Assessing Patient Non-Compliance:

A Potential Development in Total Knee Replacement

Maja D. Cuprys

Fairchild Wheeler Interdistrict Magnet High School

Abstract:
The population is growing older; this means more people will need total knee replacements to

remain healthy. However, this will require more patient compliance to increase patient

satisfaction. This project will analyze research about physiotherapy and total knee arthroplasty

and develop a mobile application that allows patient compliance, progress, and satisfaction to be

recorded by doctors and concerns to be directly addressed in real time via instant messaging for

all parties. Data collection will be done by releasing surveys to collect data about what patients

believe they need in such an application to develop a mobile app which should be user-friendly

and effective. Data will be obtained via a post-development survey, and all data will be collected

via Google Forms and extrapolated on Google Sheets to form viable conclusions. From these

conclusions, there may hopefully be more research done in regards to testing the product against

traditional physiotherapy in the future.

Problem Statement:

There are more and more people receiving knee implants. According to The American Academy

of Orthopedic Surgeons, there are over 600,000 total knee replacements performed each year,

and that number is expected to exceed 3 million by the year 2030 (American Academy of

Orthopedic Surgeons 2013), yet procedure satisfaction is very unpredictable. According to a

meta-analysis study published by the NCBI in 2016, only 22% of patients rated their satisfaction

with total knee replacements as “excellent”(Choi et al. 2016). These statistics may be attributed

to patient noncompliance or general practices that could be improved. This problem is crucial to

address because knee replacements are going to become more and more commonplace as

developed populations age with advances in medical care. Even just between 1991 and 2000 “the
incidence of primary THR increased by 18%, while the incidence of revision THR more than

doubled."(Dixon et al. 2004).

Literature Review:

Knee replacement is becoming a frequently chosen option to treat joint pain as the population

ages and lives longer. Between 1997-2009, total knee replacement increased by 84% in the

American population(American Academy of Orthopedic Surgeons 2013). However, satisfaction

rates can be very variable. Based on a study published in the NCBI, only 22% of patients rated

their satisfaction with total knee replacements as “excellent.”(Choi et al. 2016). From patient

non-compliance with unnecessarily extended hospital stays, many different factors affect patient

satisfaction after total knee replacement.

Part of what increases patient satisfaction after knee replacement is how fast one can return to

prior function. The Accelerated article Rehabilitation After Total Knee Replacement tested

different ways to expand patient mobility after total knee replacement safely. Mr. David Isaac

conducted the study with Dr. Tunde Falode, a General Manager for the Diabetes and

Cardiovascular Business Unit in the UK and Ireland. They have found methods and made

adjustments to certain aspects of knee replacement, tested them. They published their results in

the journal The Knee in the year 2004. These titles give the researchers authority on the subject

matter on hand. Fifty patients who were in the experimental group and 80 people in the control

group aged 42-88 participated in this study. There no other specific selection protocols in the

study.

The researchers wanted to test whether modifications to surgical and post-operative procedures

allowed patients to be safely discharged from the hospital earlier. The control group did not

receive accelerated rehabilitation and received the traditional surgery and post-operative
monitoring. It was predicted that more coordination between doctors and slightly modifying the

procedure would drastically reduce the length of time spent in the hospital, increasing patient

satisfaction and financially benefiting hospitals (Dixon et al., 2004). Before operation day,

patients were asked to make sure that issues that arose, whether it was lack of aid, lack of

transportation, and other factors were addressed before the operation to try to mitigate the effects

of these problems as soon as possible. When admitted to the hospital, patients were administered

their required medication and anti-embolic stockings. During surgery, each patient in both

groups was given a spinal anesthetic made of diamorphine and bupivacaine with occasional light

sedation required. All patients had one of two types of implants, and all implants were cemented.

During the operation, traditional surgical procedures were used until just before the prosthesis

was cemented. Postoperatively, the physical function of the patient’s knees was assessed on the

American Knee Society score and Oxford functional rating score. After six weeks post-op, 23

randomly selected patients would return for revaluation and to measure a range of motion of the

prosthetic knee. Eight patients from both the experimental and control group were rated on a

visual analog scale from 1-10. The hypothesis was generally supported (Dixon et al. 2004).

Patients were usually able to be safely discharged faster from the hospital. Other studies on

shortening hospital lengths of hospital stay also confirm that patients could be discharged sooner

after knee replacement and hospitals benefit financially. “The clinical pathway and the knee-

implant standardization program reduced resource utilization and hospital cost for total knee

arthroplasty without affecting short-term patient outcome in our hospital” (William et al. 2002).

The average length of hospital stay for people that were given accelerated rehabilitation was 3.6

days, shortened from around the hospital average 10.5 days in the hospital (Dixon et al. 2004).
Some patients in the experimental group even reported benefits to the accelerated remission

program.

In most cases, pain levels were lower in the patients that underwent the accelerated

rehabilitation, yet there was trouble following up with patients after their procedure; therefore,

the pain score data was not technically statistically significant (Dixon et al. 2004). Another

advantage of this approach to knee replacement was that there was not enough blood loss to

require transfusion (Dixon et al. 2004). According to the research team, it was noted that usually

at least 8-11 percent of patients need transfusions due to significant blood loss (Dixon et al.

2004). The team hypothesized this is because of the adrenaline and bupivacaine as well as the

local anesthetic given to the patients to help heal the wound faster and help patients attain some

mobility surprisingly only days post op (Dixon et al. 2004). Another important thing about these

improvements is that they are only slight modifications to already existing procedures that could

be readily adopted by medical professionals. The recommended changes include the use of

adrenaline before cementing the prosthesis, changing patient's expectations, and making sure that

everything such as prescriptions, home accommodations, and care are prepared, and better

communication between interdisciplinary doctors might be key to safe and fast discharge (Dixon

et al. 2004). Not only do the patients have more faith in their recovery and higher rates of

satisfaction, but these alterations could be a financial benefit to the hospitals. The reason this

benefits the hospitals is that they can turn over more beds and spend less money per knee

replacement patient and intensive care (Dixon et al. 2004). The one drawback of these new

methods would be more home therapy visits which would require more outpatient

physiotherapists (Dixon et al. 2004). However a positive is that there is no significant data that
supports that the experimental or control group needed more or less physiotherapy (Dixon et al.

2004).

This study supports that it is possible to release patients safely and faster from the hospital. This

observation is critical because it benefits everyone from the hospital that can save more money,

to the doctors who have more time to focus on different patients, to patients who have more faith

in themselves and their successful recovery. The more a patient believes in a return to proper and

painless function the more likely it is that they will be compliant with doing physical therapy on

their own and be motivated to get the most out of their prosthesis (Dixon et al. 2004).

Comprehending personal motivation and compliance along with systematic factors such as

hospital stays and surgical procedures is crucial to understanding patient adherence. While

adapted surgical procedures can make a difference in patient satisfaction, to ensure long-term

patient satisfaction, the patient has to make sure that the muscles around the prosthesis are well

exercised and not weaken and atrophy as is common when patients do not use their knee

rendering the prosthesis almost useless. The results of physiotherapy are very beneficial. Quoting

a research paper “Increased quadriceps and hamstring strength was observed following

treatment” (Baar et al. 1999).

Patient compliance is key to a successful recovery, and there are many reasons why patients

choose not to comply (Campbell et al., 2001). Contrary to popular belief, while laziness can be a

factor in non-compliance, there are also many reasons to believe that there are other factors that

can influence non-compliers. A study titled Why don’t patients do their exercises?

Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee had

researchers Professor Rona Campbell and her research and her team interviewing patients and

publishing their data in the Journal of Epidemiol Community Health in the year 2001. Professor
Campbell is a professor of public health involved in conducting many systematic reviews for the

WHO and others giving her decent authority on this subject. The study was conducted in various

University departments in the Bristol UK area.

Forty-three individuals were selected to do a participate in a physiotherapy program with two

phases. Initial phase and extended period that required doing kneecap taping and assigned

exercises at home. Later the physiotherapist assessed how compliant the patients were over time.

Twenty patients were picked at random, resulting in 14 female and six male patients that were to

give an interview based on either why they chose to or chose not to comply. The 43 participants

were to go through a physiotherapy program with two phases: an initial period of direct contact

with the physiotherapist and an extended period that required doing kneecap taping and assigned

exercises at home. Then the physiotherapist used improvement in muscle strength to assess how

compliant the patient was or not. Then the 20 interview participants were selected, and their

interviews were recorded and transcribed, each person detailing why they chose to comply or

not. After fact-checking and making sure the patient’s statements reflected the assessment rating

given by the therapist, researchers grouped comments based on commonalities between them.

There ended up being five major vital factors that determined patient compliance.

The significant factors found were general attitude towards exercise, perceived severity

of symptoms, personal ideas about the nature of the disorder, perceived effectiveness of the

treatment, and if there were perceived social norms that were not to be violated (Campbell et al.,

2001). While a generally good relationship with exercise prior was helpful, the primary focus of

this area is how the patients perceived their tasks related to other aspects of their lives. Compilers

saw these exercises as an opportunity to improve their health while non-compliers saw them as

obtrusive and taking time out of their schedule. Many non-compliers cited a busy lifestyle and
not enough time to do these exercises. As one test subject puts it “So many things happening ...

The boys used to come in from school or work ... people come and see [wife] and ugh ...I’m out

twice at least a week to band practice, and I have two engagements as well.” (Campbell et al.,

2001) Perceived severity of symptoms was also important in determining if a patient would

comply. Patients who saw themselves at risk for potentially losing mobility were more likely to

continue doing their exercises while non-compliers did not believe their symptoms impeded their

lives that much as put by a compliant patient “It got worse and worse, and I started falling down

... Since I started strengthening these muscles, it seems I don’t fall over so much which is good ...

it was so embarrassing.” (Campbell et al., 2001). Beliefs about the cause of their disease were

also motivating factors (Campbell et al., 2001). Patients who believed that their arthritis was out

of their control because of factors like age, weight, and wear and tear were more likely to be

resigned and unmotivated, however, patients who felt that even though it cannot be cured, there

is a change to mitigate the effects of arthritis were more compliant (Campbell et al., 2001). As

explained by a non-compliant patient “[the exercise and taping] might not help me because I’m

getting old, but it might help somebody else ...I think I’m too old really to improve.” (Campbell

et al., 2001). Most obviously, how the effectiveness of the treatment was perceived was crucial

when determining if patients would continue the program. Logically, if someone does not see an

improvement in their condition after the program, chances are they will not continue it at home.

Another study published by NCBI titled How to do care-provider and home exercise program

characteristics affect patient adherence in chronic neck and back pain: a qualitative study states

that “Our experimental findings indicate that the patient's adherence to home-based exercise is

more likely to happen when care providers' style and the content of the exercise programme are

positively experienced.” (Campbell et al., 2001). As a person who dropped the exercises states “
I was able to do [the exercises] pretty easily, but it didn’t appear to me to make much of a

difference . . . I carried them on during the time I was taking part in the programme although I’ve

dropped them since. .” (Campbell et al., 2001) Lastly, social obligations play an interesting role

in compliance (Campbell et al., 2001). If one does not want to disappoint a person in charge of

their care, they are more likely to comply. This observation explains why compliance rates are

higher during the initial phase of treatment since people felt a certain loyalty to either the

physiotherapist or to the research 2. With one man citing his loyalty to the physiotherapist “Well

I felt because [physiotherapist] took the trouble of explaining it all to me I couldn’t turn around

and say, “well blow it, why bother sort of thing? ..So when I first turned around and said that I

would do it, I felt well all right I wasn’t obligated to do it, but I felt let’s do my bit towards it,

you know. I didn’t want her to think that she was wasting her time.” (Campbell et al., 2001)

Other participants cited their loyalty to the research: “I felt that I was contributing in some ways

to research which would probably benefit other people, and that was why I went ahead with it ...I

anticipated some benefit for myself, but I thought well, this is great if this is going on, then I am

participating in something worthwhile.” (Campbell et al., 2001)

The reason it is critical to understand patient compliance is because if simple issues in

understanding, effectiveness, and communication are corrected, that could drastically increase

motivation to do physiotherapy and increase the rate of recovery and patient satisfaction and

mobility. The suggestions placed by the non-compliant patients in these interviews can be crucial

information that can be used to help physiotherapists modify their treatment plans to keep

patients motivated.

Different types of physiotherapy can be used to adapt to varying levels of compliance. For

example, if someone is less compliant overall, then maybe regular contact with a physiotherapist
would be highly beneficial. If someone is however known to be generally compliant, then an

assigned physiotherapy regimen could be particularly helpful. It is also essential to understand

what acute care under the orthopedic surgeon and hospital was like to determine how far along a

patient is when it comes to performing necessary functions.

After understanding why quick recovery and patient compliance are essential, the effect of

different types of physiotherapy is also vital to understand. Researchers Sara R. Piva1, Charity

G. Moore, Michael Schneider, and the team decided to test the effectiveness of different types of

exercises and exercise environments on post-op knee replacement patients. The team published

their results in 2015. The subjects included 240 adults who underwent total knee replacement at

least two months before the experiment. The subjects were randomly assigned into one of three

treatment methods, one being clinical physiotherapy, the second being community exercise

classes, and the control group received regular medical treatment.

Quantitative data from each group were collected before the experiment, three months, and lastly

six months into each treatment method. The control group was randomly assigned to one of the

two experimental groups after six months of study participation and completed a 9-month

follow-up. The hypothesis stated by the researchers predicts that the experimental groups will

have better general physical capacity than their control group counterparts. The primary

dependent variable was physical function measured by the Western Ontario and McMaster

Universities Osteoarthritis Index Physical Function Subscale, and physical function was

measured by performance-based tests. Secondary dependent variables included performance-

based tests and physical activity assessed by a patient survey and accelerometry-based physical

activity monitors. Other potentially essential outcomes included co-interventions, attrition, and

adverse events such as falls, and patient compliance (Pival et al., 2015). Data models have been
fitted to compare the changes in results across groups. Logistic regression was used to define

patient characteristics that predict the most functional recovery in the experimental groups. Other

methods will be used to estimate how effective each treatment method is, even in the presence of

non-compliance.

After understanding why surgical techniques and patient compliance are essential, it is time to

take a hard look at physiotherapy and what kinds of physiotherapy work. While surgical

procedures help immediate recovery and patient compliance helps patients stay on track to

recovery and a return to full function, it is crucial to observe trends in what types of physical

therapy patients are referred to be able to better capitalize on different types of therapy that are

rarely used. The reason maximizing options for patients is beneficial is because different styles

of physical therapy may work better for different patients and different patients have different

motivating factors that could influence compliance.

Researchers Justine Naylor of Fairfield Hospital, who has participated in research in over 107

papers, Alison Harmer of the University of Marlene Fransen who is disciplined in physiotherapy,

and their team set out around Australia to find evidence-based clinical guidelines and make them

available to doctors and physiotherapists during rehabilitation after total knee replacement

surgery. This research was done by giving a survey Their disciplines and credentials provide

then decent authority in this area.

The survey was based on a previous survey distributed to 4 different hospitals as well as the

researchers’ experience with total knee replacements. The final questionnaire consisted of closed

and free-answer questions about the protocols used by physiotherapists and why the doctors

chose the “primary program” where they referred their patients. A non-probability sample was

used to select appropriate hospitals to conduct the survey. Ninety-five hospitals were randomly
selected from the 270 hospitals registered with the Australian Orthopaedic Association National

Joint Replacement Registry as performing total knee replacements. Private and public hospitals

were both equally included in this survey. The survey was distributed in November with the

proportion sent to each hospital dictated by levels of representation in the Registry that

researchers used. The physiotherapists primarily responsible for overseeing each primary

program were contacted. The surveys were distributed via email, fax or mail. If participation was

declined, another hospital in the same area was randomly selected. In cases where the registered

hospital or contracted private practitioner predominantly referred patients elsewhere, the listed

facility or practice was also contacted when details were provided to minimize non-compliance,

reminders were sent two weeks after distribution of the survey.

One hundred seventy copies were distributed in total, and 65 were returned to the researchers.

Around 60 forms were returned from acute care hospitals and five were sent from post-acute

rehabilitation services. In all four hospitals and care centers declined participation. Respondents

included senior and contracted orthopedic physiotherapists and department managers. The

sample size was deemed too small to draw statistically significant conclusions between public

and private care centers (Pival et al., 2015). The researchers still found a range of

physiotherapeutic interventions found responses and response rate similar between private and

public practitioners (Pival et al., 2015). An array of types of physiotherapy was reported for the

acute postoperative period. Gait retraining exercises and specific exercise prescriptions were the

only interventions cited universally across the surveys (Pival et al., 2015). When a patient was

discharged from physiotherapy depended on factors in many areas of knee function. However,

the requirement of independent walking was almost always required with 97 percent of

participants agreeing. Routine participation in outpatient or community-based physiotherapy was

reported around 73%, to 95% percent of the time (Pival et al., 2015). While outpatient

rehabilitation was commonly cited, referral to inpatient rehabilitation was uncommon with only

3% of respondents citing it for regular use, and 45% of respondents referred patients to inpatient

physiotherapy on an as-needed basis only (Pival et al., 2015). 88% of providers sent patients to a

primary program with most of the services being offered to outpatient programs (Pival et al.,

2015). Individual treatments were offered more often than supervised group class classes by 63%

to 23%. Monitored home exercise programs were cited 9% of the time as the primary program

referred to by care specialists (Pival et al., 2015). A small subset of 12% of respondents reported

having ‘no primary program’ as only a few of their patients were referred for further

physiotherapy (Pival et al., 2015). Most participants who cited no primary program explained

this by stating that ‘further rehabilitation was not usually necessary’ or that ‘the surgeon does not

believe in rehabilitation.’

31 out of 52 centers referred patients to one-to-one treatments, 16 centers referred patients to

supervised classes or monitored exercise programs and five centers having an equal preference

for both (Pival et al., 2015). Care centers which stated that they did not provide primary

programs or acute care hospitals unable to provide information about post-discharge

rehabilitation were removed from the sample. The mean rehabilitation period reported the

duration of post-acute rehabilitation was observed to be 5.6 weeks with a range of 1 to 18 weeks.

Physiotherapy commenced at 1.9 weeks post-op (Pival et al., 2015).

This research is necessary because it demonstrates a large pool of physiotherapy options people

are not even aware of because their doctors rarely recommend them. If these people were given

more options, then perhaps they could choose an option that best suits their type of motivation.
For example, highly socio-competitive people may prefer to go to group physiotherapy classes or

highly self-motivated individuals may have an assigned exercise regimen.

The last critical factor that plays a crucial role in patient satisfaction is the exercises given as

well as individual patient progress. Without correctly paced and practical exercises, all the work

done by interdisciplinary doctors that focused on proper surgical techniques, patient compliance,

referral to the correct type of physiotherapy is destined to be undone by a patient who either

overexerts, underperforms, or does their exercises incorrectly. This finding explains why it is

essential to compare different types of physiotherapy and how effective each is. Without this

knowledge, patients will ultimately not attain progress or became their undoing or lose

motivation to do their exercises entirely.

Nizar N.Mahomed, MD a Senior Scientist at The Krembil Research Institute, Aileen M.Davis

Ph.D. trained as a physiotherapist and clinical epidemiologist and received her doctorate from

the University of Toronto and is a Senior Scientist in the Division of Health Care and Outcomes

Research and their team whose credentials are highly valid decided to test the differences

between inpatient and outpatient home therapy. They published their results in The Journal Of

Bone and Joint Surgery in August 2008. The study was conducted in various hospitals in the

New York and Toronto areas.

Two hundred thirty-four patients randomly selected, were either assigned home-based or

inpatient rehabilitation following total joint replacement. All patients followed standardized care

pathways and were evaluated, with the use of the Western Ontario and McMaster Universities

Osteoarthritis Index before surgery and at three and twelve months following surgery. The study

recruited patients undergoing total hip or knee replacements from two institutions. One was a

care referral center, and the other was a community hospital in the same area. Patient eligibility
for the study required that a patient is over the age of eighteen, were undergoing hip or knee

replacement for osteoarthritis, inflammatory arthritis, or osteonecrosis, were permanent residents

of the city where the two institutions were located, could speak English, and if they could give

informed consent to participate. Patients who met these requirements were identified by surgeons

in participating care facilities and were approached to partake in the trial by the study

coordinator. Eligible patients were only able to after informed consent was given. The protocol

of the study and patient consent forms were reviewed and approved by the Human Subject

Review Committee.

The primary dependent variable of the trial was the efficacy of inpatient compared with home-

based rehabilitation at three months after surgery when both interventions were discontinued use

of the function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index.

Minor results included the measurement of health status with use of Short Form-36 and patient

satisfaction with the use of the Hip and Knee Satisfaction Scale. Data were taken at baseline,

three-month, and twelve-month follow-up visits. The subjects completed each of the three

questionnaires at each follow-up visit. The Western Ontario and McMaster Universities

Osteoarthritis Index, the Short Form-36, and the Hip and Knee Satisfaction Scale were tests that

assess patient satisfaction with the outcome of total joint replacement regarding improvement in

pain and function. Subjects were evaluated approximately two weeks before surgery during a

pre-operative hospital visit. This evaluation included important information such as patient

demographics, valuable health information related to their condition, socioemotional support, as

well as completion of the surveys used in the study. One week before surgery, the subjects’

methods of physiotherapy were randomly selected and were informed of their randomization
before surgery to allow sufficient time to prepare their home settings if they were chosen to do

one-on-one private physiotherapy.

All subjects were admitted to an acute care hospital on operation day and were given post-op

care according to established and standardized care guidelines for total joint replacement.

Patients were excluded from the trial if any postoperative complications that delayed

participation in the rehabilitation protocol were discovered. These included heart problems,

cerebrovascular issues, fractures, wound infections, or any issues that required a return to the

operating room. The target length of inpatient stay at the hospital for both groups was five days.

All patients received the same physiotherapy protocol in the hospital before going into their

assigned outpatient care. Such exercises included active or active-assisted bed and chair

exercises, gait retraining, and assisted walking. During the first day, goals included being able to

sit and stand with minimal assistance or with a walker and staying seated in a chair for an hour.

Day 2 post-op, goals were independent movement or walking from hospital bed to the bathroom

with slight assistance. From day three until discharge, targets were to regain independent

walking and being able to climb stairs. Patients assigned to home-based rehabilitation were

deemed safe for release from the hospital when they had achieved four critical functions: the

ability to independently go from lying down to sitting, independently being able to stand,

walking a distance of at least 30 meters without assistance, and if need be climbing stairs. Then

they were referred to their respective Community Care Access Centre. This center provided an

early intervention program that ensured that each subject was seen at home by a physiotherapist

within forty-eight hours of discharge. The participants who were selected for inpatient

rehabilitation were transferred to one of two inpatient rehabilitation institutions depending on

how many beds were available with a target stay of 14 days. Subjects were discharged from the
home-based program when their physiotherapist thought that they had achieved enough

functional improvement to attend an outpatient clinic or maintain a self-directed program. All

subjects returned to the operation hospital at three and twelve months post-op for the follow-up

evaluation by their operating surgeon. Cost analysis was conducted from a health system

perspective. Therefore, only direct health-care costs were evaluated for acute care hospitals,

inpatient rehabilitation hospitals, and home-based rehabilitation services. This factor means

physician fees, medications, indirect costs to the patients or secondary caregivers were not

included.

The average length of stay was 6.3 days for the group designated for inpatient rehabilitation

before transfer to that facility compared with seven days for the home-based rehabilitation group

before being safely discharged home. The average length of stay in inpatient rehabilitation was

17.7 days. The prevalence of postoperative complications up to twelve months post-op was very

similar among both groups. There was a 2% rate of dislocation and a 3% rate of deep vein

thrombosis. The rate infection was 0% in the home-based care and 2% in inpatient care. Both

groups exhibited substantial improvement at both follow-up visits, with no drastic differences

between the groups concerning the surveys given and there was no statistically significant

difference between the treatment groups in any of the measured baseline variables (Mahomed et

al. 2008). The total care costs in CAD for the inpatient rehabilitation and home-based

rehabilitation was around $14,532 and $11,082 respectively (Mahomed et al. 2008). Two

hundred thirty-four subjects were included in the study and 119 of them were selected to

participate in inpatient rehabilitation, and 115 subjects were assigned home-based rehabilitation.

The average age of the participants was sixty-eight years, and around two-thirds of the

participants were women. The mean body mass index was 28 kilograms per square meter.
Osteoarthritis was the most commonly cited diagnosis among subjects and most had two or more

other conditions. About two-thirds of subjects were white, and 20% were working around the

time of surgery. There were nearly equal proportions of hip and knee replacements. No

participant in the trial refused to follow-up. At baseline evaluation, both treatment groups had

substantial pain and functional disability based on the surveys given, but no pre-op differences

were noted between the two groups. The statistical analysis for this study was conducted with the

use of the intention-to-treat group of 115 patients who received home-based rehabilitation and

119 patients who had inpatient rehabilitation. Since researchers could not control the availability

of either type of service, the hospital stay lengths exceeded the target of five days for both

groups. The average length of stay was 6.3 days for the inpatient therapy group, while the length

of stay was seven days for the home-based rehabilitation group. The average length of stay in

inpatient rehabilitation was 17.7 days (Mahomed et al. 2008). The range of postoperative home-

based rehabilitation visits was four to sixteen visits. All visits focused on physiotherapy and were

approximately one hour per session. The number of post-op complications up to twelve months

after surgery was around the same in all groups. There was a 2% rate of hip dislocation and a 3%

rate of deep vein thrombosis in both groups.

No patients reported infections in the home-based group and only a 2% occurrence of disease in

the inpatient therapy subjects. Overall, both treatment groups had dramatic improvements based

on the survey scores at three months compared with the preoperative scores (Mahomed et al.

2008). At twelve months, there was a mild continued improvement in the WOMAC results at

twelve months, yet this outcome is not statistically significant (Mahomed et al. 2008). A similar

pattern occurred with the SF-36 physical component scores, with both groups citing

improvement in physical competency scores at three months and continued development at

twelve months after surgery compared with preoperative scores, yet these results were also not

statistically significant. With regards to patient satisfaction, both groups generally reported

similar higher scores on the Hip and Knee Satisfaction Scale at three and twelve months post-op

(Mahomed et al. 2008). Data was also picked apart to find differences in improvement based on

joint replacement site, and the researchers found no differences in functional outcomes or patient

satisfaction by whether patients had undergone a hip or a knee replacement. The mean costs for

the stay in the acute care hospital besides operation day for the inpatient rehabilitation and home-

based rehabilitation groups were $9411 and $10,191 respectively. This slight difference may

reflect the slightly longer acute care hospital stay for the home-based rehabilitation group

compared with the inpatient rehabilitation group as progress had to be made quickly to release

patients faster. The most significant gap in cost resulted from the post-discharge physiotherapy

of the care duration. There was a nearly sixfold difference in the mean price for inpatient

rehabilitation compared with that for home-based rehabilitation with one ranging from $5120 to

$7552 and the other ranging from $891 to $1316 respectively (Mahomed et al. 2008).

Each source either discusses different types of physiotherapy, surgical procedures, or both. Some

examine the efficacy of different types of physiotherapy and others explained how perceptions of

physiotherapy affected compliance. Two articles talked about how shorter inpatient care helped

hospitals function better and save money. Most reports did reference patient compliance in one

way or another, and one had highlighted it as its central focus. Only a single study however

specifically talked about modifying surgical procedures as well as advanced physiotherapy. The

rest of the studies referenced either spoke about patient compliance or tested different types of

physiotherapy against each other. Each study used similar methods including randomized trials,

related subjects in similar age ranges, usually undergoing similar procedures. Differences
between methodologies include using different scales and ways of measuring improvements in

knee functioning. The topics were generally related. They were typically older adults who have

had painful joint conditions and have chosen to undergo total knee replacement. The subjects

were usually not selected via other criteria such as gender, race, or other demographics. The

sample sizes would range from small 20 items up to 234 subjects. The studies would last

anywhere from 3 to 12 months. Researchers generally wanted to try and find more efficient types

of physiotherapy, improve surgical procedures, or study and understand patient non-compliance.

The consensus among these articles is that quick and satisfactory recovery is ideal which requires

that patients comply with the physiotherapy regimens given. The studies that compared different

types of physiotherapy found no drastic differences in performance between types of

physiotherapy used. Each piece of research is crucial and provides useful information about

contributors successful recovery after total knee arthroplasty. The first article mentions how

important it is to hasten recovery. The second analyzes patient non-compliance, the third, fourth,

and fifth compare different types of physiotherapy. These are all critical factors which all

influence the quality of recovery and thus patient satisfaction.

A reason why this research is necessary is that the human race is living longer than ever.

According to a study published in 2010 “Since 1800, lifespans have doubled again, largely due

to improvements in the environment, food, and medicine that minimized mortality at earlier

ages.” (Finch, 2010). These improvements mean that there will be older people who will

probably want to be as self-sufficient as possible before death. Therefore improvements in how

total knee replacements and physiotherapy are handled are crucial for keeping aging people in

shape and independent for longer.

Another critical reason to advocate for this research is that with this aging population, knee

implants will inevitably become more commonplace. Already sources state that “Around 7

million Americans are living with a hip or knee replacement” ( Kremers et al., 2015) and this

number is expected to exceed 3 million by the year 2030 (American Academy of Orthopedic

Surgeons 2013). With more people opting for this surgery, it is crucial to analyze data on knee

implants and create services that will help make the recovery process more efficient.

Methods:

There are multiple sources that state physiotherapy is very beneficial and drastically improves

the condition of joints and surrounding muscles. Sources state that “Physiotherapy has proven to

be effective in the treatment and management of arthritis, diabetes, stroke and traumatic brain

injury, spinal cord injury and a range of respiratory conditions offering those afflicted with tools

and techniques to acquire and maintain an optimum level of function and pain-free

living.”(ptHealth CA n.d). However, there are multiple problems with patient noncompliance

and patient satisfaction. Studies state that “Non-compliance with physiotherapy, as with drug

therapies, is common.” (Campbell et al., 2001). Therefore this information calls for improvement

in assessment and prevention of patient noncompliance after knee replacements. In a society that

runs on technology, it is possible for physiotherapy to be monitored digitally on an app designed

to enhance physiotherapy, holding patients accountable for non-compliance, and allowing

interdisciplinary doctors to contact each other more efficiently. With constant online monitoring,

the personal loyalty that is key to initial compliance will be ever present as doctors can see

patient progress in real time and contact patients whenever concerns arise.

Limitations include potential ethical concerns regarding privacy, possible lack of willing

participants, and lack of coding knowledge. Thankfully, since the product will not directly be
tested on individuals, no medical information will be exchanged on the app as of now. Originally

participants were going to be surveyed, yet there were no survey responses; therefore, metadata

was used instead. This tactic may assess problems with filling out forms and avoids potentially

violating HIPAA rights. All studies collected for the metadata analysis had to performed within

the past thirty years, contain viable data, and had to come from peer reviewed journals. Other

limitations include Not being able to measure the effectiveness of the application. While such

information could be useful for our project, the time to develop the app is limited thus there will

be no time to test how effective the program is. Also, time constraints and other limitations such

as privacy will not allow running experiments that focus on gaining crucial information that

would prove the effectiveness of the application compared with traditional physiotherapy with

the application. Due to these constraints, the primary method of conducting this project will be

developing the app and user protocol.

Items needed to be included in the final product include a contact portal, a section where doctors

update exercises, different types of accounts, a motivation system to curb non-compliance, and

the final user protocol. The contact portal will help doctors communicate between themselves

and patients to keep the information up to date. This feature will also serve as a means to curb

noncompliance as doctors can directly contact patients if they have not been active on the app.

The most critical variable is the exercise regimen section. This section is where doctors can

modify the patients exercise regimen as the patient progresses into later stages of rehabilitation.

Lastly, a motivation system must be in place to reduce patient non-compliance. This system will

include multiple notifications per day and the ability for doctors to add memos about essential

appointments. There should be a progress section so patients can see how much they have

improved since each assessment. As mentioned in the previous research, if the patients are aware
of their improvement they are more likely to continue their program (Campbell et al., 2001). For

these sections, time is the most valuable utility listed since the more time there is to fix and

enhance the app code, the higher the quality of the app will be which should improve overall

satisfaction with the product. This feature allows the patient and doctors to stay on task and

organized during rehabilitation. Also, the literature mentioned previously states that having

people being directly involved creates a sense of loyalty to the program that curbs non-

compliance. The primary app development resource to be used will be Appypie which is notably

more straightforward to use and will provide sufficient features and framework to run the app.

Each page of the app will be developed within the months leading up to Expo day. To protect

patient privacy, all doctors involved need to have different, verified accounts which prevent

violation of HIPAA rights. In regards to protecting against data breaches, the application has to

be run through security testing. There are multiple tools such as Santoku and Drozer that can

help identify faults in security. This flaw is a critical problem since a single data breach on this

application can expose tons of personal information about healthcare and information violating

patient privacy and HIPAA law when it will be released. This foresight is why the app will run

through Santoku which offers mobile device emulators, tools to simulate network services for

dynamic analysis, decompilation, and disassembly tools, and grants access to malware databases

among other things

Multiple steps need to be executed to ensure that this project is successfully launched. First,

metadata has been collected and analyzed to see patterns of data that contribute to patient

noncompliance. After results are obtained, the additions to the main features of the application

will be decided upon, and development will ensue. After significant progress has been achieved,

the user protocol will be written out to ensure that users are aware of how to use the app. This is
the most important section is the in the final paper and will hopefully give an accurate

description of the application’s purpose and proper usage. Potential considerations for the future

include potentially furthering the development of this application by releasing surveys to users to

see how the app could benefit more people.

The primary observed independent variable is patient compliance, and the main dependent

variable that is assumed to be affected is patient satisfaction with knee replacements. Many

studies support the benefits of continued physiotherapy; therefore it is predicted that if patient

compliance is increased, so will the satisfaction of the results of physiotherapy. The reason such

a prediction is plausible is that multiple sources state that physiotherapy produces the best results

when continued regularly as the literature above states. The primary control variable will be

patients who do not use the app and give responses to patient satisfaction during the second

development survey.

Data will be collected through responses gathered via Google Forms after each survey. Google

Forms collects data automatically and can produce pie graphs that make data easy to read and

calculate percentages of total responses. Hopefully, the use of this application will reduce patient

compliance by having doctors directly observing adherence which is proven to motivate people

to comply. If statistics show that patients generally do not adhere, adhere less than average, or

are unsatisfied the outcome does not support the stated hypothesis, while an increase in

compliance and patient satisfaction means the results support the hypothesis. If there are positive

results, this means that the systems in place for helping motivate compliance work. If the data are

negative or inconclusive, then that means there must be more at play with technology, the brain,

and how these things relate to physiotherapy. There are multiple directions further research can

take. There may be future research done to see how usage of this application compares to
traditional physiotherapy. While the means to conduct this research are not present at the

moment, it would be very beneficial to compare and contrast the benefits and disadvantages of

each program to test how useful the software is. New research that could be done after is

comparing different types of knee replacement post-care and types of physiotherapy. This further

research could improve the quality of the exercises on the application making it more efficient

and helpful to use.

Results:

Based on the information from the figures and tables at the end of this paper, the most

common factors influencing patient compliance are no social circle to hold a patient accountable

(16.4%), a patient’s beliefs about their condition (14.5%), and low self-efficacy (12.7%) outside

of uncontrollable factors which have a seemingly surprisingly considerable influence on

compliance (16.4%)

Figure 3- Graphic

representation of

data grouped into

categories based

on metadata

Discussion:

Results from interpreting data show a potential correlation between certain factors and patient

compliance. These include patient beliefs about their condition, self-efficacy, and the presence of
a social group, and others. Therefore it is likely that if these factors are assessed the patient

compliance rates would not be as low as they are today. The researchers plotted a bar graph with

each compliance barrier on the Y-axis and the number of responses based on collected studies on

the right as seen in Figure 1. Based on these responses it is assumed that the most common

reason for lack of compliance is not having people to hold the patient accountable. The next two

most common reasons being low self-efficacy and other uncontrollable factors. This makes

decent sense as humans are social animals and are extremely motivated by positive

reinforcement from peers or motivated by competitive nature. Self-efficacy is logically a primary

source of lack of compliance. Lack of self-efficacy means lack of belief in one’s ability. There

are many studies that “the initially fallacious anxiety is transformed into an entirely justified

fear.”(Merton,1948). This is because people who believe they cannot do something do not put as

much effort into the task and are not as perceptive to new information that may help them learn

and grow. The reason uncontrollable factors may seem to be such a significant component of

noncompliance is because the researchers attempted to consolidate as many categories as

possible in order to draw conclusions more effectively; therefore many different types of

uncontrollable factors such as age, BMI, and lifestyle have all been consolidated under one

category probably giving it its unusually strong presence in the data. Also, it is worth noting that

the data gathered makes similar conclusions to that of a study used in the literature review

specifically Campbell et al. These results are however extremely speculative as the researchers

did not obtain enough data to establish definitive conclusions. The reason gathering data was

challenging was because of not being able to distribute the survey to the correct audience as this

study was conducted by high school researchers, HIPAA regulations that prevent the team from
legally obtaining medical records and information without the use of surveys, and general lack of

coordination amongst the researchers.

Conclusion:

This research examined contributors to patient non-compliance. Using data meta-analysis and

phenomena observed by previous studies, research has supported many potential factors that can

contribute to compliance with physiotherapy which adds to the speed and quality of recovery. It

is possible that these results are however extremely speculative as the researchers did not obtain

enough data to establish concrete conclusions and statistics might have been different if results

had been grouped differently for some of the categories. However, the data collected can be used

to draw some conclusions. Generally, patient compliance is greatly influenced by having

someone holding the patient accountable, patient beliefs about their condition, and the patient’s

levels of self-efficacy.

Graphs and Tables

Study Compliance Barrier

Schoo et al. 2005 Low baseline activity, low initial compliance,

C.H. Stenstrom et al 1997 Low baseline activity, low self efficacy, Not
 having someone to hold patient accountable

Minor and Brown 1993 Low baseline activity, poor mental health, not
having someone to hold patient accountable,
worsening of pain during exercise

Rejeski et al. 1997 Low baseline activity, low initial

compliance,poor mental health, not having
someone to hold patient accountable,
uncontrollable factors, greater initial pain

Dobkin Cohort low initial compliance, poor mental health,

uncontrollable factors, barriers to exercise
,greater initial pain,worsening of pain during
exercise,

Alewijnse et al. 2003 Low initial compliance

Oliver and Cronan 2002 Low self efficacy, poor mental health,
uncontrollable factors, not having someone to
hold patient accountable

Milne et al 2005 Low self efficacy, uncontrollable factors

Shaw et al 1994 Low self efficacy, poor mental health,

uncontrollable factors, not having someone to
hold patient accountable,

Chen et al 1999 Low self efficacy, beliefs about physiotherapy

Castenada et al 1998 Beliefs about condition, low quality of life,

uncontrollable factors,

Sluijs et al 1993 Beliefs about condition, not having someone

to hold patient accountable, barriers to
exercise

Laubach et al 1996 Beliefs about condition

Brewer et al 2002, 2003 Low self efficacy

Funch and Gale 1986 not having someone to hold patient

accountable

Fekete et al 2006 not having someone to hold patient

accountable
 Alexandre et al 2002 Barriers to exercise, uncontrollable factors

Kolt and McEvoy 2003 Uncontrollable factors

Taylor and May 1996 Low self efficacy, beliefs about condition

Kenny 2000 Beliefs about condition

Campbell et al 2001 Beliefs about condition, beliefs about

physiotherapy, other barriers to exercise, not
having someone to hold patient accountable,
low baseline activity

Tabel 1- Compliance data based on different data collected by Kirsten Jack et al

Figure 1- Compiled data into a bar graph in order to measure most common responses on

a per study basis (20 studies)

Figure 2- Compiled data into a bar graph in order to measure most common responses on a per

phenomenon basis (55 phenomena)

Figure 3- Graphic representation of data collected via a pie chart

Figure 4- Project Gantt Chart

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