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Telerehabilitation can contribute to the maintenance of successful rehabilitation regardless of location and time. The aim of this study was to investigate a specific three-month interactive telerehabilitation routine regarding its effectiveness in assisting patients with physical functionality and with returning to work compared to typical aftercare.
The aim of the study was to investigate a specific three-month interactive telerehabilitation with regard to effectiveness in functioning and return to work compared to usual aftercare.
From August 2016 to December 2017, 111 patients (mean 54.9 years old; SD 6.8; 54.3% female) with hip or knee replacement were enrolled in the randomized controlled trial. At discharge from inpatient rehabilitation and after three months, their distance in the 6-minute walk test was assessed as the primary endpoint. Other functional parameters, including health related quality of life, pain, and time to return to work, were secondary endpoints.
Patients in the intervention group performed telerehabilitation for an average of 55.0 minutes (SD 9.2) per week. Adherence was high, at over 75%, until the 7th week of the three-month intervention phase. Almost all the patients and therapists used the communication options. Both the intervention group (average difference 88.3 m; SD 57.7;
The effect of the investigated telerehabilitation therapy in patients following knee or hip replacement was equivalent to the usual aftercare in terms of functional testing, quality of life, and pain. Since a significantly higher return-to-work rate could be achieved, this therapy might be a promising supplement to established aftercare.
German Clinical Trials Register DRKS00010009; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010009
According to data from the Organization for Economic Cooperation and Development (OECD), 299 total hip and 206 total knee replacements were performed per 100,000 people in Germany in 2015. With these numbers, Germany ranks second (hip) and fourth (knee) in the world [
After an orthopedic procedure, rehabilitation as a multidisciplinary approach can improve the function of the joints and the ability to maintain a normal daily life, as well as relieve a patient’s pain [
In Germany, patients are offered numerous aftercare options, such as the multimodal intensified program (IRENA) or training rehabilitation aftercare (T‑RENA), but only about half of eligible patients take advantage of them [
In this regard, telerehabilitation seems to be the obvious choice since it can be performed irrespective of location and time, and it has the potential to increase both utilization and therapy adherence. The current telerehabilitation offerings should be adapted to the individual and indication‑specific needs of the patients and should enable contact with the supervising therapists. However, this could not be investigated with the currently available systems, as they are either not specific enough for the indications of a patient or do not offer a tool to communicate with a therapist [
Hence, the MeineReha system [
The aim of this randomized controlled trial was to examine previously developed telerehabilitation therapy in terms of its functional parameters, quality of life, and pain relief, as well as time to return to work, compared to usual aftercare programs.
From August 2016 to December 2017, after a screening of 476 patients in three inpatient rehabilitation centers, 111 patients were included in the randomized controlled trial (
Consolidated Standards of Reporting Trials flow chart for the inclusion process.
Following three weeks of inpatient rehabilitation, the patients assigned to the IG performed a three-month, home-based telerehabilitation program based on the MeineReha system, which consisted of a home component as well as a working portal for the therapist in the clinic. The main component, from the patient's perspective, was the MeineReha application that was installed on the rehab box at home. The rehab box (minicomputer with internet access) was connected to the usual peripherals (mouse and keyboard) as well as to a screen and Kinect sensor (camera) (
Hardware of the telerehabilitation system and an example exercise demonstrated by a virtual avatar.
The exercises to build up strength and improve postural control were chosen by the supervising therapist from a previously developed exercise catalog. The training intensity was individualized in terms of the choice of exercises, the number of sets and repetitions, and the duration of the breaks, which could all be adjusted by the therapist. Patients were asked to perform the training three times a week. There were different options for the patient and the therapist to communicate with each other: (1) the patient could record and send audio messages to their therapist whenever they wanted and the therapist was able to listen to it whenever their schedule gave them time to do it; (2) the therapist could respond or start a conversation with their patient at any time with individualized text messages, which the patient was shown whenever they started the system (eg, therapists could either remind the patient to do their exercises more often or just ask them about their condition); and (3) the patient and the therapist were able to make appointments for live video conferences, which they were supposed to conduct on a weekly basis to perform individual training consultation or to allow for the patient to ask questions about their training.
During the training, the exercises were demonstrated on screen by an avatar (
Real-time feedback during an exercise.
Patients in the control group did not receive any study-specific therapy after their inpatient rehabilitation. The follow-up was carried out identically to the IG three months after randomization. The patients of both groups were also offered the usual aftercare, that is IRENA and physiotherapy.
To verify the patients’ adherence, the process data for the IG (ie, frequency and duration of training, use of communication options) were read from the system. In addition, the frequency and duration of training and the use of other aftercare therapies were recorded by all patients in their training diaries. Further, all patients were investigated for functional parameters (eg, the 6-minute walk test, the Stair Ascend test, the Five-Times-Chair-Rise test, and the Timed-Up-and-Go test) at the study site (University of Potsdam) after the inpatient rehabilitation. Further, subjective parameters such as the Short Form Health Survey-36 (SF-36) on health-related quality of life, pain on the operated joint, stiffness, and function were assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC), with a patient’s ability to return to work also being assessed. In addition, patient characteristics, comorbidities, and medications were documented. The investigations were repeated after three-months follow-up. In terms of acceptance, we collected data from the IG using the Telehealth Usability Questionnaire (TUQ), including the concepts ease of use, learnability, satisfaction, future use, and reliability, on a 7-point Likert scale, with a 1 meaning disagree and a 7 meaning agree. To achieve comparability of the scales, we normalized the results as a quotient of the sum of the raw values and the total number of items, multiplied by a factor of 100.
The statistical analyses were conducted according to the description in the previously published study protocol [
At baseline, data from 87 patients from the IG (n=48) and the CG (n=37) (
According to the self-reported exercise diary, the patients in the IG performed their telerehabilitation an average of 55.0 minutes (SD 9.2) per week. The data read from the system showed a training duration of 39.0 minutes (SD 8.0). The participation rate was over 75% until the 7th week of the three-month intervention phase, but afterwards it decreased in parallel to the return to work (
Patient characteristics (n=87).
Characteristics | Control group (n=39) | Intervention group (n=48) | Total cohort (n=87) | |||
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Age (years), mean (SD) | 56.8 (5.7) | 53.3 (7.0) | 54.9 (6.7) | .012 | |
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Sex (female), n (%) | 19 (48.7) | 26 (54.2) | 45 (51.7) | .61 | |
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Normal weight: 18.5–<25, n (%) | 5 (12.8) | 8 (16.7) | 13 (14.9) | .86 |
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Overweight: 25–<30, n (%) | 17 (43.6) | 19 (39.6) | 36 (41.4) | —b |
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Obesity: ≥30, n (%) | 17 (43.6) | 21 (43.8) | 38 (43.7) | — |
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Smoking behavior (smoker), n (%) | 10 (25.6) | 13 (27.1) | 23 (26.4) | .88 | |
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Time from surgery to admission of inpatient rehabilitation (days), mean (SD) | 18.4 (8.8) | 18.8 (12.9) | 18.6 (11.3) | .61 | |
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Time of inpatient rehabilitation (days), mean (SD) | 23.3 (3.7) | 23.3 (3.5) | 23.3 (3.5) | .77 | |
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Time from surgery to baseline investigation (days), mean (SD) | 50.4 (11.6) | 46.9 (14.1) | 48.4 (13.1) | .11 | |
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Less than general or subject-linked higher education entrance qualification | 21 (53.8) | 27 (56.3) | 48 (55.2) |
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General or subject-linked higher education entrance qualification | 18 (46.2) | 21 (43.8) | 39 (44.8) |
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Less than polytechnic or university degree | 19 (48.7) | 30 (62.5) | 49 (56.3) |
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Polytechnic or university degree | 20 (51.3) | 18 (37.5) | 38 (43.7) |
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Gainfully employed, n (%) | 34 (87.2) | 42 (87.5) | 76 (87.4) | .96 | |
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Unemployed, n (%) | 2 (5.1) | 2 (4.2) | 4 (4.6) | .83 | |
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Incapacity for work before surgery (days), mean (SD) | 16.6 (49.9) | 21.3 (47.3) | 19.2 (48.2) | .27 | |
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Work intensity (moderate/severe), n (%) | 8 (20.5) | 9 (18.8) | 17 (19.5) | .84 |
aBMI: body mass index
bNot applicable
Utilization of telemedical assisted exercise therapy.
The patients in the IG could increase their 6-minute walking distance from an average of 440.6 (SD 78.2) to 530.4 meters (SD 79.0) (Difference [Delta]=88.3 m; SD 57.7 m;
Other functional parameters (eg, the Timed Up and Go Test, the Stair Ascend Test, and the Five Times Chair Rise Test) also showed similar improvements in both groups (
Functional und subjective parameters (n=87). All values presented as mean (SD).
Parameter | Baseline | Follow-up | Differences (Delta) | |||||
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IGa | CGb | IG | CG | IG | CG | ||
6-minute walk test (m) | 440.6 (78.2) | 433.3 (80.2) | .90 | 530.4 (79.0) | 513.0 (70.6) | .43 | 88.3 (57.7) | 79.6 (48.7) |
Stair Ascend Test (s) | 8.7 (2.7) | 8.6 (4.0) | .33 | 6.2 (1.2) | 6.1 (1.5) | .44 | –2.5 (2.4) | –2.5 (3.0) |
Timed Up and Go Test (s) | 9.3 (1.8) | 9.0 (2.4) | .16 | 7.5 (1.2) | 7.5 (1.6) | .93 | –1.9 (1.5) | –1.5 (2.2) |
Five Times Chair Rise Test (s) | 16.9 (3.7) | 17.1 (6.2) | .38 | 14.2 (2.7) | 13.2 (2.3) | .06 | –2.7 (3.5) | –3.8 (5.1) |
SF-36c PCSd | 33.8 (7.6) | 33.3 (7.9) | .82 | 44.6 (9.9) | 44.4 (8.3) | .80 | 10.7 (10.4) | 11.1 (7.2) |
SF-36 MCSe | 54.8 (10.6) | 53.9 (11.8) | .98 | 52.4 (10.6) | 54.1 (9.8) | .28 | –2.5 (12.4) | 0.1 (8.5) |
WOMACf Index | 26.4 (18.5) | 24.8 (16.4) | .78 | 11.5 (12.7) | 13.9 (14.3) | .51 | –14.9 (13.6) | –10.9 (13.5) |
aIG: intervention group
bCG: control group
cSF-36: Short Form Health Survey-36
dPCS: physical component scale
eMCS: mental component scale
fWOMAC: Western Ontario and McMaster Universities Osteoarthritis Index
Differences in endpoints between intervention and control group, multiple adjusted. SF: Short Form Health Survey; PCS: physical component scale; MCS: mental component scale; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index.
Regarding the health-related quality of life on the SF-36, an improvement in the physical component scale (PCS) was achieved in both groups. Furthermore, the WOMAC Index showed a significant reduction in both groups (
In terms of acceptance of the TUQ, the patients of the IG showed high consent in the normalized values of the scales of ease of use and learnability (mean 85.2; SD 2.9) as well as in satisfaction and future use (mean 79.8; SD 3.2), whereas the values of the reliability scale were lower (mean 51.8; SD 3.7).
In short, the use of telerehabilitation with patients having just undergone knee or hip replacements was equivalent to the usual aftercare in terms of the difference achieved in the 6-minute walk test. In addition, equivalent increases in both groups were demonstrated as secondary endpoints for functional mobility, health-related quality of life, and joint-related complaints. However, the patients in the intervention group were employed at a significantly higher rate at the end of the intervention.
The patients in the intervention group intensively used the telerehabilitation as a complementary aftercare option for a prolonged period of the study. The difference between the training durations given by the patient and those read out of the system can be explained by the preparation and cool-down times of the exercises, since only the exact execution time of the exercises was measured in the system. Likewise, the communication possibilities of the system, in terms of using text and voice messages, were exhausted. It is self-evident that the need for close contact with the therapist diminishes over a longer period, because the patients eventually either returned to work or all their questions about the system and training had already been answered.
The usual aftercare treatment was also used extensively by the patients in both groups. The participation rate of the control group (51%) in the IRENA aftercare program was comparable to the participation rate (50%) for the medical rehabilitation aftercare (MERENA) program in patients with chronic back pain [
During the three-month investigation phase, a significant increase in the 6-minute walking distance was recorded in both groups. For the population of knee and hip replacement patients, an improvement of 50-60 meters in the 6-minute walk test is considered clinically relevant [
Consistent with the results of the 6-minute walking test, further functional mobility tests with significant improvements in both groups demonstrated the equivalence of the telerehabilitation. In the Five Times Chair Rise Test, the control group had a statistically significant and higher improvement, however, the difference between the groups was significantly below the clinically relevant value of 2.5 seconds [
As for the WOMAC Index, values below 29.5 points are considered a treatment success for patients after a knee replacement [
For health-related quality of life, both groups achieved a significant increase on the physical component scale during the study phase. Against the background of the mainly physically oriented aftercare programs, this enhancement seems reasonable. However, despite the improvement, at the end of the intervention patients were slightly below the age‑related normative values of 47-49 points, with an average of 44 points [
Although most of the investigated endpoints did not show the superiority of the telerehabilitation, a significantly higher proportion of the IG returned to work at the end of the three-month study period. However, this fact cannot be explained by improved physical performance, quality of life, or reduced joint‑related complaints of the intervention group. It remains to be discussed whether the possibility of performing telerehabilitation regardless of time and place could have led to an earlier return to work by the IG. In addition, the high dropout rate of the control group (29.1%; 11/39) compared to the intervention group (14.1%; 7/48) should also be considered. Given the route to the study site, as well as the time of about two hours required for each baseline and follow-up investigation, there exists the possibility that the CG patients who returned to work were no longer willing to participate in the study.
In the investigated sample, an above-average education level can be ascertained (43.5% with a polytechnic or university degree). Data from the Employment Agency in Germany shows that, in the total population, only 20% of gainfully employed individuals have a polytechnic or university degree [
Another limitation of the study design is the lack of blinding of study participants and investigators. As a result, this is a possible influence on the participants during the investigations that cannot be excluded. It is known that nonblinded studies can demonstrate greater intervention effects than blinded ones [
All patients underwent inpatient rehabilitation and aftercare treatment. It is not possible to determine which improvements can be directly traced back to the effect of telerehabilitation, as due to ethical reasons the usual aftercare programs in this study were not replaced but instead complemented by the new approach.
The investigated telerehabilitation for patients having undergone knee or hip replacement was equivalent to the usual aftercare treatments in terms of improvements in the 6-minute walk test and in other functional parameters. However, at the end of the intervention, patients in the intervention group returned to work at a significantly higher rate. These results suggest that the system is complementary to the established aftercare programs in Germany (eg, IRENA or T-RENA), especially in infrastructurally weak areas.
CONSORT-EHEALTH checklist (V 1.6.2).
analysis of covariance
body mass index
control group
High Definition Multimedia Interface
intervention group
multimodal intensified aftercare
medical rehabilitation aftercare
Organization for Economic Cooperation and Development
physical component scale
Short Form Health Survey-36
training rehabilitation aftercare
Telehealth Usability Questionnaire
Western Ontario and McMaster Universities Arthritis Index
The study was funded by the German Pension Insurance Berlin-Brandenburg (grant number 10-40.07.05.07.007). We acknowledge the support of the Deutsche Forschungsgemeinschaft and Open Access Publishing Fund of University of Potsdam.
None declared.