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      Virtual reality rehabilitation following total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

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          Abstract

          Purpose

          The use of virtual reality (VR) based rehabilitation has increased substantially within orthopedic surgery, particularly in the field of total knee arthroplasty (TKA). The objective of this systematic review and meta-analysis was to compare patient-reported outcomes and cost analyses from randomized controlled trials (RCT) utilizing VR-based rehabilitation in patients following TKA.

          Methods

          MEDLINE, EMBASE, and Cochrane databases were searched for RCTs involving VR-based rehabilitation following TKA. Quantitative synthesis was conducted for pain scores and functional outcomes. Narrative outcomes were reported for results not amenable to quantitative synthesis.

          Results

          A total of 9 RCTs with 835 patients were included with follow-up ranging from 10 days to 6 months postoperatively. No differences in pain scores were demonstrated between VR-based and traditional rehabilitation at 2 weeks and 3 months postoperatively. VR-based rehabilitation demonstrated improved functional outcomes at 12 weeks ( n = 353) postoperatively [mean difference (MD) − 3.32, 95% confidence interval (CI) − 5.20 to − 1.45, moderate certainty evidence] and 6 months ( n = 66) postoperatively [MD − 4.75, 95% CI − 6.69 to − 2.81, low certainty evidence], compared to traditional rehabilitation. One trial demonstrated significant cost savings with the use of VR-based rehabilitation.

          Conclusions

          VR-based rehabilitation for patients undergoing TKA represents an evolving field that may have advantages over traditional therapy for some patients. The current review is limited by the low quality of evidence in the literature. This is a rapidly evolving field with more trials needed to determine the impact of VR-based rehabilitation on patients undergoing TKA.

          Level of evidence

          Level I; meta-analysis of randomized controlled trials.

          Supplementary Information

          The online version contains supplementary material available at 10.1007/s00167-022-06910-x.

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          Most cited references27

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          Knee Injury and Osteoarthritis Outcome Score (KOOS)--development of a self-administered outcome measure.

          E M Roos, H. P. Roos, L S Lohmander … (1998)
          There is broad consensus that good outcome measures are needed to distinguish interventions that are effective from those that are not. This task requires standardized, patient-centered measures that can be administered at a low cost. We developed a questionnaire to assess short- and long-term patient-relevant outcomes following knee injury, based on the WOMAC Osteoarthritis Index, a literature review, an expert panel, and a pilot study. The Knee injury and Osteoarthritis Outcome Score (KOOS) is self-administered and assesses five outcomes: pain, symptoms, activities of daily living, sport and recreation function, and knee-related quality of life. In this clinical study, the KOOS proved reliable, responsive to surgery and physical therapy, and valid for patients undergoing anterior cruciate ligament reconstruction. The KOOS meets basic criteria of outcome measures and can be used to evaluate the course of knee injury and treatment outcome.
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            Projected increase in total knee arthroplasty in the United States - an alternative projection model.

            M Inacio, E Paxton, S E Graves … (2017)
            The purpose of our study was to estimate the future incidence rate (IR) and volume of primary total knee arthroplasty (TKA) in the United States from 2015 to 2050 using a conservative projection model that assumes a maximum IR of procedures. Furthermore, our study compared these projections to a model assuming exponential growth, as done in previous studies, for illustrative purposes.
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              GRADE guidelines: 13. Preparing summary of findings tables and evidence profiles-continuous outcomes.

              H Guyatt, Robin Christensen, Joerg Meerpohl … (2013)
              Presenting continuous outcomes in Summary of Findings tables presents particular challenges to interpretation. When each study uses the same outcome measure, and the units of that measure are intuitively interpretable (e.g., duration of hospitalization, duration of symptoms), presenting differences in means is usually desirable. When the natural units of the outcome measure are not easily interpretable, choosing a threshold to create a binary outcome and presenting relative and absolute effects become a more attractive alternative. When studies use different measures of the same construct, calculating summary measures requires converting to the same units of measurement for each study. The longest standing and most widely used approach is to divide the difference in means in each study by its standard deviation and present pooled results in standard deviation units (standardized mean difference). Disadvantages of this approach include vulnerability to varying degrees of heterogeneity in the underlying populations and difficulties in interpretation. Alternatives include presenting results in the units of the most popular or interpretable measure, converting to dichotomous measures and presenting relative and absolute effects, presenting the ratio of the means of intervention and control groups, and presenting the results in minimally important difference units. We outline the merits and limitations of each alternative and provide guidance for meta-analysts and guideline developers. Copyright © 2013 Elsevier Inc. All rights reserved.
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                Author and article information

                Contributors
                Aaron Gazendam:
                ORCID: http://orcid.org/0000-0002-2615-4919
                aaron.gazendam@gmail.com
                Journal
                Journal ID (nlm-ta): Knee Surg Sports Traumatol Arthrosc
                Journal ID (iso-abbrev): Knee Surg Sports Traumatol Arthrosc
                Title: Knee Surgery, Sports Traumatology, Arthroscopy
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Print): 0942-2056
                ISSN (Electronic): 1433-7347
                Publication date (Electronic): 19 February 2022
                Pages: 1-8
                Affiliations
                [1 ]OrthoEvidence, Burlington, ON Canada
                [2 ]GRID grid.25073.33, ISNI 0000 0004 1936 8227, Division of Orthopaedics, Department of Surgery, , McMaster University, St. Joseph’s Hospital, ; Room G522, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
                Author information
                http://orcid.org/0000-0002-2615-4919
                Article
                Publisher ID: 6910
                DOI: 10.1007/s00167-022-06910-x
                PMC ID: 8857886
                PubMed ID: 35182172
                SO-VID: 5f4cad12-5bdb-4e01-b3fe-b1b74bc46675
                Copyright © © The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2022
                License:

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                Date received : 16 November 2021
                Date accepted : 27 January 2022
                Categories
                Subject: Knee

                ScienceOpen disciplines: Surgery
                Keywords: total knee arthroplasty,virtual reality,rehabilitation,telemedicine,telerehabilitation
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: total knee arthroplasty, virtual reality, rehabilitation, telemedicine, telerehabilitation

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