|Year : 2019 | Volume
| Issue : 3 | Page : 117-125
Hospital versus home-based rehabilitation in patients undergoing knee arthroplasty: Evaluation of current evidence through meta-analysis approach
Public Health, Indian Institute of Public Health Gandhinagar, Gandhinagar, Gujarat, India
|Date of Submission||06-May-2019|
|Date of Decision||12-Jul-2019|
|Date of Acceptance||15-Aug-2019|
|Date of Web Publication||03-Oct-2019|
Dr. Komal Shah
Indian Institute of Public Health Gandhinagar, Gandhinagar-Chiloda Road, Gandhinagar - 382 042, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Rehabilitation techniques have provided encouraging results in achieving functional goals in patients undergoing total hip &/or knee arthroplasty. Aims and Objectives: Current meta-analysis compares hospital-based rehabilitation techniques for improving pain score and functional status of patients undergoing hip and knee arthroplasty. Methods: From 1332 initial articles, 29 randomized controlled trials were included in quantitative synthesis. Results: Higher improvement in oxford knee score [MD = -0.60, 95% CI: -1.69 to 0.48, I2–58%, P = 0.05], 6 minutes' walk test [MD = 22.27, 95% CI: -1.96 to 46.49, I2–53%, P =0.06], mental health [MD = 3.56, 95% CI: -0.62 to -7.74, I2–88%, P < 0.00001] was observed with home as compared to hospital based rehabilitation. Greater cost reduction (P = 0.04) benefits were associated with home-based rehabilitation techniques. Conclusion: Home-based rehabilitation technique is clinical and cost-effective alternative of hospital-based rehabilitation in the patients undergoing knee arthroplasty.
Keywords: Home, hospital, knee arthroplasty, rehabilitation
|How to cite this article:|
Shah K. Hospital versus home-based rehabilitation in patients undergoing knee arthroplasty: Evaluation of current evidence through meta-analysis approach. J Int Soc Phys Rehabil Med 2019;2:117-25
|How to cite this URL:|
Shah K. Hospital versus home-based rehabilitation in patients undergoing knee arthroplasty: Evaluation of current evidence through meta-analysis approach. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Nov 13];2:117-25. Available from: http://www.jisprm.org/text.asp?2019/2/3/117/268524
| Introduction|| |
Total hip and knee arthroplasty are the procedures being associated with significant morbidity; chiefly-prolonged length of hospital stay and long period of bedridden position postdischarge. However in the past few decades, due to improved procedural techniques and well-focused and vigilant rehabilitation protocols, considerable reductions in the hospital stay duration, and complications are achieved which are well translated into improved quality of life in this subset of population, especially elderly patients., Although these joint replacement therapies proved excellent tool in improving pain and disability issues, they failed to address the issues dealing with muscle strength and aerobic fitness.
Rehabilitation techniques have provided encouraging results in achieving functional goals in patients undergoing total hip and/or knee arthroplasty. Evidence-based research suggested key role of exercise and physiotherapy-based intervention in improving functional status and quality of life of this population., Earlier global protocols used to follow inpatient rehabilitation system, where in spite of significant improvement in patient morbidity profile hospital cost used to be a strong drawback. Hence, more recently home-based surveillance systems of rehabilitation are becoming popular and are providing comparable results in patients undergoing arthroplasty. The factors favoring home-based rehabilitations are: (1) reduced cost, (2) increased convenience of time and place, (3) lowered risk of additional injuries occurring during transfer, especially in elderly. Although previously documented to have good results, the evidence advocating home-based rehabilitation techniques are scant and relatively scattered. Hence, herewith, we aimed to compare two different techniques of rehabilitation (1) Hospital-based and (2) Home-based for improving the pain score, functional status, and overall quality of life of patients undergoing total hip and knee arthroplasty through meta-analysis approach.
| Methods|| |
The Cochrane Handbook for Systematic Reviews of Interventions was used to plan and conduct this meta-analysis, and the results were reported as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.
Search strategies for the screening of studies
The literature search was performed using electronic databases - MEDLINE, EMBASE, PubMed, CINAHL, PsycINFO, and the Cochrane Trial Register from inception to January 2018. The search terms used were related to “hip replacement” OR “knee replacement” AND “randomized controlled trial” OR “arthroplasty” AND “rehabilitation” OR “exercise” OR “physiotherapy.” In addition, reference lists of the relevant papers were also checked through to look for any additional relevant studies. Initial search involved identification of 1332 articles, of which finally 29 unique studies meeting inclusion and exclusion criteria were selected for inclusion in this meta-analysis [Figure 1].
We included articles assessing effect either hospital-based or home-based rehabilitation techniques on patients undergoing total hip or knee arthroplasty that examined the effects of both the rehabilitation methods on osteoarthritis index (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), Oxford knee score, 6 min walk test, pain score, cost, stair climbing capacity, knee extension, knee flexion, mental and physical health as measured by short form–36 Health Survey (SF-36) at immediate follow-up. The literature search was completed independently by the investigator, to identify studies meeting criteria for inclusion with contradictions being settled by repeat review and discussion. The studies included in the analysis were based on the following criteria: (1) patients underwent either primary total knee or hip arthroplasty, (2) studies comparing outcomes of home-based versus hospital-based rehabilitation (3) studies assessing effect of either physiotherapy or exercise-based rehabilitation (4) availability of the full-text article (5) availability of follow-up. The risk of bias as recommended by the Cochrane Handbook for Systematic Reviews of Interventions was assessed by the reviewer in nonbias manner. The methodological domains considered for assessment were: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other potential threats to validity. Based on these domains, studies were labeled as high risk, some risk and low-risk categories. Details of individual study bias are presented as supplementary material [Supplementary Figures 1 and 2 [Additional file 1]]. As all our endpoints were continuous variables, mean and standard deviation value were extracted for them all at baseline and follow-up time for both hospital and home-based rehabilitation methods and mean difference (MD) was considered for calculations. Publication bias was assessed using the method of visual inspection of funnel plots which was also assessed quantitatively using Egger's and Begg and Mazumdar rank correlation test, where P < 0·05 was considered evidence for small-study effects. The comparisons of mean treatment in both the groups were displayed using forest plots showing the relative treatment effect and its 95% confidence interval (CI) for each trial.
Changes in endpoints after hospital or home-based rehabilitation on various endpoints were extracted from each study in terms of MD with 95% CI levels. Sources of heterogeneity were studied using subgroup analysis. Subgroup analysis was performed by stratifying the studies based on follow-up interval. Heterogeneity calculations were performed using Q statistics (significant at P < 0.10) with I2 indicating the level of heterogeneity (high – 75%–100%, medium – 50%–70%, and low – 0%–50%). A two-tailed value of P < 0.05 was considered as statistically significant where a fixed-effect model was used in cases with I2 was <50% and in cases of I2 >50%, a Random-effect model was adopted. The meta-analysis was performed using Review Manager (RevMan) Version 5.3, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014. The impact of home versus hospital-based rehabilitation on improving the condition of patients undergoing arthroplasty is presented using forest plots.
| Results|| |
Initially, 1332 articles were identified as potential articles to be included in the analysis, of which – were reviewed in full with 347 meeting the inclusion criteria. After reviewing the full text 318 articles were removed due to presentation of noncritical data and exclusion criteria. Finally, 29 articles were included in quantitative synthesis.,,,,,,,,,,,,,,,,,,,,,,,,,,,, Flow chart depicting literature search is shown in [Figure 1]. The characteristic details of the studies are presented in [Table 1]. The information noted were study author, year publication, mean age of the participants, sample size of the study, setting, outcome, and follow-up of the participants.
|Table 1: Demographic and baseline parameter details of the studies included in the meta-analysis|
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Overall components of WOMAC score were independently evaluated based on pain, stiffness, and physical pain [Figure 2]a, [Figure 2]b, [Figure 2]c. Four studies investigated effect of both the rehabilitation on WOMAC pain score improvement. The pooled effect showed that improvement in home-based rehabilitation was higher as compared to hospital-based rehabilitation, thought the effect was nonsignificant (MD = −0.79, 95% CI = −2.97–1.38, I2 = 48%, P = 0.12), similarly in case of WOMAC – stiffness (MD = −1.3, 95% CI = −3.95–1.36, I2 = 1%, P = 0.38) and physical function (MD = 0.14, 95% CI = −2.96–3.24, I2 = 59%, P = 0.03) scores were also comparable between both the groups (nonsignificant effect).
|Figure 2: Forest plot for home versus hospital group effect on (a) Western Ontario and McMaster Universities Osteoarthritis index pain (b) Western Ontario and McMaster Universities Osteoarthritis index stiffness (c) Western Ontario and McMaster Universities Osteoarthritis index physical function score|
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The Oxford knee score was compared between home-based and hospital-based rehabilitation in six studies. The pooling data showed that, in patients being subjected to home-based rehabilitation significantly lower score was observed as compared to hospital-based rehabilitation group patients (MD = −0.60, 95% CI = −1.69–0.48, I2 = 58%, P = 0.05) [Figure 3]a. In the contrast to that, pooled results of four randomized clinical trials (RCTs) showed nonsignificant difference between the pain score improvement with home-based rehabilitation as compared to hospital-based rehabilitation (MD = 0.16, 95% CI = −0.27–0.58, I2 = 13%, P = 0.33] [Figure 3]b.
|Figure 3: Forest plot for home versus hospital group effect on (a) oxford knee score (b) pain score improvement|
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Data from six RCTs was pooled for comparing outcome of 6-min walk test of both the mode of rehabilitation. The cumulative results favored hospital-based rehabilitation showing an overall mean improvement of 22.27 (95% CI = −1.96–46.49, I2 = 53%, P = 0.06) [Figure 4]a. Contrary to that, the improvement in stair climbing parameter favored home-based rehabilitation as compared to hospital-based rehabilitation (MD = −4.15, 95% CI = −8.27–−0.04, I2 = 86%, P = 0.008) [Figure 4]b. Pooled results of three RCTs showed that home-based rehabilitation significantly reduces the cost burden as compared to hospital-based system (MD = −0.46, 95% CI = −0.67–−0.25, I2 = 69%, P = 0.04) [Figure 4]c.
|Figure 4: Forest plot for home versus hospital group effect on (a) 6 min walk test (b) stair climbing (c) cost|
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The impact of both rehabilitations on knee extension and flexion were assessed by pooling the data from eleven RCTs [Figure 5]a and [Figures 5]b. Results of both the parameters favored home-based rehabilitation as compared to hospital-based rehabilitation (knee extension - MD = −1.91, 95% CI = −3.03–−0.80, I2 = 87%, P < 0.00001; knee flexion - MD = −0.01, 95% CI = −0.61–0.58, I2 = 48%, P = 0.04). However, in case of knee flexion the effect was nonsignificant.
|Figure 5: Forest plot for home versus hospital group effect on (a) knee extension (b) knee flexion|
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Results of rehabilitation effect on two components of SF-36 – mental and physical health are presented in [Figure 6]. Overall nine and seven studies were included in the analysis for the assessment of mental [Figure 6]a and physical health [Figure 6]b improvement, respectively. Pooled data showed nonsignificant difference between the outcome of both the groups (MD = 3.56, 95% CI = −0.62–7.74, I2 = 88%, P < 0.00001; MD = 1.06, 95% CI = −5.81–7.93, I2 = 95%, P < 0.00001). Moreover, relatively higher heterogeneity was observed in results of both the parameters.
|Figure 6: Forest plot for home versus hospital group effect on (a) mental health (b) physical health|
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Subgroup analysis according to knee extension, knee flexion, and 6 min walk test resulted into nonsignificant changes in 6 min walk test of <2 months follow-up (MD = 29.90, 95% CI = 16.73–43.08, I2 = 50%, P = 0.07) and ≥2 Month follow-up of 6 min walk test (MD = 31.65, 95% CI = 16.79–46.52, I2 = 41%, P = 0.17), nonsignificant reduction in knee flexion at 1 month follow-up (MD = −0.30, 95% CI = −2.12–1.53, I2 = 21%, P = 0.28) and nonsignificant improvement in knee flexion at 12 months follow-up (MD = −0.96, 95% CI = −3.47–1.54, I2 = 58%, P = 0.05) and also knee extension at 12 months follow-up (MD = 0.09, 95% CI = −0.13–0.30, I2 = 0%, P = 0.83) [Supplementary Figure 3a [Additional file 2]].
Hospital-based compared to home-based rehabilitation significant improvement in knee extension at 1-month and 3-month follow-up, respectively, as (MD = −1.80, 95% CI = −3.38–−0.23, I2 = 78%, P = 0.001) and (MD = −1.64, 95% CI = −3.27–−0.01, I2 = 85%, P < 0.00001) [Supplementary Figure 3b [Additional file 3]]. Knee flexion at 3-month follow-up (MD = −4.92, 95% CI = −8.73–−1.10, I2 = 78%, P < 0.00001) also shown favor to home-based compared to hospital based rehabilitation [Supplementary Figure 3c [Additional file 4]]. Subgrouping did not alter the results majorly for any of the parameter.
Publication bias was assessed using Egger's and Begg and Mazumdar rank correlation tests and Funnel plot [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]. No evidence of publication bias was noted for the effect of rehabilitations on various parameters except for knee flexion (P < 0.05), where small study effect was detected. The publication bias assessment could not be performed in case of few parameters due to limited numbers of trials which is a possible limitation of the meta-analysis.
|Figure 7: Funnel plot for home versus hospital group effect on (a) Western Ontario and McMaster Universities Osteoarthritis index pain (b) Western Ontario and McMaster Universities Osteoarthritis index stiffness (c) Western Ontario and McMaster Universities Osteoarthritis index physical function score|
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|Figure 8: Funnel plot for home versus hospital group effect on (a) oxford knee score (b) pain score improvement|
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|Figure 9: Funnel plot for home versus hospital group effect on (a) 6 min walk test (b) stair climbing (c) cost|
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|Figure 10: Funnel plot for home versus hospital group effect on (a) knee extension (b) knee flexion|
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|Figure 11: Funnel plot for home versus hospital group effect on (a) mental health (b) physical health|
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| Discussion|| |
To the best of our knowledge, this is the first meta-analysis reporting not only cost-benefit but also superior functional parameters with home-based rehabilitation as compared to hospital-based rehabilitation in the patients' who had undergone knee or hip arthroplasty. One of the latest meta-analyses performed by Li et al., showed that the results of home-based rehabilitation are comparable to the hospital-based rehabilitation according to the total WOMAC score, physical function, stiffness, walk test, and Oxford Knee Score at 12 or 52 weeks after total knee arthroplasty (P > 0.05). They also showed that neither pain nor knee flexion range of motion differed between the groups in the first 12 weeks. They even showed that the cost factor was also comparable between both the groups. Hence, basically, they reported noninferior nature of home-based rehabilitation as compared to hospital-based rehabilitation and recommended it as a viable alternative for the patients. Similarly, López-Liria et al. also provided an evidence stating that the rehabilitation treatments offered either at home or in hospital settings are equally effective. Other studies reported lack of evidence to conclude anything substantial, though pointed potential promising results by home-based rehabilitation.
Rehabilitation holds key importance in functional recovery after arthroplasty and with an increasing number of patients being subjected to arthroplasty, evaluation of involved cost and impact of rehabilitation on quality of life is worth evaluating. This area of clinical management is having two schools of thoughts: One advocating early discharge of these patients directly to home from the acute care facility with home-based rehabilitation support and this is supported by the benefits of reduction in cost and improvement in the efficiency of care. However, it favors hospital-based rehabilitation due to the presumption that home-based rehabilitation may reduce the quality of life as primary concern of patients are long-term improvement in functional and pain outcome.,,, Although scientific literature comparing both the method of rehabilitation is abundant, it is insufficient to encourage use of any one rehabilitation method. Moreover, in spite of few studies showing promising result, none of the guideline supports the early discharge and home-based rehabilitation.
The results of the current meta-analysis showed that home-based rehabilitation is superior to hospital based rehabilitation, not only on the basis of cost but it also significantly improves recovery parameters such as 6 min walk test, stair climbing capacity, ability for knee extension and flexation, and overall mental and physical health.
The current meta-analysis suffers from a limitation of significant heterogeneity various studied parameters. The second limitation is that only articles published in the English language which may have introduced a selection bias in the analysis. Moreover, there are few endpoints or variables where only two or three RCTs data are available which may have contributed in the nonsignificant findings in the overall pooled data. Hence to substantiate these findings, extensively large trials with greater sample sizes are needed to confirm the potential of home-based rehabilitation in reducing cost and improving functional status of the patients as compared to the hospital-based rehabilitation.
| Conclusion|| |
The home-based rehabilitation is superior to hospital-based rehabilitation in cost and functional outcome. Home-based rehabilitation is a comfortable and convenient approach with wider possibility of acceptance and beneficiary patient groups. One of the strategic findings of current meta-analysis is that it provides evidence that cost of delivery of care can be significantly reduced without compromising on quality of life with home-based rehabilitation. It is highly advocated as a cost and clinically effective alternative of hospital-based rehabilitation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]