Telerehab Proven Effective After Total Knee Replacement

One of the challenges of telemedicine for the past several decades has been the tendency for its supporters to align it with some health services without a natural fit. This is to say, those requiring one-on-one, live physician and nurse interactions. I have now come across one type of service, post-operative physical therapy, that seems to be a natural for telemedicine. A recent article discusses an example of a successful telerehab program (see: Telerehab Works After Knee Surgery)

In a noninferiority trial, telerehabilitation fared at least as well as conventional therapy on all study outcomes after six weeks, including the primary outcome...according [a reesearcher in the field]. In fact, telerehabilitation resulted in greater improvement on the WOMAC stiffness subscale and the Patient-Specific Functional Scale, a secondary endpoint... the researchers reported....Rehabilitation is an important adjunct to total knee arthroplasty, but access to high-quality rehabilitation services is not always possible, particularly for people living in remote areas, according to the researchers. So they performed a randomized study comparing an Internet-based rehabilitation program with conventional outpatient physical therapy....The patients in the telerehabilitation group were still required to come to the hospital, but they completed the weekly 45-minute session over the Internet in an isolated room set up to resemble a home environment. All patients were encouraged to perform a comprehensive home exercise program twice a day. The primary outcome -- WOMAC -- has been used extensively in total knee replacement and osteoarthritis clinical trials....Improvement on the WOMAC was 52.7% in the control group and 67.6% in the telerehabilitation group, a nonsignificant difference. Compliance with the home exercise program -- assessed using exercise diaries -- was similar in the two groups. "The nature of the telerehabilitation intervention, which relied more on the education of patients in the self-application of mobilization techniques and had a greater emphasis on exercise, may have provided participants with a heightened opportunity for self-treatment outside the formal physical therapy treatment session," the researchers wrote.

One of my pet theories is that we can lower healthcare costs and improve health outcomes by encouraging patients to take an active role in their own care and encouraging them to "own" many of the healthcare delivery processes. One important facet of this approach is providing them with ready access to their own health records (see: Should Patients Be "Allowed" to Read Their Medical Records?; Providing Patients Easy Access to Physician Notes in Their EMRs). Another of my ideas is that we should provide patients with web-based training/teaching videos that can supplement or replace various types of live hospital/physician office interactions.

It's not clear from the above description of "weekly 45-minute session over the Internet in an isolated room" involved live broadcasting, interactive sessions via webcam, or web-based videos. However, these differences would be somewhat irrelevant in the context of this study. Also and as noted above, all patients were encouraged to perform a comprehensive home exercise program twice a day. This new approach to improving knee function post-op fared as well as conventional therapy. That's the key point. Obviously, telerehab is far more cost-effective than conventional therapy and provides access to such services in rural areas where they may be difficult to obtain. I would not claim for a minute that telerehab is right for every patient. My sense is that prerequisites would be younger, highly-motivated patients who are generally comfortable with technology and self-education. Nevertheless, I think that an opportunity to choose telerehab needs to be made widely available across the country.

Telerehab Works After Knee Surgery

By Todd Neale, Staff Writer, MedPage Today Published: January 28, 2011 Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco. Earn CME/CE credit for reading medical news

An Internet-based rehabilitation program worked as well as conventional therapy for aiding the recovery of patients following total knee arthroplasty, researchers found. In a noninferiority trial, telerehabilitation fared at least as well as conventional therapy on all study outcomes after six weeks, including the primary outcome -- the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) -- according to Trevor Russell, PhD, of the University of Queensland in Brisbane, Australia, and colleagues. In fact, telerehabilitation resulted in greater improvement on the WOMAC stiffness subscale and the Patient-Specific Functional Scale, a secondary endpoint (P<0.05 for both), the researchers reported in the Jan. 19 issue of the Journal of Bone & Joint Surgery. Action Points   Explain that an Internet-based rehabilitation program worked as well as conventional therapy for aiding the recovery of patients following total knee arthroplasty. Note that limitations of the study included the short follow-up period and that the telerehabilitation intervention was delivered in the hospital, which might not reflect conditions when the intervention is delivered to patients in the home. "This trial provides evidence for the efficacy of low-bandwidth telerehabilitation in producing clinically relevant physical and functional results six weeks after patients have had a total knee replacement," they wrote. Rehabilitation is an important adjunct to total knee arthroplasty, but access to high-quality rehabilitation services is not always possible, particularly for people living in remote areas, according to the researchers. So they performed a randomized study comparing an Internet-based rehabilitation program with conventional outpatient physical therapy. The researchers enrolled 65 adults (mean age 68) who underwent surgery at Queen Elizabeth II Jubilee Hospital in Brisbane, and assigned 34 to conventional therapy and 31 to telerehabilitation. Patients in both groups started the six-week rehabilitation program about one week after discharge. The patients in the telerehabilitation group were still required to come to the hospital, but they completed the weekly 45-minute session over the Internet in an isolated room set up to resemble a home environment. All patients were encouraged to perform a comprehensive home exercise program twice a day. The primary outcome -- WOMAC -- has been used extensively in total knee replacement and osteoarthritis clinical trials. Secondary outcomes included the Patient-Specific Functional Scale, the Spitzer Quality-of-Life Uniscale, the timed up-and-go test, pain intensity, knee flexion and extension, quadriceps muscle strength, girth measurements at the knee, and an assessment of gait. Patients in both groups had clinically and statistically significant improvement on all measures through six weeks (P<0.01 for all). Improvement on the WOMAC was 52.7% in the control group and 67.6% in the telerehabilitation group, a nonsignificant difference. Compliance with the home exercise program -- assessed using exercise diaries -- was similar in the two groups. Patients assigned to telerehabilitation expressed a high level of satisfaction with the intervention, giving a score greater than 9 out of 10 (most satisfied) for nearly all of the items on a survey about the program. According to Russell and his colleagues, multiple factors may have facilitated rehabilitation in the Internet-based intervention. "The nature of the telerehabilitation intervention, which relied more on the education of patients in the self-application of mobilization techniques and had a greater emphasis on exercise, may have provided participants with a heightened opportunity for self-treatment outside the formal physical therapy treatment session," the researchers wrote. Also, "a higher reliance on education in the telerehabilitation group may have assisted in producing a higher technical proficiency in the home exercise program." The authors acknowledged some limitations of the study, including the short follow-up period and the fact that the telerehabilitation intervention was delivered in the hospital, which might not reflect conditions when the intervention is delivered to patients in the home. "For these reasons, this investigation should be considered as a proof-of-principle study, and future research should be conducted in the communities and homes of isolated patients to explore the impact of these factors," they wrote. Economic analyses are also needed, they added.

Comments

[DePuy Pinnacle Lawsuit]

Actually there has been a study conducted which shows the effectiveness of telephone therapy which is handled by experience therapist.

[Alan Waterman]

The HandTutor, ArmTutor and LegTutor uses a dedicated rehabilitation software that uses motivating games that can be customized to the stage of rehabilitation and the patients movement adysfunction. The HandTutor and other Tutor systems are used in hospital, community PT OT clinic and the home care supported by tele-rehabilitation.