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Article

Severe Attrition and Poor Satisfaction in Patients Undergoing Telerehabilitation vs. Standard In-Person Rehabilitation after Arthroscopic Rotator Cuff Repairs and Anterior Cruciate Ligament Reconstructions

by
Kinjal D. Vasavada
1,2,
Dhruv S. Shankar
1,3,
Amanda Avila
1,
Edward S. Mojica
1,
Eoghan T. Hurley
1,4,
Kevin Lehane
1,
Scott D. Buzin
1,
Jacob F. Oeding
1,5,
Spencer M. Stein
1,
Guillem Gonzalez-Lomas
1,
Michael J. Alaia
1,
Eric J. Strauss
1,
Laith M. Jazrawi
1 and
Kirk A. Campbell
1,*
1
Division of Sports Medicine, Department of Orthopedic Surgery, New York University Langone Health, New York, NY 10010, USA
2
Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA
3
Department of Orthopaedic Surgery and Sports Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
4
Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA
5
Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA
*
Author to whom correspondence should be addressed.
Surgeries 2024, 5(3), 627-639; https://doi.org/10.3390/surgeries5030050
Submission received: 21 July 2024 / Revised: 3 August 2024 / Accepted: 6 August 2024 / Published: 8 August 2024
Browse Figures
Versions Notes

Abstract

:
Background: The use of telerehabilitation after sports medicine procedures such as an arthroscopic rotator cuff repair (ARCR) and anterior cruciate ligament reconstruction (ACLR) has rapidly increased in recent years; however, the functional outcomes and patient satisfaction with telerehabilitation compared to in-person rehabilitation remain unclear. The purpose of this study was to compare the functional outcomes and patient satisfaction with telerehabilitation to in-person rehabilitation in a randomized controlled trial after two common sports procedures, ARCR and ACLR. Methods: Two randomized controlled trials were conducted involving patients scheduled to undergo ARCR or ACLR by one of six fellowship-trained sports medicine surgeons between October 2020 and November 2021. Each trial had an enrollment goal of 60 patients. Subjects were randomized 1:1 to receive telerehabilitation or in-person rehabilitation postoperatively. Functional outcome and satisfaction metrics were collected at baseline and at post-operative visits and compared between groups. Results: In total, 16 ACLR patients were enrolled, of whom 10 (62.5%) were assigned to in-person rehabilitation and 6 (37.5%) to telerehabilitation. Additionally, 32 ARCR patients were enrolled, of whom 20 (62.5%) were assigned in-person rehabilitation and 12 (37.5%) were assigned telerehabilitation. In total, of the 30 patients assigned to in-person rehabilitation, none reported a crossover to telerehabilitation. Of the 18 patients initially assigned to telerehabilitation, 12 (67%) completed the final follow-up survey, of which 11 (92%) reported a crossover; 9 patients completed in-person rehabilitation and 2 patients completed hybrid in-person and telerehabilitation. Conclusions: Patients preferred in-person rehabilitation compared to telerehabilitation after ACLR and ARCR, as evidenced by the nearly ubiquitous crossover from telerehabilitation to in-person rehabilitation in both studies. Our findings suggest that telerehabilitation protocols still need to be perfected, and that there may be a role for a hybrid in-person and tele-rehab model.

1. Introduction

Telemedicine was primarily developed in the 1990s, with the main objective of expanding access to health care for patients in rural, underserved, or otherwise remote settings [1]. In recent years, however, its adoption has expanded, driven by improvements in technology and reductions in cost and newly realized applications, enhancing patient and physician convenience, safety, and time, as well as cost-efficiency [2,3,4,5,6]. The changes in health care access and delivery brought about by the COVID-19 pandemic further accelerated these realizations and normalized the use of telemedicine across hospital systems worldwide [7,8,9,10,11,12]. In specialties like orthopedics, historically centered around “in-person” examination, surgery, postoperative follow-up, and postoperative rehabilitation, telemedicine was quickly adopted to conduct office visits and postoperative rehabilitation [13]. Yet, the implications of telemedicine for surgical outcomes and patient satisfaction remain unexplored. Because postoperative physical therapy is critical to a successful postoperative course, the efficacy of telerehabilitation is particularly important to evaluate in the context of a potential equivalency to in-person rehabilitation. While it is thought that the increased convenience of telerehabilitation may result in improved adherence, the loss of tactile feedback and physical guidance may reduce its efficacy.
While evidence from the arthroplasty literature suggests that functional metrics such as range of motion, balance, and strength are equivalent after in-person versus telerehabilitation [14,15,16], the effect of telerehabilitation on outcomes after common sports surgeries including arthroscopic rotator cuff repairs (ARCRs) and anterior cruciate ligament reconstructions (ACLRs) has yet to be explored. Thus, we sought to evaluate functional outcomes and patient satisfaction with telerehabilitation and in-person rehabilitation in a randomized controlled trial after two common sports procedures, ARCR and ACLR. We hypothesized that functional outcomes and patient satisfaction would not differ significantly between the rehabilitation modalities.

2. Methods

2.1. Study Design and Setting

Two randomized controlled trials were conducted; all patients of the previously mentioned six fellowship-trained sports medicine surgeons at a single urban academic medical center undergoing ARCR between the ages of 40 and 80 or patients undergoing ACLR between the ages of 18 and 40 were considered for participation.

2.2. Ethics Approval

Institutional Review Board approvals were acquired from the New York University Langone Health institutional review board before commencing study activities (ARCR: s20-01261; ACLR: s20-01313) and all recruitment was conducted with written informed consent from patients. Both studies were registered on clinicaltrials.gov (NCT04541953, NCT04541940).

2.3. Patient Eligibility Criteria

Patients were excluded if they had had a prior surgery of the affected limb, had any medical co-morbidities precluding them from complying with rehabilitation, had a multiligamentous knee injury (for the ACLR trial only), or were pregnant.

2.4. Randomization and Blinding

The active enrollment period was from October 2020 to November 2021. The total enrollment goal between both clinical trials was 120 patients (60 ACLR patients and 60 ARCR patients). Within each trial, subjects were randomized 1:1 to telerehabilitation or in-person rehabilitation, with a goal of 30 patients assigned to either treatment arm. Randomization was performed, using a computer-generated randomization algorithm, by a study team member not involved in the surgical procedure. The treating surgeon was blinded to the patient’s rehabilitation modality. Patients assigned to the in-person rehabilitation cohort followed standard postoperative protocol in person, those assigned to the telerehabilitation group followed the same protocol via telemedicine only.

2.5. ACLR Surgical Technique and Rehabilitation

All ACLRs were performed at a single academic medical center by one of six fellowship-trained sports medicine surgeons. A tourniquet was placed on the operative limb and the leg was placed in a leg holder. The ACLR was performed using bone–patellar tendon–bone, hamstring, or quadriceps autografts or allografts.
The same postoperative rehabilitation protocol was followed in both the in-person and telerehabilitation study arms. Phase I of the protocol included weight bearing, as tolerated, in a hinged knee brace locked in full extension for one week and unlocked for weeks 1–4. Patients undergoing meniscal repairs as a part of their treatment were given a modified rehabilitation protocol that included limited weight bearing during Phase I. Phase I therapeutic exercises were standardized across groups, focusing on the quadriceps and the hamstring if appropriate, with the goal of increasing the range of motion (ROM) and controlling edema. During phase II of rehabilitation (weeks 4–6), crutches were discontinued and the patient continued to be weight bearing as tolerated. The knee brace was discontinued once the patient achieved full extension and a straight leg raise without lag. Therapeutic exercises focused on progressing knee flexion and strengthening the hamstring and quadriceps if appropriate. Phase III (weeks 6–16) of postoperative rehabilitation consisted of an advancement to full weight bearing, with a full, painless ROM, with continued leg strengthening exercises and running, as tolerated, beginning at 12 weeks. Phase IV (months 4–6) of rehabilitation included a gradual return to activity at the surgeon and therapist’s discretion.

2.6. ARCR Surgical Technique and Rehabilitation

All ARCRs were performed at a single academic center by fellowship-trained sports medicine surgeons. After anesthesia induction, patients were placed in a beach-chair position or lateral decubitus position. Arthroscopes were inserted through the posterolateral portal and intraarticular structures were assessed. The RCR was performed using a technique chosen by the surgeon performing the procedure, based on the tear pattern and the needs of each individual patient [17].
The same postoperative rehabilitation protocol was followed in both the in-person and telerehabilitation study arms. Phase I (weeks 0–4) consisted of sling immobilization with abduction support, with exercises focused on elbow/wrist/hand ROM and grip strengthening, with gentle pendulum exercises at 2 weeks. Phase II of rehabilitation (weeks 4–8) focused on a progressive passive ROM, with sling discontinuation by week 6. In addition, active assisted range of motion (AAROM) exercises were initiated as tolerated by week 8, with progression to deltoid and biceps strengthening. If a biceps tenodesis was performed, no biceps strengthening was begun until week 8. Phase III (weeks 11–16) progressed to a full active range of motion (AROM) and continued with scapular strengthening and external/internal rotation isometric exercises. Finally, phase IV (months 4–6) focused on a full ROM without discomfort and advanced strengthening of the deltoid, triceps, and biceps as tolerated. Patients were cleared to return to sport after 6 months at the discretion of their treating physician and physical therapist.

2.7. Telerehabilitation’s Set-Up and Implementation

Patients initially assigned to the telerehabilitation group were given the same protocol as those assigned to the in-person rehabilitation arm of the study. Each patient was given a home exercise program through Physitrack Internet-based telerehabilitation software (Version 4.0.75, Physitrack PLC, London, UK) and enrolled in regular telerehabilitation appointments via video conference with a trained physical therapist [18]. Patients were given the option to crossover at their own discretion.

2.8. Survey Description and Outcomes Evaluated

For those undergoing ACLR, a survey of validated knee-specific questionnaires was administered via email using REDCap electronic data capture software version 14.0.32 (Vanderbilt University, Nashville, TN, USA) to ensure anonymity and blinding [19,20]. The International Knee Documentation Committee (IKDC) Subjective score was administered preoperatively and at 3 months and 6 months following surgery [21]. The final 6 month follow-up was intended to coincide with the completion of rehabilitation.
For patients undergoing ARCR, the American Shoulder and Elbow Surgeons (ASES) survey was administered via REDCap to ensure anonymity and blinding [22]. This score falls on a scale of 0 to 100, with 0 indicating the worst shoulder function and 100 indicating the best shoulder function. This survey was administered preoperatively and at 3 months and 6 months following surgery. The 6 month follow-up point coincided with the last month of rehabilitation, as per the protocol.
Satisfaction surveys were administered to both study cohorts. The questions used to assess satisfaction included a binary response to “were you satisfied with your rehabilitation modality?” and a scale from 0 to 10 (0 = completely unsatisfied and 10 = completely satisfied). Patients were asked to answer whether they would undergo the same procedure again if indicated as a categorical yes/no question.
The following questions were sent to the patients in both the in-person and telerehabilitation groups to assess their satisfaction with their respective modalities. Patients were asked (1) to rate their level of confidence in performing the assigned exercise, (2) to rate their level of confidence in returning to sport/daily activities, (3) if they had enough space at home to perform exercises, and (4) if their questions were answered at each session. Responses to all of the aforementioned questions were given on a Likert scale (1—Strongly Disagree, 5—Strongly Agree) [23].
Telerehabilitation patients were surveyed regarding (1) the ease of service implementation, (2) call quality, (3) whether telerehabilitation decreased the costs associated with their treatment, such as transportation, childcare, etc., (4) whether using telerehabilitation allowed the patient to attend more sessions, and (5) whether future programs should include a hybrid consisting of initial in-person rehabilitation followed by telerehabilitation. Responses to all of the aforementioned questions were given on a Likert Scale (1—Strongly Disagree, 5—Strongly Agree).

2.9. Sample Size Determination and Statistical Analysis

A priori power analyses were performed to determine the minimum sample sizes for both the ACLR and ARCR trials. Both analyses assumed a minimum desired statistical power (1 − β) of 80% at the 0.05 significance level (α). For the ACLR trial, the minimum per-group sample size needed to detect a 10-point difference in IKDC score (the previously reported minimum clinically important difference in this score [24]), with an assumed group standard deviation of 13 (for an assumed Cohen’s d effect size of 0.75), was estimated to be 28 patients, which was rounded up to 30 patients per group (60 patients in total). For the ARCR trial, the minimum per-group sample size needed to detect a 15-point difference in the ASES score (the previously reported minimum clinically important difference in this score [25]), with an assumed group standard deviation of 20 (for an assumed Cohen’s d effect size of 0.75), was estimated to be 29 patients, which was rounded up to 30 patients per group (60 patients total).
The baseline characteristics and outcomes of the in-person and telerehabilitation arms of each cohort were compared using Mann–Whitney U-tests for continuous variables, after an assessment of normality with the Shapiro–Wilk test, and Fisher’s exact test for categorical variables. p-values less than 0.05 were considered significant. All power analyses and statistical analyses were performed in SAS Studio version 9.4. (SAS Institute, Cary, NC, USA).

3. Results

3.1. Cohort Demographics

The demographics of the ACLR cohort are summarized in Table 1. In total, 16 patients were enrolled, of whom 10 (62.5%) were assigned to in-person rehabilitation and 6 (37.5%) were assigned to telerehabilitation. At baseline, there were no significant differences between the two groups in terms of age, sex, BMI, the KL grade of knee osteoarthritis, or preoperative IKDC score (all p > 0.05).
The demographics of the ARCR cohort are summarized in Table 2. In total, 32 patients were enrolled, of whom 20 (62.5%) were assigned to in-person rehabilitation and 12 (37.5%) were assigned to telerehabilitation. At baseline, there were no significant differences between the two groups in age, sex, BMI, the KL grade of glenohumeral osteoarthritis, or preoperative ASES Shoulder score (all p > 0.05).

3.2. Patient-Reported Outcomes over Time

The patient-reported outcomes at baseline, the 3-month follow-up, and the 6-month follow-up for the two cohorts are presented in Figure 1.
Among the ACLR cohort, subjects initially assigned to in-person rehabilitation did not show an improvement in their IKDC score at 3 months (p = 0.34) or at 6 months (p = 0.88). Subjects initially assigned to telerehabilitation did not show an improvement in their IKDC score at 3 months (p = 0.50) or at 6 months (p = 1.00). There were no significant differences in 3-month improvement (p = 0.09) or 6-month improvement (p = 0.87) between the two rehabilitation groups.
Among the ARCR cohort, subjects initially assigned to in-person rehabilitation showed a significant improvement in their ASES score at 3 months (p = 0.008) and at 6 months (p = 0.03). Subjects initially assigned to telerehabilitation did not show a significant improvement in their ASES score at 3 months (p = 0.05) or at 6 months (p = 0.05). There were no significant differences in 3-month improvement (p = 0.58) or 6-month improvement (p = 0.13) between the two rehabilitation groups.

3.3. Attrition, Crossover, and Final Interventions

In both trials combined, of the 30 patients assigned to in-person rehabilitation, 24 (80%) completed the final follow-up. Of these 24 patients, none reported a crossover to telerehabilitation.
Of the 18 patients initially assigned to telerehabilitation, 12 (67%) completed the final follow-up. Of these 12 patients, 11 (92%) reported a crossover, 9 patients completed in-person rehabilitation, and 2 patients completed hybrid in-person and telerehabilitation.
In total, 35 patients underwent in-person rehabilitation either alone or through a hybrid program and 3 patients participated in telerehabilitation either alone or through a hybrid program. A CONSORT diagram reporting these findings can be found in Figure 2.

3.4. Satisfaction with Rehabilitation Modality

The patients’ satisfaction with their chosen rehabilitation modality is summarized in Table 3.
Satisfaction was not significantly different between the groups (p = 0.21). Furthermore, the Likert-scale satisfaction scores across four other domains—confidence with correctly performing exercises, questions and concerns being appropriately addressed, confidence with return to daily activities, and confidence with return to sports—were not significantly different between the two groups (all p > 0.05). However, patient satisfaction with the availability of equipment and space was significantly lower in the telerehabilitation group (p = 0.02). In total, 97% of patients in the in-person group stated that they would undergo the same rehabilitation modality again, whereas only 2 out of 3 (67%) of telerehabilitation patients would do the same. However, this difference did not reach statistical significance (p = 0.15).
The three patients who underwent telerehabilitation attended two, two, and five sessions, respectively. Their average satisfaction with adopting and using new technology, the video quality of the calls, cost savings, and the opportunity to attend more visits than with in-person rehabilitation was between 4 and 5 (“Agree” to “Strongly Agree”).
Among the full cohort, the average Likert-scale response to the question “Do you think you would benefit more from a hybrid in-person and telerehabilitation program versus a telerehabilitation-only program?” was 4.0 ± 0.9, which corresponds to “Agree”.

4. Discussion

The present studies indicate some preference for in-person rehabilitation over telemedicine rehabilitation after both ACLR and ARCR. Although the satisfaction scores themselves were not significantly different between the groups, except for a significantly lower availability of equipment and space for patients who underwent telerehabilitation, the patient crossover from telerehabilitation to in-person rehabilitation was nearly ubiquitous. While each patient had their own reasons for crossing over to the in-person rehab group, insight from patient surveys seemed to show a common theme. The patients were missing the hands-on component and personal connection that is experienced with in-person treatment. In addition, patients often found it difficult to do their exercises correctly without a trained professional near them able to make the necessary corrections. Given the amount of crossover, the maintenance of equally randomized groups for postoperative telerehabilitation and in-person rehabilitation did not appear feasible to the authors, and therefore recruitment for both studies was intentionally halted. Neither study was significantly powered to make conclusions regarding patient satisfaction scores or functional outcomes in patients who underwent telerehabilitation versus in-person rehabilitation after either procedure, and the results were likely further impacted by severe attrition bias. In order to mitigate this, both randomized controlled trials were combined for analysis. Our results show no significant differences in functional outcomes between the groups after ARCRs both three and six months postoperatively, and no significant differences between groups after ACLRs.
Although telemedicine is not new to health care, its implementation became ubiquitous in orthopedic practices largely due to the COVID-19 pandemic. At the start of the pandemic, telemedicine was utilized to provide the full spectrum of orthopedic care, including postoperative rehabilitation [16,26,27,28,29,30,31,32,33,34]. The previously demonstrated benefits of telemedicine include patients having access to care otherwise inaccessible due to transportation and work constraints [27,35]. Moreover, several studies have reported patient [31,32,36,37] and surgeon satisfaction [38] with the use of telemedicine, garnering significant excitement about its continued role in orthopedic care. Given the uncertain landscape COVID-19 and emerging variants that demand flexibility from existing health care delivery systems, the integration of virtual care delivery may be critical to the ongoing success of orthopedic practices. The successful integration of telerehabilitation into practices requires patient and surgeon satisfaction and postoperative functional outcomes on par with, if not superior to, existing in-person rehabilitation. Our studies show that patients are not satisfied with telerehabilitation and that it may benefit from modifications.
In the literature, several orthopedic studies limited to hip and knee arthroplasties have compared the outcomes of telerehabilitation to in-person rehabilitation [14,15,16,39]. Four of these studies demonstrated no significant differences in functional outcomes [14,15,16,39] with equivalent increases in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Along similar lines, Moffet et al. (2017) reported no significant differences in patient satisfaction between groups [40]. A randomized controlled trial at our institution comparing rehabilitation modalities after arthroscopic meniscectomy showed no significant differences in functional outcomes between groups, but demonstrated superior patient satisfaction with in-person rehabilitation in spite of patients’ acknowledgement of telerehabilitation’s ease of use, optimal call quality, and reduction of treatment costs [41].
Additions to the literature continue to demonstrate the promise of telerehabilitation in postoperative orthopedic surgery patients. A systematic review evaluating the effectiveness of telerehabilitation compared to standard in-person rehabilitation for orthopedic surgery patients by Morri et al. showed pooled estimates for motor performance favored telerehabilitation compared to standard in-person rehabilitation, while pain and functional recovery did not show any significant differences between the compared study groups [42]. Greiner et al. conducted a study of a virtual home-based rehabilitation system after shoulder surgery that showed significant improvement in pain, postoperative stiffness, and medication use over the 8 week rehabilitation period, with 93% of patients recommending the virtual rehabilitation program upon completion [43].
In contrast to low-complexity arthroscopic procedures like meniscectomies, which typically involve a simple postoperative course [44], ARCR and ACLR have longer and more rigorous postoperative protocols requiring up to 4–6 months of rehabilitation. Both ARCR and ACLR’s postoperative rehabilitation protocols require significant tactile support and equipment and the rebuilding of confidence and a psychological readiness to return to activity and sport. The demanding and complex nature of the rehabilitation process may explain the overwhelming crossover of patients from telerehabilitation to in-person rehab. Low satisfaction was seen among the telerehabilitation patients due to the space and equipment availability obstacles they had to overcome. Therefore, providing these patients with simple but necessary equipment and spaces to do these exercises may improve their overall satisfaction and compliance with telerehabilitation.
Overall, patients who crossed over shared the following insights: (1) a personal connection with the physical therapist was crucial for success and best built in-person, (2) the in-person supervision of a therapist increased patients’ confidence in their abilities to perform exercises and movements correctly more than virtual supervision, and (3) while patients acknowledged that telerehabilitation was an alternative to in-person rehabilitation, they expressed that early hands-on interactions were critical to long-term success. Patients expressed a willingness to engage in a hybrid model with early in-person rehabilitation followed by later telerehabilitation, which may result in more optimal outcomes. Further research on a hybrid model and resulting patient satisfaction and functional outcomes are required for both ACLR and ARCR to determine the potential role that telerehabilitation can play.
The literature evaluating the current landscape echoes the need for innovation during postoperative rehabilitation to optimize outcomes after orthopedic surgery. In a 2024 survey assessing patient perceptions of the rehabilitation gap after ACLR surgery, Gardner et al. found that 83% of surveyed patients reported a rehabilitation gap and that current standard insurance coverage is insufficient to facilitate optimal rehabilitation [45]. Furthermore, 84% felt that digital rehabilitation strategies had a significant potential to address these gaps [45].

Limitations

There were several limitations to the present studies. First, neither the ACLR nor the ARCR trials were adequately powered to detect differences between groups (based on the a priori sample size determination) due to findings that necessitated their early study closure. Second, the follow-up was limited to six months due to the studies’ closure, although this corresponded to standard rehabilitation timelines and likely captured the functional gains experienced by patients. Third, a qualitative study of patient perceptions was not conducted as it was not within the scope of the current studies. Further research should include a qualitative component to better guide future research and the implementation of telerehabilitation in sports medicine.

5. Conclusions

Patients preferred in-person rehabilitation compared to telerehabilitation after ACLR and ARCR, as evidenced by the nearly ubiquitous crossover from telerehabilitation to in-person rehabilitation in both studies. Our findings suggest that telerehabilitation protocols still need to be perfected and that there may be a role for a hybrid in-person and telerehabilitation model.

Author Contributions

Conceptualization, S.M.S., G.G.-L., M.J.A., E.J.S., L.M.J. and K.A.C.; Data curation, K.D.V., D.S.S., A.A., E.S.M., E.T.H. and J.F.O.; Formal analysis, D.S.S.; Investigation, K.D.V., D.S.S., A.A., E.S.M. and E.T.H.; Methodology, K.D.V. and D.S.S.; Project administration, K.A.C.; Software, D.S.S.; Supervision, S.D.B., S.M.S., G.G.-L., M.J.A., E.J.S., L.M.J. and K.A.C.; Visualization, D.S.S.; Writing—original draft, K.D.V., D.S.S., A.A., K.L. and S.D.B.; Writing—review and editing, K.D.V., D.S.S., A.A., K.L., S.D.B., S.M.S., G.G.-L., M.J.A., E.J.S., L.M.J. and K.A.C. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of New York University Langone Health (protocol codes (ARCR trial: s20-01261; ACLR trial: s20-01313). Both studies were registered on clinicaltrials.gov (NCT04541953, NCT04541940).

Informed Consent Statement

All recruitment was conducted with written informed consent from patients.

Data Availability Statement

The data presented in this study are not publicly available due to privacy restrictions.

Conflicts of Interest

The following authors have disclosures that are not related to this study listed in Appendix A: Michael J. Alaia, Eric J. Strauss, Laith M. Jazrawi, and Kirk A. Campbell. The remaining authors have no financial or non-financial conflicts of interest to disclose:

Appendix A

Michael J. Alaia:
  • AAOS: Board or committee member.
  • Arthrex, Inc: Paid consultant; research support.
  • Arthroscopy: Editorial or governing board.
  • Arthroscopy Association of North America: Board or committee member.
  • Journal of Cartilage and Joint Preservation: Editorial or governing board.
  • JRF Ortho: Paid consultant.
  • Mitek: Paid consultant.
  • Orcosa, Inc: Research support.
  • Springer: Publishing royalties, financial or material support.
Eric J. Strauss:
  • AAOS: Board or committee member.
  • American Orthopaedic Association: Board or committee member.
  • Arthrex, Inc: Paid consultant; Paid presenter or speaker.
  • Arthroscopy Association of North America: Board or committee member.
  • Better PT: Stock or stock options.
  • Cartiheal: Research support.
  • Cartilage, Bulletin of the Hospital For Joint Diseases: Editorial or governing board.
  • Fidia: Paid consultant; research support.
  • Flexion Therapeutics: Paid consultant
  • Jaypee Publishing: Publishing royalties, financial or material support.
  • Joint Restoration Foundation: Paid consultant.
  • Organogenesis: Paid consultant; Paid presenter or speaker; research support.
  • Smith & Nephew: Paid consultant; paid presenter or speaker.
  • Springer: Publishing royalties, financial or material support.
  • Subchondral Solutions: Paid consultant.
  • Vericel: Paid consultant; Paid presenter or speaker.
Laith M. Jazrawi:
  • Arthrex, Inc: Research support.
  • Bulletin for the Hospital for Joint Diseases: Editorial or governing board.
  • JBJS Reviews: Editorial or governing board.
  • Mitek: Research support.
  • Smith & Nephew: Research support.
  • Wolters Kluwer Health—Lippincott Williams & Wilkins: Publishing royalties, financial or material support.
Kirk A. Campbell:
  • AAOS: Board or committee member.
  • Arthroscopy Association of North America: Board or committee member.
  • Mitek: Paid consultant.
  • Stryker: Research support.
  • ETH
  • Arthroscopy: Editorial or governing board.
  • European Society for Surgery of the Shoulder and Elbow: Board or committee member.
  • Journal of Shoulder and Elbow Surgery: Editorial or governing board.

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Surgeries 05 00050 g001
Figure 1. Patient-reported outcomes for the ACLR and ARCR cohorts. Scores that significantly changed from the baseline by 3 months or 6 months (Mann–Whitney U-test with p-value < 0.05) are marked with an asterisk (*). (A) IKDC scores for the ACL cohort. (B) ASES Shoulder scores for the ARCR cohort.
Figure 1. Patient-reported outcomes for the ACLR and ARCR cohorts. Scores that significantly changed from the baseline by 3 months or 6 months (Mann–Whitney U-test with p-value < 0.05) are marked with an asterisk (*). (A) IKDC scores for the ACL cohort. (B) ASES Shoulder scores for the ARCR cohort.
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Figure 2. CONSORT flow diagram.
Figure 2. CONSORT flow diagram.
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Table 1. ACLR cohort demographics. Mean ± standard deviation.
Table 1. ACLR cohort demographics. Mean ± standard deviation.
In-Person
(n = 10)		Telerehabilitation
(n = 6)		p Value
Age39.6 ± 15.336.2 ± 10.6>0.99
Sex
  Male3 (30%)2 (33%)>0.99
  Female7 (70%)4 (67%)
BMI28.0 ± 7.630.3 ± 6.10.32
KL Grade
  07 (70%)5 (83%)>0.99
  11 (10%)0 (0%)
  22 (20%)1 (17%)
Preoperative IKDC score51.4 ± 15.255.4 ± 10.80.43
Table 2. ARCR cohort demographics. Mean ± standard deviation.
Table 2. ARCR cohort demographics. Mean ± standard deviation.
In-Person
(n = 20)		Telerehabilitation
(n = 12)		p Value
Age58.0 ± 10.557.2 ± 7.80.58
Sex
  Male8 (40%)6 (50%)0.72
  Female12 (60%)6 (50%)
BMI31.0 ± 7.527.2 ± 5.70.13
KL Grade
  010 (50%)7 (58%)0.38
  12 (10%)3 (25%)
  24 (20%)2 (17%)
  34 (20%)0 (0%)
Preoperative ASES score46.7 ± 18.138.9 ± 18.90.46
Table 3. Satisfaction with rehabilitation modality. p-values < 0.05 are marked with asterisk (*).
Table 3. Satisfaction with rehabilitation modality. p-values < 0.05 are marked with asterisk (*).
In-Person
(n = 35)		Telerehabilitation
(n = 3)		p Value
Overall satisfaction (%)90 ± 1670 ± 270.21
Confidence with correctly performing exercises (1–5)4.6 ± 0.73.7 ± 1.50.23
Questions and concerns appropriately addressed (1–5)4.8 ± 0.45.0 ± 0.00.44
Confidence with return to daily activities (1–5)4.5 ± 0.74.3 ± 0.60.56
Confidence with return to sports (1–5)3.7 ± 1.12.7 ± 1.50.17
Availability of equipment and space (1–5)4.7 ± 0.63.7 ± 0.60.02 *
Telerehabilitation-specific questions
  Number of visitsn/a3.0 ± 1.7n/a
  Ability to adopt and use new technology (1–5)n/a4.7 ± 0.6 n/a
  Video quality of calls (1–5)n/a4.7 ± 0.6n/a
  Cost savings (1–5)n/a4.0 ± 1.0n/a
  Ability to attend more visits (1–5)n/a4.5 ± 0.7n/a
Would undergo rehabilitation modality again34 (97%)2 (67%)0.15
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MDPI and ACS Style

Vasavada, K.D.; Shankar, D.S.; Avila, A.; Mojica, E.S.; Hurley, E.T.; Lehane, K.; Buzin, S.D.; Oeding, J.F.; Stein, S.M.; Gonzalez-Lomas, G.; et al. Severe Attrition and Poor Satisfaction in Patients Undergoing Telerehabilitation vs. Standard In-Person Rehabilitation after Arthroscopic Rotator Cuff Repairs and Anterior Cruciate Ligament Reconstructions. Surgeries 2024, 5, 627-639. https://doi.org/10.3390/surgeries5030050

AMA Style

Vasavada KD, Shankar DS, Avila A, Mojica ES, Hurley ET, Lehane K, Buzin SD, Oeding JF, Stein SM, Gonzalez-Lomas G, et al. Severe Attrition and Poor Satisfaction in Patients Undergoing Telerehabilitation vs. Standard In-Person Rehabilitation after Arthroscopic Rotator Cuff Repairs and Anterior Cruciate Ligament Reconstructions. Surgeries. 2024; 5(3):627-639. https://doi.org/10.3390/surgeries5030050

Chicago/Turabian Style

Vasavada, Kinjal D., Dhruv S. Shankar, Amanda Avila, Edward S. Mojica, Eoghan T. Hurley, Kevin Lehane, Scott D. Buzin, Jacob F. Oeding, Spencer M. Stein, Guillem Gonzalez-Lomas, and et al. 2024. "Severe Attrition and Poor Satisfaction in Patients Undergoing Telerehabilitation vs. Standard In-Person Rehabilitation after Arthroscopic Rotator Cuff Repairs and Anterior Cruciate Ligament Reconstructions" Surgeries 5, no. 3: 627-639. https://doi.org/10.3390/surgeries5030050

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