Effectiveness of domiciliary rehabilitation, telerehabilitation, and home exercise program on pain, function, and quality of life in patients with total knee arthroplasty: A randomized controlled trial

Shrihari L Kulkarni; Sweta Kulkarni; Arvind D Patil; Shefali Anand Painginkar

doi:10.4103/bjhs.bjhs_57_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 7 | Issue : 2 | Page : 225-231

Effectiveness of domiciliary rehabilitation, telerehabilitation, and home exercise program on pain, function, and quality of life in patients with total knee arthroplasty: A randomized controlled trial

Shrihari L Kulkarni¹, Sweta Kulkarni², Arvind D Patil³, Shefali Anand Painginkar⁴
¹ Department of Orthopaedics, SDM Medical College and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharward, India
² SDM College of Physiotherapy, Shri Dharmasthala Manjunatheshwara University, Dharward, Karnataka, Dharwad, India
³ Department of Orthopaedics, SDM Medical College and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharward, Karnataka, India
⁴ Dr. Ketan Bhatikar's Sports Physiotherapy Aqua Rehabilitation Centre, Margao, Goa, India

Date of Submission	19-Apr-2022
Date of Decision	24-Aug-2022
Date of Acceptance	25-Aug-2022
Date of Web Publication	06-Dec-2022

Correspondence Address:
Shrihari L Kulkarni
Department of Orthopaedics, SDM Medical College and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharward, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/bjhs.bjhs_57_22

Abstract

BACKGROUND: Knee osteoarthritis (OA) is the major source of disability worldwide. OA of knee is a joint disease that affects the elderly. It is characterized by progressive articular cartilage damage which further causes pain and loss of function. Total knee replacement (TKR) is the standard treatment for severe OA knee. Telerehabilitation is one of the new treatment ways and is speedily growing as an alternative for therapies.
OBJECTIVES: The objective of this study was to compare the effects of domiciliary rehabilitation, telerehabilitation, and home exercise program on pain, function, and quality of life (QOL) in patients with TKR.
MATERIALS AND METHODS: A total of 108 individuals were enrolled as per eligibility criteria during the study period and then were randomly divided into three groups by computer-generated, randomized sequence numbers. The parameters were obtained preoperatively, postoperatively, and at the end of 1 month using the Visual Analog Scale (VAS), Knee Injury and Osteoarthritis Outcome Score, Quality of Well-being, methadone maintenance treatment (MMT), and knee range of motion (ROM) test. P < 0.05 was considered statistically significant.
RESULTS: All the three groups showed a reduction in VAS scores and improved function in patients with TKR. QOL and MMT did not prove to be significant in any of the three groups. When ROM was considered, only Groups A and C showed statistical significance whereas Groups A and B showed clinical significance according to the mean difference values.
CONCLUSION: All the three modes of rehabilitation among OA patients, i.e., domiciliary rehabilitation, telerehabilitation, and home-based exercise program, have shown similar effects on study variables including pain intensity, knee function, and QOL in patients with TKR. Therefore, we recommend to include telerehabilitation as one of the treatment approaches for patients with TKR whenever needed.

Keywords: Domiciliary rehabilitation, Knee Injury and Osteoarthritis Outcome Score, osteoarthritis, quality of life, range of motion, telerehabilitation, total knee replacement

How to cite this article:
Kulkarni SL, Kulkarni S, Patil AD, Painginkar SA. Effectiveness of domiciliary rehabilitation, telerehabilitation, and home exercise program on pain, function, and quality of life in patients with total knee arthroplasty: A randomized controlled trial. BLDE Univ J Health Sci 2022;7:225-31

How to cite this URL:
Kulkarni SL, Kulkarni S, Patil AD, Painginkar SA. Effectiveness of domiciliary rehabilitation, telerehabilitation, and home exercise program on pain, function, and quality of life in patients with total knee arthroplasty: A randomized controlled trial. BLDE Univ J Health Sci [serial online] 2022 [cited 2023 Jun 3];7:225-31. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/2/225/362838

Osteoarthritis (OA) of the knee joint is the most common joint disease affecting the elderly and is characterized by progressive articular cartilage damage causing pain and loss of function.^[1] It is a chronic degenerative disorder which is marked by reduced joint space, osteophyte formation, subchondral sclerosis, and a variety of biochemical and morphological changes in the synovial membrane and joint capsule.^[2] Patients seek treatment for this condition due to pain, stiffness, deformity, and instability implicating on every aspect of their daily life. Total knee arthroplasty (TKA) is the gold standard treatment for advanced OA knee with severe symptoms and deformity. It is a safe and effective procedure for patients with OA changes in at least two out of three compartments of the knee after failed conservative management.^[3]

Physical rehabilitation is an essential component of treatment following TKA which helps in reduction of pain and swelling and improves range of motion (ROM), muscle strength, and activities of daily living (ADLs). It plays a very important role in improving the functional outcome and early return to work.^[4] About 75%–85% of the patients receive rehabilitation post-TKA with the main focus on functional training in all aspects of ADLs (most importantly training for progressive ambulation). The main challenge faced during the rehabilitation is to increase the range of flexion in the knee without losing extension and quadriceps muscle power. It is desirable to achieve 90° of knee flexion by 2 weeks post-TKA. The ultimate goal is to make the patient independent with activities of daily living.^[5] Innovative technologies have introduced convenient health-care facilities to the medical field such as e-health, telemedicine, virtual reality wearables, and online educational tools. Compared to standard conventional therapy or face-to-face rehabilitation, services which are given through smartphones or the Internet are more useful and easier and are affordable for people living in rural or remote areas for whom accessibility to the health-care facility for rehabilitation becomes difficult. Telerehabilitation is a modern information and communication technology-based rehabilitation service for patients who live far away. It includes assessment, education, monitoring, exercise interventions, and counseling. It is widely accepted since it reduces travel cost and, more importantly, takes less time and is generally more convenient.^{[4],[6],[7],[8]} Thus, telerehabilitation has the potential to improve rehabilitation access in geographically isolated areas where adequate health-care infrastructure is lacking.

Therefore, this study was planned to compare the effects of domiciliary rehabilitation, telerehabilitation, and home-based exercise program on study variables including pain intensity, knee function, and quality of life (QOL) in patients with total knee replacement (TKR).

Materials and Methods

The present randomized controlled study was conducted in the tertiary care teaching hospital. All patients in the age group of 50–80 years who had undergone TKA from January 2021 to December 2021, by the Department of Orthopaedics, Joint Replacement Unit, Shri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Dharwad, Karnataka, India, were enrolled in the study after obtaining written informed consent. Ethical approval was obtained from the Institutional Ethics Committee through reference number SDMIEC/9/2020. The study is registered with the Clinical Trials Registry of India through reference number CTRI/2021/06/034166.

Exclusion criteria

Patients with major postoperative complications, revision TKR, vision and hearing issues, sensory or cognitive impairment, and previous neurological conditions like stroke and who were unable to use smartphone independently were excluded from the study.

A total of 108 individuals were enrolled as per eligibility criteria during the study period and then were randomly divided into three groups by computer-generated, randomized sequence numbers. The parameters were obtained preoperatively, postoperatively, and at the end of 1 month.

This randomization allocation was placed in opaque sealed envelopes:

Group A (n = 36) received standard conventional domiciliary rehabilitation intervention-face-to-face home visit rehabilitation
Group B (n = 36) received telerehabilitation intervention
Group C (n = 36) received unsupervised home exercise program.

Interventional Protocol

Group A received the standard conventional physiotherapy consisting of a 4-week face-to-face rehabilitation program, started immediately after TKR surgery. Postdischarge rehabilitation services were provided for 40-min duration, 3 days in a week. A tailor-made TKR protocol was followed postoperatively^[8],[9],[10]

Day 1–5: Patients were made to do deep breathing exercises followed by cryotherapy for 15 mins. The bedside mobility exercises included ankle pumps X 10 repetitions, isometric quadriceps exercises/ quadriceps sets, isometric gluteal exercises/gluteal sets, heel slides, active ROM exercises for hip and knee. The patients were provided with necessary assistance for bed sitting and toilet training.
2^nd week: In addition to previous exercises, the patient was made to ambulate with a walker followed by straight leg raises, seated knee bending exercises, active knee ROM exercises in standing, heel lifts, chair sitting and stair climbing with necessary assistance.
3^rd week: Same exercises continued along with a unilateral stance on the involved leg with the walker assistance, knee bending in standing, hamstring curls, and standing wall slides
4^th week: Same exercises continued in addition to lateral step up-step down and walking with the help of walker was continued. Ambulation with the help of walkers and every week progression of the distance were added.

Group B received telerehabilitation intervention. First-week same rehabilitation protocol was followed as Group A. After discharge of the patients, 12 tele-sessions (where therapist demonstrated the exercises and same were done by the patient) were delivered to the patients through the smartphone for 45–60 min for 3 days in a week. During telesessions, it was mandatory to have an attender at the patient's house to ensure the patient's safety while mobilization and in any case of emergency
Group C received a home exercise program which was not supervised by the therapist. The patient was given standard rehabilitation in the hospital after TKR till his/her hospital stay and postdischarge patient was taught home exercise program and was given a set of four videos of conventional home exercise program same as Groups A and B and patients were asked to progress the exercises every week by seeing those videos. Therapists spoke to the patient weekly once for 4 weeks on phone to check adherence to the protocol as well as patients were asked to maintain a record diary of exercises.

Study parameters

Demographic profile includes age in years and sex was noted
Visual Analog Scale (VAS) was used to assess pain intensity
The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to assess knee function
Quality of Well-being (QWB) Questionnaire was used to assess QOL.

The data were collected preoperatively, postoperatively, and at the end of 4 weeks.

Statistical analysis

Descriptive data are presented as frequencies, percentages, mean, and standard deviation. The difference between the baseline, post, and 1-month follow-up values of pain (VAS), QOL (QWB), and function (KOOS) among groups was analyzed with repeated-measures ANOVA. Statistical significance was considered P < 0.05. All the analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp).

Results

The mean age of the study participants was 63 (± 13.03) years and the mean age in the three study groups was similar. Most of the participants were in the age group of 61–70 years in all the three groups. In our study, a greater number of females underwent TKR than males. Sixty-one percent of the patients were nonworking. Most of the participants had knee complaints for 1–5 years and only 11% of the participants had complaints for more than 10 years. Hypertension was the most common comorbidity (33.3%) associated with the OA of the knee [Table 1].

Table 1: Demographics of the study participants

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One-way analysis of variance for the test of difference between pre, postsurgery, and after 1 month of follow-up for VAS identified a significant difference among the means at 1 month of follow-up for VAS. When between-group comparison was done, there was a significant difference observed at 1 month of follow-up for VAS. One-way analysis of variance for the test of difference between pre, postsurgery, and after 1 month of follow-up for VAS identified a significant difference among the means at 1 month of follow-up for VAS. When between-group comparison was done, there was a significant difference observed at 1 month of follow-up for VAS [Table 2].

Table 2: Comparison of pain intensity using the Visual Analog Scale between three study groups

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Further post hoc analysis using Bonferroni correction revealed that the mean difference of −1.16 between Group A and Group C (P = 0.01), −1.00 between Group B and Group C (P = 0.003), 1.16 between Group C and Group A (0.001), and 1.00 between Group C and Group B (P = 0.003) was statistically significant, but the mean difference between Group A and Group B of 1.00 was not significant at 1 month of follow-up [Table 3].

Table 3: Pairwise comparison of Groups A, B, and C with respect to the Visual Analog Scale by Bonferroni post hoc procedure

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One-way analysis of variance for the test of difference between pre, postsurgery, and after 1 month of follow-up for KOOS identified a significant difference among the means at the pre and a significant difference between postsurgery and at 1 month of follow-up. When between-group comparison was done, there was a significant difference observed at 1 month of follow-up for KOOS. One-way analysis of variance for the test of difference between pre, postsurgery, and after 1 month of follow-up for KOOS identified a significant difference among the means at the pre and a significant difference between postsurgery and at 1 month of follow-up. When between-group comparison was done, there was a significant difference observed at 1 month of follow-up for KOOS [Table 4].

Table 4: Comparison of knee function using the Knee Injury and Osteoarthritis Outcome Score between three study groups

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One-way analysis of variance for the test of difference between pre, postsurgery, and after 1 month of follow-up for QWB scores identified a significant difference among the means at the pre and a significant difference between postsurgery and at 1 month of follow-up. When between-group comparison was done, there was a significant difference observed at posttreatment for QWB. One-way analysis of variance for the test of difference between pre, postsurgery, and after 1 month of follow-up for QWB scores identified a significant difference among the means at the pre and a significant difference between postsurgery and at 1 month of follow-up. When between-group comparison was done, there was a significant difference observed at posttreatment for QWB [Table 5].

Table 5: Comparison of quality of life using the Quality of Well-being Questionnaire among three study groups

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Discussion

The aim of this study was to compare the effects of domiciliary rehabilitation, telerehabilitation, and home exercise program on pain, function, and QOL in patients with TKR.

In this randomized controlled trial, subjects among the age group of 50–80 years who have undergone TKR surgeries which were performed by an orthopedician in SDM College of Medical Sciences and Hospital, Dharwad, were screened as per the inclusion and exclusion criteria [Figure 1].

Figure 1: CONSORT flow diagram

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In this study, a greater number of participants belonged to the age group of 61–70 years (15%) with a mean age of 63 ± 13.03 followed by 50–60 years (14%) and 71–80 years (7%), respectively. Previous studies showed that OA of knee is the most common joint disease that affects the elderly.^[1],[11] According to a study, the disease is more common in the elderly age group and it also says that the prevalence of the radiographic OA knee joint was 19.2% among people above 45 years old and 43.7% of patients above 80 years old.^[12] When an association of gender was done, more numbers of females (61.1%) underwent TKR compared to males in our study. Males were 14 and females were 22, respectively, in all three groups [Table 1]. A cohort study has reported that female gender has a slightly higher prevalence of radiographic OA than males. Females have a greater burden of OA, and as a result, they have a greater impact on QOL.^[2] The National Health Portal India conducted a survey which suggested that 45% of Indian women had symptomatically OA whereas 70% had radiologic findings.^[13] According to the third National Health and Nutrition Examination Survey III, 60 years of age and above had 37% of radiographic knee OA features.^[7] Studies reported that the prevalence of OA in India lies from 17% to 60%.^[6]

A report by the United States Department of Health and Human Services, had reported the prevalence of knee OA in different age groups. About 7.6% were from 18 to 44 years of age, 29.8% were 45–64 years of age and almost 50% were older than 65 years and above.^[14] The Indian Society of Hip and Knee Surgeon's Joint Registry has recorded 34,470 TKR s surgeries (25% of males and 75% of females) from 2006 to April 2012.^[1]

It has been documented that female hormone estrogen is responsible for protecting the cartilage from any inflammation and thus can prevent osteo-arthritis. Therefore there is higher risk of developing osteoarthritis during menopause. Estrogen loss can further cause a decrease in bone mass with subchondral bone remodeling which is the cause of OA. Previous studies have reported that a decline in estrogen is directly proportional to OA in postmenopausal women. Hence, we can correlate our results to the previous studies.^{[15],[16],[17],[18]}

Further post hoc pairwise test using the Bonferroni correction revealed that VAS pre, post, and 1-month follow-up was statistically significant with P < 0.01. The partial eta squared used as an indicator of effect size in our study showed to be 0.95 for VAS score. The minimal clinically important difference (MCID) value for VAS in knee OA is 0.9 cm for 0–10 cm scale. When between-group comparison was done, there was a significant difference observed at 1 month of follow-up for VAS. Further post hoc analysis for comparisons of three groups with respect to VAS revealed that there was a significant difference between Groups A and C and Groups B and C, respectively. However, based on MCID values and mean difference values, Group A to Group B showed significance which says that Groups A and B were superior to Group C, but Groups A and B both were equally superior and no group was better than each other [Table 2] and [Table 3].

When the intensity of pain was assessed in patients before and 1 month after TKR on VAS, it indicated that the pain was greater before surgery compared to pain after surgery. Our study results are similar to the findings of previous studies which state that TKR plays a major role in the reduction of pain. A prospective study with repetitive measures reported a decrease in pain at the time of discharge and 1 year after TKR. Another study reported a decline in pain among knee OA patients after TKR. The authors have also reported both short-term and long-term improvements in pain and stiffness following the TKR. These studies are in support of our study which found that the postoperative patient had an improvement in pain.^{[19],[20],[21],[22]}

Functional outcome after TKR was measured by the KOOS in this study. It assesses the knee symptoms, pain, sports component, ADLs, and QOL. There was a significant improvement in knee symptoms after TKR among all the participants. However, most subjects specified the inability to squat before and after TKR [Table 4]. Regardless of this, all the subjects were found to be satisfied with their enhancement in functional activities as the symptoms reduced after TKR. Supporting this, a previous study reported 73.2% of functional improvement following the TKR. A systematic review and meta-analysis found that the joint replacement has considerable immediate and long-term progression in knee function. Similarly, another study reported 80% of functional gain in TKR subjects compared to healthy individuals. Postoperative improvement in osteoarthritic knee symptoms helps to regain confidence in the functional activity.^{[20],[21],[22]} Our present study correlates with findings from previously found literature which states that exercise therapy consisting of ROM exercises, strength training, and early ambulation improves pain in patients after TKR. Further, it reduces the fear of movement which emphasizes on doing functional activity. With physical activity, there is an increase in the flow of blood to the knee, which in turn helps in the healing of injured knee tissues.

In this study, QWB was used to evaluate the subjective QOL before and after TKR surgery. QOL of the elderly is limited due to age-related problems, which is further affected in patients with knee OA.

QOL improved immediately postoperative. We can attribute this to reduction in pain after surgery. Along with pain, patients have a reduction in stiffness and the patients after TKR are made to walk immediately from the 1^st postoperative day. The patients feel better with ambulating as preoperatively as ambulation is their major concern. Hence, we can consider that these patients had better QOL after surgery [Table 5].

When 1-month follow-up was considered, there was no statistical significance between the groups. Although there was an improvement in QOL immediately after surgery, after 1 month, patients' QOL was not significant. All these activities can be achieved after 6 weeks. However, in our study, we assessed the patients at 4 weeks/1 month. Hence, the patient was still not completely independent and socially active. Hence, the QOL at 1-month follow-up might not have improved.

Due to severe pain and stiffness of knee joints, it is difficult for the elderly with OA of the knee to ambulate. It limits social participation and recreational activities of individuals. In case of severe OA, it restricts the ambulatory function to the indoor environment or may also result in dependency for self-care activities and the use of walking aids for mobility. The difficulty in ambulation and restriction in social participation, occupation, and public transport patients may start feeling isolated leading to depression. In our study, there was a significant improvement in physical and psychological domains of QOL among most of the participants after surgery, but it did not show any improvement after 1 month of follow-up. This progression in the QOL in preoperative and postoperative is attributed to the reduction in knee joint pain, stiffness, and improved functional mobility of patients after TKR which facilitates the social participation and occupational and recreational activities of all the subjects.^{[21],[22],[23],[24],[25]}

Conclusion

Based on the result of this study, it is observed that domiciliary rehabilitation, telerehabilitation, and home exercise program showed a reduction in VAS scores in patients with TKR. QOL did not prove to be significant in any of the three groups. ROM showed statistical significance in Groups A and C whereas Group A and B showed clinical significance according to the mean difference values. When considering methadone maintenance treatment, it did not show any improvement in all the three groups.

All the three modes of rehabilitation among OA patients, i.e., domiciliary rehabilitation, telerehabilitation, and home-based exercise program, have shown similar effects on study variables including pain intensity, knee function, and QOL in patients with TKR. Therefore, we recommend to include telerehabilitation as one of the treatment approaches for patients with TKR whenever needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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