Virtual Reality Rehabilitation Following Total Knee Arthroplasty
Authored By: OrthoEvidence
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Total knee arthroplasty (TKA) is a common elective surgical procedure and gold standard treatment for patients with end-stage knee osteoarthritis (Pozzi et al., 2013). Post-operative rehabilitation aiming at functional restoration and pain relief is an essential and critical part of the recovery process (Pozzi et al., 2013). Studies have shown that post-operative rehabilitation could be beneficial to patients following TKA, including shortening hospital stays and reducing complications (Dávila Castrodad et al., 2019).
Virtual reality (VR) represents a core of technology which enables its users to be fully immersed in a simulated world and feel a sense of actual presence by providing multimodal stimuli (e.g., visual, auditory, tactile and olfactory) (A. Li et al., 2011). Over the past decade, VR technology has been widely applied in clinical settings, such as surgical training (e.g., laparoscopic operation), physical rehabilitation, pain management, and psychological therapy (L. Li et al., 2017).
VR-based rehabilitation may also be beneficial in an orthopedic setting. A recent systematic review done by Gumaa et al. (2019) showed promising results for VR use in patients with chronic neck pain and shoulder impingement syndrome. However, Gumaa et al. (2019) found that the evidence of VR effectiveness regarding rehabilitation following knee arthroplasty was inconclusive. A systematic review done by Blasco et al. (2019) examined evidence from randomized controlled trials (RCTs) published before January 2018 on the efficacy of VR-based rehabilitation in TKA, but was only able to conduct a narrative summary. A number of RCTs have been published since the release of the systematic review (Gianola et al., 2020; Jin et al., 2018; Prvu Bettger et al., 2020), and an up-to-date systematic review is needed and will be useful for clinicians and researchers.
For this OE Original, we have conducted a systematic review and meta-analysis outlining evidence from randomized controlled trials (RCTs) with regard to VR-based rehabilitation in TKA patients.
We searched Ovid Medline, Ovid Embase, and CENTRAL (Cochrane Controlled Register of Trials) from inception to October 5, 2020. We adapted the search strategy from previous systematic reviews focusing on the role of VR technology in TKA rehabilitation or orthopedic rehabilitation in general (Blasco et al., 2019; Gumaa et al., 2019). RCTs which compared VR-based rehabilitation with traditional rehabilitation among patients who had undergone TKA were included. Risk of bias and quality of evidence were determined using the Cochrane risk of bias tool and the GRADE approach, respectively.
Characteristics of included studies
In total, 7 RCTs, published between 2012 and 2020, were eligible and included (Christiansen et al., 2015; Fung et al., 2012; Gianola et al., 2020; Jin et al., 2018; Piqueras et al., 2013; Prvu Bettger et al., 2020; Roig-Casasús et al., 2018).
The Characteristics of the included RCTs are presented in Table 1. The summary of risk of bias for included studies is presented in Figure 1.
Table 1. Characteristics of included RCTs
Participants who had TKA for the treatment of advanced knee osteoarthritis
Mean (SD): Intervention: 74.8 (4.0); Comparator: 69.5 (6.4)
Rehabilitation training plus exercise with a dynamometric platform focusing on stability challenges, weight-shifting, and moving to the limits of stability
Narrative summary of key findings from included RCTs
A narrative summary of key findings from the included RCTs is shown in Table 2. Generally speaking, results were mixed. VR-based rehabilitation was found to be able to make improvements in some outcomes at some points in time, but not in others.
Table 2. Narrative summary of key findings from included RCTs
Christiansen et al., 2015
6-weeks of weight-bearing biofeedback training plus standard of care rehabilitation resulted in a five times improved sit-to-stand test time and an increase in knee extension moments during gait, compared to standard of care rehabilitation alone. However, the intervention did not improve functional weight-bearing symmetry or knee extension moments during the five times sit-to-stand test.
Fung et al., 2012
After examining the change from study enrolment to discharge, the authors found no statistically significant difference in outcomes such as pain, knee flexion and extension, walking speed, timed standing tasks, Lower Extremity Functional Scale, Activity-specific Balance Confidence Scale, or patient satisfaction, between VR-based rehabilitation (Nintendo Wii Fit gaming activity) and traditional rehabilitation (lower extremity exercise).
Gianola et al., 2020
VR-based rehabilitation resulted in a significant improvement in global proprioception, but did not improve outcomes such as pain and function, compared to traditional rehabilitation.
Jin et al., 2018
Compared to traditional rehabilitation, VR-based rehabilitation significantly reduced postoperative pain at 3, 5, and 7 days post TKA, improved Western Ontario and McMaster University osteoarthritis index (WOMAC) as well as Hospital for Special Surgery knee score (HSS) at 1, 3, 6 months post TKA. Knee range of motion was significantly higher in the VR-based rehabilitation group than traditional rehabilitation group at 3, 7, and 14 days post TKA.
Piqueras et al., 2013
VR-rehabilitation (a 2-week interactive virtual telerehabilitation), achieved improvements similar to the traditional rehabilitation group in most outcome variables (e.g., active knee flexion, visual analog pain), and was shown to be non-inferior to traditional face-to-face rehabilitation.
Prvu Bettger et al., 2020
Virtual physical therapy with telerehabilitation significantly reduced the healthcare cost at 12 weeks after discharge and was non-inferior to traditional physical therapy in terms of Knee injury and Osteoarthritis Outcome Score (KOOS), knee extension, knee flexion, gait speed, pain, and hospital readmission.
Roig-Casasús et al., 2018
VR rehabilitation might be more beneficial than traditional rehabilitation for patient recovery following TKA by improving balance performance according to the Berg Balance Scale and Functional Reach Test.
We analyzed 2 patient-reported important outcomes, including the Visual Analogue Scale (VAS) for pain on a 0 to 100 scale (the higher the score, the worse the outcome) and the Disease Specific Index (DSI) on a normalized 0 to 100 scale (the higher the score, the worse the outcome). The DSI consisted of the Western Ontario and McMaster University osteoarthritis index (WOMAC) and Knee injury and Osteoarthritis Outcome Score (KOOS).
As shown in Figure 2, no significant difference in VAS pain (= 2 weeks after TKA), VAS pain (3 months after TKA), or DSI (= 6 weeks after TKA) was found between patients who had VR-based rehabilitation and those who received traditional rehabilitation. VR-based rehabilitation made statistically significant improvements in DSI (12 weeks after TKA) [mean difference (MD): -3.32, 95% confidence interval (CI): -5.20 to -1.45] and DSI (6 months after TKA) [MD: -4.75, 95% CI: -6.69 to -2.81], compared to traditional rehabilitation.
The quality of evidence for each outcome was judged as very low.
In this OE Original, we conducted an up-to-date systematic review and meta-analysis with regard to the efficacy of VR-based rehabilitation following TKA. It is known that TKA, as one of the most successful and cost-effective surgeries in orthopedics, could significantly reduce pain and restore function in patients suffering from end-stage degenerative osteoarthritis (Varacallo et al., 2020). To emphasize the importance of pain relief and function restoration and also given the availability of data, we conducted a meta-analysis on 2 patient-reported important outcomes: VAS pain and DSI (which was obtained by transforming the WOMAC index or KOOS to a normalized 0 to 100 scale) from 4 included RCTs (Gianola et al., 2020; Jin et al., 2018; Piqueras et al., 2013; Prvu Bettger et al., 2020). Our meta-analysis showed mixed results and suggests that VR-based rehabilitation significantly improved DSI at 12 weeks and 6 months after TKA while there was no difference between VR-based rehabilitation and traditional rehabilitation in terms of VAS pain (up to 3 weeks and 3 months post TKA) and DSI (up to 6 weeks post TKA).
Other than efficacy outcomes, only Prvu Bettger et al. (2020) reported the cost and safety outcomes among the 7 included RCTs. It showed that VR-based rehabilitation costs significantly less than traditional rehabilitation [median in United States dollars: 1050 vs. 2805, p < 0.001] at 12 weeks after TKA (Prvu Bettger et al., 2020). In terms of safety outcomes, Prvu Bettger et al. (2020) reported that significantly fewer patients receiving VR-based rehabilitation were rehospitalized, compared to those who had traditional rehabilitation [12 vs. 30, P = 0.007]. However, there was no statistically significant difference in self-reported falls between patients receiving VR-based rehabilitation and those who received traditional rehabilitation [19.4% (27/139) vs. 14.6% (20/137), P = 0.286] (Prvu Bettger et al., 2020). Future RCTs need to take cost and safety outcomes into consideration.
We noticed that none of the RCTs were able to blind patients due to the nature of the intervention, which itself does not allow blinding. Blinding issues, including difficulty in blinding and underreporting, is in fact a common problem existing in physical therapy trials. Armijo-Olivo et al. (2017) surveyed 393 physical therapy trials and 43 meta-analyses and found that about 80% of the trials had blinding issues. This could pose a threat to the validity of the outcomes, especially patient-reported outcomes. For example, there might be a resentful demoralization in which patients were disappointed because they did not get the alternative treatment, which subsequently affects their response to treatment and study outcomes (Armijo-Olivo et al., 2017). A so-called Zelen randomization method was once proposed to address resentful demoralization by preventing patients in the control group from being aware of the presence of an alternative therapy; but this method was criticized for ethical concerns (i.e., lacking consent from participants) (Adamson et al., 2006; Armijo-Olivo et al., 2017).
This systematic review has limitations. For example, we only searched 3 commonly used databases, fewer than the previous systematic review done by Blasco et al. (2019), which searched 6 databases. However, our meta-analysis contains the most up-to-date evidence and will be informative and helpful to clinicians and researchers in terms of making clinical decisions and planning future research.
Finally, we rated the quality of evidence as very low, indicating that current evidence is inadequate to allow a clear conclusion. Small sample size in the meta-analysis is one of the main concerns. Despite the very low certainty of evidence, VR technology-based rehabilitation may still have great benefits in facilitating the recovery of TKA patients in the ongoing COVID-19 pandemic. A review done by Singh et al. (2020) claimed that VR technology could decrease the risk of contracting COVID-19 by reducing the in-person contact between healthcare personnel and patients, and should be considered as a “complementary medical/healthcare edify tool [that] will enhance the execution of medical deliverables.” Therefore, there is still an urgent need for more RCTs investigating VR-based rehabilitation.
The meta-analysis results of efficacy outcomes between VR-based rehabilitation and traditional rehabilitation following TKA were mixed. We found no difference in some of the efficacy outcomes but significant improvement made by VR-based rehabilitation in the rest. Due to the very low quality of evidence, no clear conclusion could be drawn. Additionally, there still lacks evidence with regard to the costs and safety of VR-based rehabilitation as opposed to traditional rehabilitation. However, in this unprecedented COVID-19 pandemic, VR-based rehabilitation could still be more beneficial to both patients and clinicians than traditional rehabilitation because it could reduce in-person interaction between patients and clinicians, and thereby decrease the risk of contracting COVID-19. More RCTs with large sample sizes comparing the efficacy, safety and cost of VR-based rehabilitation with traditional rehabilitation following TKA are required.
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Blasco, J. M., et al. (2019). The efficacy of virtual reality tools for total knee replacement rehabilitation: A systematic review. Physiotherapy Theory and Practice, 1-11. doi:10.1080/09593985.2019.1641865
Christiansen, C. L., et al. (2015). Effects of Weight-Bearing Biofeedback Training on Functional Movement Patterns Following Total Knee Arthroplasty: A Randomized Controlled Trial. The Journal of orthopaedic and sports physical therapy, 45(9), 647-655. doi:10.2519/jospt.2015.5593
Dávila Castrodad, I. M., et al. (2019). Rehabilitation protocols following total knee arthroplasty: a review of study designs and outcome measures. Annals of translational medicine, 7(Suppl 7), S255-S255. doi:10.21037/atm.2019.08.15
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