Objective. To investigate the potential of Hospital Fit (a smartphone application with an accelerometer) to enhance physical activity levels and functional recovery following orthopedic surgery.
Design. Nonrandomized, quasi-experimental pilot study.
Settings and participants. Patients scheduled for an elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) at the orthopedic ward of Maastricht University Medical Center in Maastricht, the Netherlands, were invited to participate. Patients scheduled for surgery between January 2017 and December 2018 were recruited for the control group at a rate of 1 patient per week (due to a limited number of accelerometers available). After development of Hospital Fit was completed in December 2018 (and sufficient accelerators had become available), patients scheduled for surgery between February 2019 and May 2019 were recruited for the intervention group. The ratio of patients included in the control and intervention group was set at 2:1, respectively.
At preoperative physiotherapy screenings (scheduled 6 weeks before surgery), patients received verbal and written information about the study. Patients were eligible if they met the following inclusion criteria: receiving physiotherapy after elective TKA or THA; able to walk independently 2 weeks prior to surgery, as scored on the Functional Ambulation Categories (FAC > 3); were expected to be discharged to their own home; were aged 18 years and older; and had a sufficient understanding of the Dutch language. Exclusion criteria were: the presence of contraindications to walking or wearing an accelerometer on the upper leg; admission to the intensive care unit; impaired cognition (delirium/dementia), as reported by the attending doctor; a life expectancy of less than 3 months; and previous participation in this study. Patients were contacted on the day of their surgery, and written informed consent was obtained prior to the initiation of any study activities.
Intervention. Once enrolled, all patients followed a standardized clinical care pathway for TKA or THA (see original article for additional details). Postoperative physiotherapy was administered to all participating patients, starting within 4 hours after surgery. The physiotherapy treatment was aimed at increasing physical activity levels and enhancing functional recovery. Control group patients only received physiotherapy (twice daily, 30 minutes per session) and had their physical activity levels monitored with an accelerometer, without receiving feedback, until functional recovery was achieved, as measured with the modified Iowa Level of Assistance Scale (mILAS). Intervention group patients used Hospital Fit in addition to physiotherapy. Hospital Fit consists of a smartphone-based app, connected to a MOX activity monitor via Bluetooth (device contains a tri-axial accelerometer sensor in a small waterproof housing attached to the upper leg). Hospital Fit enables objective activity monitoring, provides patients and their physiotherapists insights and real-time feedback on the number of minutes spent standing and walking per day, and offers a tailored exercise program supported by videos aimed at stimulating self-management.
Measures. The primary outcome measure was the time spent physically active (total number of minutes standing and walking) per day until discharge. Physical activity was monitored 24 hours a day; days with ≥ 20 hours of wear time were considered valid measurement days and were included in the analysis. After the last treatment session, the accelerometer was removed, and the raw tri-axial accelerometer data were uploaded and processed to classify minutes as “active” (standing and walking) or “sedentary” (lying and sitting). The secondary outcome measures were the achievement of functional recovery on postoperative day 1 (POD1). Functional recovery was assessed by the physiotherapist during each treatment session using the mILAS and was reported in the electronic health record. In the intervention group, it was also reported in the app. The achievement of functional recovery on POD1 was defined as having reached a total mILAS-score of 0 on or before POD1, using a dichotomized outcome (0 = mILAS = 0 > POD1; 1 = mILAS = 0 ≤ POD1).
The independent variables measured were: Hospital Fit use (control versus the intervention group), age, sex, body mass index (BMI), type of surgery (TKA or THA), and comorbidities assessed by the American Society of Anesthesiologists (ASA) classification (ASA class ≤ 2 versus ASA class = 3; a higher score indicates being less fit for surgery). The medical and demographic data measured were the type of walking aid used and length of stay, with the day of surgery being defined as day 1.
Analysis. Data analysis was performed according to the intention-to-treat principle. Missing values were not substituted; drop-outs were not replaced. Descriptive statistics were presented as means (SD) or as 95% confidence intervals (CI) for continuous variables. The median and interquartile ranges (IQR) were used to present non-normally distributed data. The frequencies and percentages were used to present categorical variables. A multiple linear regression analysis was performed to determine the association between the time spent physically active per day and Hospital Fit use, corrected for potential confounding factors (age, sex, BMI, ASA class, and type of surgery). A multiple logistic regression analysis was performed additionally to determine the association between the achievement of functional recovery on POD1 and Hospital Fit use, corrected for potential confounding factors. For all statistical analyses, the level of significance was set at P < 0.05. All statistical analyses were performed using SPSS (version 220.127.116.11; IBM Corporation, Armonk, NY).
Main results. Ninety-seven patients were recruited; after excluding 9 patients because of missing data, 88 were included for analysis, with 61 (69%) in the control group and 27 (31%) in the intervention group. A median (IQR) number of 1.00 (0) valid measurement days (≥ 20 hr wear time) was collected. Physical activity data for 84 patients (95%) was available on POD1 (n = 61 control group, n = 23 intervention group). On postoperative day 2 (POD2), the majority of patients were discharged (n = 61, 69%), and data for only 23 patients (26%) were available (n = 17 control, n = 6 intervention). From postoperative day 3 to day 7, data of valid measurement days were available for just 1 patient (intervention group). Due to the large reduction in valid measurement days from POD2 onward, data from these days were not included in the analysis.
Results of the multiple linear regression analysis showed that, corrected for age, patients who used Hospital Fit stood and walked an average of 28.43 minutes (95% CI, 5.55-51.32) more on POD1 than patients who did not use Hospital Fit. Also, the model showed that an increase in age led to a decrease in the number of minutes standing and walking on POD1. The results of the multiple logistic regression analysis also showed that, corrected for ASA class, the odds of achieving functional recovery on POD1 were 3.08 times higher (95% CI, 1.14-8.31) for patients who used Hospital Fit compared to patients who did not use Hospital Fit. Including ASA class in the model shows that a lower ASA class increased the odds ratio for a functional recovery on POD1.
Conclusion. A smartphone app combined with an accelerometer demonstrates the potential to enhance patients’ physical activity levels and functional recovery during hospitalization following joint replacement surgery.