Digital rehabilitation helps knee osteoarthritis; after knee replacement it does not yet

Design

Systematic review with meta-analyses, GRADE assessed, stratified by immersion depth

Population

21 trials (12 knee osteoarthritis, 9 post total knee arthroplasty), 36 to 306 participants each

Primary outcome

Pain-related functioning and pain intensity

Effect

Knee osteoarthritis interactive digital rehabilitation: pooled SMD -0.59 (95% CI -1.11 to -0.06) for function, -0.46 (-0.92 to 0.00) for pain; post-arthroplasty pain -0.12 (-0.75 to 0.52)

Twenty-one trials of extended reality were reviewed, 12 in knee osteoarthritis and nine in recovery after total knee arthroplasty, classified for the first time by depth of immersion and by clinical mechanism rather than lumped as virtual reality. Sample sizes ran from 36 to 306, and most followed patients for three months or less.

For knee osteoarthritis, interactive digital rehabilitation - screen-based guided exercise with feedback, not headsets - may improve pain-related functioning (pooled standardised mean difference -0.59, 95 per cent CI -1.11 to -0.06, five studies) and reduce pain intensity at six to eight weeks (-0.46, -0.92 to 0.00, four studies), both at low certainty. Fully immersive digitally augmented exercise gave inconsistent results at very low certainty. After knee replacement the same interactive rehabilitation improved pain-related functioning but made little difference to pain intensity at three to four months (-0.12, -0.75 to 0.52). Single trials suggested virtual reality psychoeducation lowers pain at four weeks and virtual reality distraction at six months. Adverse events were rarely reported at all.

The practical distinction is between the delivery mechanism and the headset. What has evidence here is structured, feedback-driven home exercise delivered digitally, which is a service question for a busy Indian outpatient department where supervised physiotherapy attendance is the real bottleneck. Fully immersive virtual reality remains unproven for both indications.

• Distinguish interactive digital rehabilitation from immersive virtual reality; only the former has pooled evidence.
• Offer it as an adjunct to knee osteoarthritis care, not as a replacement for supervised physiotherapy.
• Do not extend the osteoarthritis result to post-replacement pain, where the effect was near zero.
• Ask any vendor for adverse event data; five of 21 trials reported any, which is not reassuring, only uninformative.
• Follow-up beyond three months is essentially absent, so say nothing about durability.

The statistics, in plain English

A standardised mean difference of -0.59 is a moderate effect, but its prediction interval runs from -1.72 to 0.55 - meaning a future trial could plausibly find harm as well as benefit, which is what low certainty is describing. The pain intensity interval touching exactly 0.00 is on the boundary of significance and should not be reported as a clear effect. Most trials were short and small, so nothing here speaks to whether benefit persists.

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