Patient perspectives and numerical evaluation of a COVID secure hybrid rehabilitation programme following knee replacement surgery

Abstract

Keywords: Rehabilitation; COVID; Knee Purpose: COVID19 caused significant disruption to healthcare services. However, some elective knee replacement surgery continued. Recent meta-analyses demonstrated the clinical and cost effectiveness of rehabilitation following knee replacement surgery for short term physical function, pain, and range of movement (Fatoye et al., 2021) . This necessitated the development of novel methods for the delivery of COVID compliant rehabilitation. To meet this need we adopted a hybrid model (virtual consultations + pre-recorded rehabilitation content). We report the mixed methods service evaluation. Methods: All patients referred to physiotherapy following knee replacement surgery (total or unilateral) (n = 64) were contacted to establish clinical and technical suitability (adequate English language and absence of red flags). Eligible patients were given the opportunity to enrol in the hybrid programme comprising virtual consultations (attend anywhere) + unrestricted access to pre-recorded video rehabilitation (progressive home exercises, expert patient content, and recovery advice) or continue with COVID modified ‘usual care’ (telephone advice). Those enrolled in the hybrid service (n = 46) were invited to provide data (baseline, 3 months), Oxford knee score (0–48), VAS pain (0–10), sit to stand 30 (repetitions), range of movement (degrees), and self reported maximum walking duration (minutes). Pre and post intervention numerical scores (mean ± SD) are presented and compared with historical data. At 6 weeks patients were invited to provide feedback in response to a pre-planned topic guide. Qualitative data were analysed thematically (Braun and Clarke, 2006). Results: Qualitative analyses generated three themes (sub-themes), 1-Valued content (therapist and information content), 2-Covid context, and 3-Percieved barriers (logistical and clinical uncertainty). Patients valued empathetic communication, condition/person-specific support, motivation, and expert guidance. The pre-recorded programme was considered advantageous in relation to ease of access. Patients expressed contextual understanding for the provision of a remote programme. Perceived barriers included administrative delays and connectivity for virtual consultations. Concerns regarding the virtual assessment of joint swelling, wounds, and gait generated perceptions of clinical uncertainty. Mean change from baseline (±SD) showed improvements across the Oxford knee score −16.3 (6.61), VAS pain −2.48(2.23), sit to stand 5.1 (4.31), range of movement (results) and self reported walking distance 20 (17.34). These results were compared with historical data and did not show any clinically important functional difference (historical mean −14.03 (8.03) v mean hybrid −16.3 (6.61). Conclusion(s): The hybrid approach appeared feasible for delivery in this setting. Patient feedback identified valued programme aspects and areas for potential refinement. This approach preserved COVID security. No adverse events were identified and limited numerical evaluation suggests comparable outcomes with our previous programme. Some patients expressed uncertainty regarding the lack of face-to-face contact but these reports originated from patients who had previously undergone conventional rehabilitation (pre-covid). This clinical uncertainty regarding virtual consultations has been highlighted by others (Greenhalgh et al., 2020). Impact: It is envisaged that this hybrid model be retained for future refinement. Other services may wish to consider this model for future operational pressures or to extend the reach of rehabilitation provision. Funding acknowledgements: This work was not supported by funding.