**2. Hip arthroplasty**

The coxofemoral joint is formed by two articulated surfaces—the acetabulum and the femoral head—that are related to the hipbone and the femur, respectively. The THA consists of replacing the femoral head and the acetabulum with prosthesis. The surgery purpose is to reduce pain, improve mobility and quality of life the people with hip osteoarthrosis [1]. The type of THA to be performed will depend on the patient needs. In case of people with limited physical activity, a cemented THA is performed, while an uncemented THA is performed in people with high activity demands [2]. THA and knee arthroplasty are the most frequent surgical interventions in the USA, representing a high economic burden for the public and private health system [3, 4].

One of the main intervention shortcomings is related to the prosthesis lifetime, which depends on the amount of activity carried out with it. That means if the person performs activities with greater load on the lower limbs, the replacement period will be shorter compared to a person who performs less activity. Overall, the patients' progress after joint replacement is satisfactory. Nonetheless, a significant number of patients may present functional and balance limitations, even 1 year after surgery [5].

These limitations may imply deficits in the proprioceptive system that lead to altered pattern of movements (e.g., gait difficulties and poor postural control). Likewise, these alterations would disturb basic daily activities performance and patients' quality of life [6]. Therefore, balance and proprioception are key factors in the treatment to an integral rehabilitation [7]; since there is a positive association between equilibrium capacities and functional capacities [8].

#### **3. Telemedicine and telerehabilitation**

#### **3.1 Telemedicine**

The term telemedicine is used to describe the delivery of health care services, clinical information and patient education in all specialties. Telemedicine uses a

**13**

*Toward a Design of a Telerehabilitation Program for the Functional Recovery in Post-Hip…*

wide variety of technologies (internet, mobile phones, electronic medical records…) to provide healthcare from distance [9]. It provides clinical information, allows consultations and helps communication between health professionals and patients, regardless the location of the patient. Therefore, telemedicine allows increasing access to specialized medical care. Remote patient monitoring happens regularly and certain interventions can be performed in real time rapidly and effectively [10]. Telemedicine can also be an instrument that helps patients and their caregivers get

A large number of studies in a wide range of disciplines have bid to document the telemedicine effectiveness. It has been found that telemedicine is effective in the

diabetes—especially type 2 [14]; arterial hypertension [15] and multiple sclerosis [16]. In addition, positive clinical results have been presented for the patient followup and treatment in different situations such as: (1) burned [17]; (2) in palliative care [18]; (3) with acute cerebrovascular accident [19]; (4) with mental disorders [20]; (5)

Regardless the area in which telemedicine has been applied; different authors state general findings about its potential application. For instance, (1) It is a safe and feasible way to provide care and monitor certain groups of patients; (2) It leads to a decline in the number of visits to the hospital and decreases the length of stay in

TR is a telemedicine form that provides remote support (temporary or permanent), evaluation and intervention to disabled people who need rehabilitation [26]. In the last decade TR has evolved due to the great reduction of costs in health services [27]. TR development has been pushed by several factors. Firstly, there is better access to specialized services and improved capacity for remote monitoring [28]. A second factor was the mobilization difficulties that people who require the service may face [26]. It has been shown that less than a third of patients discontinue outpatient rehabilitation 3 months after discharge [29]. In rural areas, transportation can be a burden due to less availability of public transportation or climatic factors. Thirdly, TR could defeat financial barriers for families with less purchasing power, since financing or using insurance in post-acute care is usually limited and expensive [26]. This reduces expenses for both, the user and the provider, because several patients can be treated by a single program at any time [27, 30]. Lastly, a key factor for TR progress is the connection between the healthcare provider and the patient, family members and the community which results in training improve-

The implementation of this technology is held by: (i) health personnel; (ii) the influence on the economy of the patients and the health system (decreased visits to the hospital and decreases the time of hospitalization); (iii) the ability of medical care to reach distant or low-income populations; and (iv) the autonomy of the patient in his rehabilitation process [26]. TR has been appropriate to: (i) complete pre-operative evaluations; (ii) analyze patterns of movement, gait; and (iii) prescribe orthopedic material [31]. These study trials showed favorable results, by not

management of adult malnutrition [11]; asthma [12]; heart disease [13],

geriatric [21]; and (6) newborns, children and adolescents [22, 23].

(iv) involve the patient in the self-management of the disease.

ment, which indirectly expands the health workforce [30].

the hospital, therefore there is a reduction of costs in the health system; (3) Professionals and patients seem to follow and be satisfied when using the programs; and (4) It promotes self-management of the disease and adherence to treatment [24, 25]. Certainly, the increase usage of telemedicine could: (i) provide greater access to health services; (ii) offer the opportunity to carry out early interventions and even work on prevention; (iii) provide a constant follow-up, and

*DOI: http://dx.doi.org/10.5772/intechopen.85768*

involved in their own care.

**3.2 Telerehabilitation**

#### *Toward a Design of a Telerehabilitation Program for the Functional Recovery in Post-Hip… DOI: http://dx.doi.org/10.5772/intechopen.85768*

wide variety of technologies (internet, mobile phones, electronic medical records…) to provide healthcare from distance [9]. It provides clinical information, allows consultations and helps communication between health professionals and patients, regardless the location of the patient. Therefore, telemedicine allows increasing access to specialized medical care. Remote patient monitoring happens regularly and certain interventions can be performed in real time rapidly and effectively [10]. Telemedicine can also be an instrument that helps patients and their caregivers get involved in their own care.

A large number of studies in a wide range of disciplines have bid to document the telemedicine effectiveness. It has been found that telemedicine is effective in the management of adult malnutrition [11]; asthma [12]; heart disease [13], diabetes—especially type 2 [14]; arterial hypertension [15] and multiple sclerosis [16]. In addition, positive clinical results have been presented for the patient followup and treatment in different situations such as: (1) burned [17]; (2) in palliative care [18]; (3) with acute cerebrovascular accident [19]; (4) with mental disorders [20]; (5) geriatric [21]; and (6) newborns, children and adolescents [22, 23].

Regardless the area in which telemedicine has been applied; different authors state general findings about its potential application. For instance, (1) It is a safe and feasible way to provide care and monitor certain groups of patients; (2) It leads to a decline in the number of visits to the hospital and decreases the length of stay in the hospital, therefore there is a reduction of costs in the health system; (3) Professionals and patients seem to follow and be satisfied when using the programs; and (4) It promotes self-management of the disease and adherence to treatment [24, 25]. Certainly, the increase usage of telemedicine could: (i) provide greater access to health services; (ii) offer the opportunity to carry out early interventions and even work on prevention; (iii) provide a constant follow-up, and (iv) involve the patient in the self-management of the disease.

#### **3.2 Telerehabilitation**

*Assistive and Rehabilitation Engineering*

activities of daily living (ADL).

implementation of some exercises.

**2. Hip arthroplasty**

health system [3, 4].

after surgery [5].

**3.1 Telemedicine**

The coxofemoral joint is one of the most important joints in the human body, because it is fundamental for walking. The rehabilitation of these patients after surgery seeks to relieve pain, restore normal function and improve quality of life. Specifically, functional recovery plays an important role to engaging patient in

Post-surgical rehabilitation guidelines for hip arthroplasty are well known, and the correct application has a positive effect on the patients' prognosis. However, there are no complementary guidelines for physical therapy that could be used at a distance by patients through a computer platform. A recent systematic review shows that the TR application in real time combined with a conventional physiotherapy program is more favorable than isolated treatment of musculoskeletal dysfunctions. Thus, the objective of this chapter was to report the main results of a systematic review about conventional physiotherapy programs for hip arthroplasty and to propose some exercises adapted to a low-cost TR platform for the functional recovery. We will present a brief review of the THA, telemedicine/TR, conventional physical therapy approaches, the methodology used to design the therapeutic intervention program adapted to the low-cost TR platform from a systematic literature review, and present the initial results about the

The coxofemoral joint is formed by two articulated surfaces—the acetabulum and the femoral head—that are related to the hipbone and the femur, respectively. The THA consists of replacing the femoral head and the acetabulum with prosthesis. The surgery purpose is to reduce pain, improve mobility and quality of life the people with hip osteoarthrosis [1]. The type of THA to be performed will depend on the patient needs. In case of people with limited physical activity, a cemented THA is performed, while an uncemented THA is performed in people with high activity demands [2]. THA and knee arthroplasty are the most frequent surgical interventions in the USA, representing a high economic burden for the public and private

One of the main intervention shortcomings is related to the prosthesis lifetime, which depends on the amount of activity carried out with it. That means if the person performs activities with greater load on the lower limbs, the replacement period will be shorter compared to a person who performs less activity. Overall, the patients' progress after joint replacement is satisfactory. Nonetheless, a significant number of patients may present functional and balance limitations, even 1 year

These limitations may imply deficits in the proprioceptive system that lead to altered pattern of movements (e.g., gait difficulties and poor postural control). Likewise, these alterations would disturb basic daily activities performance and patients' quality of life [6]. Therefore, balance and proprioception are key factors in the treatment to an integral rehabilitation [7]; since there is a positive association

The term telemedicine is used to describe the delivery of health care services, clinical information and patient education in all specialties. Telemedicine uses a

between equilibrium capacities and functional capacities [8].

**3. Telemedicine and telerehabilitation**

**12**

TR is a telemedicine form that provides remote support (temporary or permanent), evaluation and intervention to disabled people who need rehabilitation [26]. In the last decade TR has evolved due to the great reduction of costs in health services [27]. TR development has been pushed by several factors. Firstly, there is better access to specialized services and improved capacity for remote monitoring [28]. A second factor was the mobilization difficulties that people who require the service may face [26]. It has been shown that less than a third of patients discontinue outpatient rehabilitation 3 months after discharge [29]. In rural areas, transportation can be a burden due to less availability of public transportation or climatic factors. Thirdly, TR could defeat financial barriers for families with less purchasing power, since financing or using insurance in post-acute care is usually limited and expensive [26]. This reduces expenses for both, the user and the provider, because several patients can be treated by a single program at any time [27, 30]. Lastly, a key factor for TR progress is the connection between the healthcare provider and the patient, family members and the community which results in training improvement, which indirectly expands the health workforce [30].

The implementation of this technology is held by: (i) health personnel; (ii) the influence on the economy of the patients and the health system (decreased visits to the hospital and decreases the time of hospitalization); (iii) the ability of medical care to reach distant or low-income populations; and (iv) the autonomy of the patient in his rehabilitation process [26]. TR has been appropriate to: (i) complete pre-operative evaluations; (ii) analyze patterns of movement, gait; and (iii) prescribe orthopedic material [31]. These study trials showed favorable results, by not only improving physical health, reduction of fatigue, but also recovering mental health by the lessening of depressive symptoms. In addition, high levels of satisfaction and comfort were reported, as well as significant savings in time and travel costs of users [26, 31]. A recent study has aimed to develop a low-cost, online TR platform intended to evaluate and monitor patients after a total hip arthroplasty [32].

Despite all favorable aspects of the TR program implementation; there are still many challenges to face. The first challenge is to build a good relationship between the health provider and the patient. Many patients prefer to receive personalized and face-to-face care, lessening the possibilities of adopting this new form of approach. Elderly patients tend to have doubts about this kind of treatment method whereas it is extremely easy in young patients [30]. Developing an online application in smartphones could be one way to establish a relationship through TR [33]. These applications would allow a more direct, regular and personalized interaction with the patient.

There may also be safety problems, if the patient was alone during the session the patient could have an accident or when performing the movements wrongly increases the chances to get hurt [33, 34]. In order to avoid these situations, TR platforms should include links providing the necessary therapeutic information to prevent an accident or detect a wrong execution of the exercises. Likewise, the platform should be equipped with a control system able to allow the session to the patient, as well as disable it if necessary [32].

The incompatibility of systems and platforms between different operating system providers should also be taken care of. This issue has showed conflicts in the past when integrating the contents of clinical databases [34]. On the other hand, TR is limited when it comes to detecting fine movements or tremors, movements in certain planes [33], and emotional states of patients. However, recent studies show advances in the development of computer programming for facial gestures recognition that could be used in TR platforms [35].

### **4. Conventional physiotherapy**

Physical therapy after a THA is essentially performed to improve patient's functionality through posture and gait training. Some of the main focuses during treatment are the hip range of motion (ROM), muscle strength, pain and edema. The control and improvement of these parameters allows the patient reintegration to the activities of daily life (ADL). This reintegration to the ADLs is accelerated when the rehabilitation process has an early start. Prompt physical therapy intervention helps reduce hospital stay, as well as costs to the health system [36].

Commonly the therapeutic intervention is classified as early, standard or late. The early intervention begins immediately after the surgery, and can be carried out on the same day or the next day. The standard phase begins either 1 or 2 days postoperative, while the late intervention begins after the second week post-surgery [36].

Depending on the patient activity, postoperative physical therapy can last between 8 to 24 weeks, divided into three or four phases. Stage I (peri-operative) lasts for 2 weeks where the focus is the education of the patient about their current condition (recommendations when doing certain movements, changes of position, training the walk with technical aids, etc.) and performing active mobility exercises in the appropriate ROM [37].

Stage II and III focus on muscle strengthening, load tissue adaptation and ROM recovery of the hip. This phase is usually distributed in two stages: the first lasts two to 8 weeks and the second between two and seven. Manual techniques can be used in this stage, but the progressive load with therapeutic exercise should be

**15**

*Toward a Design of a Telerehabilitation Program for the Functional Recovery in Post-Hip…*

prioritized, in open and/or closed kinetic chain exercises, resistance exercises with elastic bands or different weights. In addition, stability and proprioception work should be included, with an emphasis on lumbopelvic and hip stability [37]. Stage IV concentrates on the ADL reintegration, it can last 2 weeks up to 2 months. The objective of this stage is to reinsert the patient to their normal setting (educational, work and/or sports activities). The approach is done through imitation of motor gestures accompanied by exercises of cardiovascular resistance and progressive strength. Cheatman and colleagues [37] estimate that after 4 months of intervention, the patient can return to his medium impact activities, such as the recreational walk. Six months after surgery, the patient can return to high impact

In general, physical therapy concentrates on muscle strength, patient education, gait retraining, and improvement of hip mobility. It is recommended to perform two sessions a day, since it has been demonstrated that in early stages function recovery occurs quicker [38]. Evidence also proves that rehabilitation programs, with at least three phases, have more beneficial effects for postoperative THA patients [37]. Finally, the fulfillment of the health team recommendations and complementary work at home are important in the rehabilitation process, accelerat-

As we have shown, post-surgical rehabilitation guidelines for THA are well known, and their correct application has benefits on the patients´ prognosis. However, there are no complementary guidelines for physical therapy that could be used at a distance by patients through a computer platform. A recent systematic review shows that the TR application in real time combined with a conventional physiotherapy program is more favorable than isolated treatment of musculoskel-

An electronic search was performed to identify relevant articles in: PubMed Meta-search (1950 to March, 2017), ScienceDirect (1990 to March, 2017), PEDro (1950 to March 2017), and Cochrane Database (2000 to March 2017). Key words relating to the domains was used: (1) type of exercise: "Join mobility exercise OR Functional exercise OR Therapeutic exercise OR Rehabilitation exercise OR Posthospital Home Exercise"; (2) clinical term: "Total OR partial hip replacement, Total OR partial hip arthroplasty"; (3) type of document: "Position stand OR Clinical guide OR Systematic review OR Literature review OR Randomised controlled trials

The reviewers followed a selection protocol, developed prior to the beginning of the review that included a checklist for inclusion and exclusion criterion (**Figure 1**). Articles were eligible for inclusion if they: (a) included passive or active specific exercises to strengthen the hip, enhance the static balance and/or restore whole joint movement; (b) were carried out on individuals of all age groups and sex with total or partial hip replacement; (c) consisted of self-administered home exercise programs or a program supervised by a physical therapist; (d) reported that a criterion for entry was total or partial hip replacement of 1 day after surgery and within 12 weeks to 8 months following surgery; (e) reported one of the following outcome

*DOI: http://dx.doi.org/10.5772/intechopen.85768*

ing the patient reintegration to their setting.

**5. Systematic review methodology**

**5.1 Data sources and searches**

[RCTs];" (4) their combination.

**5.2 Study selection**

activities or sports.

etal dysfunctions [39].

#### *Toward a Design of a Telerehabilitation Program for the Functional Recovery in Post-Hip… DOI: http://dx.doi.org/10.5772/intechopen.85768*

prioritized, in open and/or closed kinetic chain exercises, resistance exercises with elastic bands or different weights. In addition, stability and proprioception work should be included, with an emphasis on lumbopelvic and hip stability [37].

Stage IV concentrates on the ADL reintegration, it can last 2 weeks up to 2 months. The objective of this stage is to reinsert the patient to their normal setting (educational, work and/or sports activities). The approach is done through imitation of motor gestures accompanied by exercises of cardiovascular resistance and progressive strength. Cheatman and colleagues [37] estimate that after 4 months of intervention, the patient can return to his medium impact activities, such as the recreational walk. Six months after surgery, the patient can return to high impact activities or sports.

In general, physical therapy concentrates on muscle strength, patient education, gait retraining, and improvement of hip mobility. It is recommended to perform two sessions a day, since it has been demonstrated that in early stages function recovery occurs quicker [38]. Evidence also proves that rehabilitation programs, with at least three phases, have more beneficial effects for postoperative THA patients [37]. Finally, the fulfillment of the health team recommendations and complementary work at home are important in the rehabilitation process, accelerating the patient reintegration to their setting.

As we have shown, post-surgical rehabilitation guidelines for THA are well known, and their correct application has benefits on the patients´ prognosis. However, there are no complementary guidelines for physical therapy that could be used at a distance by patients through a computer platform. A recent systematic review shows that the TR application in real time combined with a conventional physiotherapy program is more favorable than isolated treatment of musculoskeletal dysfunctions [39].
