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Virtual physiotherapy: a new horizon in outpatient joint replacement surgery recovery

The increase in the use of musculoskeletal care is leading to the exploration of more sustainable models to encourage high-value care. As many total joint replacement procedures are already bundled in payments, healthcare systems need to find new ways to reduce costs while maintaining clinical outcomes.

Many healthcare systems are studying the effectiveness of remote patient monitoring and digital patient engagement on preoperative patient optimization and postoperative recovery. For total knee arthroplasty (TKA) procedures, virtual physiotherapy turned out to produce similar results to outpatient physiotherapy for traditional TKAs.

Currently, between 2.8% and 5% of TKAs in the United States are performed on an outpatient basis, usually in relatively young patients with few comorbidities. However, the prevalence of same-day TKA procedures is exponentially increasingfueled by cost containment pressures and the recent removal of TKA and total hip arthroplasty (THA) procedures from the Medicare Inpatient-Only list.

Some projections predict that more than 50% of PTG will be offered as outpatient procedures within the next five years. While orthopedic practices have become much more comfortable with the benefits of remote physical therapy, there are still apprehensions about its adoption for outpatient procedures.

A study to evaluate outpatient physiotherapy versus virtual physiotherapy

Our institution designed a study to determine if formal physical therapy is necessary after outpatient TKA procedures. Patients undergoing same-day discharge TKAs between August 2019 and March 2021 were randomized to receive either outpatient physiotherapy (OPT) or an internet-based virtual physiotherapy program (VPT).

Of the 194 patients who met the inclusion criteria, 99 were randomized to OPT and 95 to VPT. After withdrawals and crossovers due to clinical indications or patient preference, the study included 89 OPT patients and 72 VPT patients, with no significant difference in baseline variables (sex, age, BMI, and laterality of the procedure ) between groups.

All patients were enrolled in a remote care management and patient engagement platform throughout their care episode. The platform provides individualized care pathways based on the patient’s demographic profile and clinical status, adjusted to reflect the patient’s current activity level, pain, and range of motion.

All patients received preoperative education via a virtual joint class with reminder questions, which provides procedure-specific content to help patients prepare and prepare their homes for recovery. In a previous study examining virtual or in-person preoperative training for total joint replacements, there were no statistically significant differences in patient satisfaction or functional outcomes.

For 90 days post-surgery, OPT patients completed a standard course of physiotherapy, while VPT patients were enrolled in physiotherapy remotely through the care management platform. Patients watched videos and performed a series of prescribed exercises, such as assisted squats, as they progressed through the phases of their care plan.

The care management platform enabled remote monitoring of all patients’ adherence to their evidence-based care plan. Providers were notified if their patients were experiencing increased pain or reduced range of motion, allowing care teams to provide targeted intervention in the form of follow-up phone calls or in-person appointments.

In addition, all patients had access to the platform’s doctor-patient direct messaging function.

Patients who were concerned about their pain, medication or swelling could contact their providers for an answer. Research shows that direct doctor-patient messaging can facilitate rapid, in-person treatment of wound complications while avoid unnecessary visits for wounds showing the normal healing process.

Patient assessment methods and study results

All patients completed the Veteran RAND 12-Point Health Survey (VR-12), which assesses physical and mental health, before the operation and at six weeks, twelve weeks and one year after the operation. Patients also completed the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement Survey (KOOS, JR), which measures overall knee health after TKA, at six weeks, twelve weeks, and one year postoperatively. At these same time intervals, patients rated their pain intensity via a numerical rating scale (NRS) and answered patient satisfaction questions.

Functional assessments of all patients were performed in the clinic by the physiotherapy team both preoperatively and six weeks postoperatively. These assessments assessed the patient’s knee flexion, knee extension, four-meter gait (4M), and start-and-go time (TUG). The TUG assesses the time it takes a patient to rise from a chair, walk three meters, turn around and return to a sitting position, and is correlated with short-term measures and long-term function following arthroplasty.

The study results were presented at the annual meeting of the American Academy of Orthopedic Surgeons in March. We found no significant difference between the OPT and VPT groups in:

  • VR-12 physical and mental component scores at 6 weeks, 12 weeks, and 1 year postoperatively
  • KOOS Jr, NRS Pain or patient satisfaction scores at 6 weeks, 12 weeks and 1 year postoperatively
  • In-person functional assessments at six weeks postoperative
    • TUG scores at 6 weeks (9.49 for the OPT group versus 9.85 for the VPT group; p=0.49)
    • 4-meter walk (1.13 for the OPT group versus 1.12 for the VPT group; p = 0.92)
    • Knee flexion (117.77 for the OPT group versus 117.79 for the VPT group; p=0.99)
    • Extension (0.51 for the OPT group versus 0.86 for the VPT group; p=0.29)

Additionally, patient-reported satisfaction rates with the overall experience of care were higher for the VPT cohort. This may be due to the significant savings in time and money associated with performing physical therapy at home. On average, patients in the OPT cohort attended 11.6 physical therapy sessions, which cost an average of $15.05 in co-payment and required an average of 11.5 minutes of travel time per visit.

Offering greater convenience, lower costs and similar results

Discovering that a well-researched, evidence-based virtual physiotherapy program produces the same functional and patient-reported outcomes as outpatient physiotherapy, even for outpatient TKA procedures, is a game-changer.

As healthcare systems begin to incorporate virtual therapy programs into their orthopedic care protocols, it’s important to remember that one size does not fit all. Each individual’s plan of care should be tailored to their situation, clinical status and preferences. Successful orthopedic practices will need to offer a variety of rehabilitation options.

In our study, we had a small minority of clinical crossovers from the VPT cohort to the OPT cohort. Further research is needed to determine if predictors can identify patients who would be better served by outpatient physiotherapy. For example, functional considerations may include history of falls, need for mobility aids, or objective gait assessment performance. Other considerations might include computer literacy and the presence of a strong home support system.

Throughout the study, we found that the direct messaging component of our care management platform provided a critical communication channel, especially for patients in the VPT group who were not seeing a physical therapist in person. When patients know they will receive a timely response, they are less likely to seek help through the ER or urgent care. Research shows that providing a care management platform with direct messaging decreases readmission rates in all musculoskeletal procedures.

Within our healthcare system, this study demonstrated that virtual physiotherapy is the way of the future for the majority of patients. Changing the recovery paradigm to embrace remote rehabilitation has multiple benefits without compromising clinical outcomes.

Photo: Liubomyr Vorona, Getty Images