Commentary on an article by Trevor G. Russell, MD, et al.: “Internet-Based Outpatient Telerehabilitation for Patients Following Total Knee Arthroplasty. A Randomized Controlled Trial”

This well-written article has important implications for a new model of health care that can be efficiently and inexpensively delivered to the community. The authors performed a single-blinded, prospective, randomized, controlled, noninferiority trial comparing physical therapy done in the conventional manner with an Internet-based telerehabilitation program. The trial was performed on patients following total knee arthroplasty, and the groups were compared with use of well-accepted primary and secondary outcome measures. Patients who have had a total knee replacement require more intense and more closely supervised physiotherapy than do patients following a total hip replacement. I think that this is well accepted by the orthopaedic community. Some patients have difficulty attending outpatient physical therapy because it is not available, is expensive, or is inaccessible to those who live in rural areas. The authors described an Internet-based technique that can overcome these problems in an extremely efficient and effective way. Their study demonstrated that the telerehabilitation method was not inferior to the conventional physical therapy session, in which the patients were supervised one on one in an outpatient physical therapy department. The paper has some weaknesses as the authors did not discuss the costs of the telerehabilitation method in comparison with the costs of conventional physical therapy. The other weakness of the paper is that the telerehabilitation method was carried out in a hospital setting that was trying to simulate a home environment, which was somewhat artificial. This also meant that the patients who participated in the telerehabilitation part of the study had to be completely compliant, whereas if they had been at home, compliance could not have been guaranteed. However, this was the trial arm of the study and it could not be effectively carried out in any other way. Another minor weakness in the study was that the authors included patients with unicompartmental knee replacement, which requires less vigorous physical therapy than a conventional total knee replacement. In addition, in the Results section, the authors did not state whether there were more unicompartmental knee replacements in one group than the other. Fortunately, the number of patients with a unicompartmental knee replacement was small compared with the number who had a total knee replacement. Other than these minor criticisms, the study was well carried out with sound methodology. This type of program has profound implications for the delivery of health care. Telemedicine programs exist in many of the medical and surgical specialties to provide outreach and deliver health care to remote areas. However, this study is, to my knowledge, the first attempt at delivering postoperative physical therapy by means of the Internet to patients who have had a knee replacement. This method would be much more efficient than conventional rehabilitation programs as one physical therapist could administer therapy to larger numbers of patients who do not have to leave their homes. The cost implications are obvious, and the improvement and availability of physical therapy are also important. In our community, patients who are discharged from the hospital to home receive physical therapy by means of home care on a limited basis as one therapist can see only one patient at a time. This is expensive, inefficient, and very limiting with regard to the numbers of patients who can be treated. Some of the advantages of the conventional physical therapy session are that the patient’s progress can be monitored by the therapist and patient compliance can be better assessed. However, with the use of webcam techniques such as Skype, it would be possible for the physical therapist and the patients who are receiving the telerehabilitation technique to have an equally close relationship vis-á-vis their progress. Other advantages of the use of Skype include its ability to allow patients to ask questions and demonstrate their knee range of motion and muscle strength. I think that the Internet-based telerehabilitation program described in this article has important implications for the delivery of one aspect of health care that is crucial following knee replacement. The program also has the potential for use in preoperative physical therapy, which could include a video presentation by a surgeon or a physical therapist to explain the entire course of the surgical procedure, thus increasing surgeon efficiency during preoperative consultations. This would allow the patients to formulate questions for the surgeon and the physical therapist when they have their one-on-one visit. The advantages with regard to expense, efficiency, and the delivery of health care to patients in remote areas and to patients who may have financial hardship are obvious. I think the authors should be complimented on this trial, and the next step would be to conduct the trial in a more realistic situation, in which the telerehabilitation is delivered into the home. I think that many insurance companies and health-care providers would be interested in this type of methodology.

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