{"paper_id":"119e12f3-1667-48a3-8c3b-14c19ed0bd2b","body_text":"Effectiveness of a Mobile Telerehabilitation Tool Versus Conventional Treatment in Total Knee Replacement: A Randomized Open-Label Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of a Mobile Telerehabilitation Tool Versus Conventional Treatment in Total Knee Replacement: A Randomized Open-Label Controlled Trial Camila Arias Montes, Sofia Muñoz-Medina, Andrés Arbona Celaya, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7491477/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To assess the effectiveness and safety of mobile tools guided by artificial intelligence versus conventional rehabilitation during the first 3 postoperative months following total knee replacement (TKR). Methods: An open-label, randomized controlled clinical trial was conducted in patients undergoing TKR, comparing interactive virtual telerehabilitation (IVT) with a control group receiving home-based physical therapy. Primary outcomes included adherence, pain measured by the visual analogue pain scale, knee range of motion, Oxford knee scale for functionality, and satisfaction at the end of follow-up. Results : A total of 210 patients were included (102 in the conventional group and 108 in TVI group), with a mean age of 68.14 years (standard deviation: 7.98 years); the majority of the participants were women (63.81%). Both groups showed similar results in pain control and range of mobility; however, functionality and adherence were significantly higher in the IVT group (p < 0.05). Only one adverse event was reported in the IVT group (a minor fall), which did not require hospital care. Conclusions: IVT was associated with higher adherence and greater functional improvement compared to conventional physical therapy. Level of evidence I Knee osteoarthritis Telerehabilitation Arthroplasty Knee replacement Mobile application Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction According to the World Health Organization, life expectancy has increased substantially in recent decades owing to advancements in healthcare systems and technologies. These improvements have contributed to global population growth, and consequently, to population aging, which was projected to surpass 8 billion individuals in 2024 [1]. Knee osteoarthrosis is the most prevalent degenerative musculoskeletal disorder, and its prevalence rises as life expectancy increases. Approximately 13% of women and 10% of men aged 60 years or older exhibit symptoms of knee osteoarthrosis [2]. Over the past two decades, the number of total knee replacement (TKR) procedures has doubled. It is estimated that by 2030, approximately 3.5 million TKRs will be performed in the United States, making it the primary treatment when conservative management fails [3]. TKR is considered a cost-effective intervention, providing obvious benefits such as pain relief, improved physical activity, and improved quality of life [3]. However, TKR success largely depends on postoperative rehabilitation, which must begin early and be tailored to individual patient needs. Rehabilitation is essential for the patient’s reintegration into daily life [2,4]. In this process, a structured rehabilitation plan led by physical therapists plays a critical role in achieving optimal clinical outcomes in terms of functionality and patient satisfaction, promoting independence and facilitating the attainment of functional goals [5]. It has been reported that over 50% of patients fail to complete their rehabilitation protocols due to factors such as rural residence, comorbidities, long travel times to rehabilitation centers, need for a caregiver, and transportation costs [6]. Telerehabilitation has emerged as an alternative to conventional physical therapy, allowing patients to perform exercises guided by a physiotherapist either at home or in dedicated facilities. Although satisfactory outcomes have been reported, it was during the COVID-19 pandemic—with limited mobility and restricted appointment availability—that telerehabilitation protocols were widely adopted [7]. The benefits of this therapy are that there is no need for the patient and/or therapist to travel and there is no exposure to nosocomial diseases, creating a good acceptance. Among the various modalities, interactive virtual telerehabilitation (IVT) integrates artificial intelligence software to provide real-time guidance and monitoring. Patients are represented by avatars that demonstrate each exercise step-by step. The software immediately awards a score based on patients’ performance, which is reported to the therapist. This enables the therapist to intervene and offer prompt feedback if needed. Telerehabilitation has demonstrated comparable outcomes to in-person rehabilitation in terms of pain control and short-term functional recovery after knee arthroplasty [6,7]. TeleRehabilitation Assisted Keypoints (TRAK) is a tool created and used in Spain where IVT is implemented. This technology has been extremely useful to ensure compliance with postoperative rehabilitation protocols by enabling patients to perform therapy at home, increasing adherence. However, its success requires patients and caregivers to adapt to the technology to ensure proper implementation and effective interaction between patients, physical therapists, and treating physicians [6]. This study aimed to evaluate the effectiveness and safety of mobile tools guided by artificial intelligence compared with conventional rehabilitation during the first 3 postoperative months following TKR. Methodology This was an open-label randomized controlled clinical trial, conducted between December 2023 and February 2024 in patients undergoing primary TKR in two health institutions in Bogotá, Colombia: a tertiary-level center and a quaternary-level center. The inclusion criteria comprised patients aged 40–90 years with degenerative knee osteoarthritis and a medical indication for primary TKR, who underwent surgery at one of the two participating institutions. Eligible patients had to be functionally independent in the postoperative period; receive outpatient management; have access to a mobile device, tablet, and/or computer with internet connection; possess adequate space to perform rehabilitation at home; and provide informed consent to participate. Exclusion criteria included body mass index (BMI) greater than 35 kg/m 2 , psychiatric conditions, dementia or cognitive alterations. To calculate the sample size, we sought to find a mean difference of at least 0.7 on the functionality scale [8,9], with a power of 80%, alpha 0.05, and a standard deviation of 2.4–2.7. Anticipating a 10% dropout rate, a final sample size of 210 patients (105 per group) was determined using Stata version 17. Randomization was performed using Microsoft Excel to assign patients to either the IVT group or the conventional rehabilitation group. Patients in the IVT group received a user manual detailing how to use the platform. All participants were explained that if after five IVT sessions, they experienced no clinical improvement or were dissatisfied with the intervention, they could switch to conventional therapy without affecting the continuity or quality of their care. The principal investigators were aware of each patient’s group allocation before surgery. Intervention: Patients assigned to the IVT group downloaded the application free of charge onto their mobile device, tablet, or computer, with authorization from the developers. The application was responsible for collecting patient data. At the beginning of the program, patients were represented on-screen by an avatar reflecting their own movements. Using artificial intelligence, the software guided them through each exercise, providing step-by-step narration and immediate corrective feedback when necessary (biofeedback). This information was accessible to the physiotherapists, who used it to assess improvements in range of motion (ROM). Patients’ questions were addressed during daily virtual sessions with a physiotherapist, held Monday through Friday, where they could ask questions and receive feedback. Patients in the control group were required to schedule an appointment with a physiotherapist and complete 10 home-based sessions under the supervision of a trained therapist, depending on their availability. During the session, progress was measured through ROM, strength and stability, and immediate correction of exercises if required. All patients underwent surgery following the same surgical protocol, performed by the same surgeons (JFRC and ART), and received monthly follow-up for the first 3 postoperative months. To assess outcomes, the scale of functionality and ability to perform activities of daily living was used, which was evaluated by means of a scale (Oxford). The overall score ranged from 0 to 48 (48 being the best functional outcome) and was interpreted as poor (0 to 19), moderate (20 to 29), good (30 to 39), and excellent (40 to 48) [10]. Secondary outcomes included postoperative pain as measured by the visual analog scale (VAS), patient satisfaction via telephone survey, and degrees of knee flexion and extension (ROM) measured preoperatively and at 3 months postoperatively to compare outcomes between groups. Statistical Analysis: A descriptive analysis was conducted for all variables in each group. Quantitative variables were summarized using measures of central tendency and dispersion and assessed for normality using the Shapiro–Wilk test. Qualitative variables were described using absolute and relative frequencies. A per-protocol analysis was performed due to the high level of adherence observed. Bivariate analyses were conducted to compare the intervention and control groups. Differences between groups were evaluated using Fisher’s exact test or the chi-square test and Student’s or Wilcoxon’s t-test for the results of effectiveness (pain, mobility, and functionality results) and adverse events. For the repeated measures, analysis of variance test was used, reporting its 95% confidence intervals and the p-value, with p-values of <0.05 being statistically significant. The analysis was performed with the Stata 17 software. Results A total of 210 patients were included in the study, with 102 allocated to the conventional group and 108 to the IVT group. The study was conducted between December 2022 and February 2024. The mean age of the participants was 68.14 years (standard deviation (SD): 7.98); the majority of the participants were women (63.81%). Baseline characteristics of the patients were similar between the two groups ( Figure 1 ). No complications such as fractures, dislocations, implant failure, joint stiffness, hospital readmission, or death were reported in either group. A single case of wound dehiscence occurred in the conventional therapy group, which was managed successfully without further complications. One adverse event related to physical therapy was recorded in the IVT group: a minor fall from standing height during the first postoperative month. The patient did not sustain any fractures, bruising, ligament injuries, hematomas, or require additional medical intervention. No other adverse events were reported in the study population. When comparing the variables with respect to conventional and IVT management, it was found that both groups had a similar age range as well as weight and BMI. The number of sessions was higher in the IVT group due to the good adherence and the possibility of performing several sessions during the day since it did not require a physiotherapist present ( Figures 2 and 3). The median difference between initial and final pain score was 7 (interquartile range [IQR]: 6–8) in the conventional group and 6.5 (IQR: 5.5–8) in the IVT group, although this difference was not statistically significant (p: 0.74 ). Figure 4 . BMI was slightly higher in the IVT group, with 29.1 kg/m² versus 28.1 kg/m² in the conventional group (p = 0.03). Other variables assessed during the study yielded comparable results between groups, with no statistically significant differences, as shown in Table 1 . Notably, the IVT group included patients from rural areas, which was not the case in the conventional therapy group. Table 1. Comparison between types of rehabilitation Variables Conventional n = 102 (48.57%) TRAK n = 108 (51.43%) p-value Age (years), mean (SD) 68,75 (8,56) 67,58 (7,37) 0,29 Sex Female Male 61 (59,80) 41 (40,20) 73 (67,81) 35 (32,41) 0,24 Size (meters), median (IQR) 1,58 (1,52–1,68) 1,58 (1,52–1,65) 0,54 BMI (kg/m 2 ), median (IQR) 28,1 (25–31,1) 29,1 (26,2–32,3) 0,03 Socioeconomic stratum, median (IQR) 3 (2–3) 3 (2–3) 0,10 History of arterial hypertension 46 (45,1) 38 (35,19) 0,14 History of diabetes 0 (0) 3 (2,78) 0,09 History of rheumatoid arthritis 2 (1,96) 6 (5,56) 0,17 History of autoimmune disease 2 (1,96) 4 (3,70) 0,45 History of stroke 3 (2,94) 2 (1,85) 0,61 History of COPD 0 (0) 0 (0) History of AMI 5 (4,9) 2 (1,85) 0,22 Laterality of joint replacement Right Left 74 (73,27) 27 (26,73) 66 (61,11) 42 (38,89) 0,06 Complications Wound dehiscence 1 (0,98) 0 (0) 0,302 Initial VAS, median (IQR) 8 (7–9) 8 (7–8,5) 0,79 Final VAS, median (IQR) 1 (0–2) 1 (0–2) 0,91 Difference final VAS, median (IQR) 7 (6–8) 6,5 (5,5–8) 0,74 Functionality scale Preoperative, median (IQR) Postoperative 3 months, median (IQR) 38 (32–42) 38 (33–42) 39 (36–42) 40 (36–43) 0,18 0,03 Difference in functionality, median (IQR) 0 (0–0) 0 (0–1,5) 0,00 Preoperative extension, median (IQR) 0 (0–5) 0 (0–3) 0,76 Preoperative flexion, median (IQR) 116 (105–124) 114 (100–123) 0,60 Extension arcs 1 month, median (IQR) 2 months, median (IQR) 3 months, median (IQR) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0 (0–0) 0,29 0,29 0,29 Flexion arcs 1 month, median (IQR) 2 months, median (IQR) 3 months, median (IQR) 100 (90–110) 110 (100–112) 120 (110–125) 100 (90–107) 110 (100–110) 114 (109–120) 0,16 0,18 0,06 Difference between extension arcs at baseline and after 3 months, median (IQR) 0 (0–0) 0 (0–3) 0,88 Difference between flexion arcs at baseline and after 3 months, median (IQR) 2 (0–6) 0 (−5–10) 0,29 Number of therapy sessions, median (IQR) 10 (10–10) 18,5 (11,5–46) 0,00 Percentage of adherence, mean (SD) 100 (100–100) 100 (100–100) 0,69 Adverse event during therapy (fall) 0 (0) 1 (0,93) 0,33 Discussion This study followed 210 patients who underwent total knee arthroplasty and were assigned to either conventional physical therapy (n = 102) or IVT (n = 108) during the first 3 postoperative months. The aim was to assess outcomes related to mobility, pain, and adverse events in both rehabilitation approaches. A 2020 study has already demonstrated the effectiveness of similar mobile tools, showing comparable outcomes in ROM and gait speed at 6 weeks between groups, with no evidence of inferiority in either group (p = 0.102 and p = 0.415, respectively). Additionally, the use of mobile rehabilitation significantly reduced healthcare costs by improving access and timeliness of care [4]. To achieve optimal outcomes with telerehabilitation, it is essential to ensure adequate patient education and digital literacy. This can be facilitated through structured training, goal setting, and self-management strategies supported by visual and auditory tools—such as brochures, exercise videos, text messages, and video consultations [4]. In this study, patients were explained and provided a handbook on this type of technology on their last appointment before surgery, to reinforce the information provided before rehabilitation. Patients also had access to a virtual communication channel with a physiotherapist who was available to clarify doubts and provide ongoing guidance. This interaction was key to empowering patients to independently manage their rehabilitation from home. It is difficult to establish a clear recommendation regarding the optimal type of rehabilitation, as the intervention groups in the various studies included in a systematic review of clinical trials were heterogeneous due to the different types of interventions evaluated. However, all telerehabilitation interventions had a positive impact on quality of life compared to the control group. Moreover, 78% of these studies reported greater effectiveness in at least one of the functional outcomes, but none in all outcomes with statistically significant differences in quality of life, with an overall pooled standardized mean difference of 1.01 (95% CI: 0.18 to 1.84) [6]. In this study, a significantly greater difference was found in terms of adherence and the possibility of performing a greater number of sessions (p = 0.00) and that as an outcome gave better scores in terms of fine functionality (Oxford). Van Egmond et al. considered physical and mental health outcomes included in the International Classification of Functioning, Disability and Health, demonstrating a positive association between telerehabilitation and improved quality of life [6]. This association was reflected in greater patient motivation and engagement, which translated into higher adherence rates in the telerehabilitation group compared to the conventional physical therapy group—consistent with the findings of this study. Similarly, Bäcker et al. reported improvements in adherence and comfort, as measured by increased consistency and intensity of exercise across hours and weeks. These improvements were associated with reductions in pain and decreased short-term opioid use (p = 0.03). functionality. Additionally, they observed greater BMI reduction among patients who used mobile tools (p = 0.05). The impact on the decrease in BMI is important given that about 14% to 32% of complications following knee joint replacement are related to obesity [7]. In this study, BMI was not analyzed longitudinally because obese patients were excluded due to their higher risk of falls and complications during rehabilitation. However, the intervention group demonstrated higher adherence, and pain outcomes remained similar across both groups. Eichler et al. highlighted the positive impact of telerehabilitation in improving access to care in areas with limited healthcare infrastructure. In their study, the 6-Minute Walk Test (6MWT)—a standard assessment of mobility and functional recovery—showed no long-term differences between telerehabilitation and conventional groups. However, in the short term, improvements were attributed to the motivational effect of the virtual environment [11]. In our study, we also observed greater adherence among patients living in rural areas, likely due to reduced transportation costs, improved scheduling flexibility, and fewer geographic barriers to care. A Cochrane review based on five randomized clinical trials evaluated the efficacy of early multidisciplinary rehabilitation programs (initially in-hospital and subsequently at home) in patients undergoing hip or knee arthroplasty. Results showed a significant improvement in functional independence (p < 0.05) and mobility (p < 0.01) as well as a reduction in hospital stay compared to standard care. Home rehabilitation showed functional benefits at 6 months (Oxford Hip Score: mean difference −7; 95% CI: −10.36 to −3.64; p < 0.001). The authors conclude that there is limited but favorable evidence for early post-surgical multidisciplinary rehabilitation, although they highlight the need for higher quality studies and prolonged follow-up [12], ratifying physical therapy as a fundamental pillar in patients’ functional recovery and return to daily activities. In this study, some patients in the conventional therapy group reported low satisfaction due to difficulties in scheduling appointments, often caused by healthcare system overload. These delays adversely affected rehabilitation outcomes and may have contributed to joint stiffness and reduced ROM. Conversely, digital rehabilitation programs have shown comparable long-term outcomes to conventional therapy and offer additional benefits, including convenience, easier access for patients, and lower costs for healthcare systems [13,14]. Telerehabilitation interventions have been shown to be an encouraging and expandable strategy in the postoperative period after total knee arthroplasty. Pellegrini et al. (2021) described the NEAT!2 protocol, a platform using haptic mobile sensors to reduce prolonged sedentary periods by alerting patients via scheduled therapist calls twice weekly. At 12 and 24 weeks, reductions in sedentary time were observed [15]. Similarly, Zhao et al. (2024) conducted a randomized controlled clinical trial in 100 patients, comparing a mobile telerehabilitation application versus a control group (home rehabilitation) with ambulatory guidance; at 12 weeks, the interventionist group showed significantly greater ROM (p = 0.01) as well as improvements in functional capacity with no evidence of any complications [16]. In parallel, Pritwani et al. (2024) reported on the TReAT project, a digital platform incorporating remote supervision via video calls and email, which demonstrated high patient acceptance [17]. These digital tools have been shown to enhance motivation, reduce inactive periods, and increase the frequency and adherence to physical therapy sessions—ultimately leading to better functional outcomes and higher patient satisfaction. These findings align with our results and support the scalability and applicability of telerehabilitation models in TKR patients Conroy et al. (2025) developed a telemedicine platform with virtual reality that guides and monitors the postoperative period in hip and knee arthroplasty, showing an adherence higher than 40% with significant functional improvement with satisfaction levels higher than 90%. However, this study qualitatively assessed patient experience and satisfaction [18], achieving results quite similar to those observed with IVT. Antón et al. used the KiReS rehabilitation system and integrated automatic exercise selection and bidirectional teleimmersion after shoulder and hip arthroplasty. The system showed a significant increase in satisfaction (p = 0.0363), supporting feedback and the possibility of correcting exercises in real time [19]. As in IVT, it was shown that the possibility of performing the therapy in a controlled and assisted manner from home increased the degree of satisfaction and adherence in patients. Jiang et al. conducted a pilot study with 10 patients after knee arthroplasty taken to multimodal therapy with virtual reality and haptic feedback. The latter potentiated the accuracy of movements and decreased errors in different postures. However, this study did not perform a quantitative rating, which generated strong limitations [20]. In IVT, patient satisfaction and functionality were estimated as well as ranges of mobility and adherence compared with control group. The use of telerehabilitation technologies must be paired with appropriate patient selection and personalized follow-up. Successful implementation requires that patients be able to follow clear instructions, have access to the necessary technology, and receive support at home. Although these tools were initially developed during the COVID-19 pandemic, they continue to provide significant benefits—specifically for patients in rural areas with limited access to urban areas or in contexts where scheduling in-home sessions is difficult due to high demand. Among the strengths of this study is its large and homogeneous sample of patients. Participants demonstrated high adherence to management, predominantly in patients taken to IVT, which is highly applicable in populations to expedite access to care and in patients who are in rural areas. Additionally, IVT showed good safety with very low complications and statistically significant results in terms of functionality as measured by the Oxford scale. There were some limitations in this study. The lack of blinding, short-term follow-up since it was given for 3 months, possibly generating biases, the need for electronic devices and differences in terms of adherence, and that the patients taken to IVT had the possibility of having more sessions, which could influence the final results as well as the participation of TRAK, which could have generated biases. Conclusions This study demonstrated that patients undergoing total knee arthroplasty who received IVT using the TRAK platform achieved significantly greater functional improvement—as measured by the Oxford Knee Score—and higher adherence to treatment compared to those receiving conventional physical therapy. No significant differences were observed between groups in terms of ROM or pain intensity assessed by the VAS at 3 months postoperatively. Abbreviations IVT: Interactive virtual telerehabilitation TKR: Total knee replacement TRAK: TeleRehabilitation Assisted by Keypoints VAS: Visual analog scale ROM: Range of motion BMI: Body mass index SD: Standard deviation Declarations Data availability statement: The data supporting this study cannot be disclosed due to ethical and legal restrictions, in accordance with Resolution 1995 of 1999 and the Habeas Data Law, which governs the management of medical records. All data were handled solely by the researchers and the methodological advisor. Funding statement: This study was sponsored by TRAK (TeleRehabilitation Assisted by Keypoints), which granted free access to the IVT group’s patients and physiotherapists between December 2022 and April 2024. Conflict of interest disclosure: Two researchers from the Interactive Virtual Telerehabilitation (IVT) team were involved in the study during protocol development. However, they did not participate in data analysis or in any interventions related to outcomes assessed by the IVT TeleRehabilitation Assisted by Keypoints (TRAK) team. Authors’ contributions: Patient consent statement: All participants in the clinical trial received detailed information and signed an informed consent form in compliance with the Declaration of Helsinki and the Colombian Resolution 8430 of October 4, 1993. This study was classified as a minimal risk study. Permission to reproduce material from other sources: Ethics statement: This study was approved by the institutional ethics committee CEIFUS 102-22 UNV, act number 261. All participants provided written informed consent form. Anonymity and data confidentiality were preserved. The study is registered in ClinicalTrials.gov under identifier: NCT 06735547. For clinical trials: Level of evidence: I Acknowledgments: We would like to thank all the people and institutions that made this clinical trial possible. We would like to thank the physiotherapists, for their dedication, commitment and valuable support in the care and guidance of the patients, which was essential for the development of the study. In addition, we would like to thank Dr. Andrés Sandoval for his collaboration in data collection and for his constant willingness to contribute to the project. References Zhang Y, Jordan JM (2008) Epidemiology of Osteoarthritis. Rheum Dis Clin North Am 34:515–529. https://doi.org/10.1016/j.rdc.2008.05.007 Hsu H, Siwiec A, RM. Knee osteoarthritis continuing education activity. StatPearls, Treasure Island Masaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K (2017) Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: a systematic review with meta-analysis. PLoS One 12:e0178295. https://doi.org/10.1371/journal.pone.0178295 Prvu Bettger J, Green CL, Holmes DN, Chokshi A, Mather RC, Hoch BT, de Leon AJ, Aluisio F, Seyler TM, Del Gaizo DJ, Chiavetta J, Webb L, Miller V, Smith JM, Peterson ED (2020) Effects of virtual exercise rehabilitation in-home therapy compared with traditional care after total knee arthroplasty. J Bone Joint Surg Am 102:101–109. https://doi.org/10.2106/jbjs.19.00695 Henderson KG, Wallis JA, Snowdon DA (2018) Active physiotherapy interventions following total knee arthroplasty in the hospital and inpatient rehabilitation settings: a systematic review and meta-analysis. Physiotherapy 104:25–35. https://doi.org/10.1016/j.physio.2017.01.002 van Egmond MA, van der Schaaf M, Vredeveld T, Vollenbroek-Hutten MMR, van Berge Henegouwen MI, Klinkenbijl JHG, Engelbert RHH (2018) Effectiveness of physiotherapy with telerehabilitation in surgical patients: a systematic review and meta-analysis. Physiotherapy 104:277–298. https://doi.org/10.1016/j.physio.2018.04.004 Bäcker HC, Wu CH, Schulz MRG, Weber-Spickschen TS, Perka C, Hardt S (2021) App-based rehabilitation program after total knee arthroplasty: a randomized controlled trial. Arch Orthop Trauma Surg 141:1575–1582. https://doi.org/10.1007/s00402-021-03789-0 Bittner AK, Wykstra SL, Yoshinaga PD, Li T (2020) Telerehabilitation for people with low vision. Cochrane Database Syst Rev 2020:CD011019. https://doi.org/10.1002/14651858.cd011019 Ramkumar PN, Haeberle HS, Ramanathan D, Cantrell WA, Navarro SM, Mont MA, Bloomfield M, Patterson BM (2019) Remote patient monitoring using mobile health for total knee arthroplasty: validation of a wearable and machine learning-based surveillance platform. J Arthroplasty 34:2253–2259. https://doi.org/10.1016/j.arth.2019.05.021 Afanador-Acuña EW, Da S-C (2020) Dolor protésico de rodilla en pacientes con baja probabilidad de infección y gammagrafía ósea positiva. Rev Colomb Ortop Traumatol 34:100–108. https://doi.org/10.1016/j.rccot.2020.02.004 Eichler S, Rabe S, Salzwedel A, Müller S, Stoll J, Tilgner N, John M, Wegscheider K, Mayer F, Völler H (2017) Effectiveness of an interactive telerehabilitation system with home-based exercise training in patients after total hip or knee replacement: study protocol for a multicenter, superiority, no-blinded randomized controlled trial. Trials 18:438. https://doi.org/10.1186/s13063-017-2173-3 Khan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L (2008) Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev 2010. https://doi.org/10.1002/14651858.cd004957.pub3 Tripuraneni KR, Foran JRH, Munson NR, Racca NE, Carothers JT (2021) A smartwatch paired with a mobile application provides postoperative self-directed rehabilitation without compromising total knee arthroplasty outcomes: a randomized controlled trial. J Arthroplasty 36:3888–3893. https://doi.org/10.1016/j.arth.2021.08.007 Stauber A, Schüßler N, Palmdorf S, Schürholz N, Bruns D, Osterbrink J, Nestler N (2020) RECOVER-E – a mobile app for patients undergoing total knee or hip replacement: study protocol. BMC Musculoskelet Disord 21:282. https://doi.org/10.1186/s12891-020-3090-2 Pellegrini CA, Lee J, DeVivo KE, Harpine CE, Del Gaizo DJ, Wilcox S (2021) Reducing sedentary time using an innovative mHealth intervention among patients with total knee replacement: rationale and study protocol. Contemp Clin Trials Commun 22:100810. https://doi.org/10.1016/j.conctc.2021.100810 Zhao R, Cheng L, Zheng Q, Lv Y, Wang Y-M, Ni M, Ren P, Feng Z, Ji Q, Zhang G (2024) A smartphone application-based remote rehabilitation system for post-total knee arthroplasty rehabilitation: a randomized controlled trial. J Arthroplasty 39:575–581.e8. https://doi.org/10.1016/j.arth.2023.08.019 Pritwani S, Girotra S, Shrivastava P, Kumar A, Swamy AM, Batra S, Sharma N, John R, Praveen D, Gara S, Malhotra R, Maddison R, Devasenapathy N (2024) Design and development of a mobile health intervention for rehabilitation support after knee arthroplasty: TeleRehabilitation after knee ArThroplasty (TReAT) project. BMC Musculoskelet Disord 25:890. https://doi.org/10.1186/s12891-024-08003-x Conroy CL, Brunetti GM, Barmpoutis A, Fox EJ (2025) Integrated telehealth and extended reality to enhance home exercise adherence following total hip and knee arthroplasty. In: 2025 IEEE Conference on Virtual Reality and 3D User Interfaces Abstracts and Workshops (VRW), Saint Malo, France. IEEE, New York, 2025, pp. 959–964. https://doi.org/10.1109/VRW66409.2025.00195 Anton D, Berges I, Bermúdez J, Goñi A, Illarramendi A (2018) A telerehabilitation system for the selection, evaluation and remote management of therapies. Sensors 18:1459. https://doi.org/10.3390/s18051459 Jiang Y, Li Z, Dang Z, Zhang H, Liang J, Xu K (2022) Facilitating self-monitored physical rehabilitation with virtual reality and haptic feedback. https://arxiv.org/abs/2209.12018 Additional Declarations Competing interest reported. A.A. and O. are affiliated with BioKeralty, Spain, and provided support with the Trak mobile platform; however, they had no role in data collection, analysis, interpretation, or manuscript writing. All other authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7491477\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":513965623,\"identity\":\"8e22af4a-2790-4b69-b040-8298403ee21b\",\"order_by\":0,\"name\":\"Camila Arias Montes\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYLCCBBDB3gBhsEHEmInQwnMAqoWNGC1gIJEAZRDSwt/A/OzDg5q6aH7JN2YPHvyxy+OTb378gaHCOrGB/fABrGYfYDOekXDscO7M2TnmBoltycVsbGxmEgxn0hMbeNISsGkxYGAwZkhgO5C74XaOmURiA3NiGxuDGQNj2+HEBgkeA+xa2D8zJPyry91w84yZRMKfeqAW9s8fGP/h08JjzJDYxpy74QYPUAvbYaAWHgMJxgbcWiQO8xQzJPYB/dKTViaR2HYcqCWnTCLhWLpxGw6/8Le3b2b88a0ut5/98DbJH3+qE+c3H9/84UONtWw/jhDDEf4g49mwyoyCUTAKRsEoIAYAAHVCWiSW9CYLAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Fundación Universitaria Sanitas. Bogotá\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Camila\",\"middleName\":\"Arias\",\"lastName\":\"Montes\",\"suffix\":\"\"},{\"id\":513965624,\"identity\":\"39addf93-d722-49ff-b061-94b796f91983\",\"order_by\":1,\"name\":\"Sofia Muñoz-Medina\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Fundación Universitaria Sanitas. Bogotá\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sofia\",\"middleName\":\"\",\"lastName\":\"Muñoz-Medina\",\"suffix\":\"\"},{\"id\":513965625,\"identity\":\"7b15ce1b-72dc-4053-a2ab-47195550eeb9\",\"order_by\":2,\"name\":\"Andrés Arbona Celaya\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Biokeralty\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Andrés\",\"middleName\":\"Arbona\",\"lastName\":\"Celaya\",\"suffix\":\"\"},{\"id\":513965626,\"identity\":\"8f02770f-e9d3-434a-a1a6-fe3dc0530871\",\"order_by\":3,\"name\":\"Oihane Ibarrola Moreno\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Biokeralty\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Oihane\",\"middleName\":\"Ibarrola\",\"lastName\":\"Moreno\",\"suffix\":\"\"},{\"id\":513965627,\"identity\":\"b1221353-9558-40e0-926f-8d4c9c96ec02\",\"order_by\":4,\"name\":\"Mario Arturo Isaza Ruget\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Fundación Universitaria Sanitas. Bogotá\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mario\",\"middleName\":\"Arturo Isaza\",\"lastName\":\"Ruget\",\"suffix\":\"\"},{\"id\":513965628,\"identity\":\"5777bf03-6bcb-4ff4-93ae-5efa11eb4768\",\"order_by\":5,\"name\":\"Oscar Fernando Gomez Ricaurte\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Fundación Universitaria Sanitas. Bogotá\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Oscar\",\"middleName\":\"Fernando Gomez\",\"lastName\":\"Ricaurte\",\"suffix\":\"\"},{\"id\":513965629,\"identity\":\"558b174f-d51f-4c49-9135-11a5542e4761\",\"order_by\":6,\"name\":\"Juan David Diazgranados Osorio\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Fundación Universitaria Sanitas. Bogotá\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Juan\",\"middleName\":\"David Diazgranados\",\"lastName\":\"Osorio\",\"suffix\":\"\"},{\"id\":513965630,\"identity\":\"6654d93b-4557-41f6-bec7-f46628cb1afc\",\"order_by\":7,\"name\":\"Álvaro Reyes Trujillo\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Clínica Universitaria Colombia, Clínica Colsanitas, Fundación Universitaria Sanitas. Bogotá\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Álvaro\",\"middleName\":\"Reyes\",\"lastName\":\"Trujillo\",\"suffix\":\"\"},{\"id\":513965631,\"identity\":\"22f50e04-ed10-4a21-94c1-4861ea921cf8\",\"order_by\":8,\"name\":\"José Francisco Reyes Copello\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Clínica Universitaria Colombia, Clínica Colsanitas. Bogotá\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"José\",\"middleName\":\"Francisco Reyes\",\"lastName\":\"Copello\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-08-29 20:53:11\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7491477/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7491477/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":91303801,\"identity\":\"60de0312-fc4c-483c-ba36-4d39239057f5\",\"added_by\":\"auto\",\"created_at\":\"2025-09-15 06:20:43\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":72797,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFlow chart for patient selection and inclusion\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7491477/v1/49ab7d81578f034f7377a0a0.png\"},{\"id\":91303792,\"identity\":\"4942eebb-6e7b-43de-8916-986543721fe0\",\"added_by\":\"auto\",\"created_at\":\"2025-09-15 06:20:41\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":20475,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFunctionality scale at 3 months in patients managed with conventional therapy and IVT\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7491477/v1/7316686d484d38b859eefe23.png\"},{\"id\":91303808,\"identity\":\"2435109a-066b-47e7-a9a6-b6b70244d461\",\"added_by\":\"auto\",\"created_at\":\"2025-09-15 06:20:43\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":8495,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eNumber of sessions carried out at 3 months in the conventional group and in the IVT group\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7491477/v1/411a641ff09cfb784460ccb5.png\"},{\"id\":91303820,\"identity\":\"1f685683-3e85-47c6-9b78-8de7992db5b3\",\"added_by\":\"auto\",\"created_at\":\"2025-09-15 06:20:43\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":16331,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePreoperative and 3 months postoperative VAS in the conventional and IVT groups\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7491477/v1/7850d1ffdbf14ab6f50ced26.png\"},{\"id\":91592900,\"identity\":\"b16497eb-02eb-40b8-9b49-c9eabbf1579b\",\"added_by\":\"auto\",\"created_at\":\"2025-09-18 07:02:28\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":794944,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7491477/v1/9f64a40c-779c-4e86-800b-c632cbc5d47a.pdf\"}],\"financialInterests\":\"Competing interest reported. A.A. and O. are affiliated with BioKeralty, Spain, and provided support with the Trak mobile platform; however, they had no role in data collection, analysis, interpretation, or manuscript writing. All other authors declare no competing interests.\",\"formattedTitle\":\"Effectiveness of a Mobile Telerehabilitation Tool Versus Conventional Treatment in Total Knee Replacement: A Randomized Open-Label Controlled Trial\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eAccording to the World Health Organization, life expectancy has increased substantially in recent decades owing to advancements in healthcare systems and technologies. These improvements have contributed to global population growth, and consequently, to population aging, which was projected to surpass 8 billion individuals in 2024 [1]. Knee osteoarthrosis is the most prevalent degenerative musculoskeletal disorder, and its prevalence rises as life expectancy increases. Approximately 13% of women and 10% of men aged 60 years or older exhibit symptoms of knee osteoarthrosis [2]. Over the past two decades, the number of total knee replacement (TKR) procedures has doubled. It is estimated that by 2030, approximately 3.5 million TKRs will be performed in the United States, making it the primary treatment when conservative management fails [3].\\u003c/p\\u003e\\n\\u003cp\\u003eTKR is considered a cost-effective intervention, providing obvious benefits such as pain relief, improved physical activity, and improved quality of life [3]. However, TKR success largely depends on postoperative rehabilitation, which must begin early and be tailored to individual patient needs. Rehabilitation is essential for the patient\\u0026rsquo;s reintegration into daily life [2,4]. In this process, a structured rehabilitation plan led by physical therapists plays a critical role in achieving optimal clinical outcomes in terms of functionality and patient satisfaction, promoting independence and facilitating the attainment of functional goals [5]. It has been reported that over 50% of patients fail to complete their rehabilitation protocols due to factors such as rural residence, comorbidities, long travel times to rehabilitation centers, need for a caregiver, and transportation costs [6].\\u003c/p\\u003e\\n\\u003cp\\u003eTelerehabilitation has emerged as an alternative to conventional physical therapy, allowing patients to perform exercises guided by a physiotherapist either at home or in dedicated facilities. Although satisfactory outcomes have been reported, it was during the COVID-19 pandemic\\u0026mdash;with limited mobility and restricted appointment availability\\u0026mdash;that telerehabilitation protocols were widely adopted [7]. The benefits of this therapy are that there is no need for the patient and/or therapist to travel and there is no exposure to nosocomial diseases, creating a good acceptance. Among the various modalities, interactive virtual telerehabilitation (IVT) integrates artificial intelligence software to provide real-time guidance and monitoring. Patients are represented by avatars that demonstrate each exercise step-by step. The software immediately awards a score based on patients\\u0026rsquo; performance, which is reported to the therapist. This enables the therapist to intervene and offer prompt feedback if needed. Telerehabilitation has demonstrated comparable outcomes to in-person rehabilitation in terms of pain control and short-term functional recovery after knee arthroplasty [6,7].\\u003c/p\\u003e\\n\\u003cp\\u003eTeleRehabilitation Assisted Keypoints (TRAK) is a tool created and used in Spain where IVT is implemented. This technology has been extremely useful to ensure compliance with postoperative rehabilitation protocols by enabling patients to perform therapy at home, increasing adherence. However, its success requires patients and caregivers to adapt to the technology to ensure proper implementation and effective interaction between patients, physical therapists, and treating physicians [6]. This study aimed to evaluate the effectiveness and safety of mobile tools guided by artificial intelligence compared with conventional rehabilitation during the first 3 postoperative months following TKR.\\u003c/p\\u003e\"},{\"header\":\"Methodology\",\"content\":\"\\u003cp\\u003eThis was an open-label randomized controlled clinical trial, conducted between December 2023 and February 2024 in patients undergoing primary TKR in two health institutions in Bogotá, Colombia: a tertiary-level center and a quaternary-level center.\\u003c/p\\u003e\\n\\u003cp\\u003eThe inclusion criteria comprised patients aged 40–90 years with degenerative knee osteoarthritis and a medical indication for primary TKR, who underwent surgery at one of the two participating institutions. Eligible patients had to be functionally independent in the postoperative period; receive outpatient management; have access to a mobile device, tablet, and/or computer with internet connection; possess adequate space to perform rehabilitation at home; and provide informed consent to participate. Exclusion criteria included body mass index (BMI) greater than 35 kg/m\\u003csup\\u003e2\\u003c/sup\\u003e, psychiatric conditions, dementia or cognitive alterations.\\u003c/p\\u003e\\n\\u003cp\\u003eTo calculate the sample size, we sought to find a mean difference of at least 0.7 on the functionality scale [8,9], with a power of 80%, alpha 0.05, and a standard deviation of 2.4–2.7. Anticipating a 10% dropout rate, a final sample size of 210 patients (105 per group) was determined using Stata version 17. Randomization was performed using Microsoft Excel to assign patients to either the IVT group or the conventional rehabilitation group. Patients in the IVT group received a user manual detailing how to use the platform. All participants were explained that if after five IVT sessions, they experienced no clinical improvement or were dissatisfied with the intervention, they could switch to conventional therapy without affecting the continuity or quality of their care. The principal investigators were aware of each patient’s group allocation before surgery.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eIntervention:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePatients assigned to the IVT group downloaded the application free of charge onto their mobile device, tablet, or computer, with authorization from the developers. The application was responsible for collecting patient data. At the beginning of the program, patients were represented on-screen by an avatar reflecting their own movements. Using artificial intelligence, the software guided them through each exercise, providing step-by-step narration and immediate corrective feedback when necessary (biofeedback). This information was accessible to the physiotherapists, who used it to assess improvements in range of motion (ROM). Patients’ questions were addressed during daily virtual sessions with a physiotherapist, held Monday through Friday, where they could ask questions and receive feedback. Patients in the control group were required to schedule an appointment with a physiotherapist and complete 10 home-based sessions under the supervision of a trained therapist, depending on their availability. During the session, progress was measured through ROM, strength and stability, and immediate correction of exercises if required. All patients underwent surgery following the same surgical protocol, performed by the same surgeons (JFRC and ART), and received monthly follow-up for the first 3 postoperative months.\\u003c/p\\u003e\\n\\u003cp\\u003eTo assess outcomes, the scale of functionality and ability to perform activities of daily living was used, which was evaluated by means of a scale (Oxford). The overall score ranged from 0 to 48 (48 being the best functional outcome) and was interpreted as poor (0 to 19), moderate (20 to 29), good (30 to 39), and excellent (40 to 48) [10]. Secondary outcomes included postoperative pain as measured by the visual analog scale (VAS), patient satisfaction via telephone survey, and degrees of knee flexion and extension (ROM) measured preoperatively and at 3 months postoperatively to compare outcomes between groups.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStatistical Analysis:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA descriptive analysis was conducted for all variables in each group. Quantitative variables were summarized using measures of central tendency and dispersion and assessed for normality using the Shapiro–Wilk test. Qualitative variables were described using absolute and relative frequencies. A per-protocol analysis was performed due to the high level of adherence observed. Bivariate analyses were conducted to compare the intervention and control groups. Differences between groups were evaluated using Fisher’s exact test or the chi-square test and Student’s or Wilcoxon’s t-test for the results of effectiveness (pain, mobility, and functionality results) and adverse events. For the repeated measures, analysis of variance test was used, reporting its 95% confidence intervals and the p-value, with p-values of \\u0026lt;0.05 being statistically significant. The analysis was performed with the Stata 17 software.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 210 patients were included in the study, with 102 allocated to the conventional group and 108 to the IVT group. The study was conducted between December 2022 and February 2024. The mean age of the participants was 68.14 years (standard deviation (SD): 7.98); the majority of the participants were women (63.81%). Baseline characteristics of the patients were similar between the two groups (\\u003cstrong\\u003eFigure 1\\u003c/strong\\u003e). No complications such as fractures, dislocations, implant failure, joint stiffness, hospital readmission, or death were reported in either group. A single case of wound dehiscence occurred in the conventional therapy group, which was managed successfully without further complications. One adverse event related to physical therapy was recorded in the IVT group: a minor fall from standing height during the first postoperative month. The patient did not sustain any fractures, bruising, ligament injuries, hematomas, or require additional medical intervention. No other adverse events were reported in the study population.\\u003c/p\\u003e\\n\\u003cp\\u003eWhen comparing the variables with respect to conventional and IVT management, it was found that both groups had a similar age range as well as weight and BMI. The number of sessions was higher in the IVT group due to the good adherence and the possibility of performing several sessions during the day since it did not require a physiotherapist present (\\u003cstrong\\u003eFigures 2 and 3).\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe median difference between initial and final pain score was 7 (interquartile range [IQR]: 6\\u0026ndash;8) in the conventional group and 6.5 (IQR: 5.5\\u0026ndash;8) in the IVT group, although this difference was not statistically significant (p: 0.74\\u003cem\\u003e).\\u003c/em\\u003e \\u003cstrong\\u003eFigure 4\\u003c/strong\\u003e. BMI was slightly higher in the IVT group, with 29.1 kg/m\\u0026sup2; versus 28.1 kg/m\\u0026sup2; in the conventional group (p = 0.03). Other variables assessed during the study yielded comparable results between groups, with no statistically significant differences, as shown in \\u003cstrong\\u003eTable 1\\u003c/strong\\u003e. Notably, the IVT group included patients from rural areas, which was not the case in the conventional therapy group.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1.\\u003c/strong\\u003e Comparison between types of rehabilitation\\u003c/p\\u003e\\n \\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"614\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eVariables\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eConventional\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003en = 102 (48.57%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTRAK\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003en = 108 (51.43%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep-value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eAge (years), mean (SD)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e68,75 (8,56)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e67,58 (7,37)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eSex\\u003c/p\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e61 (59,80)\\u003c/p\\u003e\\n \\u003cp\\u003e41 (40,20)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e73 (67,81)\\u003c/p\\u003e\\n \\u003cp\\u003e35 (32,41)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,24\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eSize (meters), median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e1,58 (1,52\\u0026ndash;1,68)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e1,58 (1,52\\u0026ndash;1,65)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,54\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eBMI (kg/m\\u003csup\\u003e2\\u003c/sup\\u003e), median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e28,1 (25\\u0026ndash;31,1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e29,1 (26,2\\u0026ndash;32,3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0,03\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eSocioeconomic stratum, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e3 (2\\u0026ndash;3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e3 (2\\u0026ndash;3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eHistory of arterial hypertension\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e46 (45,1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e38 (35,19)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eHistory of diabetes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e3 (2,78)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,09\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eHistory of rheumatoid arthritis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e2 (1,96)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e6 (5,56)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,17\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eHistory of autoimmune disease\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e2 (1,96)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e4 (3,70)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eHistory of stroke\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e3 (2,94)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e2 (1,85)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,61\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eHistory of COPD\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eHistory of AMI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e5 (4,9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e2 (1,85)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,22\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eLaterality of joint replacement\\u003c/p\\u003e\\n \\u003cp\\u003eRight\\u003c/p\\u003e\\n \\u003cp\\u003eLeft\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e74 (73,27)\\u003c/p\\u003e\\n \\u003cp\\u003e27 (26,73)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e66 (61,11)\\u003c/p\\u003e\\n \\u003cp\\u003e42 (38,89)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0,06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eComplications\\u003c/p\\u003e\\n \\u003cp\\u003eWound dehiscence\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e1 (0,98)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0,302\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eInitial VAS, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e8 (7\\u0026ndash;9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e8 (7\\u0026ndash;8,5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,79\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eFinal VAS, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e1 (0\\u0026ndash;2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e1 (0\\u0026ndash;2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,91\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eDifference final VAS, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e7 (6\\u0026ndash;8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e6,5 (5,5\\u0026ndash;8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,74\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eFunctionality scale\\u003c/p\\u003e\\n \\u003cp\\u003ePreoperative, median (IQR)\\u003c/p\\u003e\\n \\u003cp\\u003ePostoperative 3 months, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e38 (32\\u0026ndash;42)\\u003c/p\\u003e\\n \\u003cp\\u003e38 (33\\u0026ndash;42)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e39 (36\\u0026ndash;42)\\u003c/p\\u003e\\n \\u003cp\\u003e40 (36\\u0026ndash;43)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0,18\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0,03\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eDifference in functionality, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;1,5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0,00\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003ePreoperative extension, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,76\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003ePreoperative flexion, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e116 (105\\u0026ndash;124)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e114 (100\\u0026ndash;123)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,60\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eExtension arcs\\u003c/p\\u003e\\n \\u003cp\\u003e1 month, median (IQR)\\u003c/p\\u003e\\n \\u003cp\\u003e2 months, median (IQR)\\u003c/p\\u003e\\n \\u003cp\\u003e3 months, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;0)\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;0)\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;0)\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;0)\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0,29\\u003c/p\\u003e\\n \\u003cp\\u003e0,29\\u003c/p\\u003e\\n \\u003cp\\u003e0,29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eFlexion arcs\\u003c/p\\u003e\\n \\u003cp\\u003e1 month, median (IQR)\\u003c/p\\u003e\\n \\u003cp\\u003e2 months, median (IQR)\\u003c/p\\u003e\\n \\u003cp\\u003e3 months, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e100 (90\\u0026ndash;110)\\u003c/p\\u003e\\n \\u003cp\\u003e110 (100\\u0026ndash;112)\\u003c/p\\u003e\\n \\u003cp\\u003e120 (110\\u0026ndash;125)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e100 (90\\u0026ndash;107)\\u003c/p\\u003e\\n \\u003cp\\u003e110 (100\\u0026ndash;110)\\u003c/p\\u003e\\n \\u003cp\\u003e114 (109\\u0026ndash;120)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0,16\\u003c/p\\u003e\\n \\u003cp\\u003e0,18\\u003c/p\\u003e\\n \\u003cp\\u003e0,06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eDifference between extension arcs at baseline and after 3 months, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e0 (0\\u0026ndash;3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eDifference between flexion arcs at baseline and after 3 months, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e2 (0\\u0026ndash;6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e0 (\\u0026minus;5\\u0026ndash;10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eNumber of therapy sessions, median (IQR)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e10 (10\\u0026ndash;10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e18,5 (11,5\\u0026ndash;46)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0,00\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003ePercentage of adherence, mean (SD)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e100 (100\\u0026ndash;100)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e100 (100\\u0026ndash;100)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,69\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 255px;\\\"\\u003e\\n \\u003cp\\u003eAdverse event during therapy (fall)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e0 (0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e1 (0,93)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0,33\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study followed 210 patients who underwent total knee arthroplasty and were assigned to either conventional physical therapy (n = 102) or IVT (n = 108) during the first 3 postoperative months. The aim was to assess outcomes related to mobility, pain, and adverse events in both rehabilitation approaches. A 2020 study has already demonstrated the effectiveness of similar mobile tools, showing comparable outcomes in ROM and gait speed at 6 weeks between groups, with no evidence of inferiority in either group (p = 0.102 and p = 0.415, respectively). Additionally, the use of mobile rehabilitation significantly reduced healthcare costs by improving access and timeliness of care [4].\\u003c/p\\u003e\\n\\u003cp\\u003eTo achieve optimal outcomes with telerehabilitation, it is essential to ensure adequate patient education and digital literacy. This can be facilitated through structured training, goal setting, and self-management strategies supported by visual and auditory tools\\u0026mdash;such as brochures, exercise videos, text messages, and video consultations [4]. In this study, patients were explained and provided a handbook on this type of technology on their last appointment before surgery, to reinforce the information provided before rehabilitation. Patients also had access to a virtual communication channel with a physiotherapist who was available to clarify doubts and provide ongoing guidance. This interaction was key to empowering patients to independently manage their rehabilitation from home.\\u003c/p\\u003e\\n\\u003cp\\u003eIt is difficult to establish a clear recommendation regarding the optimal type of rehabilitation, as the intervention groups in the various studies included in a systematic review of clinical trials were heterogeneous due to the different types of interventions evaluated. However, all telerehabilitation interventions had a positive impact on quality of life compared to the control group. Moreover, 78% of these studies reported greater effectiveness in at least one of the functional outcomes, but none in all outcomes with statistically significant differences in quality of life, with an overall pooled standardized mean difference of 1.01 (95% CI: 0.18 to 1.84) [6]. In this study, a significantly greater difference was found in terms of adherence and the possibility of performing a greater number of sessions (p = 0.00) and that as an outcome gave better scores in terms of fine functionality (Oxford).\\u003c/p\\u003e\\n\\u003cp\\u003eVan Egmond et al. considered physical and mental health outcomes included in the International Classification of Functioning, Disability and Health, demonstrating a positive association between telerehabilitation and improved quality of life [6]. This association was reflected in greater patient motivation and engagement, which translated into higher adherence rates in the telerehabilitation group compared to the conventional physical therapy group\\u0026mdash;consistent with the findings of this study. Similarly, B\\u0026auml;cker et al. reported improvements in adherence and comfort, as measured by increased consistency and intensity of exercise across hours and weeks. These improvements were associated with reductions in pain and decreased short-term opioid use (p = 0.03). functionality. Additionally, they observed greater BMI reduction among patients who used mobile tools (p = 0.05). The impact on the decrease in BMI is important given that about 14% to 32% of complications following knee joint replacement are related to obesity [7]. In this study, BMI was not analyzed longitudinally because obese patients were excluded due to their higher risk of falls and complications during rehabilitation. However, the intervention group demonstrated higher adherence, and pain outcomes remained similar across both groups.\\u003c/p\\u003e\\n\\u003cp\\u003eEichler et al. highlighted the positive impact of telerehabilitation in improving access to care in areas with limited healthcare infrastructure. In their study, the 6-Minute Walk Test (6MWT)\\u0026mdash;a standard assessment of mobility and functional recovery\\u0026mdash;showed no long-term differences between telerehabilitation and conventional groups. However, in the short term, improvements were attributed to the motivational effect of the virtual environment [11]. In our study, we also observed greater adherence among patients living in rural areas, likely due to reduced transportation costs, improved scheduling flexibility, and fewer geographic barriers to care.\\u003c/p\\u003e\\n\\u003cp\\u003eA Cochrane review based on five randomized clinical trials evaluated the efficacy of early multidisciplinary rehabilitation programs (initially in-hospital and subsequently at home) in patients undergoing hip or knee arthroplasty. Results showed a significant improvement in functional independence (p \\u0026lt; 0.05) and mobility (p \\u0026lt; 0.01) as well as a reduction in hospital stay compared to standard care. Home rehabilitation showed functional benefits at 6 months (Oxford Hip Score: mean difference\\u0026nbsp;\\u0026minus;7; 95% CI: \\u0026minus;10.36 to\\u0026nbsp;\\u0026minus;3.64; p \\u0026lt; 0.001). The authors conclude that there is limited but favorable evidence for early post-surgical multidisciplinary rehabilitation, although they highlight the need for higher quality studies and prolonged follow-up [12], ratifying physical therapy as a fundamental pillar in patients\\u0026rsquo; functional recovery and return to daily activities. In this study, some patients in the conventional therapy group reported low satisfaction due to difficulties in scheduling appointments, often caused by healthcare system overload. These delays adversely affected rehabilitation outcomes and may have contributed to joint stiffness and reduced ROM. Conversely, digital rehabilitation programs have shown comparable long-term outcomes to conventional therapy and offer additional benefits, including convenience, easier access for patients, and lower costs for healthcare systems [13,14].\\u003c/p\\u003e\\n\\u003cp\\u003eTelerehabilitation interventions have been shown to be an encouraging and expandable strategy in the postoperative period after total knee arthroplasty. Pellegrini et al. (2021) described the NEAT!2 protocol, a platform using haptic mobile sensors to reduce prolonged sedentary periods by alerting patients via scheduled therapist calls twice weekly. At 12 and 24 weeks, reductions in sedentary time were observed [15]. Similarly, Zhao et al. (2024) conducted a randomized controlled clinical trial in 100 patients, comparing a mobile telerehabilitation application versus a control group (home rehabilitation) with ambulatory guidance; at 12 weeks, the interventionist group showed significantly greater ROM (p = 0.01) as well as improvements in functional capacity with no evidence of any complications [16]. In parallel, Pritwani et al. (2024) reported on the TReAT project, a digital platform incorporating remote supervision via video calls and email, which demonstrated high patient acceptance [17]. These digital tools have been shown to enhance motivation, reduce inactive periods, and increase the frequency and adherence to physical therapy sessions\\u0026mdash;ultimately leading to better functional outcomes and higher patient satisfaction. These findings align with our results and support the scalability and applicability of telerehabilitation models in TKR patients\\u003c/p\\u003e\\n\\u003cp\\u003eConroy et al. (2025) developed a telemedicine platform with virtual reality that guides and monitors the postoperative period in hip and knee arthroplasty, showing an adherence higher than 40% with significant functional improvement with satisfaction levels higher than 90%. However, this study qualitatively assessed patient experience and satisfaction [18], achieving results quite similar to those observed with IVT. Ant\\u0026oacute;n et al. used the KiReS rehabilitation system and integrated automatic exercise selection and bidirectional teleimmersion after shoulder and hip arthroplasty. The system showed a significant increase in satisfaction (p = 0.0363), supporting feedback and the possibility of correcting exercises in real time [19]. As in IVT, it was shown that the possibility of performing the therapy in a controlled and assisted manner from home increased the degree of satisfaction and adherence in patients.\\u003c/p\\u003e\\n\\u003cp\\u003eJiang et al. conducted a pilot study with 10 patients after knee arthroplasty taken to multimodal therapy with virtual reality and haptic feedback. The latter potentiated the accuracy of movements and decreased errors in different postures. However, this study did not perform a quantitative rating, which generated strong limitations [20]. In IVT, patient satisfaction and functionality were estimated as well as ranges of mobility and adherence compared with control group. The use of telerehabilitation technologies must be paired with appropriate patient selection and personalized follow-up. Successful implementation requires that patients be able to follow clear instructions, have access to the necessary technology, and receive support at home. Although these tools were initially developed during the COVID-19 pandemic, they continue to provide significant benefits\\u0026mdash;specifically for patients in rural areas with limited access to urban areas or in contexts where scheduling in-home sessions is difficult due to high demand.\\u003c/p\\u003e\\n\\u003cp\\u003eAmong the strengths of this study is its large and homogeneous sample of patients. Participants demonstrated high adherence to management, predominantly in patients taken to IVT, which is highly applicable in populations to expedite access to care and in patients who are in rural areas. Additionally, IVT showed good safety with very low complications and statistically significant results in terms of functionality as measured by the Oxford scale. There were some limitations in this study. The lack of blinding, short-term follow-up since it was given for 3 months, possibly generating biases, the need for electronic devices and differences in terms of adherence, and that the patients taken to IVT had the possibility of having more sessions, which could influence the final results as well as the participation of TRAK, which could have generated biases.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eThis study demonstrated that patients undergoing total knee arthroplasty who received IVT using the TRAK platform achieved significantly greater functional improvement\\u0026mdash;as measured by the Oxford Knee Score\\u0026mdash;and higher adherence to treatment compared to those receiving conventional physical therapy. No significant differences were observed between groups in terms of ROM or pain intensity assessed by the VAS at 3 months postoperatively.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eIVT: Interactive virtual telerehabilitation\\u003c/p\\u003e\\n\\u003cp\\u003eTKR: Total knee replacement\\u003c/p\\u003e\\n\\u003cp\\u003eTRAK: TeleRehabilitation Assisted by Keypoints\\u003c/p\\u003e\\n\\u003cp\\u003eVAS: Visual analog scale\\u003c/p\\u003e\\n\\u003cp\\u003eROM: Range of motion\\u003c/p\\u003e\\n\\u003cp\\u003eBMI: Body mass index\\u003c/p\\u003e\\n\\u003cp\\u003eSD: Standard deviation\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eData availability statement:\\u0026nbsp;\\u003c/strong\\u003eThe data supporting this study cannot be disclosed due to ethical and legal restrictions, in accordance with Resolution 1995 of 1999 and the Habeas Data Law, which governs the management of medical records. All data were handled solely by the researchers and the methodological advisor.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding statement:\\u003c/strong\\u003e This study was sponsored by TRAK (TeleRehabilitation Assisted by Keypoints), which granted free access to the IVT group\\u0026rsquo;s patients and physiotherapists between December 2022 and April 2024.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflict of interest disclosure:\\u003c/strong\\u003e Two researchers from the Interactive Virtual Telerehabilitation (IVT) team were involved in the study during protocol development. However, they did not participate in data analysis or in any interventions related to outcomes assessed by the IVT TeleRehabilitation Assisted by Keypoints (TRAK) team.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; contributions:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePatient consent statement:\\u003c/strong\\u003e All participants in the clinical trial received detailed information and signed an informed consent form in compliance with the Declaration of Helsinki and the Colombian Resolution 8430 of October 4, 1993. This study was classified as a minimal risk study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePermission to reproduce material from other sources:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics statement:\\u003c/strong\\u003e This study was approved by the institutional ethics committee CEIFUS 102-22 UNV, act number 261. All participants provided written informed consent form. Anonymity and data confidentiality were preserved. The study is registered in ClinicalTrials.gov under identifier: NCT 06735547.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFor clinical trials:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLevel of evidence: I\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments:\\u003c/strong\\u003e We would like to thank all the people and institutions that made this clinical trial possible.\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to thank the physiotherapists, for their dedication, commitment and valuable support in the care and guidance of the patients, which was essential for the development of the study.\\u003c/p\\u003e\\n\\u003cp\\u003eIn addition, we would like to thank Dr. Andr\\u0026eacute;s Sandoval for his collaboration in data collection and for his constant willingness to contribute to the project.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eZhang Y, Jordan JM (2008) Epidemiology of Osteoarthritis. Rheum Dis Clin North Am 34:515\\u0026ndash;529. https://doi.org/10.1016/j.rdc.2008.05.007\\u003c/li\\u003e\\n\\u003cli\\u003eHsu H, Siwiec A, RM. Knee osteoarthritis continuing education activity. StatPearls, Treasure Island\\u003c/li\\u003e\\n\\u003cli\\u003eMasaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K (2017) Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: a systematic review with meta-analysis. PLoS One 12:e0178295. https://doi.org/10.1371/journal.pone.0178295\\u003c/li\\u003e\\n\\u003cli\\u003ePrvu Bettger J, Green CL, Holmes DN, Chokshi A, Mather RC, Hoch BT, de Leon AJ, Aluisio F, Seyler TM, Del Gaizo DJ, Chiavetta J, Webb L, Miller V, Smith JM, Peterson ED (2020) Effects of virtual exercise rehabilitation in-home therapy compared with traditional care after total knee arthroplasty. J Bone Joint Surg Am 102:101\\u0026ndash;109. https://doi.org/10.2106/jbjs.19.00695\\u003c/li\\u003e\\n\\u003cli\\u003eHenderson KG, Wallis JA, Snowdon DA (2018) Active physiotherapy interventions following total knee arthroplasty in the hospital and inpatient rehabilitation settings: a systematic review and meta-analysis. Physiotherapy 104:25\\u0026ndash;35. https://doi.org/10.1016/j.physio.2017.01.002\\u003c/li\\u003e\\n\\u003cli\\u003evan Egmond MA, van der Schaaf M, Vredeveld T, Vollenbroek-Hutten MMR, van Berge Henegouwen MI, Klinkenbijl JHG, Engelbert RHH (2018) Effectiveness of physiotherapy with telerehabilitation in surgical patients: a systematic review and meta-analysis. Physiotherapy 104:277\\u0026ndash;298. https://doi.org/10.1016/j.physio.2018.04.004\\u003c/li\\u003e\\n\\u003cli\\u003eB\\u0026auml;cker HC, Wu CH, Schulz MRG, Weber-Spickschen TS, Perka C, Hardt S (2021) App-based rehabilitation program after total knee arthroplasty: a randomized controlled trial. Arch Orthop Trauma Surg 141:1575\\u0026ndash;1582. https://doi.org/10.1007/s00402-021-03789-0\\u003c/li\\u003e\\n\\u003cli\\u003eBittner AK, Wykstra SL, Yoshinaga PD, Li T (2020) Telerehabilitation for people with low vision. Cochrane Database Syst Rev 2020:CD011019. https://doi.org/10.1002/14651858.cd011019\\u003c/li\\u003e\\n\\u003cli\\u003eRamkumar PN, Haeberle HS, Ramanathan D, Cantrell WA, Navarro SM, Mont MA, Bloomfield M, Patterson BM (2019) Remote patient monitoring using mobile health for total knee arthroplasty: validation of a wearable and machine learning-based surveillance platform. J Arthroplasty 34:2253\\u0026ndash;2259. https://doi.org/10.1016/j.arth.2019.05.021\\u003c/li\\u003e\\n\\u003cli\\u003eAfanador-Acu\\u0026ntilde;a EW, Da S-C (2020) Dolor prot\\u0026eacute;sico de rodilla en pacientes con baja probabilidad de infecci\\u0026oacute;n y gammagraf\\u0026iacute;a \\u0026oacute;sea positiva. Rev Colomb Ortop Traumatol 34:100\\u0026ndash;108. https://doi.org/10.1016/j.rccot.2020.02.004\\u003c/li\\u003e\\n\\u003cli\\u003eEichler S, Rabe S, Salzwedel A, M\\u0026uuml;ller S, Stoll J, Tilgner N, John M, Wegscheider K, Mayer F, V\\u0026ouml;ller H (2017) Effectiveness of an interactive telerehabilitation system with home-based exercise training in patients after total hip or knee replacement: study protocol for a multicenter, superiority, no-blinded randomized controlled trial. Trials 18:438. https://doi.org/10.1186/s13063-017-2173-3\\u003c/li\\u003e\\n\\u003cli\\u003eKhan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L (2008) Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev 2010. https://doi.org/10.1002/14651858.cd004957.pub3\\u003c/li\\u003e\\n\\u003cli\\u003eTripuraneni KR, Foran JRH, Munson NR, Racca NE, Carothers JT (2021) A smartwatch paired with a mobile application provides postoperative self-directed rehabilitation without compromising total knee arthroplasty outcomes: a randomized controlled trial. J Arthroplasty 36:3888\\u0026ndash;3893. https://doi.org/10.1016/j.arth.2021.08.007\\u003c/li\\u003e\\n\\u003cli\\u003eStauber A, Sch\\u0026uuml;\\u0026szlig;ler N, Palmdorf S, Sch\\u0026uuml;rholz N, Bruns D, Osterbrink J, Nestler N (2020) RECOVER-E \\u0026ndash; a mobile app for patients undergoing total knee or hip replacement: study protocol. BMC Musculoskelet Disord 21:282. https://doi.org/10.1186/s12891-020-3090-2\\u003c/li\\u003e\\n\\u003cli\\u003ePellegrini CA, Lee J, DeVivo KE, Harpine CE, Del Gaizo DJ, Wilcox S (2021) Reducing sedentary time using an innovative mHealth intervention among patients with total knee replacement: rationale and study protocol. Contemp Clin Trials Commun 22:100810. https://doi.org/10.1016/j.conctc.2021.100810\\u003c/li\\u003e\\n\\u003cli\\u003eZhao R, Cheng L, Zheng Q, Lv Y, Wang Y-M, Ni M, Ren P, Feng Z, Ji Q, Zhang G (2024) A smartphone application-based remote rehabilitation system for post-total knee arthroplasty rehabilitation: a randomized controlled trial. J Arthroplasty 39:575\\u0026ndash;581.e8. https://doi.org/10.1016/j.arth.2023.08.019\\u003c/li\\u003e\\n\\u003cli\\u003ePritwani S, Girotra S, Shrivastava P, Kumar A, Swamy AM, Batra S, Sharma N, John R, Praveen D, Gara S, Malhotra R, Maddison R, Devasenapathy N (2024) Design and development of a mobile health intervention for rehabilitation support after knee arthroplasty: TeleRehabilitation after knee ArThroplasty (TReAT) project. BMC Musculoskelet Disord 25:890. https://doi.org/10.1186/s12891-024-08003-x\\u003c/li\\u003e\\n\\u003cli\\u003eConroy CL, Brunetti GM, Barmpoutis A, Fox EJ (2025) Integrated telehealth and extended reality to enhance home exercise adherence following total hip and knee arthroplasty. In: 2025 IEEE Conference on Virtual Reality and 3D User Interfaces Abstracts and Workshops (VRW), Saint Malo, France. IEEE, New York, 2025, pp. 959\\u0026ndash;964. https://doi.org/10.1109/VRW66409.2025.00195\\u003c/li\\u003e\\n\\u003cli\\u003eAnton D, Berges I, Berm\\u0026uacute;dez J, Go\\u0026ntilde;i A, Illarramendi A (2018) A telerehabilitation system for the selection, evaluation and remote management of therapies. Sensors 18:1459. https://doi.org/10.3390/s18051459\\u003c/li\\u003e\\n\\u003cli\\u003eJiang Y, Li Z, Dang Z, Zhang H, Liang J, Xu K (2022) Facilitating self-monitored physical rehabilitation with virtual reality and haptic feedback. https://arxiv.org/abs/2209.12018\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Knee osteoarthritis, Telerehabilitation, Arthroplasty, Knee replacement, Mobile application\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7491477/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7491477/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003ePurpose:\\u003c/strong\\u003e To assess the effectiveness and safety of mobile tools guided by artificial intelligence versus conventional rehabilitation during the first 3 postoperative months following total knee replacement (TKR).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e An open-label, randomized controlled clinical trial was conducted in patients undergoing TKR, comparing interactive virtual telerehabilitation (IVT) with a control group receiving home-based physical therapy. Primary outcomes included adherence, pain measured by the visual analogue pain scale, knee range of motion, Oxford knee scale for functionality, and satisfaction at the end of follow-up.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e: A total of 210 patients were included (102 in the conventional group and 108 in TVI group), with a mean age of 68.14 years (standard deviation: 7.98 years); the majority of the participants were women (63.81%). Both groups showed similar results in pain control and range of mobility; however, functionality and adherence were significantly higher in the IVT group (p \\u0026lt; 0.05). Only one adverse event was reported in the IVT group (a minor fall), which did not require hospital care.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions:\\u003c/strong\\u003e IVT was associated with higher adherence and greater functional improvement compared to conventional physical therapy.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLevel of evidence I\\u003c/strong\\u003e\\u003c/p\\u003e\",\"manuscriptTitle\":\"Effectiveness of a Mobile Telerehabilitation Tool Versus Conventional Treatment in Total Knee Replacement: A Randomized Open-Label Controlled Trial\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-09-15 06:20:36\",\"doi\":\"10.21203/rs.3.rs-7491477/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"e9ef760c-df51-41a7-b0fe-16085216b1ed\",\"owner\":[],\"postedDate\":\"September 15th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-09-18T06:54:17+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-09-15 06:20:36\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7491477\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7491477\",\"identity\":\"rs-7491477\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}