RECOVERY APP- The use of a smartphone based application to improve and personalize preparation for and rehabilitation of patients undergoing knee replacement surgery; a feasibility and usability study.

The RECOVERY APP will guide participants: • With an animated surgeon which provides two separate voiced-animations (VA) that are designed to introduce participants to the both the prehabilitation and the rehabilitation programs. A component of the study is to evaluate if participants can successfully download the Recovery App, "onboard" and learn to use the App without the assistance of a health professional as this App is intended for use in both urban and rural settings. In this pilot study, participants will download the App at 4 weeks preoperatively. At the 3 week preoperative clinic visit at RNSH, one of the project team physiotherapists will assess the participants on how successfully they have learnt to use the App and also how well they are doing their exercises. • On a graded prehabilitation exercise program which will commence 4 weeks before total knee arthroplasty (TKA) surgery. The exercises used are the exercises that they will be expected to perform on the day of surgery, as soon as possible after they return to the ward. Participants will be expected to learn how to do the exercises from the VAs on the Recovery App and will not be given any assistance with this unless a request is made to the nominated orthopaedic registrar. At his/ her discretion, contact can be made with nominated physiotherapists at RNSH for further explanation or assistance. In addition participants will be supplied with crutches and instructed on their use with the assistance of a VA at their preoperative visit 3 weeks before surgery if they are deemed suitable at the time of assessment. Participants will be notified on the exercise screen how many repetitions are recommended by the physiotherapist and the participant will click on a numbers table which is a pop-up on the screen to indicate how many repetitions they achieved. Total time on prehabilitation exercises is expected to be 15-30 minutes twice per day for 4 weeks, in addition to tracking steps taken with a goal of graded increases in daily steps pre-operatively. • on the use of active pain management strategies (pacing, mental imagery, problem solving, managing pain flare-ups and applied relaxation) through a series of VA embedded in the APP. • functional data and scores on self report questionnaires will be displayed in tables or graphically • on a rehabilitation program which commences on the day of surgery and continues for 6 weeks. Rehabilitation exercises are expected to take 15-45 minutes, 3-4 times per day in addition to graded increase in daily steps taken (with reduction in gait aids as patient's balance and strength improves). After 6 weeks participants will not be guided on exercises but will be asked to complete the same questions. Any need for further exercise progressions will be according to usual care by physiotherapy and their surgeon. There will be a further completion at 12 weeks of the same battery of validated psychosocial questionnaires that were completed 4 times previously during the pilot study. The exercises used in this program are voiced animations of the exercises in the AdvaNSYD Pathway of the North Shore Local Health District New South Wales Australia (NSLHD) and the animations are also approved by our project team physiotherapists. Use of the APP will be monitored based on participant recording (or not) of number exercises completed, completion of questionnaires, APP analytics, steps taken recorded via accelerometer in phone (predicated on participants carrying phone) Exercises included: Prehabilitation phase- Static Quads, Heel slides, Bridges, Inner range Quadriceps, Sit to stand, Seated press-ups , Wall push ups, 1/4 squat at bar, Heel raises, Step up, Walking, Practice using crutches Rehabilitation phase- Ankle circles, Static Quads, Heel slides, Inner range Quadriceps, Sit to stand, Seated knee flexion, Heel raises, Walking (initially with assistive devices), Knee flexion/ lunges on step, Hamstring stretch, Heel raises, Calf stretch, Balance exercises: step stance, 1/4 squat at a bar. Stair climbing and descending, Prone knee flexion: hamstring curl, Prone quadriceps stretch, Prone knee extension The exercises included are a relatively low level of intensity when performed at low repetitions, the intensity is increased by increasing number of repetitions or number of sets of exercises. The AdvanSYD pathway is an initiative by the NSLHD which aims to deliver excellent care for patients requiring lower limb arthroplasty by providing appropriate, efficient, equitable care which aligns with evidence based practice. This is a district wide initiative with patients related goals of patients receiving appropriate, efficient and equitable care measured through: - Patient outcome measures are collected and evaluated; outcome measures are achieving state benchmarks. - Reduced variation in care processes. - Improved cost-effectiveness compared to state benchmarks. - Informed recommendation of appropriate strategy for prostheses management; prostheses use is cost effective and clinical outcomes are maintained. The processes used to achieve this are: 1. Providing a ‘Patient Roadmap’ that outlines appointment/steps a patient will take, and key messages e.g. that most patients return directly home 2. Patients attending a ‘Joint Class Education Session’ that reinforces these messages and allows an opportunity to answer questions. 3. A GP Letter is sent to GPs with the waitlist letter and given to patients at Joint Class 4. Anaesthesia and Analgesia Guidelines are distributed and followed as appropriate 5. A Protocol for the ‘Quickstep Group’ (Low risk patients) is followed, including: a. Surgeons liaise with Anaesthetists regarding intraoperative recommendations b. Surgeons direct patients to the Quickstep Protocol as appropriate, and orthopaedic ward staff follow the protocol as per role c. A ‘Patient Recovery Guide’ (a daily checklist) is given to patients to follow 6. A Discharge Path and Criteria including: a. Patients are discharged using the ‘criteria led discharge’ and discharge path, with reference to the Acute Post Acute Care Outline b. Patient follow-up and escalation is arranged as per protocol. Within the pathway, consensus recommendations for typical anesthetic/analgesic treatments and typical mobilization/ exercises have been developed.