Telehealth for Knee Arthroplasty

Original Editor - Binaya Kandel Top Contributors - Uchechukwu Chukwuemeka, Kim Jackson, Tony Lowe and Lucinda hampton  

Introduction

Telehealth and Telemedicine are often used interchangeably. However, both have distinct definitions. Telemedicine refers specifically to the “remote delivery of healthcare services and clinical information using telecommunications technology, such as the internet, wireless, satellite, and telephones.” In contrast, Telehealth is defined as the “use of electronic communications to share medical information from one place to another with the intention of improving a patient’s health.” Telemedicine focuses on the curative aspect of Telehealth that encompasses preventive, promotive, and curative models of health care system. Rehabilitation being another important model of the modern health care system, its delivery via digital platform has already been defined earlier. Telerehabilitation, one of the emerging fields of telemedicine, is defined as the set of tools, procedures, and protocols to deliver the rehabilitation process remotely. Rehabilitation has increased its demand, increasing the cost thereby threatening the sustainability of the existing health care system. Tele-rehabilitation to some extend can assist by the early discharging of patients from points of care and improving the patient’s adherence to rehabilitation service. Tele-rehabilitation though has a long history of practice it has been consistently advocated in the literature to be practiced routinely after the SARS COVID-19 pandemic outbreak.

The novel coronavirus was first recognized in December 2019 and its infection was declared as a global pandemic by the World Health Organization (WHO) in March 2020. WHO has instructed various measures to control its spread like social/physical distancing, area lockdown, travel restriction to the contaminated zones, workplace closure, postponement of medical visits unless it is an emergency, etc. Face to face clinical consultation is also restricted to contain the spread of infection 5-7 . This has opened a new era of teleconsultation for medical services, including rehabilitation.

Knee Arthroplasty

Knee arthroplasty is an orthopedic surgical procedure of replacing the articular surface of the knee joint. The femoral condyle(s) and tibial plateau are replaced with a metal surface with at least one polyethylene insert between them. In this procedure, patellar resurfacing may or may not be done. It is indicated in cases of severe pain that limits the activities of daily living due to end-stage osteochondral damage or osteoarthritis. A procedure with patellar resurfacing is known as total knee arthroplasty. In contrast, partial knee arthroplasty can be total (TKA) or unicompartmental (UKA) depending on the number of femoral condyle replaced8-9. UKA is bone conserving and ligament sparing procedure with enough evidence to demonstrate good medium to long term success in restoring the physical function and decreasing the pain10. A rehabilitation program with an emphasis on physiotherapy and exercises before and after the surgery is well advocated in the literature11. Studies show that early interventions of the physiotherapy program improve the physical function at least in short term after primary knee arthroplasty 12. Modern days physiotherapy in knee arthroplasty can be subdivided into three phase:

1. Preoperative phase: Including Patient education, Maintaining Knee range and strength, improving overall physical function of the patient
2. Early Postoperative Phase: Restoring range of knee motion, maintaining the strength of lower limb muscles, and participation of the patient in activities of daily living
3. Late Postoperative phase: Strength and function-specific task training,  social participation/integration

Home-based exercise after the discharge of patients from an acute hospital setting is also an evidence-based measure of improving patient adherence to the rehabilitation program and overall improvement in the outcome.

Effectiveness of Tele-rehabilitation in TKR

There has been an increasing cost and demand for joint arthroplasty (Hip and Knee) in the past decade. It has been predicted to continue increasing significantly. At the same time, the hospital-based and community-based rehabilitation resources are getting restriced13. The average length of hospital stay is currently decreasing from less than 5 days post-operative. Tele rehabilitation can complement the match of the increasing demand for physical rehabilitation outside the hospital with the efficient use of resources including manpower. A systematic study carried out recently concluded that tele rehabilitation for lower limb arthroplasty showed improvement in physical functioning similar to that of patients completing conventional in-person outpatient physical therapy, without an increase in adverse events or resource utilization. It is also a practical alternative to conventional in-person outpatient physical therapy. However, More robust studies, however, are needed to build evidence14.

A systematic review and meta-analysis by Shukla et al compared the effectiveness of telerehabilitation versus conventional rehabilitation programs15.  The study analyzed various outcome measures, of which results from randomized control trials are summarized in following table 1.

Table 1. Comparisons of various outcomes after Tele-rehabilitation with conventional rehabilitation program.
Outcome Measure	Results (Tele-rehabilitation Vs Conventional Rehabilitation program)	Number of Studies
Change in active knee extension	Results (Tele-rehabilitation Vs Conventional Rehabilitation program)	3
Change in active knee flexion	No significant difference	6
Quadriceps muscle strength (Kg)	Tele-rehabilitation showed significant improvement	2
Hamstring muscle strength (Kg)	No significant difference	1
Swelling of knee joint (cm).	No significant difference	1
Visual Analogue Scale for pain.	No significant difference	2
WOMAC scale	Tele-rehabilitation showed significant low stiffness score	2
Quality of Life as per SF-36.	Conventional rehabilitation showed significant improved QoL after 12 weeks of rehabilitation	1
WOMAC : Western Ontario and McMaster Universities Osteoarthritis Index Qol: Quality of life

The study suggested that telerehabilitation is as effective as the conventional rehabilitation in active knee flexion and extension, improving hamstring muscle strength, reducing the swelling of knee joints, and even superior in some of the outcomes such as improving quadriceps muscle strength, and stiffness subsection of the WOMAC scale.

Another systematic review and metanalysis published in the Journal of Telemedicine and telecare has shown similar results. The meta-analysis of VAS scores and active flexion range showed no statistically significant difference between the telerehabilitation group and the face-to-face rehabilitation group for active flexion range. Moreover, telerehabilitation treatment showed a significantly improved WOMAC, extension range, and quadriceps strength as compared to face-to-face rehabilitation. The study clearly suggested that telerehabilitation could obtain comparable pain control and better improvement of functional recovery compared to face-to-face rehabilitation, and is recommended for patients after knee arthroplasty16.

Cost-effectiveness and Patient Satisfaction

There are limited high-quality studies to analyze the cost-effectiveness and satisfaction of patients with telerehabilitation compared with face-to-face rehabilitation. Few multi-centre randomized trials are in favor of telerehabilitation. A study done in Canada demonstrated the cost savings of tele-treatment compared to home visits for patients post-TKA17. Another study to compare the level of satisfaction between patients receiving in-home telerehabilitation after TKA to face-to-face rehabilitation demonstrated that both groups had a similar level of satisfaction regarding the delivery of health-care services18. However, the comparison of such factors depends on the contextual, economic, and cultural background of the study sites. The results should be carefully analyzed before generalization.

Further Implication

Tele-rehabilitation is a newer concept, the patient and the therapist should be well oriented with the technology and issues related to it including cybersecurity, laws regulation of the country, cost of implementation. There are limited studies till date. Multi-centre, high-quality studies to assess all these aspects should be executed.