Evaluation of a Virtual, Comprehensive Care Program Before and After Total Hip and Knee Arthroplasty

This study will assess the outcomes of an integrated program of patient education and exercise before and after total hip or knee arthroplasty. The program will be home-based and remote-monitored, but will include physiotherapy-led home visits, telehealth consultations and tele-messaging. A program of specific muscle strengthening exercises and cycle ergometry will focus on muscle power as the therapeutic target. The custom-built cycle ergometer and supporting digital application (App) is the 'device' being evaluated in this study. The cycling program will be fully measured (power output and workout adherence) and adjusted based on patient performance and feedback obtained via remote monitoring. Outcomes of the pre-operative phase and early post-operative recovery will be the focus of the study. The pre-operative phase commences 4 weeks before surgery, and post-operative phase starts immediately after surgery until 6 weeks post-surgery. Commencement of post-operative cycle workouts may vary depending on the patients capacity to use the ergometer. Specifically, the interventions will include: 1. Patient Education – Patient education booklet which has been developed by the hospital in which patients have their surgery, summarises preparation for surgery, surgery and hospital stay information, and advice on early management at home 2. Exercise program – Guideline-based exercises with an emphasis on range of motion, muscle function and gait re-education as outlined in previous joint arthroplasty studies (Sattler et al 2019). These exercises will be completed at two times each day - usually morning and afternoon. The exercises and repetitions will be standardised for all patients, but modifications may be recommended by the physiotherapist as needed. Exercises will include active range of motion, isometric muscle strengthening (quadriceps and gluteal), dynamic strengthening (1/4 squats, quadriceps in sitting) and muscle stretching (calf and hamstring). Adherence to this part of the exercise program will not be measured specifically but will be monitored by the physiotherapist and patients encouraged to complete the exercises as prescribed 3. Cycle ergometer exercise with measured muscle power and patient feedback. Remote monitoring of muscle power (average and maximum) is obtained for each cycle exercise session from power meters in the cycle pedal cranks. Power data is transferred to a digital application so that it can be viewed by the clinical team on a computer portal. Patient feedback for each ride (pain intensity and effort - 0 to 10 scale) is also transferred to the clinician portal. Modifications to the exercise program are based on both power output and patient feedback, with changes to the prescribed ergometer workouts (workout duration, intensity, workouts per day) being directed by the physiotherapist. The timing of the exercises and cycle workouts will be recommended by the physiotherapist, and may vary between patients. 4. Tele-messaging – patient guidance and support via the digital application messaging system. Messages can be sent to the clinical team at any time if non-urgent assistance is needed or patients have a question related to their exercise or cycling program 5. Home visits from a physiotherapist (approx 1 hour duration) - patient education, exercise prescription, cycle ergometer set-up and education and completing outcome measures. Home visits are scheduled for week 1 (pre-operative) and weeks 1, 4 and 6 post-operative. Patient education will be delivered with reference to the patient information booklet outlined above. Exercises will be demonstrated and corrected by the physiotherapist, in addition to orientation to the cycle ergometer. 6. Physiotherapy telehealth consultations – these will be conducted in weeks 1, 3 and 5 in the post-operative recovery phase. Consultations will review patient progress with the exercise and cycling program and assist with any problems related to the rehabilitation program or recovery more broadly. The duration of the consultation will be between 20 and 30 minutes. 7. Mobility equipment – provision and education in safe use of walking aids, specifically elbow crutches, will be conducted in the first home visit and reviewed prior to discharge from hospital, and in the initial post-operative home visit.