Accepted Manuscript

Title: Telerehabilitation is non-inferior to usual care following

total hip replacement – A randomized controlled
non-inferiority trial

Authors: M. Nelson, M. Bourke, K. Crossley, T. Russell

PII: S0031-9406(18)30224-4
DOI: https://doi.org/10.1016/j.physio.2019.06.006
Reference: PHYST 1115

To appear in: Physiotherapy

Please cite this article as: Nelson M, Bourke M, Crossley K, Russell T,

Telerehabilitation is non-inferior to usual care following total hip replacement
– A randomized controlled non-inferiority trial, Physiotherapy (2019),
https://doi.org/10.1016/j.physio.2019.06.006

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Telerehabilitation is non-inferior to usual care following total hip replacement – A randomized

controlled non-inferiority trial

Mr Nelson, M, BPhty (Hons), Director of Physiotherapya,* mark.nelson@health.qld.gov.au,

Bourke, M, BPhty, PhD, Adjunct Senior Lecturer b m.bourke@uq.edu.au, Crossley, K,

Professorc k.crossley@latrobe.edu.au, Russell, T, Professorb t.russell@uq.edu.au

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a
QEII Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Australia

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b
Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane,

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Australia

c
La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and

Engineering, Melbourne, Australia U

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*
Corresponding author: Department, Physiotherapy, Institution, QEII Jubilee Hospital, Coopers Plains,
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Brisbane, 4109, Australia

Tel. +61 7 3182 6974, Mob, +61 431 673 389

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Email mark.nelson@health.qld.gov.au
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Abstract:

Objectives: Determine if outpatient physiotherapy care via telerehabilitation is as effective as in-

person physiotherapy care after total hip replacement.

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Design: Randomised, single-blind, controlled, non-inferiority clinical trial.

Setting: QEII Jubilee Hospital, Brisbane, Australia.

Participants: Seventy patients receiving a total hip replacement entered the study, sixty-nine

completed the study.

Interventions: The control group (n=35; 𝑥 age 67; female 60%) received in-person outpatient

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physiotherapy and a paper-based home exercise programme. The intervention group (n=35; 𝑥 age

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62; female 66%) received remotely delivered telerehabilitation directly into their homes and a

technology-based home exercise program using an iPad application.

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Main outcome measures: The primary outcome was the quality of life subscale of the Hip disability

and Osteoarthritis Outcome Score measured at six weeks post-operatively. Secondary outcomes

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included objective strength and balance outcomes, self-reported function and satisfaction outcomes,
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and home exercise program compliance.
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Results: No between group difference was detected in the Hip disability and Osteoarthritis Outcome
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Score quality of life subscale at the primary end point of six weeks (p= 0.970). Strength, balance and
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self-reported function showed no between group differences. Overall satisfaction was high across

both groups, with the intervention group scoring higher for ease of attending appointments
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(intervention 95 (10), control 86 (18), mean difference 9 (95% CI 2 - 16), p=0.017. The intervention

group were more compliant with their home exercise programme (intervention 86% (20%), control
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74% (26%), mean difference 12% (95% CI 0.5% - 23%), p=0.048).

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Conclusions: Telerehabilitation programmes can be delivered to total hip replacement patients in

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their own homes, using readily available technology while maintaining high levels of satisfaction.

More importantly, telerehabilitation patients appear to achieve non-inferior physical and functional

outcomes as those receiving in-person rehabilitation programmes.

Telerehabilitation Following THR Page 2 of 25

Trial Registration: ACTRN12615000824561. (Australian New Zealand Clinical Trials Registry)

Contribution of the Paper:

Key messages:

- Telerehabilitation for post-operative THR patients achieves non-inferior physical and self-

reported outcomes to in-person rehabilitation

- Telerehabilitation can successfully be delivered directly into the homes of THR patients

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- Telerehabilitation achieves equally high levels of patient satisfaction to in-person

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rehabilitation

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New knowledge added by this study:

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- This paper provides evidence that outpatient telerehabilitation is non-inferior to in-person

rehabilitation in the THR population

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Key words: Arthroplasty Replacement Hip, Randomized Controlled Trial, Telemedicine, Physical
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Therapy Specialty
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Manuscript:
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Introduction
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Hip replacement is the gold standard treatment for severe hip osteoarthritis. A rising trend has seen

an increase of approximately 55% in procedures over the last decade, with over 45,000 and 85,000

hip replacements being performed in Australia and the United Kingdom respectively in 2016 [1, 2].

Telerehabilitation Following THR Page 3 of 25

Optimizing acute post-operative care after THR through enhanced recovery programmes is effective

in reducing length of hospital stay and improving patient outcomes [3, 4]. These programmes include

pre-operative consultation, multimodal analgesia and early physiotherapy intervention.

Optimal care beyond discharge from hospital remains unknown. Effectiveness of physical

rehabilitation for THR patients following discharge is supported by evidence [5-9] but variation

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amongst existing trials prevents conclusions on the optimal programmes. Documented rehabilitation

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strategies include arm ergometer interval exercise [5], aerobic type dance routines [10], strength and

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range of motion (ROM) exercises with and without resistance [6-8, 11, 12] and walking programmes

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[8, 12]. Programmes also vary with respect to quantity, timing to commencement and frequency [5-

8, 10-13]. Timing to commencement ranges from immediately following hospital discharge [6] to

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greater than six months post-operatively [10, 13], and frequency from twice daily [13] to twice
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weekly [10].
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A national survey of Australian physiotherapists (116/151, 77%) from public and private facilities
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revealed usual care physiotherapy generally consists of: patients are referred for outpatient
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physiotherapy following hospital discharge, programs involve three to four total sessions of

physiotherapy at a frequency of one to two times per fortnight; programs commence within two
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weeks of hospital discharge and last five to six weeks; physiotherapy sessions include strengthening
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of hip abductors and extensors, hip and knee flexors, education on hip precautions and exercise

progression, gait re-training, stairs practice, ROM exercises for hip abduction, extension and flexion;
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physiotherapy sessions are complemented by a home exercise program (HEP) [14].

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Accessing post discharge care at facilities is difficult for THR patients due to challenges associated

with driving and transport[15]. Domiciliary services incur financial costs [16] that impact on the

feasibility of this option. Travelling distances and duration compound access barriers for non-

metropolitan patients [17, 18]. Alternatively, a telerehabilitation model of care delivering

rehabilitation programmes directly into patients’ homes has the potential to address access issues.

Efficacy of telerehabilitation after total knee replacement (TKR) compared to in-person programmes

has been demonstrated [19-21] with comparable physical and functional outcomes achieved while

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maintaining high levels of patient satisfaction [22, 23]. Similar research for the THR population

remains unreported.

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This study aimed to determine, is a telerehabilitation model of care delivered remotely, non-inferior

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to in-person rehabilitation for total hip replacement patients following hospital discharge?
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Methods

The methods for this study are published in a detailed protocol manuscript (ACTRN12615000824561)
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[24].
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Design
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A single centre, randomised, single-blind, controlled, non-inferiority clinical trial was conducted

comparing a technology-based outpatient THR rehabilitation programme to in-person care.

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Participants received a six week intervention and were followed up for six months. Outcomes were

collected at baseline (pre-operatively), discharge from inpatient physiotherapy, six weeks and six

months post-operatively. The primary analysis timepoint was six weeks.

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Randomisation using a random numbers generator allocated participants to the in-person (control)

or telerehabilitation (intervention) group.

Participants and care providers were not blinded to allocation. The physiotherapists assessing

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outcomes at each time point were blinded to group allocation.

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Participants, therapist, centres

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All patients undergoing primary THR between September 2015 and April 2017 at “X” were invited by

a physiotherapist to consent to participation.

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Participants were eligible for inclusion if: they were undergoing primary elective THR, could attend
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five in-person appointments, and were able to independently provide signed informed consent.
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Participants were excluded if: they had comorbidities preventing participation in rehabilitation, were
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undergoing revision THR, experienced intraoperative complications that prevented participation in

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the Queensland Health inpatient THR clinical pathway, or were unable to mobilize full weight-
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bearing.
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Participants formally entered the study and were randomized following their operation after

intraoperative complications were excluded.

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Intervention

Interventions [24] for both groups were performed by registered physiotherapists who were trained

in the delivery of a standardised exercise programme. The programme was progressed based on the

physiotherapists’ assessment during the six-week intervention period. At the conclusion of the

intervention period, all participants were provided with a paper-based HEP to continue

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independently.

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All participants had outcome measures collected during an in-person assessment at six weeks post-

operatively by a blinded physiotherapist. Additional in-person sessions were provided if blinded

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assessment revealed reliance on a walking aid during the Timed Up and Go test (TUG) [25] if
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preoperatively the participant had mobilised unaided. All sessions beyond the six-week intervention
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period were in-person appointments, regardless of allocation to the control or intervention group.
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In-person

On discharge from hospital the control group received usual care [14] defined as a standardized
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paper-based HEP targeting strengthening exercises for quadriceps, hip abductors, extensors, and
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flexors. Participants were instructed to perform the HEP three times daily and self-monitor
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compliance using an exercise diary. At two, four, and six weeks post-operatively participants

attended the QEII Jubilee Hospital physiotherapy outpatient department for a 30-minute in-person
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physiotherapy session focussing on gait and reviewing and progressing their HEP.

Telerehabilitation Following THR Page 7 of 25

Telerehabilitation

The intervention programme was identical in content to the control programme, with the mode of

delivery being via telerehabilitation technology on an Apple iPadTM into participants’ homes. Two

applications were used to deliver this programme. HEPs were facilitated using the Wellpepper clinic

(Wellpepper Inc, Seattle, WA) application and physiotherapy sessions conducted via the eHAB

application (NeoRehab, Brisbane, Australia). Wellpepper enables health care professionals to create

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exercise programs for patients to follow on a tablet device. The application provides videos and

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instructions of the HEP. The physiotherapist used Wellpepper to monitor HEP compliance and

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communicate via the in-built messaging feature. eHAB is a clinically validated telerehabilitation

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system that enables real-time videoconferencing into the home.

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One to two days prior to discharge, the intervention group were loaned an iPad with Wellpepper and
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eHAB installed to use for the duration of the six-week intervention period. They underwent 15
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minutes of training then independently familiarised themselves with the applications prior to

discharge. All iPads were enabled with prepaid mobile internet access used for the duration of the
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intervention.
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The intervention group received three automated reminders per day via Wellpepper to perform their
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HEP. Two weeks after discharge, the intervention group received a physiotherapy session via real-
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time videoconferencing using eHAB where analysis and advice regarding gait and their HEP were
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undertaken. If deficiencies were apparent in mobility (gait pattern and reliance on walking aid) or the

ability to perform their HEP at this time, an additional eHAB appointment at four weeks post-

Telerehabilitation Following THR Page 8 of 25

operatively was scheduled. Participants continued to use Wellpepper to facilitate their rehabilitation

until six weeks postoperatively.

Outcome Measures

Outcome measures were collected at four time points, pre-operatively, day of discharge from in-

patient physiotherapy, six weeks and six months post-operatively. Per the study protocol [24], not all

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outcome measures were collected at each time point.

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Primary Outcome

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The primary outcome was the Quality of Life (QOL) subscale of the Hip disability and Osteoarthritis

Outcome Score (HOOS), collected at six weeks. The HOOS is a self-administered questionnaire that
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assesses participants’ opinions about their hip and associated problems, and evaluates symptoms
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and functional limitations related to the hip during a therapeutic process [26]. The HOOS consists of
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five subscales; pain, other symptoms, function in daily living, function in sport and recreation, and
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hip related QOL. A five item Likert scale (0-4) is scored from which a normalized score is calculated

for each subscale (100 indicating no symptoms and 0 indicating extreme symptoms). The HOOS has
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established content validity in a THR population and high test-retest reproducibility (ICC >0.78)[26,

27].
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Secondary Outcome Measures

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Questionnaires

Functional health and well-being from was measured using the Short Form-12 (SF-12) [28]. Health

related QOL was assessed using the EuroQol 5-Dimension 5 Level questionnaire (EQ-5D-5L) [29]. A

satisfaction questionnaire pertaining to the rehabilitation programme they received was completed

[30].

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Physical Outcomes

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Functional mobility was assessed via the TUG, a reliable and valid test for quantifying functional

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mobility and following clinical change over time [25]. Hip strength (flexion, extension, abduction,

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adduction, internal rotation, and external rotation) and knee strength (extension) were measured as

peak isometric force (kgs) using a calibrated Lafayette 01165 manual muscle dynamometer. All

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assessors were trained by the primary investigator to ensure a standardised method of muscle
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testing. Dynamic standing balance was assessed via the step test, a reliable balance outcome
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measure in the hip osteoarthritis and postsurgical hip fracture populations [31, 32].
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Other Outcomes
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The System Usability Scale was completed by the intervention group, a reliable tool for measuring

usability of a technology-based system [33]. Intervention group HEP compliance was collected via the
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Wellpepper application. The control group completed a paper-based exercise diary. If a participant
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completed at least one set of an exercise from their HEP, that day was considered compliant.
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Telerehabilitation Following THR Page 10 of 25

Data Analysis

The non-inferiority power calculation described by Jones [34] was used to determine sample size and

is described in detail in the protocol paper [24]. In summary, a minimal clinically important

improvement (MCII) for the quality of life (QOL) subscale (17 points) of the HOOS [26] was applied as

the non-inferiority delta margin. Calculations were based on 80% power and an alpha value of 0.05.

A sample size of 30 participants per study arm was calculated. Allowing for a 15% dropout rate, a

sample size of 35 participants per group (n=70) was recruited.

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Intention-to-treat analyses as recommended in the extension of the Consolidated Standards of

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Reporting Trials (CONSORT) guideline for non-inferiority trials was performed [35]. Prior to statistical

analysis, data was tested for normality as per the assumptions of parametric statistics. Data failing to

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meet these assumptions was analysed via non-parametric equivalents. Statistical analysis of group
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differences at baseline (demographic information, physical outcomes and self-report questionnaire
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results) were conducted. Ratio and interval data were analysed using a univariate general linear
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model with the intervention group and time as fixed factors. The interaction of time and group was
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then used to compare groups. This test is commonly used for comparing the means of two

independent groups. Nominal data was compared using the non-parametric Mann-Whitney U test.
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Non-inferiority of the intervention was implied if the lower limit of a 1-sided 95% confidence interval
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of the difference between groups between baseline and six weeks was within the pre-stated MCII

value of 17 points for the HOOS QOL subscale [36]. Analysis with a linear mixed model (LMM) was
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also performed to ensure no statistically significant differences existed between groups. The

outcome of primary interest was the interaction effect between group and time. An alpha level of

0.05 was used. Generalised estimating equations were used to analyse between group differences

Telerehabilitation Following THR Page 11 of 25

for ordinal data. A baseline difference in age was detected between groups and therefore was used

as a covariate for all intervention effect analyses.

Results

Flow of participants, therapists and centres through the study

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Participant flow is outlined in Figure 1. Seventy participants were enrolled in the study with 69

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receiving the allocated intervention. All 34 telerehabilitation participants received their two-week

telerehabilitation appointment and 17 (50%) went on to have an additional four-week

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telerehabilitation appointment. From the in-person group, one patient failed to attend at two weeks,

three failed to attend at four weeks and one failed to attend at six weeks. Ten participants received

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additional physiotherapy following the six-week intervention period, six from the control group, four
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from the intervention group. The number of additional appointments received ranged from one to
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four. The six control group participants received an average of 2.2 additional sessions each compared
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to 1.8 for the four intervention participants.

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Baseline characteristics
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Baseline comparisons are outlined in table 1. Age was used as a covariate in all intervention effect

analyses to control for the baseline difference detected.

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Intervention Effects
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Primary Outcome

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Mean change from baseline to six weeks for the HOOS QOL subscale revealed no between group

difference (control 46 (SD 18), intervention 44 (SD 28)) (Figure 2). Non-inferiority for the primary

outcome was implied given the lower limit of a 1-sided 95% confidence interval of the difference

between groups between baseline and six weeks (12.9) is within the pre-stated MCII value of 17

points for the HOOS QOL subscale.

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Linear mixed model analysis indicated no between group difference in the HOOS QOL subscale

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(p=0.52). A time effect was present indicating an improvement in both groups over time (p=<0.001),

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however there was no group-by-time interaction (p=0.92) (Table 2).

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Secondary Outcomes U
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As per Table 2, all HOOS subscales, SF-12 and EQ-5D showed no between group differences. The
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same was true for the TUG, step test and muscle strength (Table 3). Significant improvements in
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muscle strength across time were seen for knee extension (p=0.001) and hip internal rotation
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(p=0.002). Hip extension (p=0.055), hip adduction (p=0.137, hip abduction (p=0.865) and hip flexion

(p=0.224) all demonstrated no change over time. Hip external rotation strength significantly
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decreased across time (p=<0.001).

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Satisfaction was high (>85%) across both groups for all 14 items in the health care satisfaction

questionnaire (appendix 1) [30]. The only between group difference was for the item ‘my therapy

session was easy to attend’ in which the intervention group scored higher (intervention 95 (10),

control 86 (18), mean difference 9 (95% CI 2 - 16), p=0.017). Results were identical for the overall

satisfaction item, ‘in general, you were satisfied with the health care and services you received’

(intervention 97 (10), control 97 (10), p=0.96).

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The intervention group were more compliant with their HEP with an overall compliance of 86% (SD

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20%) compared to 74% (SD 26%) for the control group (mean difference 12% (95% CI 0.5% - 23%),

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(p=0.048).

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Wellpepper (𝒙=88%, SD 12%) and eHAB (𝒙=88%, SD 16%) both scored highly on the system usability
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scale [37] indicating participants found them user friendly. Additionally, over 85% of participants
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from the intervention group agreed or strongly agreed to questions pertaining to the ease of seeing
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(25/28, 89%) and hearing (25/29, 86%) their therapist while using eHAB.
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Discussion
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Remotely delivered telerehabilitation for post-operative THR is non-inferior to in-person

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rehabilitation assessed by the primary outcome of the HOOS QOL subscale at six weeks post-
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operatively. This supports previous trials demonstrating the efficacy of telerehabilitation in

orthopaedic populations [19-21].

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Previous orthopaedic telerehabilitation studies have been either short interventions (two weeks),

involved simulated home environments or required research assistants to assist participants with set

up. This study’s unique strength is the remote delivery of a six-week intervention into participants’

homes, without on-site technical support, or any pre-requisites for quality of internet connection or

mobile data coverage, giving it wide generalisability to the Australian population. Further, the

technology used in this study (iPads and widely available applications) are readily accessible and

commonly owned by the general population.

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Non-inferiority for intervention effects was demonstrated across a broad range of outcomes

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including self-reported function, QOL and satisfaction, balance, strength and compliance with HEP.

Satisfaction scores for ‘my appointment was easy to attend’ and HEP compliance rates were the only

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outcomes where a difference was detected, both favouring the intervention group. Difference
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between these two outcomes is unsurprising given the convenience of physiotherapy interventions
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delivered directly into one’s home and daily reminders via the Wellpepper application to complete
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the HEP.
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An unexpected result of this study was the lack of significant strength gains in some muscles over

time, namely hip extension, adduction, abduction and flexion. Of particular note was a reduction in
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external rotation muscle strength at six weeks and six months compared to baseline. Post-operative
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strength deficits in hip extension, hip abduction, knee flexion and extension compared to healthy

populations are reported in THR populations [38, 39] however deficits in hip external rotation are
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not. One explanation may be that 93% (65/70) of participants in this study received a posterior

approach where external rotators were divided and variably repaired, possibly leading to low

Telerehabilitation Following THR Page 15 of 25

external rotation strength. Regardless, self-reported outcomes, TUG and step test showed significant

improvement over time, questioning the functional relevance of this incidental finding.

Methodological factors such as the use of randomisation, validated outcome measures and low drop-

out rates strengthen this study. However, certain limitations must be considered. Despite

randomisation, the intervention group was younger. It is possible that age may influence the rate of

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recovery post-operatively and may also influence the attitude of the participants toward the use of

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technology for rehabilitation. In an attempt to control for this factor, age was included as a covariate

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in all intervention analyses.

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Some participants elected not to be involved in the trial due to unwillingness to undertake a
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telerehabilitation programme. Offsetting this were a group of patients who were willing to
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participate in the trial and take advantage of the convenience that telerehabilitation offers.
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Unfortunately, many of these participants were excluded due to their inability to travel to the

hospital for appointments should they have been randomised to the control group.
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Another potential weakness was the same experienced orthopaedic physiotherapist delivered all of
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the telerehabilitation sessions, while the control group was managed by multiple physiotherapists.
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Participants in the control group may not have always seen the same physiotherapist for each

session. Consistency of therapist in the intervention group could have led to greater satisfaction
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given a stronger therapist-participant relationship.

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Adherence was recorded automatically via the Wellpepper application for the telerehabilitation

group, whereas the in-person group were required to complete a paper diary. The automatic nature

of data collection in the telerehabilitation group meant participants were perhaps not acutely aware

of data collection. The self-reported approach by the in-person group may be prone to inflated

scoring by participants leading to overestimation of adherence rates [40]. Despite this, the

telerehabilitation group achieved a significantly higher rate of compliance.

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This study demonstrates telerehabilitation programs can be delivered to THR patients in their own

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homes, using readily available technology while maintaining high levels of satisfaction. More

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importantly, telerehabilitation patients appear to achieve non-inferior physical and functional

outcomes as those receiving in-person rehabilitation programmes.

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With the emphasis placed on clinicians and service providers to deliver value-based healthcare,
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future research should concentrate on developing and evaluating telerehabilitation models for
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existing physiotherapy interventions backed by a strong evidence base. Gaining a stronger

understanding of the applicability of telerehabilitation to varying demographic groups (elderly, ethnic

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background, educational background) is important for its development. Ensuring new

telerehabilitation models are easily translatable will enhance uptake, and ultimately improve patient
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choice and care.

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Funding: This work was supported by the Queensland Orthopaedic Physiotherapy Network.

Declaration of Interest: One author (Trevor Russell) has a material interest in the eHAB

telerehabilitation system used in this study. To prevent bias, Trevor was not involved in the collection

of data or analysis of results for this study.

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Ethical Approval: The Metro South Human Research Ethics Committee (HREC/14/QPAH/628) and

University of Queensland Medical Research Ethics Committee (2015000056) approved this study. All

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participants gave written informed consent before data collection began.

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 Figure 1. Flow of participants through study

Enrolment Assessed for eligibility (n=142)

Excluded pre-op (n=70)

 Exclusion criteria (n=35)
 Declined to participate (n=21)
 Did not receive surgery during trial
period (n=10)
 Did not attend baseline measures

T
(n=6)
Baseline Measures (T1)

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Baseline measures
Pre-op collected (n=72)
Excluded post-op due to

R
intra-operative complications
(n=2)

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Randomized (n= 70)

Allocation
Allocated to control group (n=35) U
Allocated to intervention group (n= 35)
N
 Received allocated intervention (n= 35 )  Received allocated intervention (n=34)
 Did not receive allocated intervention (n=0)  Did not receive allocated intervention (n=1)
A
- Participant withdrew from trial,
baseline measures retained
M
ED

Outcomes collected (n=35) Follow-Up (T2) Outcomes collected (n=34)

D/C from in-patient physio
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Follow-Up (T3)
E

Outcomes collected (n=35) Outcomes collected (n=34)

6 weeks post-op
CC

Follow-Up (T4)
A

Outcomes collected (n=35) Outcomes collected (n=34)

6 months post-op

Analysed (n=35) Analysis Analysed (n=35)

Telerehabilitation Following THR Page 21 of 25

 T
R IP
SC
Figure 2. Mean baseline, six-week and six-month HOOS QOL scores by group

U
N
A
M
ED
E PT
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A

Telerehabilitation Following THR Page 22 of 25

 Outcome measure Control (n=35) Tele (n=35) P

Gender (% F) 21 (60%) 23 (66%) 0.62

Surgical Approach (% posterior) 32 (91%) 33 (94%) 0.61

Computer Access (% Yes) 31 (89%) 27 (77%) 0.21

Age (years) (mean (SD)) 67 (11) 62 (9) 0.03

T
IP
Length of Stay (days) (mean (SD)) 2.9 (1.0) 2.9 (0.9) 0.90

R
Table 1. Baseline comparisons between group

SC
U
N
A
M
ED
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 R I
SC
Change Baseline to Mean Group by Time
Baseline* Six Weeks* Six Months*
Six Weeks* difference at Effect ˄
Outcome Subscale

U
six weeks
Tele Con Tele Con Tele Con Tele Con F (d.f) P
(95% CI)

N
Symptoms 37 (17) 38 (16) 80 (15) 82 (13) 44 (17) 43 (20) 1 (-10 to 8) 88 (13) 88 (12) 0.04 0.96

A
(1,34)

M
Pain 35 (16) 36 (13) 86 (15) 85 (14) 52 (16) 50 (18) 2 (-10 to 6) 92 (12) 89 (13) 0.3 (1,34) 0.72
HOOS
ADLs 38 (17) 35 (15) 83 (14) 84 (12) 46 (17) 48 (19) 2 (-6 to 11) 91 (10) 88 (11) 0.5 (1,34) 0.62

Sport
ED
24 (22) 21 (17) 71 (25) 74 (17) 50 (36) 50 (18) 0 (-14 to 16) 85 (18) 80 (19) 0.8 (1,28) 0.44

QOL 18 (15) 16 (13) 63 (21) 62 (20) 44 (28) 46 (18) 2 (-10 to 13) 79 (22) 77 (21) 0.1 (1,34) 0.92
PT
Mental 48 (15) 48 (12) 55 (10) 56 (11) 7 (14) 7 (12) 0 (-6 to 7) 53 (10) 55 (10) 0.3 (1,33) 0.73
SF-12
Physical 29 (10) 29 (8) 44 (8) 40 (8) 16 (10) 12 (10) 4 (-8 to 2) 47 (10) 43 (10) 0.8 (1,33) 0.47
E

VAS 64 (23) 65 (17) 82 (16) 79 (16) 20 (26) 15 (11) 5 (-15 to 4) 82 (14) 81 (18) 0.8 (1,33) 0.50
EQ-5D
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Utility Score 0.3 (0.3) 0.3 (0.2) 0.7 (0.2) 0.8 (0.2) 0.5 (0.3) 0.4 (0.2) 0.1 (-0.2 to 0.1) 0.8 (0.2) 0.8 (0.2) 0.5 (1,35) 0.47

* Mean (SD)
˄
A

Results of linear mixed model analysis for group by time effect across all timepoints
EQ-5D was the only outcome collected at discharge from inpatient physiotherapy therefore is not displayed in table 2. It was included in the group by time
effect analysis.
Table 2. Mean (SD) HOOS, SF-12 and EQ-5D scores by group, and results of linear mixed model analysis for group by time effect.

Telerehabilitation Following THR Page 24 of 25

 R I
SC
Change Baseline to Mean difference Group by
Baseline* Six Weeks* Six Months*
Six Weeks* at six weeks Time Effect ˄
Outcome

U
(95% CI)
Tele Con Tele Con Tele Con Tele Con F (1,31) P

N
TUG (s) 14.6 (8.0) 14.9 (7.1) 9.5 (2.6) 11.6 (4.4) -5.4 (6.7) -2.7 (6.1) 2.7 (-0.4 to 5.9) 7.9 (2.3) 9.4 (3.0) 1.6 0.20

A
Step Test Affected Leg (count) 11.1 (6.5) 8.5 (4.9) 13.1 (5.3) 10.7 (5.8) 2.5 (3.9) 2.1 (4.4) 0.4 (-2.4 to 1.6) 15.2 (4.0) 13.6 (4.6) 0.2 0.85

Step Test Non-affected Leg (count) 11.2 (5.7) 8.3 (4.5) 13.2 (4.8) 10.8 (5.3) 2.5 (4.1) 2.5 (4.0) 0.0 (-1.9 to 2.0) 15.3 (4.0) 13.9 (4.4) 0.4 0.67

M
Knee Ext Strength (kgs) 8.1 (4.7) 7.8 (5.3) 9.8 (3.3) 8.9 (4.2) 2.0 (3.3) 0.5 (3.8) 1.5 (-3.2 to 0.2) 11.5 (4.4) 10.3 (4.7) 0.2 0.81

Hip Ext Strength (kgs)

ED 7.8 (3.7) 6.7 (2.3) 8.2 (2.7) 8.3 (3.1) 0.5 (3.6) 1.5 (3.0) 1.0 (-0.6 to 2.6) 8.6 (2.9) 8.1 (2.7) 0.7 0.48

Hip Add Strength (kgs) 3.8 (1.9) 3.8 (1.6) 4.2 (1.5) 4.5 (2.0) 0.5 (2.0) 0.6 (2.0) 0.1 (-0.9 to 1.1) 4.5 (1.4) 4.1 (1.4) 0.7 0.51

Hip Abd Strength (kgs) 4.9 (2.7) 4.3 (2.1) 4.5 (1.6) 4.5 (1.8) -0.2 (2.4) 0.2 (1.9) 0.4 (-0.7 to 1.4) 4.9 (2.0) 4.5 (1.8) 0.5 0.61
PT

Hip IR Strength (kgs) 3.2 (1.8) 2.9 (1.2) 3.6 (1.5) 3.7 (1.7) 0.5 (1.6) 0.8 (1.4) 0.3 (-0.5 to 1.0) 4.0 (1.5) 3.9 (1.3) 0.4 0.70
E

Hip ER Strength (kgs) 3.2 (1.8) 2.9 (1.6) 2.0 (0.7) 1.8 (0.8) -1.1 (1.5) -1.2 (1.2) 0.1 (-0.7 to 0.6) 2.3 (1.0) 2.0 (0.8) 0.1 0.93
CC

Hip Flex Strength (kgs) 6.3 (3.6) 6.1 (3.2) 6.2 (2.1) 6.8 (3.3) 0.0 (3.2) 0.5 (2.5) 0.5 (-0.9 to 1.9) 7.2 (2.5) 7.0 (1.9) 0.5 0.64

* Presented as mean (SD)

˄ Results of linear mixed model analysis for group by time effect across all timepoints
A

TUG was the only outcome collected at discharge from in-patient physiotherapy therefore is not displayed in table 3. It was included in the group by time effect
analysis.
Table 3. Means (SD) for TUG, Step Test and Muscle Strength (kgs) by group, and results of linear mixed model analysis for group by time effect.

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