Patients Use – and Like – Telerehabilitation After Total Joint Arthroplasty

    With the introduction of commercial and Medicare bundled payment models for total joint arthroplasty, surgeons have become more attuned to the cost of every aspect of managing a joint replacement patient throughout the episode of care – including the costly post-acute rehabilitation phase.

    The realization that a patient’s participation in outpatient or home-based rehabilitation represents a significant expense has pushed surgeons to look for alternatives that save money without sacrificing patient outcomes. A study from Yale University School of Medicine has shown that tele-rehabilitation may be one such alternative.

    In a study presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, the Yale researchers showed that the use of telerehabilitation following total hip and knee arthroplasty lowers costs, increases patient compliance with rehabilitation exercises, and leads to high patient satisfaction.

    The study included 40 patients who had undergone total hip arthroplasty (THA) or total knee arthroplasty (TKA) and who were enrolled in the telerehabilitation program following surgery. Only patients who could ambulate with an assistive device were offered the opportunity to participate this program. Patients did daily exercises at home with an animated avatar (VERA; Reflexion Health, San Diego, California) and had 4 to 6 face-to-face physical therapy sessions. Compliance, accuracy, functional outcomes, and satisfaction rates were recorded via the device set up in the patient’s home.

    “One of the strengths of this system is that you actually know if the patient is doing therapy,” said Mary I. O’Connor, MD, FAOA, FAAHKS, FAAOS, director of the Center for Musculoskeletal Care and professor of orthopaedics and rehabilitation at Yale School of Medicine. “Unlike before, I know if a patient has logged on and done their exercises.

    “Another nice feature is that the physical therapist can interact live with the patient. It is another opportunity to have a higher-quality touchpoint with the patient without the patient having to come into the office.”

    Outcomes for the telerehabilitation patients were compared with outcomes of 614 patients who were discharged to home and who underwent home or outpatient physical therapy following THA or TKA. Readmission rates at 30 and 90 days were not significantly different for the telerehabilitation group compared with the traditional therapy group (30 days, 2.5% vs. 4.2%; 90 days, 2.5% vs. 5.7%). There was a near identical rate of emergency department visits at 90 days (telerehabilitation, 10%; traditional therapy, 9.8%).

    Among the research findings:

    • Patients had high rates of accuracy in performing exercises: 93% for the TKA group and 90% for the THA group.
    • The TKA group averaged a total of 24 minutes of exercise per day, compared with 12 minutes per day for the THA group.
    • None of the TKA telerehabilitation patients required manipulation for knee stiffness.
    • Patient satisfaction with the program was very high, with an approval score of 91.2%.
    • Cost analysis showed a minimum cost savings of $1,000 per patient when telerehabilitation was utilized.

    “Physical therapy with a physical therapist is a resource-heavy model,” Dr. O’Connor said. “Any time you involve a skilled professional, as a physical therapist is, it is going to increase your cost. When the patient can do routine exercises on their own with guidance and support through telerehabilitation, you are going to lower your cost. It doesn’t eliminate the need for skilled physical therapist, but it is an extender of physical therapy.

    “We have been very pleased with our experience to date, particularly the very high level of patient satisfaction. An elderly knee replacement patient of mine told me how much she loved VERA. I asked her why and her response surprised me. She said: ‘Dr. O’Connor, I don’t have to make sure my house is clean, or my hair is done and I have makeup on as when the physical therapist comes to the house. I can do my exercises in my housecoat.’”

    VERA is a digital therapy platform that includes:

    • A broad menu of prescription rehabilitation exercises
    • An animated avatar coach
    • A 3D imaging system for measuring movement and form
    • Functional assessments
    • An intuitive dashboard for remote clinical review
    • Automatic report generation
    • Telemedicine capability to deliver the home-based rehabilitation experience.

    Patients do not need to apply or wear any sensors or monitoring devices when using VERA.


    O’Connor MI, Moore AR, Rubin LE. Tele-Rehabilitation for Total Hip and Knee Arthroplasty Patients: No Increase in Readmissions (Paper 850). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.