Effectiveness and Cost-effectiveness of Outpatient Physiotherapy After Knee Replacement for Osteoarthritis: Study Protocol for a Randomised Controlled Trial

Background: Primary total knee replacement is a common operation that is performed to provide pain relief and restore functional ability. Inpatient physiotherapy is routinely provided after surgery to enhance recovery prior to hospital discharge. However, international variation exists in the provision of outpatient physiotherapy after hospital discharge. While evidence indicates that outpatient physiotherapy can improve short-term function, the longer term benefits are unknown. The aim of this randomised controlled trial is to evaluate the long-term clinical effectiveness and cost-effectiveness of a 6-week group-based outpatient physiotherapy intervention following knee replacement. Methods/design: Two hundred and fifty-six patients waiting for knee replacement because of osteoarthritis will be recruited from two orthopaedic centres. Participants randomised to the usual-care group (n = 128) will be given a booklet about exercise and referred for physiotherapy if deemed appropriate by the clinical care team. The intervention group (n = 128) will receive the same usual care and additionally be invited to attend a group-based outpatient physiotherapy class starting 6 weeks after surgery. The 1-hour class will be run on a weekly basis over 6 weeks and will involve task-orientated and individualised exercises. The primary outcome will be the Lower Extremity Functional Scale at 12 months post-operative. Secondary outcomes include: quality of life, knee pain and function, depression, anxiety and satisfaction. Data collection will be by questionnaire prior to surgery and 3, 6 and 12 months after surgery and will include a resource-use questionnaire to enable a trial-based economic evaluation. Trial participation and satisfaction with the classes will be evaluated through structured telephone interviews. The primary statistical and economic analyses will be conducted on an intention-to-treat basis with and without imputation of missing data. The primary economic result will estimate the incremental cost per quality-adjusted life year gained from this intervention from a National Health Services (NHS) and personal social services perspective. Discussion: This research aims to benefit patients and the NHS by providing evidence on the long-term effectiveness and cost-effectiveness of outpatient physiotherapy after knee replacement. If the intervention is found to be effective and cost-effective, implementation into clinical practice could lead to improvement in patients’ outcomes and improved health care resource efficiency.

Designing and Developing Digital and Blended Learning Solutions

The continuous advancement in computing, together with the decline in its cost, has resulted in technology becoming ubiquitous (Arbaugh, 2008, Gros, 2007). Technology is growing and is part of our lives in almost every respect, including the way we learn. Technology helps to collapse time and space in learning. For example, technology allows learners to engage with their instructors synchronously, in real time and also asynchronously, by enabling sessions to be recorded. Space and distance is no longer an issue provided there is adequate bandwidth, which determines the most appropriate format such text, audio or video. Technology has revolutionised the way learners learn; courses are designed; and ‘lessons’ are delivered, and continues to do so. The learning process can be made vastly more efficient as learners have knowledge at their fingertips, and unfamiliar concepts can be easily searched and an explanation found in seconds. Technology has also enabled learning to be more flexible, as learners can learn anywhere; at any time; and using different formats, e.g. text or audio. From the perspective of the instructors and L&D providers, technology offers these same advantages, plus easy scalability. Administratively, preparatory work can be undertaken more quickly even whilst student numbers grow. Learners from far and new locations can be easily accommodated. In addition, many technologies can be easily scaled to accommodate new functionality and/ or other new technologies. ‘Designing and Developing Digital and Blended Learning Solutions’ (5DBS), has been developed to recognise the growing importance of technology in L&D. This unit contains four learning outcomes and two assessment criteria, which is the same for all other units, besides Learning Outcome 3 which has three assessment criteria. The four learning outcomes in this unit are: • Learning Outcome 1: Understand current digital technologies and their contribution to learning and development solutions; • Learning Outcome 2: Be able to design blended learning solutions that make appropriate use of new technologies alongside more traditional approaches; • Learning Outcome 3: Know about the processes involved in designing and developing digital learning content efficiently and what makes for engaging and effective digital learning content; • Learning Outcome 4: Understand the issues involved in the successful implementation of digital and blended learning solutions. Each learning outcome is an individual chapter and each assessment unit is allocated its own sections within the respective chapters. This first chapter addresses the first learning outcome, which has two assessment criteria: summarise the range of currently available learning technologies; critically assess a learning requirement to determine the contribution that could be made through the use of learning technologies. The introduction to chapter one is in Section 1.0. Chapter 2 discusses the design of blended learning solutions in consideration of how digital learning technologies may support face-to-face and online delivery. Three learning theory sets: behaviourism; cognitivism; constructivism, are introduced, and the implication of each set of theory on instructional design for blended learning discussed. Chapter 3 centres on how relevant digital learning content may be created. This chapter includes a review of the key roles, tools and processes that are involved in developing digital learning content. Finally, Chapter 4 concerns delivery and implementation of digital and blended learning solutions. This chapter surveys the key formats and models used to inform the configuration of virtual learning environment software platforms. In addition, various software technologies which may be important in creating a VLE ecosystem that helps to enhance the learning experience, are outlined. We introduce the notion of personal learning environment (PLE), which has emerged from the democratisation of learning. We also review the roles, tools, standards and processes that L&D practitioners need to consider within a delivery and implementation of digital and blended learning solution.