patients with acute MSK conditions involving several body areas. Major strengths of this study are the large sample size, the wide range of MSK conditions studied, the breadth of outcomes measured, and the very high retention rate and adherence level. The major limitation regards to the absence of a control group.

Conclusions

We observed very high completion and engagement rates, as well as clinically relevant changes in all health-related outcomes and productivity recovery. We believe this DCP holds great potential in the delivery of effective and scalable MSK care.

Trial registration

NCT, NCT04092946. Registered 17/09/2019;

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04891-5.

Telehealth Treatment for Non-Specific Low Back Pain: A Review of the Current State in Mobile Health

INTRODUCTION

Non-specific low back pain (LBP) is an idiopathic musculoskeletal condition that affects 4 out of 5 individuals in their lifetime and is the leading cause of job-related disability in the United States (US). The interest in interactive and dynamic telehealth treatments for LBP continues to grow, and it is important for the medical community to remain up-to-date on the state of the science.

LITERATURE SURVEY

Relevant studies published from March 2016 until March 2021 were identified through a systematic search of EMBASE, MedLine and Web of Science. The search strategy combined the concepts of back pain, telehealth and mobile applications.

METHODOLOGY

Titles and abstracts were screened to select full text randomized controlled trials or protocols and methodological quality and risk of bias was assessed using the Cochrane risk-of-bias tool. Data were synthesized narratively.

SYNTHESIS

We included seven concluded randomized controlled trials and two study protocols reporting mobile health (mHealth) solutions for LBP. Six of the seven concluded trials found a significant improvement in self-reported numerical pain rating scale compared to the control group. A single trial compared a mHealth solution to physical therapy, with the majority of studies comparing interventions to "usual care." Substantial heterogeneity in reporting of sample characteristics was found, indicating a lack of standardization through the field.

CONCLUSIONS

mHealth solutions may positively impact people with LBP. Larger trials should be encouraged and the field should coalesce around a set of baseline variables for collection and reporting. As many interventions involve patient engagement, future trials should aim to further quantify adherence levels and begin to define telehealth 'doses' associated with better outcomes. This article is protected by copyright. All rights reserved.

Digital Rehabilitation for Acute Ankle Sprains: Prospective Longitudinal Cohort Study

Background

Ankle sprains are one of the most prevalent soft-tissue injuries worldwide. Physical therapy, especially progressive exercise, has proven effective in improving function, while preventing recurrence.

Objective

We aim to present the results of a fully remote and digitally guided rehabilitation program for acute ankle sprains.

Methods

We performed a prospective longitudinal cohort study of individuals eligible for workers’ compensation, who were referred for digital rehabilitation therapy for a sprained ankle. Therapeutic exercise sessions were to be performed independently by the patient at home using the biofeedback device provided by SWORD Health. Primary endpoints were the change in self-reported Numerical Pain Rating Scale (NPRS) and Foot and Ankle Ability Measure–activities of daily living (FAAM–ADL) and FAAM–Sports scores. Participants were assessed at baseline, end of the program, and 6 months after program completion. Secondary outcomes included digital therapy dosage, pain and fatigue during sessions, and satisfaction.

Results

In total, 93 (89.4%) patients completed the program and 79 (76.0%) were available for follow-up. Changes in the primary outcomes between baseline and the 6-month follow-up were both significant (P<.001) and clinically meaningful: mean difference of –2.72 points (95% CI –3.31 to –2.13) on the NPRS (49.8% reduction), 21.7 points (95% CI 17.13-26.27) on the FAAM–ADL (41.1% increase), and 37.8 points (95% CI 30.45-45.15) on the FAAM-Sports (151.8% increase). Longer waiting periods between the accident date and treatment initiation were found to negatively impact functional status at baseline and at the end of the program, triggering an extension in the program duration. The total training volume (12.5 hours, SD 10.5 hours) was similar to that of other interventions for ankle sprains, but the dosage per week was much higher (2.4 hours per week, SD 0.87 hours per week). The mean patient satisfaction score was 8.8 (SD 1.57) out of 10. Among program completers, 83.9% attained full recovery and were discharged with no residual disability.

Conclusions

Being far less demanding in terms of human resources, the digital program presented constituted a viable, clinically effective, and convenient solution for ankle sprain rehabilitation, particularly during the pandemic. This is the first study presenting a fully remote home-based rehabilitation program for acute ankle sprains, with patients achieving sustained long-term results. This was a prospective cohort study and, as such, did not include a control group, but the results appear comparable to those published for face-to-face interventions.

Trial Registration

ClinicalTrials.gov NCT04819022; https://clinicaltrials.gov/ct2/show/NCT04819022

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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.

App-Based Feedback for Rehabilitation Exercise Correction in Patients With Knee or Hip Osteoarthritis: Prospective Cohort Study

Background

The use of digital therapeutic solutions for rehabilitation of conditions such as osteoarthritis provides scalable access to rehabilitation. Few validated technological solutions exist to ensure supervision of users while they exercise at home. Motion Coach (Kaia Health GmbH) provides audiovisual feedback on exercise execution in real time on conventional smartphones.

Objective

We hypothesized that the interrater agreement between physiotherapists and Motion Coach would be noninferior to physiotherapists’ interrater agreement for exercise evaluations in a cohort with osteoarthritis.

Methods

Patients diagnosed with osteoarthritis of the knee or hip were recruited at a university hospital to perform a set of 6 exercises. Agreement between Motion Coach and 2 physiotherapists’ corrections for segments of the exercises were compared using Cohen κ and percent agreement.

Results

Participants (n=24) were enrolled and evaluated. There were no significant differences between interrater agreements (Motion Coach app vs physiotherapists: percent agreement 0.828; physiotherapist 1 vs physiotherapist 2: percent agreement 0.833; P<.001). Age (70 years or under, older than 70 years), gender (male, female), or BMI (30 kg/m² or under, greater than 30 kg/m²) subgroup analysis revealed no detectable difference in interrater agreement. There was no detectable difference in levels of interrater agreement between Motion Coach vs physiotherapists and between physiotherapists in any of the 6 exercises.

Conclusions

The results demonstrated that Motion Coach is noninferior to physiotherapist evaluations. Interrater agreement did not differ between 2 physiotherapists or between physiotherapists and the Motion Coach app. This finding was valid for all investigated exercises and subgroups. These results confirm the ability of Motion Coach to detect user form during exercise and provide valid feedback to users with musculoskeletal disorders.

Evaluation of Safety and Efficacy of ReHub in Patients Who Underwent Primary Total Knee Arthroplasty: Study Protocol for a Randomized Controlled Trial

Background:

Total Knee Arthroplasty (TKA) is an intervention that can significantly improve the quality of life of patients with advanced knee osteoarthritis. Early start of rehabilitation and its continuation at home once the patient is discharged are key factors for the success of the process.

This study aims to assess the effectiveness of a home-based telerehabilitation solution (ReHub) on improving functional capacity and clinical outcomes for patients who underwent TKA.

Methods/design:

The study is a randomized, open-label with blinded outcome assessor, parallel assignment clinical trial with a sample size of 52 patients that is conducted according to the SPIRIT recommendations. After the TKA intervention, the patients are randomly allocated to the control group or the experimental group with a 1:1 ratio. Both groups follow a Fast Track recovery protocol which includes discharge after 2–3 days from surgery, a daily plan of 5 exercises for autonomous rehabilitation and domiciliary visits by a physiotherapist starting approximately 2 weeks after surgery. The experimental group uses the sensor-based telerehabilitation system ReHub to perform the exercises. The primary outcome measure is the range of motion of the knee. Secondary outcomes include physical performance, quality of life, pain intensity, muscle strength, treatment adherence and satisfaction with the ReHub system. The outcomes assessment is performed at hospital discharge (baseline), at stitch removal (2 weeks after baseline) and 2 weeks after stitch removal (4 weeks after baseline).

The study conforms to the guidelines of the Declaration of Helsinki and was approved by the hospital’s ethics committee.

Discussion:

The study will address an important gap in the evidence base by reporting the effectiveness of an affordable and low-cost home-based telerehabilitation solution in patients who underwent TKA.

Ethics and dissemination:

The study was approved by the hospital’s ethics committee (“Comité Ético de Investigación Clínica del HCB”, reg. HCB/2019/0571). The trial was registred at ClinicalTrials.gov (NCT04155957). The results of this study will be published in peer-reviewed journals as well as national and international conferences.

Trial registration:

NCT04155957 (ClinicalTrials.gov).

Highlights:

The efficacy of remote virtual care in comparison to traditional clinical visits for elective orthopaedic patients: A meta-analysis of prospective randomised controlled trials

INTRODUCTION

The Orthopaedic Trauma Association has recommended limitation of in-person encounters to absolute necessity. One method of ensuring standard patient care within these guidelines is through the implementation of telemedicine.

AIMS

To evaluate the efficacy of telemedicine for elective orthopaedic patients in the recovery and/or rehabilitation period.

METHODS

A systematic review and meta-analysis of articles in Medline/PubMed and The Cochrane Library databases was performed according to the PRISMA guidelines for prospective randomised controlled trials to compare clinical and symptomatic measures for elective patients managed routinely with remote care compared to those managed with standard in-clinic management. To be included for meta-analysis, parameters must be evaluated in ≥3 studies.

RESULTS

Eleven studies were included in the meta-analyses. Both telemedicine and control cohorts were comparable for patient satisfaction (RR, 0.98; 95% CI, 0.90-1.07; I² = 0%; p = 0.52) and patient retention analysis (RR, 1.25; 95% CI, 0.51-3.06; p = 0.54; I² = 0%). Similarly, there was no statistical difference appreciated between cohorts for overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (p = 0.30), Timed Up and Go Test (p = 0.40), and Stair Test (p = 0.18). Significant difference did exist for visual analogue scale (VAS) scores (p = 0.02) in favour of in-clinic management.

CONCLUSION

Telemedicine will serve an integral aspect of healthcare delivery throughout the current COVID-19 pandemic and beyond in an effort to deliver safe, efficient and time-sensitive care to the orthopaedic patient population. The results of our meta-analyses indicate that virtual consultations are as effective as traditional in-person consultations for the care of elective orthopaedic patients in the recovery and rehabilitation period. However, further studies are needed to evaluate for initial consultations and certain sub-specialties of orthopaedics.

Determinants of the behavioral intention to use a mobile nursing application by nurses in China

BACKGROUND

Although a mobile nursing application has began to adopt in nursing, few studies have focused on nurses' behavioral intention of it. The objective of this study is to gain insight into the behavioral intention of nurses, i.e. chinese nurses of the future, to use a mobile nursing application. This study adopted an extension of the Unified Theory of Acceptance and Use of Technology to examine Chinese nurses' acceptance of a mobile nursing application.

METHODS

A total of 1207 nurses participated in the cross-sectional survey. The majority of nurses were female (96.2%). The mean age of the participants was 34.18 (SD 7.39). The hypothesized relationships were tested using AMOS structural equation model.

RESULTS

All constructs exhibited an acceptable level of reliability and validity with Cα and CR > 0.7 and AVE > 0.5. An extension of the Unified Theory of Acceptance and Use of Technology Model had good explanatory power for nurses' behavioral intention of a mobile nursing application. Although effort expectancy and perceived risks had a surprisingly insignificant effect on nurses' behavioral intention to use a mobile nursing application, performance expectancy, social influence, facilitating conditions, self-efficacy, and perceived incentives demonstrated significant influence with β = .259, p < .001, β = .296, p < .001, β = .063, p = .037, β = .344, p < .001, β = .091, p = .001, respectively.

CONCLUSION

With 70.2% of the variance in behavioral intention to use a mobile nursing app explained by this model, it could be helpful for potential adopters, and further investigation should test the actual usage behavior for a mobile nursing app and investigate the related factors.

The effect of innovative smartphone application on adherence to a home-based exercise programs for female older adults with knee osteoarthritis in Saudi Arabia: a randomized controlled trial

PURPOSE

To examine the effects of an Arabic smartphone application on adherence to home exercise programs (HEPs) and the effectiveness of mobile-based HEPs on pain, physical function, and lower-limb muscle strength among older women with knee osteoarthritis (OA).

MATERIALS AND METHODS

This randomised control trial (ClinicalTrials.gov: (NCT04159883) enrolled 40 women aged ≥50 years with knee OA who were randomised into the app group (experimental; n = 20) receiving HEPs using an Arabic smartphone application called "My Dear Knee", whereas the paper group (control; n = 20) receiving HEPs as hand-outs. Both groups had the same exercise program. Outcome measures were self-reported adherence, changes in the Arabic Numeric Pain Rating Scale, the Arabic version of the reduced Western Ontario, McMaster Universities Osteoarthritis Index-Physical Function subscale, and Five-Times Sit-To-Stand Test scores. All participants were assessed at baseline, at week 3 and week 6. Using completer-only analyses, the repeated measures ANOVA was used to compare the means of the outcome measures between the two groups.

RESULTS

At the end of week 6, the app group reported greater adherence to HEPs (p = .002) and significant reduction in pain (p = .015).

CONCLUSIONS

A smartphone application with motivational and attractive features could enhance adherence to HEPs in this patient cohort.IMPLICATIONS FOR REHABILITATIONOlder adults with knee OA may face many obstacles that prevent or limit their adherence to the prescribed HEP.Smart device apps supported with attractive and motivational features could be an effective strategy to enhance adherence to HEPs among older adults with knee OA.Using such remote technology appears to overcome the barriers that may limit the ability of older women to receive supervised physical therapy in a clinical setting.

Smartphone App with an Accelerometer Enhances Patients' Physical Activity Following Elective Orthopedic Surgery: A Pilot Study

Low physical activity (PA) levels are common in hospitalized patients. Digital health tools could be valuable in preventing the negative effects of inactivity. We therefore developed Hospital Fit; which is a smartphone application with an accelerometer, designed for hospitalized patients. It enables objective activity monitoring and provides patients with insights into their recovery progress and offers a tailored exercise program. The aim of this study was to investigate the potential of Hospital Fit to enhance PA levels and functional recovery following orthopedic surgery. PA was measured with an accelerometer postoperatively until discharge. The control group received standard physiotherapy, while the intervention group used Hospital Fit in addition to physiotherapy. The time spent active and functional recovery (modified Iowa Level of Assistance Scale) on postoperative day one (POD1) were measured. Ninety-seven patients undergoing total knee or hip arthroplasty were recruited. Hospital Fit use, corrected for age, resulted in patients standing and walking on POD1 for an average increase of 28.43 min (95% confidence interval (CI): 5.55-51.32). The odds of achieving functional recovery on POD1, corrected for the American Society of Anesthesiologists classification, were 3.08 times higher (95% CI: 1.14-8.31) with Hospital Fit use. A smartphone app combined with an accelerometer demonstrates the potential to enhance patients' PA levels and functional recovery during hospitalization.