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Shop Talk: Telerehab Part 2

December 8, 2020 • Research • Sheila Schindler-Ivens

Shop Talk is a newsletter published by The Evidence Workshop, LLC.  It helps clinicians integrate the best, available research evidence into front-line practice. 

Welcome to Part 2 of our miniseries on telerehabilitation for musculoskeletal disorders. Today we’ll take a look at telerehab after total knee arthroplasty (TKA). For the non-PTs in the bunch, TKA is a fancy term for knee replacement surgery. You know, the surgery your mom, dad, or uncle had when their arthritis became too painful to bear.

Using the Turolla et al. report from PTJ as a guide, we identified 5 systematic reviews or meta-analyses citing 13 papers on telerehab after TKA. All 5 systematic reviews concluded that telerehab provides similar or superior outcomes to face-to-face care. The most compelling evidence comes from a 2015 randomized controlled trial (RCT) by Moffet et al.The study was a noninferiority RCT designed to examine whether in-home telerehab is inferior to in-home, face-to-face care. With a PEDro score of 8/10, confounding factors were tightly controlled. Points lost on the PEDro score were unavoidable because it’s impossible to blindpatients and therapists as to whether they are doing tele- or in-person rehab. Results strongly suggest that telerehab after TKA is not inferior to face-to-face care. The outcomes examined were numerous and included range of motion, strength, pain, stiffness, endurance, stair climbing, function, and quality of life. Measurements were made immediately after a 2-month bout of therapy and 2 months after formal therapy ended.

The remaining 12 papers comprise other RCTs, single-arm trials of telerehab only, retrospective chart reviews, and preliminary studies. These papers also suggest that remote delivery of rehab after TKA will not compromise outcomes. But none are as well controlled or relevant to real-life telerehab as the Moffet trial.

What’s the upshot?

If you are worried that remote delivery of rehab after TKA will compromise your patients’ recovery, the Moffet work should ease your mind. But, before you shudder your clinic and upgrade your webcam, be sure to look closely at the Moffet protocol and the characteristics of their participants. If your intervention or patient population is substantially different from theirs, results may not generalize to your practice.

Thanks for reading today.  If you want to examine this topic more closely, check out the materials below. If you like what we’re doing, forward this blog to a friend and consider supporting our work at https://www.buymeacoffee.com/ptworkshop.

Until next time, be well.

Additional Resources

Learn more about the PEDro scoring system here.

Read the Moffet RCT

  • In-Home Telerehabilitation Compared with Face-to-Face Rehabilitation After Total Knee Arthroplasty: A Noninferiority Randomized Controlled Trial. Moffet H, Tousignant M, Nadeau S, Mérette C, Boissy P, Corriveau H, Marquis F, Cabana F, Ranger P, Belzile ÉL, Dimentberg R. J Bone Joint Surg Am. 2015 Jul 15;97(14):1129-41. doi: 10.2106/JBJS.N.01066. PMID: 26178888.

Read the Turolla perspective from PTJ

  • Musculoskeletal Physical Therapy During the COVID-19 Pandemic:
    Is Telerehabilitation the Answer? Turolla A, Rossettini G, Viceconti A,
    Palese A, Geri T. Phys Ther. 2020 Aug 12;100(8):1260-1264. doi:
    10.1093/ptj/pzaa093. PMID: 32386218.

Systematic Reviews and Meta-Analyses

  1. Evidence of Benefit of Telerehabitation After Orthopedic Surgery: A Systematic Review. Pastora-Bernal JM, Martín-Valero R, Barón-López FJ, Estebanez-Pérez MJ. J Med Internet Res. 2017 Apr 28;19(4):e142. doi: 10.2196/jmir.6836. PMID: 28455277.
  2. Role of telerehabilitation in patients following total knee arthroplasty: Evidence from a systematic literature review and meta-analysis. Shukla H, Nair SR, Thakker D. J Telemed Telecare. 2017 Feb;23(2):339-346. doi: 10.1177/1357633X16628996. Epub 2016 Jul 9. PMID: 26843466.
  3. Rehabilitation protocols following total knee arthroplasty: a review of
    study designs and outcome measures. Dávila Castrodad IM, Recai TM, Abraham MM, Etcheson JI, Mohamed NS, Edalatpour A, Delanois RE.Ann Transl Med. 2019 Oct;7(Suppl 7):S255. doi: 10.21037/atm.2019.08.15. PMID: 31728379.
  4. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Cottrell MA, Galea OA, O'Leary SP, Hill AJ, Russell TG. Clin Rehabil. 2017 May;31(5):625-638. doi: 10.1177/0269215516645148. Epub 2016 May 2.PMID: 27141087.
  5. The comparison of telerehabilitation and face-to-face rehabilitation after total knee arthroplasty: A systematic review and meta-analysis. Jiang S, Xiang J, Gao X, Guo K, Liu B. J Telemed Telecare. 2018 May;24(4):257-262. doi: 10.1177/1357633X16686748. Epub 2016 Dec 27. PMID: 28027679.

Single Studies

  1. Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Kramer JF, Speechley M, Bourne R, Rorabeck C, Vaz M. Clin Orthop Relat Res. 2003 May;(410):225-34. doi: 10.1097/01.blo.0000063600.67412.11.PMID: 12771834.
  2. Computer-aided multimedia training in orthopedic rehabilitation. Eisermann U, Haase I, Kladny B. Am J Phys Med Rehabil. 2004 Sep;83(9):670-80. doi: 10.1097/01.phm.0000137307.44173.5d. PMID: 15314531.
  3. Effectiveness of telemedical applications in postoperative follow-up after total joint arthroplasty. Sharareh B, Schwarzkopf R. J Arthroplasty. 2014 May;29(5):918-922.e1. doi: 10.1016/j.arth.2013.09.019. Epub 2013 Dec 15. PMID: 24342278
  4. A randomized controlled trial of home telerehabilitation for post-knee arthroplasty. Tousignant M, Moffet H, Boissy P, Corriveau H, Cabana F, Marquis F. J Telemed Telecare. 2011;17(4):195-8. doi: 10.1258/jtt.2010.100602. Epub 2011 Mar 11. PMID: 21398389.
  5. Rehabilitation after total knee replacement via low-bandwidth telemedicine: the patient and therapist experience. Russell TG, Buttrum P, Wootton R, Jull GA. J Telemed Telecare. 2004;10 Suppl 1:85-7. doi: 10.1258/1357633042614384. PMID: 15603622
  6. Low-bandwidth telerehabilitation for patients who have undergone total knee replacement: preliminary results. Russell TG, Buttrum P, Wootton R, Jull GA. J Telemed Telecare. 2003;9 Suppl 2:S44-7. doi: 10.1258/135763303322596246. PMID: 14728759.
  7. Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. Russell TG, Buttrum P, Wootton R, Jull GA. J Bone Joint Surg Am. 2011 Jan 19;93(2):113-20. doi: 10.2106/JBJS.I.01375. PMID: 21248209.
  8. Interrater agreement between telerehabilitation and face-to-face clinical outcome measurements for total knee arthroplasty. Cabana F, Boissy P, Tousignant M, Moffet H, Corriveau H, Dumais R. Telemed J E Health. 2010 Apr;16(3):293-8. doi: 10.1089/tmj.2009.0106. PMID: 20406116
  9. Effectiveness of an interactive virtual telerehabilitation system in patients after total knee arthoplasty: a randomized controlled trial. Piqueras M, Marco E, Coll M, Escalada F, Ballester A, Cinca C, Belmonte R, Muniesa JM. J Rehabil Med. 2013 Apr;45(4):392-6. doi: 10.2340/16501977-1119. PMID: 23474735.
  10. Web-Based, Self-Directed Physical Therapy After Total Knee Arthroplasty Is Safe and Effective for Most, but Not All, Patients. Klement MR, Rondon AJ, McEntee RM, Greenky MR, Austin MS. J Arthroplasty. 2019 Jul;34(7S):S178-S182. doi: 10.1016/j.arth.2018.11.040. Epub 2018 Dec 3. PMID: 30591206
  11. Reply to Letter to the Editor on "Web-Based, Self-Directed Physical Therapy After Total Knee Arthroplasty Is Safe and Effective for Most, but Not All, Patients". Klement MR, Rondon AJ, McEntee RM, Greenky MR, Austin MS.J Arthroplasty. 2019 Aug;34(8):1859. doi: 10.1016/j.arth.2019.01.041. Epub 2019 Jan 24. PMID: 30770237.
  12. Use of Nintendo Wii Fit™ in the rehabilitation of outpatients following total knee replacement: a preliminary randomised controlled trial. Fung V, Ho A, Shaffer J, Chung E, Gomez M. Physiotherapy. 2012 Sep;98(3):183-8. doi: 10.1016/j.physio.2012.04.001. Epub 2012 Jul 10. PMID: 22898573.

Sheila Schindler-Ivens

Dr. Sheila Schindler-Ivens is a licensed physical therapist who earned her PhD in Rehabilitation Science from the University of Iowa and completed a postdoctoral fellowship at the Feinberg School of Medicine at Northwestern University. Dr. Schindler-Ivens joined the faculty in the Dept. of Physical Therapy at Marquette University in 2005. She directs an independent research...

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