Research in Focus: Telerehabilitation is Non-inferior to Usual Care Following Total Hip Replacement

  •   June 3, 2020
  •  Leanne Loranger, PT

Citation: Nelson M, Bourke M, Crossley K, Russell T. Telerehabilitation is Non-inferior to Usual Care Following Total Hip Replacement – A Randomized Controlled Non-Inferiority Trial. Physiotherapy 2020; 107:19-27      

Background

Total hip replacement (THR) is a common orthopedic surgery, with more than 6,014 THRs completed in Alberta in 2016-17 (the last year for which data is available).1 Standard post-operative care includes physiotherapy, however the optimal post-discharge rehabilitation is unknown, with a wide range of treatment interventions and timing to commence post-operative intervention reported in published research.2

Post-discharge physiotherapy care for THR patients can be impaired due to challenges related to access to care, including transportation-related barriers to care. In Australia, where the current study was conducted, prior research has demonstrated the efficacy of telerehabilitation following total knee replacement (TKR) and its utility to address access issues.

This study aimed to determine if a telerehabilitation model of post-discharge THR care was non-inferior to in-person rehabilitation.

Methods

Design

  • Single center, randomized, single-blind, controlled, non-inferiority trial

Patient Inclusion Criteria

  • Undergoing primary elective THR
  • Able to attend five in-person appointments
  • Able to provide signed informed consent

Patient Exclusion Criteria

  • Comorbidities that prevent participation in rehabilitation
  • Revision THR
  • Intraoperative complications preventing participation in THR clinical pathway
  • Unable to mobilize full weight-bearing

Intervention Group – Telerehabilitation (n=35; one participant withdrew after allocation)

  • Standardized home exercise program (HEP)
  • Delivered using two apps – Wellpepper and eHAB
    • Wellpepper – exercise program delivery, three automated exercise reminders per day, monitored HEP compliance, and messaging feature
    • eHAB – real-time videoconferencing
  • Participants received 15 minutes of training in the use of the apps prior to discharge from hospital
  • One eHAB visit completed at two-weeks post discharge to review gait and provide HEP advice
  • Second eHAB visit at four-weeks post discharge if gait deficits noted at two-week appointment

Control Group (n=35; none lost to follow-up)

  • Standardized HEP (same content as intervention group)
  • Exercise diary to document compliance with HEP
  • Patients to perform exercises three times a day
  • 30-minute in-person physiotherapy sessions at two, four and six-weeks post-op, focusing on gait and progressing HEP

Outcome Measures

  • Primary Outcome:
    • Quality of Life subscale of the Hip disability and Osteoarthritis Outcome Score (HOOS) at six weeks
  • Secondary Outcomes:
    • Functional health and wellbeing: Short Form – 12
    • Health-related quality of life: EuroQol 5-Dimension 5 Level questionnaire
    • Physical Outcomes: TUG; hip strength (peak isometric force); dynamic standing balance (Step Test)
    • System Usability Scale – to assess usability of the apps and technology
    • Exercise compliance – collected via Wellpepper app or exercise diary

Findings

  • 70 participants enrolled in the study; 69 received the allocated intervention
  • HOOS - No between group differences in mean change from baseline to 6-weeks
  • SF-12 AND EQ-5D showed no between group differences
  • TUG, step test and muscle strength showed no between group differences
  • Satisfaction was high for both groups
  • “Only between group difference was for the item ‘my therapy session was easy to attend’ in which the intervention group scored higher”
  • Intervention group was also more complaint with their HEP
  • Both Wellpepper and eHAB scored highly on the System Usability Scale

“Remotely delivered telerehabilitation for post-operative THR is non-inferior to in-person rehabilitation… at six weeks post-op.”

Limitations

  • Despite randomization, the intervention group mean age was younger, which may impact rate of recovery and attitude towards the intervention.
    • Age was included as a covariate in all analyses to control for this effect.
  • One physiotherapist delivered all telerehabilitation sessions, while control group participants were seen by a group of several physiotherapists, potentially impacting upon the patient-Physiotherapist relationship and patient satisfaction.
    • This may have impacted on the accuracy of the findings by artificially reducing control group participation and satisfaction relative to the intervention group.
  • Wellpepper automatically monitored exercise program compliance, whereas the control group self-reported exercise compliance, which may have impacted accuracy of compliance reported by each group.
    • However, improved accuracy of HEP compliance by the control group would not alter the outcomes related to the HOOS, strength, TUG, step test, SF-12 AND EQ-5D and the study’s overall finding that telerehabilitation delivered services are non-inferior to in-person care for post-operative THR patients.

Relevance to physiotherapy practice in Alberta

In the context of rapid adoption of telerehabilitation to meet patient care needs during the COVID-19 pandemic, evidence regarding the effectiveness of these services as compared to ‘usual’ or ‘in-person’ services is crucial.

Disclaimer

The purpose of this summary is to highlight recently published research findings that are not openly accessible. Every effort is made to ensure accuracy and clarity of the summary. Readers are encouraged to review the published article in full for further information.


  1. CIHI. Hip and Knee Replacements in Canada – Canadian Joint Replacement Registry, 2016-2017 Quick Stats. Available at: https://www.cihi.ca/en/access-data-reports/results?query=total+hip+replacement&Search+Submit= Accessed on May 26, 2020.
  2. Nelson M, Bourke M, Crossley K, Russell T. Telerehabilitation is Non-inferior to Usual Care Following Total Hip Replacement – A Randomized Controlled Non-Inferiority Trial. Physiotherapy 2002; 107:19-27