ArticlePDF Available

Abstract and Figures

To compare a computer-aided training program with a conventional training program in orthopedic rehabilitation. The study was a randomized, nonblinded, controlled trial in which follow-up data were obtained at 6 mos. In an inpatient rehabilitation center, a consecutive sample was taken of patients with first total hip replacements or first total knee replacements 23-42 days after surgery. Indication groups were examined separately. The study population included 189 women and 85 men. Mean age was 69 yrs (38-86 yrs). Patients received either computer-aided training (case group) or conventional training (control group) within the framework of their inpatient rehabilitation program. The main outcome measures were levels of acceptance and effectiveness (Harris Hip Score, Hospital for Special Surgery Score, FIM instrument, and Hanover Functional Ability Questionnaire). Both forms of training showed significant improvements until discharge in scores and items used for the result evaluation independent of patient sex, age, and educational level. The 6-mo follow-up showed that between the groups, there was no statistically significant difference in the level of improvement concerning functional capacity. Furthermore, patients displayed their acceptance of the system by rating it with average values between "good" and "very good." For patients with total hip replacements or total knee replacements, computer-aided training can be regarded as the equivalent to conventional training in relationship to the results of the rehabilitation program. The system is a new tool in orthopedic rehabilitation. To identify the relative importance of the system, further research is needed.
Content may be subject to copyright.
Authors:
Uwe Eisermann, PhD
Ingo Haase, PhD
Bernd Kladny, MD
Affiliations:
From the University of Applied
Sciences KufsteinTirol, Kufstein,
Austria (UE); Research and Quality
Management, Clinic Group
Enzensberg, Füssen, Germany (IH);
and the Department of Orthopedic
Rehabilitation, Rehabilitation Clinic
Herzogenaurach, Herzogenaurach,
Germany (BK).
Disclosures:
Siemens paid benefits to a research
fund of a health institution
(Rehabilitation Clinic
Herzogenaurach) with which two of
the authors (B. Kladny, I. Haase) are
affiliated or associated.
FIM™ is a trademark of the Uniform
Data System for Medical
Rehabilitation, a division of UB
Foundation Activities, Inc.
Correspondence:
All correspondence and requests for
reprints should be addressed to Uwe
Eisermann, PhD, Ing. A. Gerber-Str.
4, A-6330 Kufstein, Austria.
0894-9115/04/8309-0670/0
American Journal of Physical
Medicine & Rehabilitation
Copyright © 2004 by Lippincott
Williams & Wilkins
DOI: 10.1097/01.PHM.0000137307.44173.5D
Computer-Aided Multimedia
Training in Orthopedic
Rehabilitation
ABSTRACT
Eisermann U, Haase I, Kladny B: Computer-aided multimedia training in or-
thopedic rehabilitation. Am J Phys Med Rehabil 2004;83:670680.
Objective: To compare a computer-aided training program with a conven-
tional training program in orthopedic rehabilitation.
Design: The study was a randomized, nonblinded, controlled trial in which
follow-up data were obtained at 6 mos. In an inpatient rehabilitation center, a
consecutive sample was taken of patients with first total hip replacements or
first total knee replacements 23– 42 days after surgery. Indication groups were
examined separately. The study population included 189 women and 85 men.
Mean age was 69 yrs (3886 yrs). Patients received either computer-aided
training (case group) or conventional training (control group) within the frame-
work of their inpatient rehabilitation program. The main outcome measures
were levels of acceptance and effectiveness (Harris Hip Score, Hospital for
Special Surgery Score, FIM™ instrument, and Hanover Functional Ability
Questionnaire).
Results: Both forms of training showed significant improvements until dis-
charge in scores and items used for the result evaluation independent of
patient sex, age, and educational level. The 6-mo follow-up showed that be-
tween the groups, there was no statistically significant difference in the level of
improvement concerning functional capacity. Furthermore, patients displayed
their acceptance of the system by rating it with average values between
“good” and “very good.”
Conclusions: For patients with total hip replacements or total knee replace-
ments, computer-aided training can be regarded as the equivalent to conven-
tional training in relationship to the results of the rehabilitation program. The
system is a new tool in orthopedic rehabilitation. To identify the relative impor-
tance of the system, further research is needed.
Key Words: Rehabilitation, Total Hip Replacement, Total Knee Replace-
ment, Tele-rehabilitation, Computer-Aided Training
670 Am. J. Phys. Med. Rehabil. Vol. 83, No. 9
Research Article
Orthopedics
Orthopedic knee and hip impair-
ments can lead to permanent disabil-
ities because of lack of training dur-
ing and after inpatient rehabilitation.
A new concept developed in Germany
supplements this training with re-
mote monitoring and periodic reas-
sessment. This concept, called Uni-
versal Training Assistant, is a tele-
rehabilitation system consisting of
hardware and software components
with training and training analysis
and with information and communi-
cation functions. It enables a patient
at all stages of orthopedic rehabilita-
tion to benet from remote medical
or therapeutic treatment.
Tele-rehabilitation in general is
the remote delivery of rehabilitative
services such as monitoring and
training of persons with disabilities
using telecommunication technolo-
gy.
1
Reported ndings from early ex-
ploratory trials are encouraging.
24
However, there have been no ran-
domized, controlled trials demon-
strating clinical effectiveness in reha-
bilitation so far.
The Universal Training Assistant
was tested in a German rehabilitation
clinic with respect to effectiveness
using this new type of training
method. The basic idea was to com-
pare this computer-aided training us-
ing the Training Assistant with train-
ing provided in a conventional
manner. The intention was to raise
the levels of acceptance (measured in
terms of declaration of consent) and
effectiveness (effects on functional
status, activities of daily living, pain,
etc.).
Conceptually, the idea was to de-
velop comprehensive, closed-loop
tele-medical treatment and care for
patients undergoing orthopedic reha-
bilitation. In this context, the word
comprehensivenot only stands for
dening ideal individual training pro-
grams for the patient by the thera-
pist, but also for analyzing the pa-
tients current training performance
and course of therapy, keeping the
patient informed and involved and
communicating and interacting with
him or her. The closed loop is dened
by qualitative and quantitative vari-
ables entered manually by the patient
or automatically calculated for train-
ing and course of therapy, which are
transferred on completion of training
to the therapist, such as details of
intensity and frequency of training.
Based on these results and the infor-
mation originating from the interac-
tion with the patient, the therapist
species further individual optimized
training programs. The system also
allows incorporation of new exercises
into the patients training schedule to
keep the treatment up to date in ac-
cordance with current guidelines and
the patients training progress.
METHODS
Patients received either comput-
er-aided training (case group) or con-
ventional self-training (control
group) within the framework of their
3- or 4-wk inpatient rehabilitation
program. To perform the computer-
aided training, the patient was in-
structed for half an hour by a phys-
iotherapist, who explained the system
and selected and modied the exer-
cises for the patient on the Training
Assistant. In accordance with their
individual capacities, the patients
used the system 35 times a week for
30 mins without supervision. The
conventional self-training was per-
formed in a group of 8 10 patients
under supervision of a physiothera-
pist. The patients received an exercise
program that was either performed
without or with simple tools like balls
or rubber bands. This training was
performed 35 times a week for 30
mins. The subjects were assessed dur-
ing a 4-mo interval between Decem-
ber 2000 and March 2001. A compre-
hensive program of inpatient
rehabilitation was provided to each
patient, tailored to meet each pa-
tients skills and abilities. The follow-
ing services were provided as part of
the rehabilitation program to both
groups: medical services, nursing,
physical therapy, and occupational
therapy.
Description of the Intervention
Computer-Aided System. The Uni-
versal Training Assistant is used to
perform a selection of computer-
aided, multimedia, real-time training
exercises relevant to rehabilitation of
motor abilities and skills (basic train-
ing and special training). The system
features two different versions espe-
cially designed for the needs of the
user groups, patients, and therapists.
In the therapists version, the special-
ist creates the ideal training program
for the individual performance capac-
ity of the patient by dening suitable
exercises (Fig. 1).
The exercises are grouped into
poolsfor specic indications and
correspond exactly with those used in
conventional rehabilitative training.
In addition, the therapist can set
analysis variables for each exercise to
obtain feedback on training perfor-
mance. Depending on the specica-
tions, devices for describing or re-
cording movement, such as
accelerometers, Web cams, chest sen-
sors, and wristbands, are activated
automatically. By implementing
these devices into the training sched-
ule, the visualization and interpreta-
tion of the training and the assess-
ment of the patients compliance is
feasible. Furthermore, the therapist
can specify questions the patient has
to answer at the end of a training unit
(e.g., about the course of training and
acceptance, perceived pain, and
strenuousness;these factors are
important for planning the course of
further training). Finally, the thera-
pist can receive a record of the train-
ing unit (date and time, duration,
type and execution of the training,
answers, and patients remarks) and
also refer back to the patient record
and send news to the patient.
September 2004 Computer-Aided Training 671
The patients version offers the
training programs created by the
therapist (i.e., the Training Assistant
conducts the patient through the
program). Assistance is available for
each exercise, and each set comprises
movement description, training load,
and multimedia assists (video anima-
tions and audio sequences). To en-
hance communication, the patient
has the opportunity to send a mes-
sage to the therapist. With the aim to
offer quick and reliable program op-
eration, especially for computer-illit-
erate users, a simple, clear, and visu-
ally attractive interface has been
designed that features large buttons
and lettering and virtually excludes
the possibility of input errors (Fig. 2).
Structure. All data generated by the
patient using the patient station are
transferred to a server of the service
supplier or provider. The therapist
can review the data using his or her
therapist station, evaluate it, and if
appropriate, select a new training
program adapted to the altered abili-
ties and skills of the patient. This
program will then again be trans-
ferred to the server and will appear
during the next training session. The
basis for this system structure (Fig.
3) is a client-server communication
infrastructure consisting of a central
server and dedicated clients (patient
and therapist workstations). This in-
frastructure makes possible tele-
training, tele-monitoring, and tele-
coaching, and it fullls all security-
relevant criteria (e.g., data security,
authentication).
Subjects
Selection criteria for the sample
included all persons referred to a re-
habilitation clinic within 5 mos with
total hip replacement or total knee
replacement. Other prerequisites
were that patients had to be able to
train and to ll in a questionnaire.
Patients who fullled these inclusion
criteria were randomized to receive
either computer-aided training with
the Training Assistant (case group) or
conventional training (control
group) within the frame of their in-
patient rehabilitation program.
Patients with hip arthroplasty
and patients with knee arthroplasty
were examined separately. The target
per study was at least 2 60 patients
(cases and controls). This database is
large enough to be able to draw con-
clusions concerning statistically sig-
nicant average values for both de-
pendent and independent samples
with an error probability of
0.05
and 1
0.80.
5
Figures 4 and 5 outline the
progress of subjects through the var-
ious phases of the randomized, con-
trolled trial. There were no statisti-
cally signicant differences between
Figure 1: Example of patientstime schedule.
672 Eisermann et al. Am. J. Phys. Med. Rehabil. Vol. 83, No. 9
the groups for the baseline demo-
graphics of patients.
Instruments
For ascertaining aspects of func-
tional status, activities of daily living,
pain, and range of motion, established
assessment instruments were used:
Staffelstein-Score for total hip and total
knee replacements,
6
Harris Hip Score,
7
Hospital for Special Surgery Score,
8
and the FIMinstrument.
911
The
data were collected by a number of
rehabilitation physicians who had been
introduced to the instruments and
scores beforehand. Staffelstein-Score is
similar to Harris Hip Score and Hospi-
tal for Special Surgery Score. The
Hanover Functional Ability Question-
naire (FFbH)
12,13
was lled in by pa-
tients. The FFbH for patients with os-
teoarthritis is part of a series of short,
self-administered questionnaires for
the assessment of functional limita-
tions in activities of daily living among
patients with musculoskeletal disor-
ders. The resulting FFbH scores can
range between 0 (minimal functional
capacity) and 100 (maximal functional
capacity). A score of 70 points has to
be viewed as normal functional capac-
ity and an improvement of 12% as
clinically meaningful.
Procedure
Data were collected during the
clinical inpatient period at two refer-
ence points: the time of admission
and the time of discharge. A 6-mo
follow-up was done to assess the
long-term benet of the treatment on
patients using a questionnaire, which
included the FFbH.
Descriptive statistics were com-
puted for all relevant variables. Non-
parametric tests were performed to
examine differences regarding scores
of outcome measures. Change from
pretreatment to posttreatment was
analyzed using the Wilcoxons test.
Group averages were compared using
the Kolmogorov-Smirnov test. Data
were analyzed with the SPSS 10
package (SPSS, Chicago, IL).
In addition, computer-aided sur-
veys were done. These surveys were
used to establish the level of accep-
tance. They were carried out in the
following way: after a specied num-
ber of training units with the com-
puter, the patients of the case groups
were given a questionnaire by the
computer (i.e., they were questioned
on-line regarding the criteria manag-
ing the system, arrangement of the
training, training times, effectiveness
Figure 2: To offer quick and reliable program operation, especially for computer-illiterate users, a simple, clear, and
visually attractive interface has been designed that features large buttons and lettering and virtually excludes the
possibility of input errors.
September 2004 Computer-Aided Training 673
of the training, recommendations for
training, and enthusiasm for the
training). The patients assessed most
of the criteria on the basis of 5-point
scales ranging from 2to2. For
managing the system in general and
multimedia arrangement of the com-
puter-aided training there were mean
values ranging between goodand
very good.
Supplementing the acceptance as-
pect, physician and therapist focus
group discussions
14
were held. Specic
kinds of data, surveyed using qualita-
tive methods, are only comparable with
a limited extent, but they offer a much
better picture of how the subject actu-
ally thinks and feels. The results ob-
tained from qualitative procedures
were combined with the results ob-
tained from quantitative procedures
and interpreted collectively.
RESULTS
Acceptance and Practicability
Dropouts. In total, 77 of 373 patients
(21%) meeting the inclusion criteria
declined to take part in the study. The
main reason for this was that these
patients (68 of 77, 88%) rejected
computer-aided training; apparently,
these patients had been put off by
warnings related to certain health
problems they had. For example, pa-
tients with poor eyesight were in-
formed that overexertion might affect
their vision. Three patients dropped
out of the study early because they
did not feel comfortable operating
the computer (Figs. 4 and 5).
Acceptance of Computer-Aided
Training from the Patients’ View-
point (Case Groups). To establish the
level of acceptance, all 142 patients of
the case groups were questioned on-
line (see above). Duration (of an in-
dividual training unit) and frequency
(i.e., number of training units per
week) were predominantly consid-
ered to be reasonable.Effectiveness
of the training, on average, was rated
1.4 (SD 0.6) regarding physical t-
ness and 1.3 (SD 0.8) regarding
general strain, in each case on a
5-point scale ranging from 2 (very
helpful) to 2 (useless). A total of
131 of 142 cases (92.3%) would rec-
ommend this training to other pa-
tients with similar complaints, and
only one patient (0.7%) would not be
able to recommend it to others. As-
sessment of enthusiasm for training
was similarly positive.
Acceptance of Computer-Aided
Training from the Viewpoint of the
Figure 3: Client-server communication infrastructure consisting of a central server and dedicated clients (patient and
therapist workstations). This infrastructure makes possible tele-training, tele-monitoring, and tele-coaching, and it fullls
all security-relevant criteria (e.g., data security, authentication).
674 Eisermann et al. Am. J. Phys. Med. Rehabil. Vol. 83, No. 9
Physicians and Therapists. To estab-
lish the level of acceptance, the phy-
sicians and therapists were invited to
give their assessments in a focus
group discussion on the criteria:
course of training, arrangement of
training, its effectiveness, supervi-
sion, and enthusiasm for training.
They were asked to observe the crite-
ria from their own viewpoint and to
describe the patients in this light (ac-
ceptance of the training by the pa-
Figure 4: Recruitment of patients with total hip replacements.
September 2004 Computer-Aided Training 675
tients as evaluated by the physicians
and therapists).
The rst subject discussed was
the course of training, which was as-
sessed positively by the physicians
and therapists. They were able to op-
erate the Training Assistant and to
conrm that the patients were able to
handle the program. As far as validity
is concerned, this conrmation must
be examined in detail to be certain
that the patients were indeed able to
Figure 5: Recruitment of patients with total knee replacements.
676 Eisermann et al. Am. J. Phys. Med. Rehabil. Vol. 83, No. 9
operate the Training Assistant and
that the criterion course of training
in the on-line questionnaire has been
correctly evaluated in terms of their
abilities.
The arrangement of training was
also assessed positively. Physicians
and therapists alike regarded the ar-
rangements in general as attractive
and the movement descriptions as
vivid. They emphasized the impor-
tance of the video animations and the
audio sequences. However, it should
be mentioned that for some of the
patients, the movement descriptions
were not adequate.
Assessment of the trainings ef-
fectiveness was similar throughout,
to the extent that all regarded the
computer-aided training as being just
as effective as conventional training.
In fact, three participants (one physi-
cian, two therapists) thought that the
computer-aided training was more
effective because the patients were
more meticulous and conscientious
in carrying out the multimedia exer-
cises led by a computer-animated
trainer moving in real time. The phy-
sicians and therapists conrmed the
patientsself-assessments. The great
majority of the patients described the
computer-aided training as helpful
for their performance and recovery.
Training supervision was also re-
garded positively in the respect that
preparation of patients for the com-
puter-aided training was unproblem-
atic and with duration of 30 mins
claimed no more time than the prep-
aration required for conventional
training. Admittedly, it might be
helpful for the training if the thera-
pist carrying out the patients prepa-
ration were the same one who was
available during the training or su-
pervising it.
Corresponding with the positive
trend of enthusiasm for the training
shown by the patients, the physicians
and therapists would also continue to
make use of the Training Assistant,
for their in-, out-, and ambulatory
patients.
Randomized, Nonblinded,
Controlled Trial
Patients with Total Hip Replace-
ments. Patients with total hip re-
placement who fullled the inclusion
criteria were randomized to receive
either computer-aided training or
conventional training during their
inpatient rehabilitation. Table 1
shows that the baseline characteris-
tics of these patients were similar in
the two groups.
Both forms of training showed
signicant improvements in scores
used for the result evaluation until
discharge. Effect sizes
15,16
ranged
from 0.67 to 1.34 (cases), respec-
tively, from 0.76 to 1.34 (controls)
(Table 2). There was no statistically
signicant difference between these
two groups on Harris Hip Score,
Staffelstein Score, FIM score, and
FFbH.
At the 6-mo follow-up, all pa-
tients with total hip replacement who
had completed the inpatient rehabil-
itation program were mailed a ques-
tionnaire and asked to report their
functional status using the FFbH for
patients with osteoarthritis. Nine pa-
tients did not return the question-
naire (Fig. 4).
Six months after the program,
the average functional capacity of the
case group was 72.7 (SD 22.8)
compared with a rating of 37.4 (SD
16.8) in the same patients before
treatment. This was a statistically sig-
nicant improvement (WilcoxonsZ
⫽⫺6.6, P0.001). The control
group score increased in a very sim-
ilar way from 38.3 (SD 19.2) to
74.8 (SD 23.0). There was no effect
and no statistically signicant differ-
ence in improvement between groups
(Kolmogorov-Smirnov Z 0.639,
P0.809).
Looking back on their training
program during the inpatient reha-
bilitation, patients marked very good
on a 5-point rating scale (2 very
good; 2very bad) for both com-
puter-aided training using the Train-
ing Assistant and conventional train-
ing. The average case group rating
was 1.26 (SD 0.59) compared with
a rating of 1.21 (SD 0.73) in the
control group. Also, 22 of 65 cases
and 22 of 57 controls indicated very
good. There was no statistically sig-
nicant difference between the two
groups.
Patients with Total Knee Replace-
ments. Patients with total knee re-
placement who fullled the inclusion
criteria were randomized to receive
either computer-aided training or
conventional training during their
TABLE 1
Baseline characteristics of patients with total hip
replacements
Cases
(n74)
Controls
(n64)
Comparison
(PValue)
Sex 60.8% women 70.3% women NS
Age, yrs 67.8 69.3 NS
Employed 9.5% 6.3% NS
Living alone 31.1% 31.3% NS
No. of days from operation to
rehabilitation admission
22.5 23.5 NS
Rehabilitation length of stay, days 19.8 19.8 NS
Median admission HHS 62 65 NS
Median admission FIMscore 117 116.5 NS
Median admission FFbH score 35.7 33.3 NS
NS, not signicant (P0.05); HHS, Harris Hip Score; FFbH, Hanover
Functional Ability Questionnaire.
September 2004 Computer-Aided Training 677
inpatient rehabilitation too. Table 3
shows that the baseline characteris-
tics of these patients in the study
were similar in the two groups.
Both forms of training showed
signicant improvements in scores
and items used for the result evalua-
tion until discharge. Effect sizes,
11,12
which were computed using the stan-
dard deviation of admission (pre)
scores range from 0.73 to 1.40
(cases), respectively, from 0.96 to
1.16 (controls) (Table 4). There was
no statistically signicant difference
between these two groups on Hospi-
tal for Special Surgery Score, Staffel-
stein Score, FIM score, and FFbH.
At the 6-mo follow-up, as was
done for patients with hip arthro-
plasty, all patients with knee arthro-
plasty who had completed the inpa-
tient rehabilitation program were
mailed a questionnaire and asked to
report their functional status using
the FFbH for patients with osteoar-
thritis. One patient was deceased, and
ve patients did not return the ques-
tionnaire (Fig. 5).
Six months after the program,
the average functional capacity of the
case group was 76.9 (SD 16.8) as
compared with a rating of 46.4 (SD
14.4) in the same patients before
treatment. This was a statistically sig-
nicant improvement (WilcoxonsZ
⫽⫺6.0, P0.001). The control
group score also increased signi-
cantly from 48.3 (SD 16.7) to 70.6
(SD 20.6). Differences between fol-
low-up and admission scores showed
a small effect to the credit of the case
group (effect size 0.38). However,
statistically speaking, there was no
signicantly better improvement for
the case group (Kolmogorov-Smir-
nov Z 1.134, P0.153).
At the 6-mo follow-up, patients
with total knee replacement marked
very good on a 5-point rating scale (2
very good) for both computer-
aided training and usual training.
The average case group rating was
1.26 (SD 0.81) compared with a
rating of 1.28 (SD 0.74) in the
control group. Also, 23 of 54 cases
and 27 of 60 controls indicated very
good. There was no statistically sig-
nicant difference between the two
groups.
Relationship of Demographic Vari-
ables to Functional Gain. One pur-
pose of our analysis was to under-
stand the inuence of basic
demographic variables on change in
functional ability within the case
group. For this analysis, FFbH
change was made the dependent vari-
able, whereas sex, age, educational
level, and indication where desig-
nated as the independent variables.
TABLE 2
Effect sizes for patients with total hip replacements
Scores/Measured Values
Cases (n74) Controls (n64)
Diff T2-T1
a
SD T1
b
ESpre
c
Diff T2-T1
a
SD T1
b
ESpre
c
StS hip 14.8 11.3 1.31 17.1 12.8 1.34
HHS 14.8 13.1 1.13 16.2 15.2 1.07
FIM2.6 3.9 0.67 3.4 4.5 0.76
FFbH 22.5 16.8 1.34 23.4 19.2 1.22
Distancewalked 640.8 269.9 2.37 671.3 224.1 3.00
Flexion 6.6 12.7 0.52 5.2 14.8 0.35
StS, Staffelstein Score; HHS, Harris Hip Score; FFbH, Hanover Functional Ability Questionnaire.
a
Difference between discharge and admission scores.
b
Standard deviation of admission scores.
c
Effect size standardized with standard deviation of admission (pre) scores.
TABLE 3
Baseline characteristics of patients with total knee
replacements
Cases
(n68)
Controls
(n68)
Comparison
(PValue)
Sex 66.2% women 79.4% women NS (P0.061)
Age, yrs 70.2 69.7 NS
Employed 4.4% 2.9% NS
Living alone 36.8% 35.3% NS
No. of days from operation to
rehabilitation admission
21.6 24.1 NS
Rehabilitation length of stay,
days
20.1 19.9 NS
Median admission HSS 59.5 58.5 NS
Median admission FIM118 118 NS
Median admission FFbH 47.2 48.6 NS
NS, not signicant (P0.05); HSS, Hospital for Special Surgery Score;
FFbH, Hanover Functional Ability Questionnaire.
678 Eisermann et al. Am. J. Phys. Med. Rehabil. Vol. 83, No. 9
Table 5 shows that there were no
signicant or clinically meaningful
differences in the change of the aver-
age functional ability measure.
DISCUSSION AND
CONCLUSIONS
Computer-aided training is a
new tool in orthopedic rehabilitation.
The patient trains and transmits
training variables to the therapist.
The therapist analyzes, adapts and
transfers new training congurations
to the patient. They communicate
with each other by mutual exchange
of certain kinds of data. Little is
known about practicability and effec-
tiveness of tele-rehabilitation systems
or to what extent the patients would
accept them as an alternative to con-
ventional therapy. This study was
performed to evaluate just such a
programthe Universal Training As-
sistantimplemented in the every-
day operation of a rehabilitation
clinic.
The computer-aided training
should at least lead to equal treat-
ment results when compared with a
self-training program in groups su-
pervised by a therapist as part of the
rehabilitation setting. The ndings of
our present study demonstrate that
treatment with the Training Assistant
improves functional status, activities
of daily living, functional indepen-
dence, and range of motion and re-
duces pain just as well as conven-
tional training. Training was effective
and safe. Adverse events were not re-
ported across the groups. For pa-
tients with total hip replacement or
total knee replacement, the comput-
er-aided training can be regarded as
equivalent to the conventional train-
ing relating to the results of the re-
habilitation program.
Regarding acceptance, the com-
puter-aided training was assessed in a
positive manner. For all criteria, only
average values between good and very
good were seen. All patients, regardless
of sex, age, and educational level were
able to use the system without major
problems and were compliant. The re-
sult of the group discussion was that
both physicians and therapists recog-
nize the Training Assistant as a new
instrument to assist rehabilitation.
Overall, the study showed that
this new approach is feasible and
practicable in principle. It has led to
results that correspond to those that
TABLE 4
Effect sizes for patients with total knee replacements
Scores/Measured Values
Cases (n68) Controls (n68)
Diff. T2-T1
a
SD T1
b
ESpre
c
Diff. T2-T1
a
SD T1
b
ESpre
c
StS knee 16.4 12.2 1.34 15.7 14.2 1.11
HSS 14.8 10.7 1.38 14.2 12.2 1.16
FIM2.9 4.0 0.73 2.6 2.7 0.96
FFbH 20.1 14.4 1.40 16.1 16.7 0.96
Distance walked 569.7 263.1 2.17 571.9 166.7 3.43
Flexion 10.4 18.3 0.57 9.4 18.3 0.51
StS, Staffelstein Score; HSS, Hospital for Special Surgery Score; FFbH, Hanover Functional Ability Questionnaire.
a
Difference between discharge and admission scores.
b
Standard deviation of admission scores.
c
Effect size standardized with standard deviation of admission (pre) scores.
TABLE 5
Average functional ability measure change by sex, age,
educational level, and indication in the case group
Variables
Pretreatment to Posttreatment
Change in Hanover Functional
Ability Questionnaire
Mean
Standard
Deviation
Comparison
(PValue)
Sex 0.109
Female (n90) 19.8 16.7
Male (n52) 23.9 14.6
Age, yrs 0.418
65 (n38) 23.6 15.6
6574 (n72) 19.8 15.5
74 (n32) 22.1 17.9
Education level 0.922
9-yrs of elementary school (n121) 21.6 16.2
Higher levels (n16) 22.2 16.0
Indication 0.327
Total hip replacement (n74) 22.5 17.7
Total knee replacement (n68) 20.1 14.1
September 2004 Computer-Aided Training 679
can be achieved by self-training.
Therewith, reported ndings from re-
cently published exploratory trials
24
were conrmed.
It calls for complementary re-
search in inpatient and outpatient
settings to determine whether these
results are sufcient to justify a wid-
ening of the system. In addition, fur-
ther studies would have to examine
which particular patient groups
would prot most by employing such
a tele-rehabilitation system.
According to the authors, the
Universal Training Assistant has a
great deal of potential in outpatient
applications. In an ideal set-up, the
patient learns to operate the system
as an inpatient and continues to use
it after dismissal. The patient com-
pletes the specied training program
and is analyzed by the therapist re-
garding performance of training. The
patient then offers the therapist feed-
back based on objective achievements
and subjective assessments. Addi-
tional tools like Web cams or accel-
erometers for controlling the exer-
cises during outpatient rehabilitation
have to be developed and integrated
in the system. The existence of such
tools would increase the compliance
levels of the patients and, at the same
time, reduce the risk that the system
will be put in the closet like many
ortheses. Experiences made with car-
diologic patients have shown that
computer-supported, remote-con-
trolled training has a very positive
effect on the patientsmotiva-
tion.
17,18
Therefore, future studies
should test the effects that orthope-
dic tele-rehabilitation systems have
on motivation levels.
REFERENCES
1. Lathan CE, Kinsella A, Rosen MJ, et al:
Aspects of human factors engineering in
home telemedicine and telerehabilitation
systems. Telemed J 1999;5:169 75
2. Burdea G, Popescu V, Hentz V, et al:
Virtual realitybased orthopedic telereha-
bilitation. IEEE Trans Rehabil Eng 2000;
8:430 2
3. Palsbo SE, Bauer D: Telerehabilitation:
Managed cares new opportunity. Manag
Care Q 2000;8:56 64
4. Liu L, Miyazaki M: Telerehabilitation
at the University of Alberta. J Telemed
Telecare 2000;6 (suppl 2):479
5. Bortz J, Döring N: Forschungsmetho-
den und Evaluation. Berlin/Heidelberg,
Springer, 1995
6. Torbati T, Schladitz G: Evaluation of
course and results of indoor rehabilita-
tion measures with the Staffelstein Score
after total hip arthroplasty. Orthopä-
dische Praxis 2001;37:236 42
7. Harris WH: Traumatic arthritis of the
hip after dislocation and acetabular
fractures: Treatment by mold arthro-
plasty. An end result study using a new
method of result evaluation. J Bone Joint
Surg (Am) 1969;51:73755
8. Ranawat CS, Shine JJ: Duocondylar
total knee arthroplasty. Clin Orthop 1973;
94:18595
9. Stineman MG, Hamilton BB, Granger
CV, et al: Four methods for characteriz-
ing disability in the formation of function
related groups. Arch Phys Med Rehabil
1994;75:127783
10. Langen EG de, Fommelt P, Wied-
mann KD, et al: Evaluation of functional
independence in rehabilitation by the
Functional Independence Measure (FIM).
Rehabilitation 1995;34:4 11
11. FIM Funktionale Selbständigkeits-
messung, german version (FIM-Arbe-
itskreis Deutschland, Österreich,
Schweiz). München, Internationale Vere-
inigung zum Assessment in der Reha-
biliation, 1997
12. Kohlmann T, Raspe H: The Hannover
Functional Ability Questionnaire for mea-
suring back pain-related functional limi-
tations (FFbH-R). Rehabilitation 1996;
35:18
13. Kohlmann T, Richter T, Heinrichs K,
Peschel U, Knahr K, Kryspin-Exner I. En-
twicklung und Validierung des Funk-
tionsfragebogens für Patienten mit Ar-
throsen der Hüft- und Kniegelenke
(FFbH-OA). In: Schliehe F, Schunter-
mann MF, editors. 8th Rehabilitation-
swissenschaftliches Kolloquium. Reha-
Bedarf–Effektivität–Ökonomie; 03/8–10/
99; Norderney, Germany. Frankfurt/M.:
WDV Wirtschaftsdienst: 1999:40 2
14. Khan ME, Anker M, Paatel BC, et al:
The use of focus groups in social and
behavioural research: Some methodolog-
ical issues. World Health Stat Q 1991;44:
1459
15. Cohen J: Statistical Power Analysis
for the Behavioral Sciences. Hillsdale, NJ,
Erlbaum, 1988
16. Maier-Riehle B, Zwingmann C: Effect
size variations in the single group pre-
post study design: A critical view. Reha-
bilitation 2000;39:189 99
17. Tegtbur U, Jung K, Markolsky U, et
al: Entwicklung eines chipkartenges-
teuerten Heimergometertrainings für die
Reha-Phase. Herz/Kreisl 2000;32:334
18. Gerling J, Denkler P, Haase I: Com-
puter-based cardiac tele-rehabilitation,
in: Second World Congress of the Inter-
national Society of Physical and Rehabil-
itation Medicine (ISPRM), Prague, May
18–22, 2003, Abstracts. Prague, ISPRM,
2003, pp 221
680 Eisermann et al. Am. J. Phys. Med. Rehabil. Vol. 83, No. 9
... There were 5 eligible studies (N = 1143) using webbased therapies, including educational software and interactive online platform, for participants following TKR (N = 594, mean age = 65.4 years) or THR (N = 549, mean age = 62.2 years). Three studies provide multimedia online training platform used by therapists for 149 TKR and 149 THR participants, respectively [43]. Two studies use asynchronous educational software designed for handheld devices for 29 TKR participants [44]. ...
... Two studies showed no between-group differences in the number of exercise sessions finished daily [31,32]. Four trials (N = 757) reported user experience and showed similar levels of satisfaction with both the intervention and the control [40,43,44,48]. One trial of an educational software demonstrated positive user experiences, such as good clarity of instruction, ease of taking or sharing a video and ease of seeing their progress [44]. ...
... One trial of an educational software demonstrated positive user experiences, such as good clarity of instruction, ease of taking or sharing a video and ease of seeing their progress [44]. Another study of training software also received positive feedback from participants and therapists [43]. When participants were asked what they liked most about the application, no travelling to the hospital was cited by 57% and ease of access by 21% [44]. ...
Article
Full-text available
Background: To evaluate the effectiveness and safety of technology-assisted rehabilitation following total hip/knee replacement (THR/TKR). Methods: Six electronic databases were searched without language or time restrictions for relevant studies: MEDLINE, EMBASE, Cochrane Library, CINAHL, SPORTDiscus, Physiotherapy Evidence Database (PEDro); from inception to November 7th, 2018. Two reviewers independently applied inclusion criteria to select eligible randomised controlled trials (RCTs) that investigated the effectiveness of technology-based interventions, compared with usual care or no intervention for people undergoing THR/TKR. Two reviewers independently extracted trial details (e.g. patients' profile, intervention, outcomes, attrition and adverse events). Study methodological quality was assessed using the PEDro scale. Quality of evidence was critically appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach. Results: We identified 21 eligible studies assessing telerehabilitation, game- or web-based therapy. There were 17 studies (N = 2188) in post-TKR rehabilitation and 4 studies (N = 783) in post-THR rehabilitation. Compared to usual care, technology-based intervention was more effective in reducing pain (mean difference (MD): - 0.25; 95% confidence interval (CI): - 0.48, - 0.02; moderate evidence) and improving function measured with the timed up-and-go test (MD: -7.03; 95% CI: - 11.18, - 2.88) in people undergoing TKR. No between-group differences were observed in rates of hospital readmissions or treatment-related adverse events (AEs) in those studies. Conclusion: There is moderate-quality of evidence showed technology-assisted rehabilitation, in particular, telerehabilitation, results in a statistically significant improvement in pain; and low-quality of evidence for the improvement in functional mobility in people undergoing TKR. The effects were however too small to be clinically significant. For THR, there is very limited low-quality evidence shows no significant effects.
... There were 5 eligible studies (N = 1143) using webbased therapies, including educational software and interactive online platform, for participants following TKR (N = 594, mean age = 65.4 years) or THR (N = 549, mean age = 62.2 years). Three studies provide multimedia online training platform used by therapists for 149 TKR and 149 THR participants, respectively [43]. Two studies use asynchronous educational software designed for handheld devices for 29 TKR participants [44]. ...
... Two studies showed no between-group differences in the number of exercise sessions finished daily [31,32]. Four trials (N = 757) reported user experience and showed similar levels of satisfaction with both the intervention and the control [40,43,44,48]. One trial of an educational software demonstrated positive user experiences, such as good clarity of instruction, ease of taking or sharing a video and ease of seeing their progress [44]. ...
... One trial of an educational software demonstrated positive user experiences, such as good clarity of instruction, ease of taking or sharing a video and ease of seeing their progress [44]. Another study of training software also received positive feedback from participants and therapists [43]. When participants were asked what they liked most about the application, no travelling to the hospital was cited by 57% and ease of access by 21% [44]. ...
... In two studies (40,41) web-based interactions (e.g., remote viewing of x-ray images) were used to perform a follow-up meeting with the surgeon. Eisermann et al. (36) used computer-supported training. Three studies used mobile applications to deliver the training and education to patients (54,59,60). ...
... The main unmet criterion was not blinding the study personnel. Specifically, eight studies either fail to blind the personnel (35, 38, 40, 42, 49-51, 56, 57) or 11 did not provide sufficient information on blinding the personnel (33,34,36,37,45,47,48,(52)(53)(54)(55)58). Incomplete outcome data for all outcomes and other sources of bias (e.g., not reporting funding sources) were the other two unmet criteria. ...
Article
Full-text available
Objective: This study aimed to compare the effectiveness and costs of eHealth tools with usual care in delivering health-related education to patients' undergoing total hip or knee arthroplasty due to osteoarthritis. Data Sources: Six electronic databases were searched to identify randomized controlled trials and experimental designs (randomized or not) examining the effect of eHealth tools on pre- or post-operative care. Only manuscripts written in English were included. In the current study, no specific primary or secondary outcomes were selected. Any study that investigated the impacts of eHealth tools on hip or knee arthroplasty outcomes were included. Review Methods: Two researchers reviewed all titles and abstracts independently and in duplicate. Two researchers also conducted full-text screening and data extraction from the 26 selected articles. Results: The data were descriptively reported, and themes could emerge from each outcome. Two researchers separately assessed the Risk of Bias for each paper using the Cochrane risk of bias assessment tool. The majority of studies evaluated the impact of eHealth tools on physical ( n = 23) and psychosocial outcomes ( n = 19). Cost-related outcomes were measured in 7 studies. eHealth tools were found to be equivocal to usual care, with few studies reporting statistically significant differences in physical or psychosocial outcome measures. However, cost-related outcomes showed that using eHealth tools is more cost-effective than usual care. Conclusions: This review demonstrated that eHealth tools might be as effective as usual care, and possibly more cost-effective, a crucial implication for many overly burdened health care systems.
... Eisermann et al [64] provided a telerehabilitation program using custom computer software and several sensors to track the patient's performance. Patients were asked to perform individualized exercises based on the training program prescribed by the therapist; the program could be modified based on the patient's feedback. ...
Article
Full-text available
Background: Telerehabilitation programs are designed with the aim of improving the quality of services as well as overcoming existing limitations in terms of resource management and accessibility of services. This review will collect recent studies investigating telerehabilitation programs for patients with knee osteoarthritis while focusing on the technologies and services provided in the programs. Objective: The main objective of this review is to identify and discuss the modes of service delivery and technologies in telerehabilitation programs for patients with knee osteoarthritis. The gaps, strengths, and weaknesses of programs will be discussed individually. Methods: Studies published in English since 2000 were retrieved from the EMBASE, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Physiotherapy Evidence Database (PEDro), and PsycINFO databases. The search words “telerehabilitation,” “telehealth,” “telemedicine,” “teletherapy,” and “ehealth” were combined with “knee” and “rehabilitation” to generate a data set of studies for screening and review. The final group of studies reviewed here includes those that implemented teletreatment for patients for at least 2 weeks of rehabilitation. Results: In total, 1198 studies were screened, and the full text of 154 studies was reviewed. Of these, 38 studies were included, and data were extracted accordingly. Four modes of telerehabilitation service delivery were identified: phone-based, video-based, sensor-based, and expert system–based telerehabilitation. The intervention services provided in the studies included information, training, communication, monitoring, and tracking. Video-based telerehabilitation programs were frequently used. Among the identified services, information and educational material were introduced in only one-quarter of the studies. Conclusions: Video-based telerehabilitation programs can be considered the best alternative solution to conventional treatment. This study shows that, in recent years, sensor-based solutions have also become more popular due to rapid developments in sensor technology. Nevertheless, communication and human-generated feedback remain as important as monitoring and intervention services.
... Enhanced efficacy from arthroplasty and the favorable outcomes are closely associated with postoperative rehabiliotation. Controversies exist over therapy guidelines determining the design and time parameters of the rehabilitation programs for THA patients [4,28]. Some authors suggest that physical therapy sessions and message, kinesiotherapy exercises, workout with exercise and rehab equipment, etc. can be applied for rehabilitation of THA patients. ...
Article
Full-text available
Introduction Total hip arthroplasty (THA) is one of the most successful orthopedic procedures performed today. Rates of THA have been steadily increasing over the past several decades with increasing number of patients who need proper effective rehabilitation therapy after orthopaedic surgery. Evaluation and introduction of new rehabilitation techniques is crucial for patients undergoing replacement of major joints. Objective Review the literature and our own findings with various rehabilitation programs used for THA patients to aid recovery following surgery at a short and long term. Material and methods The study included 57 THA patients referred to rehabilitation department of the Kurgan Ilizarov Center to help manage pain at different terms following surgery. The sample was divided into main (n = 29) and control (n = 28) groups. Post-isometric relaxation techniques were included in rehabilitation program of the main group. Clinical outcomes were evaluated with VAS, the Lequesne Index, McGill Pain Questionnaire, WOMAC, and Harris Hip Score. Results Outcome measures showed 1.5 times improvement in controls with high statistical significance (p > 0.01) and 3.3 times improvement in patients who received post-isometric relaxation therapy with greater significance level (p > 0.001). Conclusion The findings suggest that post-isometric relaxation techniques applied as a part of restorative treatment facilitate improved outcomes of rehabilitation. The optimal rehabilitation protocols have been shown to be largely unknown for THA patients.
... The current telerehabilitation offerings should be adapted to the individual and indication-specific needs of the patients and should enable contact with the supervising therapists. However, this could not be investigated with the currently available systems, as they are either not specific enough for the indications of a patient or do not offer a tool to communicate with a therapist [16][17][18][19][20][21][22]. The telerehabilitation systems studied until now often differ in terms of their communication structures and their feedback options. ...
Article
Full-text available
Background: Telerehabilitation can contribute to the maintenance of successful rehabilitation regardless of location and time. The aim of this study was to investigate a specific three-month interactive telerehabilitation routine regarding its effectiveness in assisting patients with physical functionality and with returning to work compared to typical aftercare. Objective: The aim of the study was to investigate a specific three-month interactive telerehabilitation with regard to effectiveness in functioning and return to work compared to usual aftercare. Methods: From August 2016 to December 2017, 111 patients (mean 54.9 years old; SD 6.8; 54.3% female) with hip or knee replacement were enrolled in the randomized controlled trial. At discharge from inpatient rehabilitation and after three months, their distance in the 6-minute walk test was assessed as the primary endpoint. Other functional parameters, including health related quality of life, pain, and time to return to work, were secondary endpoints. Results: Patients in the intervention group performed telerehabilitation for an average of 55.0 minutes (SD 9.2) per week. Adherence was high, at over 75%, until the 7th week of the three-month intervention phase. Almost all the patients and therapists used the communication options. Both the intervention group (average difference 88.3 m; SD 57.7; P=.95) and the control group (average difference 79.6 m; SD 48.7; P=.95) increased their distance in the 6-minute-walk-test. Improvements in other functional parameters, as well as in quality of life and pain, were achieved in both groups. The higher proportion of working patients in the intervention group (64.6%; P=.01) versus the control group (46.2%) is of note. Conclusions: The effect of the investigated telerehabilitation therapy in patients following knee or hip replacement was equivalent to the usual aftercare in terms of functional testing, quality of life, and pain. Since a significantly higher return-to-work rate could be achieved, this therapy might be a promising supplement to established aftercare.
... The current telerehabilitation offerings should be adapted to the individual and indication-specific needs of the patients and should enable contact with the supervising therapists. However, this could not be investigated with the currently available systems, as they are either not specific enough for the indications of a patient or do not offer a tool to communicate with a therapist [16][17][18][19][20][21][22]. The telerehabilitation systems studied until now often differ in terms of their communication structures and their feedback options. ...
Article
Full-text available
Background: Telerehabilitation can contribute to the maintenance of successful rehabilitation regardless of location and time. The aim of this study was to investigate a specific three-month interactive telerehabilitation routine regarding its effectiveness in assisting patients with physical functionality and with returning to work compared to typical aftercare. Objective: The aim of the study was to investigate a specific three-month interactive telerehabilitation with regard to effectiveness in functioning and return to work compared to usual aftercare. Methods: From August 2016 to December 2017, 111 patients (mean 54.9 years old; SD 6.8; 54.3% female) with hip or knee replacement were enrolled in the randomized controlled trial. At discharge from inpatient rehabilitation and after three months, their distance in the 6-minute walk test was assessed as the primary endpoint. Other functional parameters, including health related quality of life, pain, and time to return to work, were secondary endpoints. Results: Patients in the intervention group performed telerehabilitation for an average of 55.0 minutes (SD 9.2) per week. Adherence was high, at over 75%, until the 7th week of the three-month intervention phase. Almost all the patients and therapists used the communication options. Both the intervention group (average difference 88.3 m; SD 57.7; P=.95) and the control group (average difference 79.6 m; SD 48.7; P=.95) increased their distance in the 6-minute-walk-test. Improvements in other functional parameters, as well as in quality of life and pain, were achieved in both groups. The higher proportion of working patients in the intervention group (64.6%; P=.01) versus the control group (46.2%) is of note. Conclusions: The effect of the investigated telerehabilitation therapy in patients following knee or hip replacement was equivalent to the usual aftercare in terms of functional testing, quality of life, and pain. Since a significantly higher return-to-work rate could be achieved, this therapy might be a promising supplement to established aftercare. Trial registration: German Clinical Trials Register DRKS00010009; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010009.
Article
Full-text available
Objective The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation. Design: Scoping review Literature search A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library. Study selection criteria All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included. Data synthesis The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool. Results There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88–99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT. Conclusion The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER). Pre-registration OSF:https://osf.io/9ku8a/
Thesis
Einleitung Die Implantation einer Knie- oder Hüft-Totalendoprothese (TEP) ist eine der häufigsten operativen Eingriffe. Im Anschluss an die Operation und die postoperative Rehabilitation stellt die Bewegungstherapie einen wesentlichen Bestandteil der Behandlung zur Verbesserung der Gelenkfunktion und der Lebensqualität dar. In strukturschwachen Gebieten werden entsprechende Angebote nur in unzureichender Dichte vorgehalten. Zudem zeichnet sich ein flächendeckender Fachkräftemangel im Bereich der Physiotherapie ab. Die Tele-Nachsorge bietet daher einen innovativen Ansatz für die postrehabilitative Versorgung der Patienten. Das Ziel der vorliegenden Untersuchung war die Überprüfung der Wirksamkeit einer interaktiven Tele-Nachsorgeintervention für Patienten mit Knie- oder Hüft-TEP im Vergleich zur herkömmlichen Versorgung (usual care). Dazu wurden die Funktionalität und die berufliche Wiedereingliederung untersucht. Methode Zwischen August 2016 und August 2017 wurden 111 Patienten (54,9 ± 6,8 Jahre, 54,3 % weiblich) zu Beginn ihrer stationären Anschlussheilbehandlung nach Implantation einer Knie- oder Hüft-TEP in diese randomisiert, kontrolliert, multizentrische Studie eingeschlossen. Nach Entlassung aus der orthopädischen Anschlussrehabilitation (Baseline) führte die Interventionsgruppe (IG) ein dreimonatiges interaktives Training über ein Telerehabilitationssystem durch. Hierfür erstellte ein betreuender Physiotherapeut einen individuellen Trainingsplan aus 38 Übungen zur Verbesserung der Kraft sowie der posturalen Kontrolle. Zur Anpassung des Trainingsplans übermittelte das System dem Physiotherapeuten Daten zur Quantität sowie zur Qualität des Trainings. Die Kontrollgruppe (KG) konnte die herkömmlichen Versorgungsangebote nutzen. Zur Beurteilung der Wirksamkeit der Intervention wurde die Differenz der Verbesserung im 6MWT zwischen der IG und der KG nach drei Monaten als primärer Endpunkt definiert. Als sekundäre Endpunkte wurden die Return-to-Work-Rate sowie die funktionelle Mobilität mittels des Stair Ascend Tests, des Five-Times-Sit-to-Stand Test und des Timed Up and Go Tests untersucht. Weiterhin wurden die gesundheitsbezogene Lebensqualität mit dem Short-Form 36 (SF-36) und die gelenkbezogenen Einschränkungen mit dem Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) evaluiert. Der primäre und die sekundären Endpunkte wurden anhand von baseline-adjustierten Kovarianzanalysen im intention-to-treat-Ansatz ausgewertet. Zusätzlich wurde die Teilnahme an Nachsorgeangeboten und die Adhärenz der Interventionsgruppe an der Tele-Nachsorge erfasst und evaluiert. Ergebnisse Zum Ende der Intervention wiesen beide Gruppen einen statistisch signifikanten Anstieg ihrer 6MWT Strecke auf (p < 0,001). Zu diesem Zeitpunkt legten die Teilnehmer der IG im Mittel 530,8 ± 79,7 m, die der KG 514,2 ± 71,2 m zurück. Dabei betrug die Differenz der Verbesserung der Gehstrecke in der IG 88,3 ± 57,7 m und in der KG 79,6 ± 48,7 m. Damit zeigt der primäre Endpunkt keine signifikanten Gruppenunterschiede (p = 0,951). Bezüglich der beruflichen Wiedereingliederung konnte jedoch eine signifikant höhere Rate in der IG (64,6 % versus 46,2 %; p = 0,014) festgestellt werden. Für die sekundären Endpunkte der funktionellen Mobilität, der Lebensqualität und der gelenkbezogenen Beschwerden belegen die Ergebnisse eine Gleichwertigkeit beider Gruppen zum Ende der Intervention. Schlussfolgerung Die telemedizinisch assistierte Bewegungstherapie für Knie- oder Hüft-TEP Patienten ist der herkömmlichen Versorgung zur Nachsorge hinsichtlich der erzielten Verbesserungen der funktionellen Mobilität, der gesundheitsbezogenen Lebensqualität und der gelenkbezogenen Beschwerden gleichwertig. In dieser Patientenpopulation ließen sich klinisch relevante Verbesserungen unabhängig von der Form der Bewegungstherapie erzielen. Im Hinblick auf die berufliche Wiedereingliederung zeigte sich eine signifikant höhere Rate in der Interventionsgruppe. Die telemedizinisch assistierte Bewegungstherapie scheint eine geeignete Versorgungsform der Nachsorge zu sein, die orts- und zeitunabhängig durchgeführt werden kann und somit den Bedürfnissen berufstätiger Patienten entgegenkommt und in den Alltag der Patienten integriert werden kann. Die Tele-Nachsorge sollte daher als optionale und komplementäre Form der postrehabilitativen Nachsorge angeboten werden. Auch im Hinblick auf den zunehmenden Fachkräftemangel im Bereich der Physiotherapie und bestehende Versorgungslücken in strukturschwachen Gebieten kann der Einsatz der Tele-Nachsorge innovative und bedarfsgerechte Lösungsansätze bieten.
Article
Full-text available
The use of focus groups as a qualitative method for rapid assessment is discussed. A focus-group session is an in-depth discussion in which a small number of people (usually 8-12) from the target population discuss topics that are of importance for a particular study or project. Generally the participants are chosen purposively, and it is recommended that they should be homogeneous with respect to characteristics which might otherwise impede the free flow of discussion. Focus groups can be used for idea generation, in conjunction with a quantitative method, or as a primary data-collection method. However, if focus groups are used as a primary data-collection method, their results must be treated with caution. The main advantage of using focus-group discussions during rapid assessment is that they provide in-depth information without requiring full-scale anthropological investigations. The informal group setting is believed to make people feel at ease, encouraging them to express their views freely. However, there are a number of limitations to focus-group discussions. The samples are small and purposively selected, and therefore do not allow generalization to larger populations. In addition, as with other qualitative methods, the chances of introducing bias and subjectivity into the interpretation of the data are high. There are a number of methodological issues which still need to be addressed in order to further develop the method. Little is known about how many discussion sessions are needed to be reasonably sure that most aspects related to the subject of inquiry have been explored.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
An end-result analysis is presented of thirty-nine mold arthroplasties performed at the Massachusetts General Hospital between 1945 and 1965 in thirty-eight consecutive private patients for arthritis of the hip following fractures of the acetabulum or dislocations of the hip. Of the nineteen unilateral cases in the second half of the series, sixteen were rated good or excellent. Results in the second half of the series were significantly better statistically than those in the first half of the series. Possible reasons for this improvement are discussed. No significant deterioration occurred with the passage of time. Among the thirty-nine hips, three revisions were required. One patient had postoperative sepsis after arthroplasty. Four patients who had had intra-articular sepsis prior to arthroplasty showed no evidence of sepsis postoperatively. Factors influencing the choice between hip fusion and hip arthroplasty in these cases are presented. A new system for rating hip function is proposed and is compared with the systems of Larson and Shepherd.
Article
The indications, contraindications, design, and technic of insertion of the duocondylar total knee replacement are presented to report that the immediate results are encouraging but so much information is lacking about durability that only the most cautious use is justifiable at this time.
Article
The Functional Independence Measure-Function Related Groups (FIM-FRGs) were developed to classify medical rehabilitation inpatients into homogeneous groups based on length of stay (LOS). Patients are first grouped into clinically relevant rehabilitation impairment categories, then by functional status, as expressed by the FIM, and in certain cases by patient age. The statistical approach used to form the final groupings was a recursive partitioning algorithm applied to the FIM scores and patient age within impairment category. This analysis compares four FIM-FRG classification schemes developed from four scale sets that combine FIM items differently: (1) use of the 18 FIM items as separate variables, (2) the combination of FIM items into six clinical subscales, (3) the combination of the six clinical subscales into motor and cognitive subscales, and (4) the combination of all FIM items into a single scale. The FIM-FRG schemes explain similar amounts of variance in the logarithm of LOS and contain approximately equal numbers of FRGs. The motor and cognitive subscale scheme is recommended for use in payment, however, this scheme and the other schemes have additional uses. Each FRG scheme provides different insight into the clinical relationship between disability and LOS.
The present study was undertaken to investigate the effect on ergonomic conditions by Labour Inspectorate intervention at the work place and to follow health and employment among occupationally injured. 195 reports on occupational musculo-skeletal injury (accidents and diseases) from men and women with different occupations were collected consecutively at three Labour Inspectorate offices. Fifteen Labour Inspectors volunteered to investigate half of the reports by work place visits within three months. The other half was kept for control. The inspectors were trained in ergonomics and also got complementary training in ergonomic work place assessment. A check-list was designed for the purpose and tested for validity and reliability. Eighteen months after the time of the injury reports, all work places were visited by ergonomists to evaluate possible improvements in ergonomic conditions. Due to turnover and prolonged sick-leaves, evaluations were performed for only 92 of the injured. At 160 work places other employees had performed similar tasks as the injured at the time of the injury report. Evaluations of possible improvements in ergonomic conditions were performed also for these employees. As regards changes at the work place there were no differences between the injured in the study and control groups. The inspectors had delivered 11 inspection notices to the employers demanding improvements for the injured and 14 notices regarding the conditions of work-mates. For this latter group there was a significant association between delivered notices and improved ergonomic conditions eighteen months after the reports. Three years after the time of the reports a postal questionnaire on health, psychological well-being and employment was distributed to the injured. The response rate was 93%. Questionnaire answers were compared to results from other studies, where identical questions were used. There was a significantly higher prevalence of musculo-skeletal and psychological symptoms in the study group compared to data from population groups. Activities in daily life were more restricted in the study group. 109 persons were in active employment. The association between the two effect measures improved ergonomic conditions and active employment, and both individual and work-related characteristics was analysed. The odds for improved working conditions were increased where the employer had given an informative injury description in the injury report, probably indicating that an understanding of the mechanisms of injury is a prerequisite for effective prevention. Sick-leaves for more than 6 months during the year following the report had a significant negative association with active employment, whereas male sex and higher education, respectively, had a positive association. The studied musculo-skeletal injuries were associated with a high prevalence of physical and psychological symptoms. Identification and investigation of ergonomic hazards, as appearing in informative reports on the origin of injuries and in inspection notices, seemed to have a positive influence on the process of prevention.
Article
Human factors engineering and system design are critical elements in the newly developing field of telerehabilitation. Telerehabilitation is the remote delivery of rehabilitative services such as monitoring, training, and long-term care of persons with disabilities using telecommunications technology. This paper describes projects at the Rehabilitation Engineering Research Center (RERC) on Telerehabilitation in the context of three conceptual models: telecounseling and training, telemonitoring and assessment, and teletherapy. Issues pertaining to human factors engineering design are identified, and ongoing challenges are discussed.