Mental Health in a Workers’ Comp Injury: A Case Report
Introduction
Home exercise plans (HEP) are commonly prescribed after orthopedic injuries or surgeries. Studies have shown that these HEPs are important for full recovery and improved outcomes in various procedures. (1,2). However, in practice, poor HEP adherence has been shown to be common (3). In current practice, providers merely ask patients what exercises have been performed, which has been shown to be overestimated in diaries and with less than acceptable reliability (4). Even with regular physical rehabilitation visits to see a therapist, most of the rehabilitative program time is at-home, where non-adherence to prescribed at-home rehab exercises has been estimated to be as high as 70%(5).
Successful postoperative rehabilitation has been shown to lead to shorter hospital stays, fewer complications, reduced utilization of follow-up services, and improved patient pain, activity, and quality of life outcomes (6,7). Furthermore, pre-habilitation (pre-surgical) exercises performed prior to surgery have also been demonstrated to improve post-operative outcomes (8,9), reduce length of hospital stay (10), and even reduce pre-operative patient anxiety (11). More specifically, evidence supports improved immediate recovery after procedures such as Total Knee Arthroplasty (TKA) (12, 13).
Previous studies have shown progress after TKA and benefits from rehabilitation. A study (14) showed an average increase in ROM of 27% after two weeks and 50% after 6 weeks. Another study showed similar results with knee flexion ROM with unsupervised exercise compared to in person physical therapy (15).
In terms of pain, researchers tracked patient’s recovery after Total Knee Arthroplasty (TKA) in a study performed at Northwestern University (16). These patients received both inpatient (hospitalization) and outpatient physical therapy, and after one month, they reported an average pain of 3.68 when set on a 1-10 scale, with 44% of patients demonstrating a pain level of 4/10 or greater.
Complications are also a major problem after surgery and a cause for increased medical use and cost. Infections can result in further surgeries and a poor outcome (17). Another common complication after joint replacement surgery is the failure to regain range of motion. In these cases, a manipulation under anesthesia (MUA) is a common treatment (18), with a frequency between 0.5 and 10% (19). Aside from being another procedure, MUA after TKA is associated with worse outcomes, including an increased chance for future revision surgeries (20).
In this study, we compared outcomes after Total Knee Arthroplasty from one orthopedic practice. One group of these patients used the Recupe platform, created by Plethy. A mobile app guides patients through home exercises prescribed by their healthcare professional, in an unsupervised setting. The second group did not use Recupe. We compared the pain, range of motion, and the propensity for MUA between the Recupe group and the non-Recupe Group to see if the use of Recupe would result in a significant difference in outcomes.
Methods and Procedures Subject Selection
Chart review was performed on the EHR of Summit Orthopedics in California. A search was performed for all patients who had a TKA performed by searching for the CPT code for TKA, with 170 patients identified. The date range of this search was from 9/1/21 to 4/30/22. For patients using Recupe, patient engagement data was gathered from the Recupe database on these patients. The minimum use of Recupe was selected as three times per week for this study.
Three patients had TKAs on both knees. Each surgery was classified as a separate patient for this study. One patient had no data available and was removed. 13 subjects were eliminated due only performing Recupe prior to surgery. Finally, 20 subjects were eliminated because they used Recupe less than 3x per week.
The remaining patients were classified into two groups as follows:
41 patients in the Recupe group. Recupe use was on average 5.1 times per week. 95 patients in the non-Recupe group.
Intervention
One method to measure and ensure exercise adherence is through wearable tracking sensors. Plethy has this technology offered through their Recupe app and sensor. Along with adherence, it tracks pain, joint range of motion with exercises, red flag symptoms, patient engagement, and patient behavioral/sentiment. . This data is stored for patients using the Recupe mobile app. It supports surgical and non-surgical diagnoses, pre-surgical exercises, and enables remote monitoring and visibility to physical training sessions and care journey data. Patients and clinicians can receive objective, real-time feedback on performance, and have a record of the data from their exercise sessions. The data collected during patient rehabilitation include a broad range of data types including Patients in the Recupe group were trained in the use of the Recupe app and received weekly follow up and encouragement from coaches. Home exercise programs (HEP) were designed by doctors or physical therapists and coaches encouraged patients to adhere to their HEP.
Both the Recupe and Non-Recupe groups were prescribed outpatient physical therapy as well. However, our data did not give sufficient detail as to the frequency and use of these treatments.
Demographics
For the Recupe group, the average age of patients was 68.11 (sd 8.87). By gender, there were 57.14% male and 42.8% female.
For the non-Recupe group, the average age was 69.35 (sd 9.44) By gender, there were 58.95% male and 41.05% female.
Results
At all times, Recupe patients report lower pain than non-recupe patients.
Post-Op Pain:
1-2 weeks after surgery
Pain is highest at the first visit, which occurs 1-2 weeks after surgery.
For patients using Recupe – average 4/10 (sd 2.55)
For all non-Recupe patients – average 6/10 – (sd 2.88) p-value – .14
One month after surgery
Post-op pain decreases 1 month after surgery
For patients using Recupe – average 2/10 (sd 1.89)
For all non-Recupe patients – average 2.6/10 (sd 2.52) p-value – .24
Pre-op pain
Pre-op pain was lower for Recupe patients
For patients using Recupe – average 2/10 (sd 2.37)
For all Non-Recupe patients – average 4/10 (sd 3.11) p-value – .056
For the Recupe group, this data came from 36 Recupe patients who did pre-op exercises, averaging 28.9 days of pre-op exercises, similar to the 4 weeks to 8 weeks often used for pre-operative studies (21).
Range of Motion (ROM)
Pre-op knee flexion ROM
Recupe – average 114 degrees (sd 10.76)
Non recupe – average 112 degrees (sd 13.69) p-value – .18
Post op knee flexion ROM
For patients using Recupe – average 120 degrees (sd 9.08)
For all Non-Recupe patients – average 112 degrees (sd 11.56)
p-value – .0037
So, knee flexion ROM starts with no significant difference between groups, but after surgery, Recupe patients have significantly improved knee flexion ROM. Also, there is less variation between patient’s ROM for those using Recupe, and hence fewer negative outliers. This data excludes 1-2 week post-op ROM data due to this data being missing in a large portion of patients.
MUA
Manipulation under anesthesia was significantly less likely for patients who used Recupe 3x per week.
non-recupe – 111 patients – 5 MUA – 5%
Recupe – 41 patients – 1 MUA – 2%
P-value – less that 1.0 e-25.
So, Recupe patients had a significantly reduced risk of MUA.
Discussion
For this study, three times a week was chosen as the exercise frequency for inclusion due to support from research (21). With this frequency, use of Recupe appears to provide an advantage in pain, ROM, and complications, . In terms of pain, while the p-value was not as strong, the pain reported was lower for those who used Recupe. The closest to the desired alpha level of .05 was for pre-op pain, where the patients performed close to the minimum range of 30 days of pre-op exercises used in prior research (22), so it is possible that a longer pre-operative program could have resulted in more significant values. Compared to the study cited earlier (16), both groups demonstrated lower pain after one month. With decreased pain compared to previous research, there also appears to be no decrease in quality from unsupervised exercise (15).
For Range of Motion, the Recupe group demonstrated greater ROM, indicating improved recovery, and the average reached 120 degress, which is often used as a target for recovery (23). Also with less variation in results, there were fewer outliers in the Recupe group, and hence fewer negative outliers.
This leads directly to the lower percentage of MUA for Recupe patients. Since MUA is performed on patients who are failing to recover their knee ROM, the fewer negative outliers for the Recupe group result in fewer MUA. This is very significant due to the potential complications from additional procedures, as well as the costs to patients and the medical system. Also, MUAs are associated with many poor outcomes, including a knee revision (20).
Overall, these results show advantages over the non-Recupe group. It is important to note that many in the non-Recupe group attended outpatient physical therapy and all were given some home exercises.
Some in the Recupe group also attended physical therapy. The use of outpatient physical therapy could affect the outcomes such as pain and ROM. Unfortunately, the records did not contain sufficient data on physical therapy used. What can be confirmed is that the Recupe group performed exercises at least 3 times per week, with an average of 5.1 days per week. This is substantially better than the up to 70% non-adherence from previous studies (5).
With the benefits shown in the Recupe group, it appears that this form of unsupervised physical therapy provides benefits, as previous research showed (15), and could be superior to physical therapy alone, likely due to increased engagement (5).
There are some limitations to this study. First, though the demographics were very similar, the populations were not randomized. Second, there were gaps where data was not recorded, such as knee flexion ROM 1-2 weeks after surgery. Also, physical therapy outside of Recupe was not recorded or controlled. Finally, multiple patients started Recupe, but either did not use it often enough, or did not use it after surgery.
Future Research Possibilities
Statistical analysis will reveal relationships between all these variables. In addition, predictive analytics is expected to deliver recovery maps, personalized care plans, and continuous risk stratification. Insights delivered from analytics are expected to significantly enhance the Recupe solution by enabling identification of non-adherent patients and by understanding what patient-specific variables are most likely to improve pain and function outcomes.
While this data shows a significant reduction in MUA with use of Recupe, further research is required in this area. A greater number of MUAs from a larger population could better demonstrate the relationship between Recupe and MUAs after TKA.
(Ethics to be completed)
