Purpose: To determine if a telerehabilitation model of care delivery remotely is non-inferior to in-person rehabilitation for patients who have had total hip replacement following hospital discharge?
Methods/Design: Single, center, randomized, controlled, non-inferiority clinical trial. 6 week intervention with 6 mos follow-up. Outcomes collected at baseline (pre-op), D/C from PT, 6 weeks and 6 mos post-op. **Primary analysis was at 6 weeks. **Participants and care providers were not blinded to allocation because well…you can’t really.
Inclusion criteria: undergoing elective THR, could attend 5 in-person appointments and able to sign informed consent.
Exclusion criteria: if they had comorbidities preventing rehab participation, were undergoing THR revision, experienced intraoperative complications that prevented participation or were unable to mobilize full WB.
Intervention:
In person: standardized paper-based HEP targeting strengthening exercises for quadriceps, hip abductors, extensors and flexors. Participants were instructed to perform HEP 3x/daily and self monitor compliance with exercise diary. At 2, 4 and 6 weeks post-op participants attended the clinic for a 30 minutes in-person PT session focusing on gait and reviewing and progressing HEP. ***So 4 visits totals over a 6 week period.
Telerehabilitation: Intervention was identical to above with the mode of delivery being via telerehab thru iPad. Intervention group received 3 automated remindes per/day for exercise performance. 2 weeks post D/C from hospital, videoconferencing was used to perform gait analysis/training and progression of HEP performed as indicated. If deficiencies were apparent in mobility (gait and reliance on walking aid) or difficulties with HEP performance, an additional telerehab session 2 weeks later was scheduled.
Outcome measures
Primary: Hip Disability and Osteoarthritis Outcome Score (HOOS) collected at 6 weeks.
Secondary: Short Form-12 for functional health and well-being
Physical Outcomes: TUG, hip strength (flexion, extension, abduction, adduction, IR, ER) and knee extension using peak force from a calibrated Lafayette 01165 manual muscle dynamometer
Other Outcomes: HEP compliance collected via wellpepper (app used for intervention group) and paper-based diary for control group. **If the participant completed at least one set of an exercise from their HEP that day was considered compliant.
Results:
Flow of participants, therapists and centers through the study
Control Group 1 person failed to attend at 2 weeks, 3 failed to attend at 4 weeks and 1 failed at 6 weeks. 6 participants received additional PT following 6-week intervention period
Intervention Group All 34 participants received their two week telerehab appointment and 17 (50%) went on to have an additional 4 week telerehab appointment. 4 went on to have additional appointment following 6-week intervention period.
***Intervention Effects***
Primary Outcomes
Mean change from baseline to 6 weeks for the HOOS QOL subscale revealed NO between group difference.
Secondary Outcomes
No between group differences for SF-12, TUG, step test and muscle strength.
Satisfaction was high (>85%) across both groups for all 14 items in the health care satisfaction questionnaire
***The intervention group were more compliant with their HEP with an overall compliance of 86% vs 74% for the control group. Was this due to the automated reminders in the intervention group??? I think so.
Discussion
“Remotely delivered telerehabilitation for post-operative THR is non-inferior to in-person rehabilitation assessed by the primary outcomes of the HOOS QOL subscale at six weeks post-operatively.”
“An unexpected result of this study was the lack of significant strength gains in some muscles over time, namely hip extension, adduction, abduction and flexion” I think this speaks to commonplace in PT that is many not challenging their patients enough to induce real strength changes.