Challenges in rehabilitation and continuum of care provision after knee replacement: a mixed-methods study from a low- and middle-income country

Abstract

Purpose

Continuum-of-care is crucial following knee replacement. This is an understudied area in the context of low- and middle-income countries. We report findings of a mixed-methods study conducted to understand patient’s postoperative experiences in following unsupervised home-based physiotherapy protocols and healthcare provider’s experiences in providing rehabilitation care.

Methods

Consecutive adults (n = 79) scheduled or had undergone knee replacement, attending an urban tertiary care hospital in India completed a 22-item questionnaire to gauge attitude towards physical rehabilitation. We conducted in-depth interviews with nine patients, ten physiotherapists, and three surgeons using a phenomenology approach. Data were interpreted using the capability, opportunity, and motivation-behaviour (COM-B) framework.

Results

Patients were motivated to do exercises and valued family support during the recovery period. However, they desired physiotherapy support, especially during the early recovery period due to post-operative pain. Healthcare providers reported poor adherence with the exercise regimen and desired a mechanism to monitor patient progress after discharge. Patients and health care providers identified accessibility to rehabilitation centre as a major barrier in availing affordable and reliable physiotherapy services.

Conclusion

There is a need for a continuum of care to improve patient experience during recovery and for health care providers to monitor progress and provide personalised progressive exercise therapy.

IMPLICATIONS FOR REHABILITATION

• In India, regular monitoring following knee replacement is essential in home-based rehabilitation protocols necessitating clinic visits.

• Barriers to rehabilitation included post-surgical pain and difficulty in accessing physiotherapy services, while patient motivation and family support were facilitators to rehabilitation adherence.

• There is a need for remote monitoring mechanisms to facilitate health care providers in India, to monitor progress and reduce out of pocket expenditure for patients.

Keywords:

• Knee arthroplasty
• physical therapy
• rehabilitation
• continuum of care
• rehabilitation adherence

Acknowledgments

The authors would like to thank distinguished Prof Gordon Guyatt, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada for providing expert comments.

Ethics statement

The study was approved by the Institutional Ethics Committee of All India Institute of Medical Sciences Delhi (IEC-709\01.10.2021) and The George Institute for Global Health India (REF-19/2021).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by DBT/Wellcome Trust India Alliance under grant number [IA/CPHI/20/1/505224].