A Chatbot Can Improve Mental and Physical Health When TJA Is Delayed

    Unanticipated delays in elective hip or knee arthroplasty – as in the delays associated with the COVID-19 pandemic – can cause mental and physical decline as patients struggle with ongoing pain and dysfunction and the uncertainty around when they will be able to undergo surgery.

    A paper recently published online ahead of print by the Journal of Arthroplasty shows that use of automated mobile phone messaging robots – known as chatbots – can support these patients by delivering encouraging messages that can not only boost patients’ mental health, but that can also benefit their physical health.

    “We think it is very significant that we saw benefits in both mental and physical health,” said the study’s lead author, Christopher Anthony, MD, Associate Director of Hip Preservation at Penn Medicine and an Assistant Professor of Orthopaedic Surgery in the Perelman School of Medicine at the University of Pennsylvania.

    “This demonstrates the importance of the relatively unexplored area between a patient’s psychological well-being and their joint function.”

    Focus on Patients’ Health Goals

    Amid the COVID-19 pandemic, especially in its early stages, elective surgeries at hospitals across the US were postponed as surges in the virus strained hospital resources. Among the elective surgeries that were delayed were total hip and total knee procedures.

    Dr. Anthony had experience with using chatbots to deliver targeted messaging to patients, and he and his study co-authors wanted to determine if this technique could help patients affected by pandemic-related delays manage their pain and remain positive.

    Their study included 90 patients whose total hip and total knee procedures had been postponed indefinitely due to the COVID-19 pandemic. They randomized these patients into 2 groups: a treatment group that would receive texts from the chatbot twice a day (morning and evening) for 14 days and a control group that would not receive the texts or any other communications from their surgeons.

    The automated chatbot system is based on the psychotherapeutic concept, Acceptance and Commitment Therapy, which emphasizes the patient’s own goals for themselves and their health while directly addressing feelings of pain or disappointment. For example, 1 message said, in part, “If you are experiencing some pain today, we encourage you to acknowledge it and then turn your focus to the things in your life that matter most to you.”

    Better Mental and Physical Health

    The researchers used validated questionnaires to collect patient-reported outcomes and assess patients’ mental and physical status before and after the 14-day study period, including:

    • Patient-Reported Outcome Measure Information System (PROMIS) Global Health 10 Short Form with Mental Health (PROMIS MH) and Physical Health (PROMIS PH) component summary scores
    • PROMIS Pain Intensity 3A Short Form
    • PROMIS Pain Interference 8A Short Form
    • PROMIS Emotional Distress – Anxiety 8A Short Form
    • Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) or Knee Disability and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR), depending on which procedure was delayed

    Overall, patients enrolled in the text messaging system scored better on all measured outcomes except anxiety, for which neither group showed improvement.

    Among the mental health measures:

    • 31% of patients who received texts experienced clinically significant improvement on the PROMIS MH, compared with 25% of those in the control group
    • 16% of patients in the texting program experienced a decline in mental health while their surgery was delayed, compared with 32.5% in the control group

    But the benefits of the texting program appeared to extend beyond mental health into physical health, with the researchers reporting that:

    • 38% of patient who received texts had improved physical health (PROMIS PH) over the study period, compared with 17.5% of those in the control group
    • 24% of patients who received texts had significant improvement in their joint health (18% for HOOS JR and 29% for KOOS JR), compared with only 2.5% of those in the control group

    In addition, patients could request more text messages after the initial text, and the researchers found that 29% of participants did so on at least 1 study day.

    Application to Future Crises

    The texting program used in the study was the same one that Dr. Anthony had previously used to carefully decrease the number of prescription opioid pills taken by his joint arthroplasty patients following surgery. That effort was shown to result in a third fewer opioids being used.

    With the evidence he’s gathered across these studies, Dr. Anthony believes that a program like this could have significant benefits in future crises.

    “We would like to see our methods utilized by others and implemented in practice given the ongoing pandemic needs,” Dr. Anthony said. “We really think this could help some people.”


    Anthony CA, Rojas E, Glass N, et al. A psychological intervention delivered by automated mobile phone messaging stabilized hip and knee function during the COVID-19 pandemic: a randomized controlled trial. J Arthroplasty. 2021 Dec 11;S0883-5403(21)00941-4. doi: 10.1016/j.arth.2021.12.006. Online ahead of print.