Telerehabilitation Versus Clinic-Based Rehabilitation for Functional Recovery Following Primary Total Knee Arthroplasty

This randomised controlled, single-blinded, non-inferiority trial compared telehealth-delivered versus clinic-based (in-person) early-stage rehabilitation following primary total knee arthroplasty (TKA).

Following written informed consent and pre-operative baseline assessment, participants were randomised to either a Telerehabilitation or Clinic group using a computer-generated sequence, with allocation concealed by an independent researcher. The primary outcome assessor remained blinded to group allocation throughout the study.

Both groups received an identical rehabilitation protocol comprising nine supervised sessions delivered over a 6-week post-operative period (twice weekly for the first three weeks, followed by once weekly for a further three weeks), commencing 4-7 days after surgery. Each session lasted approximately 30 minutes and was delivered by Accredited Exercise Physiologists. Sessions addressed pain and swelling management, safe and progressive ambulation, activities of daily living, review and progression of a structured Home Exercise Program (HEP), and monitoring of knee range of motion.

The Clinic group attended sessions in person at a single private rehabilitation clinic. The Telerehabilitation group received the same sessions remotely via a telehealth platform (Coviu, Sydney, Australia). Both groups were provided the HEP through an online exercise-delivery platform (Physitrack, Physitrack Ltd., London, UK), which included video-based exercise demonstrations, adherence monitoring, and secure patient-provider messaging. HEP frequency and intensity were progressively modified over the 6-week program according to individual pain tolerance, knee range of motion progression, and treating therapist judgement.

Outcome assessments were conducted pre-operatively and at 7 weeks (following completion of the rehabilitation intervention), and at 6 and 12 months post-surgery. All in-person clinical assessments were conducted by a single therapist who remained blinded to group allocation.

The study hypothesis was that telerehabilitation would be non-inferior to clinic-based rehabilitation with respect to the primary outcome measure, with no clinically meaningful differences expected between groups in secondary patient-reported outcomes, active knee range of motion, or objective measures of lower-limb function.

Sample size was calculated to detect non-inferiority at the 7-week timepoint, using a non-inferiority margin of 10 points (based on the published minimal clinically important difference for the primary outcome measure), an assumed standard deviation of 12.5 points, an alpha level of 0.05, and 90% power. This yielded a requirement of 42 participants per group, increased to 54 per group (108 total) to allow for an anticipated 25% loss to follow-up. Both intention-to-treat and as-treated analyses were performed in accordance with CONSORT guidelines for non-inferiority trials.

Inclusion criteria

• undergoing primary elective TKA for the treatment of end stage knee OA
• ability to independently provide informed consent
• a willingness to attend all rehabilitation sessions and assessment time points, irrespective of the delivery

Exclusion criteria

• comorbidities preventing participation in rehabilitation (e.g., severe obstructive pulmonary disease, hemiplegia)
• revision TKA
• intra-operative complications precluding rehabilitation
• likely difficulties with follow-up
• inability to read or speak English
• unable to attend in person clinic visits due to travel distance
• unwillingness to comply with the rehabilitation protocol