Home-Based Rehabilitation Found As Effective As Inpatient After Knee Replacement

MedicalResearch.com Interview with:
Justine M. Naylor, PhD
Braeside Hospital, HammondCare, Australia
South West Sydney Clinical School, University of New South Wales, Liverpool Hospital
South West Sydney Local Health District, Liverpool 2170, NSW, Australia

MedicalResearch.com: What is the background for this study?

Response: Total knee arthroplasty (replacement) for end-stage arthritis is a very successful procedure for relieving the associated pain and functional impairments. Formalized rehabilitation following the surgery is also considered an essential adjunct to optimise recovery. World-wide, the volume of knee arthroplasty surgeries is increasing each year. In the US, for example, the prevalence of this surgery increased 11-fold from 1980 to 2010. The costs of the procedures (including the acute and rehabilitation costs) are also increasing. Because of these trends, there is concern for the future sustainability of these procedures. Research devoted to identifying the most cost-effective strategies in this field is required.

Our group conducted a randomized trial comparing 10-days of inpatient rehabilitation to a simple, clinician-monitored home program in people who underwent total knee arthroplasty for end-stage osteoarthritis. Inpatient rehabilitation in a rehabilitation facility is commonly provided after knee arthroplasty in various countries including Australia, the US and Switzerland, and is comparatively expensive. In particular, it is a commonly available option for people with private healthcare insurance. Essentially, we wanted to compare 2 extremes – a resource-intensive program to one with far less resource requirements. Because patients who experience complications immediately after surgery may require inpatient rehabilitation to aid their recovery, we only included patients who did not experience a significant complication while in hospital, thus, were otherwise deemed able to be discharged directly home.

MedicalResearch.com: What are the main findings?

Response: We randomized 165 public (Medicare) patients to the treatment groups – 81 received inpatient therapy plus the home program, and 84 received the home program only. The home program required patients to attend 2-3 clinic sessions over an 8-week period. The patient group was typical for this type of surgery – average age of participants was 67 yrs and most (68%) were female. Another 87 formed an observational group and received the home program only. Compliance with the programs was excellent and very few people were lost to follow-up.

We observed no significant differences between the inpatient and home-based groups across a range of outcomes at 10, 26 and 52 weeks after surgery. There were improvements in all groups in walking speeds, and their self-reported knee pain and function, and health-related quality of life, but the improvements were similar regardless of the rehabilitation program received. A minority of patients (around 12%) were in paid employment at the time of surgery; weeks taken to return to work were similar in both randomized groups. Interestingly, satisfaction with the rehabilitation program was significantly higher for those in the inpatient group (92 vs 83%), but both were well received generally. The higher satisfaction with the inpatient program was not entirely unexpected as the inpatient model is associated with conveniences such as not having to cook for yourself and ready access to many health professionals.

We did not conduct a cost-effectiveness analysis as this is generally only required if differences between treatments are found.

MedicalResearch.com: What should readers take away from your report?

Response: For people who undergo total knee arthroplasty for osteoarthritis, participation in an inpatient rehabilitation program does not guarantee a better recovery compared with a much simpler program. This is important given the expected cost differentials in the provision of these programs. In Australia, private health insurers reimburse inpatient rehabilitation facilities approximately $700 per day and knee arthroplasty patients stay, on average, for 12 days. These costs far exceed the physical therapy costs associated with a simple home program. Adoption of simpler rehabilitation models should help reduce upward pressure on private health insurance premiums, thus encouraging people to maintain their private insurance cover. This too is very important because the private health sector helps reduce the burden on the public health sector.

It is also important for people to know that if they do not have access to inpatient rehabilitation facilities after this type of surgery (such as those who live in rural areas or are not privately insured), they are not being disadvantaged as less intensive rehabilitation is associated with similar recovery in mobility, function and quality of life.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: We would recommend further investigations into whether this outcome is replicated with other procedures, for example, total hip arthroplasty. We would also suggest the need for research identifying which patient groups do benefit most from inpatient rehabilitation.

MedicalResearch.com: Is there anything else you would like to add?

Response: The study was funded in part by the HCF Research Foundation. The funder had no influence in the study design or presentation of the results.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.


Buhagiar MA, Naylor JM, Harris IA, Xuan W, Kohler F, Wright R, Fortunato R. Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee ArthroplastyThe HIHO Randomized Clinical Trial. JAMA. 2017;317(10):1037-1046. doi:10.1001/jama.2017.1224

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