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.


Introduction
Physical therapy following knee replacement aids early and optimal functional recovery [1].Physical rehabilitation protocols include pain management, lower limb muscle strengthening, range of motion restoration, and gait training.While there is a large variation in the intensity, modality, and mode of delivery of rehabilitation across countries, health systems, and practices [2], structured physical therapy during the initial months of recovery is beneficial [3].Physical therapy and monitoring of progress via clinic or home visits or telerehabilitation [4] have been the most common approaches to address the challenges faced by patients during the recovery phase [5].While home-based rehabilitation has been advocated to save health care costs, [6] unsupervised home exercise protocols have shown poor adherence due to a lack of self-management abilities, self-efficacy, and access to a continuum of care [7][8][9].each year over 0.2 million knee replacements are performed in india and that the number is projected to exponentially increase [10].the standard care pathway in most public health care settings in india after discharge to home is, home-based unsupervised rehabilitation, with clinic-visits when required [11].
in a recent cross-sectional study conducted at a referral hospital in india, half of the patients sought support from trained physiotherapists after discharge to home, contributing to a significant portion (32%) of out-of-pocket expenditure as a fee towards this service during the first three months of rehabilitation [12].the key reasons to avail support was the inability to recall advices, unclear instructions about the duration and frequency of exercises, and the inability to manage pain [12].similar reasons were found in the literature review we did while conceptualising the present study (table s1 and Figure s1 in supplementary file).
there are several other challenges specific to india that can affect the rehabilitation phase, such as, crowded and over-burdened tertiary care hospitals that reduce patient-physician interaction time [13], higher dependency of the elderly on family members, and a non-inclusive, disable-unfriendly transport systems [14] making it difficult to visit the hospital frequently.addressing such multilevel factors (individual, health systems, and societal level) will need context-specific strategies [15].
existing literature on strategies to improve the continuum of care is mainly driven by studies from high-income countries and may not be directly applicable to low-and middle-income countries [16]. in continuation of our effort [12,17] to document the challenges of patients undergoing knee replacement and find feasible ways to improve care, we conducted a mixed-methods hospital-based study.the study explored facilitators and barriers for patients to follow unsupervised home-based rehabilitation protocol and health care provider's (hcPs) experiences in providing a continuum of care after patients are discharged to home.this work informed the components of a tele-rehabilitation monitoring program we are developing to improve the experiences of patient undergoing knee replacement in india.

Study design
a mixed-methods cross-sectional exploratory study as a formative phase activity was conducted at a tertiary care academic hospital in india.the guidelines laid out by leech and Onwuegbuzie [18] for the mixed-methods design was followed.the functional purpose for the use of this design was complementarity, development, and expansion, that would enhance the richness and interpretation of the data.We first completed the rehabilitation adherence quantitative survey and then used qualitative methods to identify attitudes, experiences, and behaviour on a subset of similar participants.the integration between quantitative and qualitative methods happened at the planning of the research question, during sampling, and while interpretating the results [19].the standard reporting guidelines for observational studies and qualitative research was followed [20,21].

Research objectives
to explore patients and hcPs perspective of facilitators and barriers to follow rehabilitation protocol in unsupervised home-based programs.

Setting and participants
We approached consecutive adult patients advised or scheduled for knee replacement or who had undergone knee replacement for osteoarthritis (between February-March 2022) from the orthopaedics and physiotherapy out-patient department of a tertiary care hospital in india, to participate in the quantitative interviews (Figure 1).Patients who were willing to be contacted again and available for face-to-face or telephonic interview were approached for in-depth interview (iDi).the physiotherapists and surgeons who were primarily involved in joint surgeries were purposively selected to understand their challenges in providing rehabilitation care.No formal sample size calculations were done.For the qualitative component, data collection was stopped when no new information was discovered during the interviews (data saturation).
We obtained written informed consent from patients and oral consent from hcPs to ensure confidentiality and anonymity.the data collection was initiated after institutional ethics committee approvals.

Data collection
Quantitative component a 22-item questionnaire was developed to capture attitudes and behaviours towards rehabilitation based on our previous work in this topic [12].this is not a psychometrically validated questionnaire.three team members independently categorised the items into three domains, capability (6-items), opportunity (6-items), and motivation (10-items).the participants completed the questionnaire in hindi and chose one of the four responses that ranged from "strongly disagree to strongly agree" for 20 items and "always to Never" for two items (table s2 in supplementary file).We also collected basic socio-demographic and knee-related information.
Qualitative component the phenomenological approach [22] was used to develop a semi-structured topic guide to explore the facilitators and barriers in adhering to rehabilitation protocols and return to routine activity following knee replacement.the initial version of the iDi guide was guided by a thorough literature review of studies reporting patients and hcPs perspective on challenges faced during the rehabilitation phase.the findings from these published studies were grouped into capability, opportunity, and motivation-behaviour (cOM-B) framework prescribed by Michie et al. [23].(table s1 and Figure s1-literature summary and table s3-in-depth interview guide in supplementary file).the iDis with patients who agreed to participate after the quantitative survey (sequential design nested sampling) were audio recorded.Face-to-face iDis were conducted at the same visit or via telephone later depending upon the feasibility and convenience of the participant.the hcPs at the hospital were interviewed to understand the challenges they experience when providing rehabilitation care (table s4in-depth interview guide in supplementary file).interviews were conducted by two interviewers; one interviewer was a public health graduate and the other was a physiotherapist from the research team with several years of clinical experience.Both the interviewers were involved in the literature review work while designing this study, however they bracketed out prior experiences to limit the impact on the research process.Moreover, the involvement of multiple experienced researchers supports the trustworthiness of the study.
Following the first two interviews, the topic guide was modified for clarity, refinement of prompts, and to ensure that participants provided rich information.the interviews were transcribed verbatim and translated by one researcher, were checked by the second researcher not involved in data collection for completeness and appropriateness.

Data management and analysis
We entered the quantitative data in ReDcap, a web-based data capture platform.Data entry quality was maintained by randomly checking 10% of the records by an independent researcher.Responses to the 22-item rehabilitation adherence questions were coded as 1-4, where 1 represented "best adherence" and 4 represented "poorest adherence".We presented percentages of response to each item grouped by the three domains (capability, opportunity, and motivation).We assigned unique iD for data collected from participants and safely stored paper copies and electronic versions of data with access restricted only to the research team.transcripts of iDis were coded independently in Microsoft Word, using an inductive-deductive approach followed by thematic and content analysis.all analyses were conducted concurrently and independently by two researchers to reduce over-representation. the codes were compared for variation and similar ideas and codes were grouped into categories before organizing them into overarching themes.the identified themes were categorised into capability, opportunity, and motivation domains and were finalised upon discussion with the larger research team.the themes from the qualitative study and responses to the rehabilitation adherence questionnaire were grouped based on the cOM-B framework [23].

Participant characteristics
the mean age of participants was 60 years, and 66% of respondents were women.Most (81%) of the participants resided in cities. the sample covered all levels of education.(table 1). the responses to the 22-item questionnaire are displayed in Figure 2.For items, missing exercises without any reason (item 6), need for family members presence for doing the exercise (item 22), lack of understanding the purpose of doing the exercise (item 4 and 14) higher percentage of responses fell under the poor and poorest category of rehabilitation adherence.We report the rest of the response to this questionnaire in the text under each relevant theme of the "post-discharge rehabilitation challenges" section.
Nine patients, five women and four men completed the iDi's with age ranging between 53 and 82 years and the time since surgery was between 1 and 6 months (table 2).thirteen hcPs

Post-discharge rehabilitation challenges
the five themes we identified are: know and recall what exercises to do, interference in performing exercises due to pain, social support, access to rehabilitation, and desire to be functionally independent.in table 3 we provide the verbatim statements supporting the themes.

Theme 1: know and recall what exercises to do (capability)
Patients reported to be aware of the exercises they must do (item 11, 99% responded strongly agree or agree) and always prioritised exercises over other things (item 16, 73%).however, almost half (52%) reported that they sometimes forget doing the exercise (item 8) and miss it for no reason (item 6, 72%).Our iDis also revealed, that patients perceived they attempted to perform exercises appropriately and adequately.
….99% i remember, 1% i might miss out.i ask my children if there is anything.i asked for a leaflet of exercise as well and i used to keep that leaflet during the exercises.they haven't taught me much of the exercises, just 4 or 5 which i am continuing to do.(Patient, male, 62 years) i remember them very well.i even prescribed it to others who had similar problems.the fact about exercising is it might be painful at first but later it gives you relief.two months have passed, and i remember all the exercises.(Patient, female, 53 years) however, hcPs strongly felt patients tend to forget the exercises or do not do it with the required intensity and dose.they attributed the inadequate results of the knee function to non-adherence to advice despite successful surgery.Rehabilitation adherence.the response categories to each of 22 items (item numbers are represented within parenthesis) were coded as 1-4. the responses were either strongly agree to strongly disagree or always to never.these responses were recoded to represent best to poorest adherence ….compliance remains an issue because once they are discharged, we don't know if they will comply to the exercises or not, we just have to rely that we have given them enough impetus to do the exercises.(Physiotherapist, male, 35 years) some patients did not come for regular follow up …. how honestly the patient is doing the exercises at home by himself.(Physiotherapist,female, 42 years) …Once the patient goes home, they don't exercise with that much intensity and energy and when they come to us for follow up, they come in poor condition with deformity.(Physiotherapist, female, 24 years)

Theme 2: interference in performing exercises due to pain (capability)
almost three-fourth (71%) of patients found pain as a major obstacle in performing the exercises (item 7) and 98% reported they could do exercise only if they took pain medication (item 9) (Figure 3), which was concordant with the findings of the iDis.i am taking pain killer for that, two times a day, morning, and evening.i am doing exercise 4 times a day, and doctor is saying that by exercising, gradually the pain will go away.(Patient, female, 57 years) hcPs also reiterated the importance of good pain management as an essential element for improving adherence to exercise protocols, especially during clinic visits.
When the patient is not in the hospital, we ensure that the whenever the patient comes for physiotherapy, we give them a prior dose of pain killers so that they are able to easily go through physiotherapy.(surgeon, male, 29 years) the patients do not co-operate because they are in pain, so pain management is very important.Only when the patient is pain free then he would be able to follow our commands and do the exercises.(Physiotherapist, female, 42 years) Theme 3: social support (opportunity) the majority (86-90%) of patients appreciated the support provided by the family members during the recovery phase (items 2 and 18).Family members also seemed to play a major role in patients adhering to exercise, as 60% of respondents felt they exercised hard when family members were around (item 22).they found their home environment suitable for the rehabilitation needs (item 21, 100%) and had the required privacy at home to perform the exercises (item 5, 96%).a large proportion (84%) felt, the need to do exercise, and did not impact their social life (item 17). the iDis revealed how much the patients valued the support and assistance provided by family members and hcPs.
i had a lot of pain after surgery because of which i used to stop lifting my leg out of pain.But my therapist and my family members made me do the exercise until a point required.they used to tell me that if i don't exercise properly then there would be no benefits of doing the surgery and the surgery would get wasted.Now i have no issues while exercising.they taught me 4 exercises and i do 4 exercises twice a day.(Patient, female, 53 years) …the doctors told me to have courage, have faith, and gradually everything will be fine.(Patient, female, 57 years) hcPs also emphasized on the role of social support and supervision during recovery to achieve the desired results.
surgeries like knee replacement are objective based surgeries.We have to achieve certain objectives in such surgeries.On the 14th day post-surgery, patient should be able to bend their knees to 90°, by the end of 2 months, it should be 110°.so, if they don't have supervision and they don't have the social support they need, then they might not be able to achieve this.and whatever they might've achieved till their discharge, they might even lose it after going home….if we don't monitor the patient, we can't achieve the goals and all the progress they must've made could also be reversed and the achievements would be lost.(surgeon, male, 33 years)

Theme 4: access to rehabilitation (opportunity)
Patients and healthcare providers recognized the challenges in commuting to the health centers and physiotherapy services, out-of-pocket expenditure to avail reliable healthcare services, and lack of trust on local healthcare providers as barriers.
….i do have a lot of challenges in travelling.i don't have enough money to travel in first class.so, i come in coach for disabled people.(Patient, female, 53 years) Yes, the experience is very good, the doctors have done their part.the only thing is when my incision was left open at that time, i wish i had come to aiiMs [sic] only, rather than going to the private hospital.then i wouldn't have to go through all this pain again.i don't have trust in private hospitals, it's just that sometimes i am obliged to go.(Patient, female, 57 years) ….the ability to reach a good physiotherapy setup is something a patient should be allowed to.some of the patients who come to us are hailing from North-east, Bihar, south.so, for them, to come back here for physiotherapy is a very big thing, they can't come.so, a very big step towards it would be, something that is accessible to the patients to indirectly communicate with the doctor.(surgeon, male, 29 years)

Theme 5: effort to become functionally independent (motivation)
almost all the patients (99%) felt they were taking a conscious effort to do the exercises (item 13).however, around half of them (48%) felt the need to exercise only when they feel any discomfort in their knees (item 14).Patients were aware that if they do the exercises, it will help their knee to recover (80%) (item 3).all the patients reported to be confident to continue the exercises until required and even if they felt low (item 1 and 20).however, they "i do all the exercises taught in supine, prone, i keep moving my legs.i don't have swelling like i had before, earlier i used to have ankle swelling as well."(Patient, female, 65 years) "i remember them very well.i even prescribed it to others who had similar problems.the fact about exercising is it might be painful at first but later it gives you relief.two months have passed, and i remember all the exercises."(Patient, female, 53, years) "99% i remember, 1% i might miss out.i ask my children if there is anything.i asked for a leaflet of exercise as well and i used to keep that leaflet during the exercises.they haven't taught me much of the exercises, just 4 or 5 which i am continuing to do." (Patient, male, 62 years) "Most of the physiotherapy is done by the patient himself/herself.so, if they do it, it's well and good, but the issue is they are non-compliant."(Surgeon, male, 29 years) "Challenges are definitely there because you can't follow up what the patient did on a daily basis.When the patient goes home and comes back after 2 weeks with the same condition, you cannot challenge him that he didn't do it, because he'll say that he did."(Surgeon, male, 29 years) "Generally, the patients are not dedicated to the exercises.…. sometimes they skip doing the exercises at home."(Physiotherapist, male, 40 years) "once the patient goes home, they don't exercise with that much intensity and energy and when they come to us for follow up they come in poor condition with deformity."(Physiotherapist, female, 24 years) "after going home, they come back with extensor lag knee flexion deformity because they don't exercise after going home.they exercise for one day two days five days and later leave it after that because they feel that they are fine now.once they are not able to extend their full knee then they feel that they have some problems then they come to us later."(Physiotherapist, female, 23 years) "Compliance remains an issue because once they are discharged, we don't know if they will comply to the exercises or not, we just have to rely that we have given them enough impetus to do the exercises."(Physiotherapist, male, 35 years) "some patients did not come for regular follow up …. how honestly the patient is doing the exercises at home by himself."(Physiotherapist, female, 42 years) "Patients are not able to do the exercises at home or maybe they are unable to learn it here because the initial 2-4 days are very painful for the patient and even if the patient tries to understand, we don't know how much he is able to register in his mind which results in deformity in his knees.there should be some coordination in between and the patient should be called for regular and early follow up."(Physiotherapist, female, 42 years) theme 2: interference of pain with exercise (capability) "no, there was no pain as such after surgery.i was given pain killer medicines because of which i had no pain."(Patient, female, 53 years) "i am taking pain killer for that, two times a day, morning, and evening.i am doing exercise 4 times a day, and doctor is saying that by exercising, gradually the pain will go away."(Patient, female, 57 years) "When the patient is not in the hospital, we ensure that the whenever the patient comes for physiotherapy, we give them a prior dose of pain killers so that they are able to easily go through physiotherapy."(Surgeon, male, 29 years) "since there will be pain related to surgery and many other complications like vomiting because of anesthesia or anything, patients will be a little bit of reluctant to do the physiotherapy.so, the knee may again go stiff and once the stiffness occurs over the period of time, when they start the physiotherapy in the later stage when the pain has subsided, during that time they may not get the results which is expected."(Physiotherapist, male, 31 years) "the day they get operated, they compliant of having no sensation in their legs.once the sensation comes, nausea starts.once the nausea goes away, they have a lot of pain and they do not want to walk or do slR, even if they are able to do so…… they have pain in knee RoM exercises and slR.they give up, they stay in bed." (Physiotherapist, male, 29 years) "the patients do not co-operate because they are in pain, so pain management is very important.only when the patient is pain free then he would be able to follow our commands and do the exercises."(Physiotherapist, female, 42 years) theme 3: social support (opportunity) "i had a lot of pain after surgery because of which i used to stop lifting my leg out of pain.but my therapist and my family members made me do the exercise until a point required.they used to tell me that if i don't exercise properly then there would be no benefits of doing the surgery and the surgery would get wasted.now i have no issues while exercising.they taught me 4 exercises and i do 4 exercises twice a day."(Patient, female, 53 years) "My family's support was 100% during recovery."(Patient, male, 65 years) "i'm free, they're helping me.they tell me that if i can do it on my own, then do it, there is no responsibility on me.i am relaxed.they all check on me all the time, they support me, they see to it that i am not having any trouble."(Patient, female, 57 years) "the doctors told me to have courage, have faith, and gradually everything will be fine."(Patient, female, 57 years) "My family members help me while exercising, they help to bend my knee.if they are sitting idle or watching tV, they help me too."(Patient, female, 65 years) "surgeries like knee replacement are objective based surgeries.We have to achieve certain objectives in such surgeries.on the 14 th day post-surgery, patient should be able to bend their knees to 90 degrees, by the end of two months, it should be 110 degrees.so, if they don't have supervision and they don't have the social support they need, then they might not be able to achieve this.and whatever they might've achieved till their discharge, they might even lose it after going home….if we don't monitor the patient, we can't achieve the goals and all the progress they must've made could also be reversed and the achievements would be lost."(Surgeon, male, 33 years) "at home we cannot tell them but as far as possible we can advise them fully tell them to learn the exercise and whosoever physiotherapist looks after them at home, maybe they need Physiotherapy help professional supervision."(Physiotherapist, male, 55 years) theme 4: access to rehabilitation (opportunity) "yes, the experience is very well, the doctors have done their part.the only thing is when my incision was left open at that time, i wish i had come to aiiMs only, rather than going to the private hospital.then i wouldn't have to go through all this pain again.i don't have trust in private hospitals, it's just that sometimes i am obliged to go." (Patient, female, 57 years) "i do have a lot of challenges in travelling.i don't have enough money to travel in first class.so i come in coach for disabled people."(Patient, female, 53 years) "i used to go for exercise sessions but now i have stopped them.i went 5 to 7 times and stopped because it was very far."(Patient, female, 55 years) "Getting treatment at such a low cost is a very big thing.i have heard that in private hospitals the cost for the surgery is very high.so, what else could be better than getting such a good treatment at low cost.We spend less at XyZ but end up spending more at traveling.Getting reservation for 2 people then booking return journey for tatkal then reaching railway station taking auto from there to XyZ hospital.this is my main spending.other than that, the services and medicines are at low cost only.the issue is it takes a lot of time to reach oPD." (Patient, male, 62 years) "i do not get a reservation on the train and i have to do my booking in tatkal for returning as i don't know when i'll be back.We booked the departure journey one month priorly.We end up spending a lot of money.but the benefit is we get to see the doctor and my issues get resolved.My children are there with me to help me with travel.the auto driver asks for a lot of money but eventually i get relief.the main issue is we have to stand in the queue since four aM in the morning.even when we tell the guards that we are handicapped, they don't listen.it takes a lot of time to get inside the hospital from the gate.i can't walk fast so many people are ahead of me.there should be some facility for people like me." (Patient, male, 62 years) "there is a problem in coming, i get pain in my knees due going to and coming from Delhi.i get tired after sitting for a longer duration.there is no issue travelling to smaller distances, but longer distances are a problem" (Patient, female, 65 years) felt little need to know how the exercises help (28%) (item 4) and were ready to tolerate the discomfort for the sake of their knee (item 19, 100%).similarly, patients reported during iDis that they performed the exercises to be self-reliant and be able to bend their knees.
i want to get back on my feet, don't want to be dependent on anyone, this is the reason.i don't want to get bed ridden, i want to keep walking till i am alive, don't want to be disabled.(Patient, female, 57 years) i am exercising so that i would be able to bend my knees properly.i think about sitting down, which i am unable to do right now.i go to the gurdwara, i can't sit down there to touch my forehead to the ground.(Patient, female, 65 years) hcPs considered the patient's "will" to exercise as an important factor for better recovery after surgery.through a multi-modal approach we are able to drive away the pain but then the patients are always lazy.We have to push them towards doing physiotherapy.and when we send them for physiotherapy, they do it as told, but the willingness they would've shown for pre-operative physiotherapy, that they don't show for post-operative physiotherapy.(surgeon, male, 29 years) in Figure 3, we bring together the findings in the cOM-B framework and present the facilitators and barriers to physical and psychological capability, social and environmental opportunity, and reflective and automatic motivation for following the rehabilitation protocol by patients and hcPs.
the content analysis of the hcPs narrative on patient and health system level challenges in providing care before surgery, during the hospital stay, and post-discharge is illustrated in Figure 4. short-window period before surgery, compounded by pain due to the severity of osteoarthritis was a key challenge for prehabilitation.Following discharge, the inability to visit the hospital due to distance, lack of understanding about rehabilitation protocols due to low literacy levels of patients and lack of remote monitoring methods in the hospital was commonly reported by hcPs.theme 1: exercise recall and ability to exercise (capability) "First, i had a fever… and this facility was not there in the village where i was staying.i got physiotherapist support as well but couldn't continue it.some of the reason for it is CoViD too." (Patient, male, 64 years) "i have been coming to the hospital continuously for 25 days and came once before that for stitch removal.i am coming to exercise, in physiotherapy department.i come by metro.Metro is a problem.My legs slip in the metro.i have to use lift mostly.i can't climb the stairs, yet i am trying to climb the stairs."(Patient, male, 64 years) "there is Dr XyZ's hospital in Kanpur for knee replacement, so after knee replacement he sends his physiotherapist to the house for at least two months and he is his paid employee.and he charges 500 to 800 inR from patient to patient for each session.so basically, a man ends up spending more for physiotherapy than what he has spent for his surgery."(Patient, male, 65 years) "any specialist who is a physiotherapist, when he himself makes you exercise, he knows up to what extend one has to bend the knees.he bends it to a degree and if there is pain, he tells you to bear the pain as it will give you relief.so, he will bend the knees as required.but when you do it yourself, you will do as much as you can bear.this is a big difference between the two.but the problem is that the position of physiotherapists of private doctors is such that they start asking for so much money that a man hesitates to call them at home." (Patient, male, 65 years) "Pain is not there as such, when i get up and sit then there's some pain.if this swelling will reduce, then only i'll get relief.i consulted the doctor for the same, but he didn't understand.the doctor is not good here where i stay.if the swelling would be gone, i'll be able to bend my knees.if i have to travel somewhere, then after longer hours of sitting, there will be pain and swelling."(Patient, female, 65 years) "yes, i used to go for exercise sessions but now i have stopped them.i went 5 to 7 times and stopped because the centre was very far."(Patient, female, 55 years) "the ability to reach a good physiotherapy setup is something a patient should be allowed to.some of the patients who come to us are hailing from north-east, bihar, south.so for them, to come back here for physiotherapy is a very big thing, they can't come.so a very big step towards it would be, something that is accessible to the patients to indirectly communicate with the doctor."(Surgeon, male, 29 years) "Mostly the patients are unable to go through prehabilitation.We advise it, but mostly the patients are outsiders, so they are unable to go for it."(Surgeon, male, 33 years) "in some cases, after going home, the rehabilitation centre is far away from their home, so they are not able to access it."(Physiotherapist, male, 40 years) "the second challenge is distance, which is a hindrance to patients even if he wants to come….Patients usually don't get conveyance or social support like getting off from the transport, reaching here for visits.they are also misinformed in terms of where they are supposed to go.they get lost here, don't know where to go.these things also waste their time."(Physiotherapist, female, 35 years) "here we can have a dedicated unit for knee replacement and osteoarthritis patients, so that the patients can visit the therapist regularly.i think this will improve compliance.Depending upon the reachability of the institute if they are living nearby, they can visit frequently and often."(Physiotherapist, male, 35 years) "the biggest challenge is that they do not have access to good physiotherapy centres who are well equipped and well versed about what has to be done…… if a patient has to come here from XyZ place for physiotherapy even once in two weeks, then also he spends 3-4 h on road just to get here."(Surgeon, male, 29 years) "People do surgeries outside.the patients operated in private hospitals are not as compliant with physiotherapy. the protocols of post operative rehabilitation are very low and the patients are therefore not too happy, as we see in our own oPD."(Surgeon, male, 29 years) theme 5: to become independent (motivation) "look, it was my mistake, not of the doctors or nurses.i did not do the exercises.if i had done the exercises for the initial 10 days, then this problem would not have arisen.Right now, i am unable to straighten the knee up, it is bending inwards, it is difficult to walk." (Patient, male, 64 years) i want to get back on my feet, don't want to be dependent on anyone, this is the reason.i don't want to get bed ridden, i want to keep walking till i am alive, don't want to be disabled."(Patient, female, 57 years) "Right now, i feel like i can't go outside.i actually don't feel good walking with a stick.10-15 more days i will come here.then i will wean off the stick.i'll try to be independent.i am a social worker, i still bring people to aiiMs to help them with consultation, i try to counsel them."(Patient, male, 64 years) "if i do exercises then my legs will work or else, they won't.there will be no movement if i won't exercise."(Patient, male, 82 years) "if i do the exercises, i will be able to bend my knees and walk properly hence i exercise."(Patient, male, 62 years) "i am exercising so that i would be able to bend my knees properly.i think about sitting down, which i am unable to do right now.i go to the gurdwara, i can't sit down there to touch my forehead to the ground."(Patient, female, 65 years) "through multi-modal approach we are able to drive away the pain but then the patients are always lazy.We have to push them towards doing physiotherapy.and when we send them for physiotherapy, they do it as told, but the willingness they would've shown for pre-operative physiotherapy, that they don't show for post operative physiotherapy."(Surgeon, male, 29 years)

Discussion
this mixed methods study from a referral hospital in india provides an insight on the practical challenges faced by patients and health care providers during the recovery period following knee replacement.We found that the patients were motivated to follow the advice, but wished for reliable and accessible professional support, especially in the early periods of recovery.healthcare providers reported poor adherence and challenges in monitoring patient progress after discharge to home, leading to less optimal functional recovery.this study also highlights the crucial role of family members during the recovery period.Pain management is an important aspect during the recovery phase.Pain interference in following the rehabilitation protocol was similar to previous research findings [24,25].however, participants in this study did not express hesitancy in taking pain medications during the acute phase unlike in previous studies, which reported a lack of understanding about using pain medications [26,27].there were also reservation by patients to take pain medications in spite of intense pain, due to concern of side-effects or dependency [26][27][28].the differences in finding could be due to the use of opioid analgesics in the West, compared to the very limited use of opioid analgesics in india for pain management [29,30].
Following discharge, patients reported the feeling of being left alone at home and a lack of support from family [9,25,27,31,32].they felt the need for a peer-support group for motivation to do exercises and engage with other patients to share their  experiences [26,31,33,34].Patients also were eager to seek psychological support from healthcare providers over and above the advice and instructions [9,25,32] regarding the exercises.these findings were discordant in the present study and may result from the socio-cultural context.Participants mostly lived with their children, as in most cases of the older population in india.those living alone or only with their spouse stayed with their children or relatives after surgery until they could return to routine activities.hence, the crucial role of the family during the recovery period should be taken into consideration for designing interventions in india or other similar contexts.
One-third of patients who underwent surgery at this hospital were from distant localities of the country and the rest were from within the state but requiring significant travel time in private transportation to reach the hospital.this is a common scenario in any referral public hospital of the country.to avoid travel-related expenditure, discomfort during travel, and disruption to the work of the family members, patients availed private physiotherapy services, leading to out-of-pocket expenditure [12].Difficulty in reaching physiotherapy clinics and loss of wages due to frequent visits have been reported previously [25,33,[35][36][37][38]. however, the indirect costs due to productivity loss of the accompanier could be higher in our context, as in our experience, patients rarely travelled alone or visited a hospital without an accompanier due to over-crowding and challenges in navigating within the hospital.the other aspect that was observed in several of our interviews was the mistrust that patient had on private hcPs and hence, they tried to visit the same referral hospital for follow-up where they underwent surgery.We did not observe such concerns in the literature.however, a lack of linkages or connections with private physiotherapists or doctors with the primary hospital have been previously reported [9,25,39,40].
in the present study, most patients intended to perform their rehabilitation, which would in-turn help them be off pain medication and be self-reliant for self-care [24,25,28].however, in the context to india individuals post-knee replacement were expecting to be able to do mainly light household activities or social activities such as visiting friends or religious places.this was in contrast with the level of expectations individuals had in the high-income countries context [37], which included return to sports or managing all household activities independently.We need further exploration in the context to developing countries to understand patient expectations and any underlying reasons for limited expectations.
Overall, we found patients were satisfied doing the few exercises they were taught at the time of suture removal.they perceived that they were performing the exercises as prescribed and had the intention to do so for the sake of their knees.in contrast, the hcPs were not satisfied with their patient's adherence to exercise.the physiotherapists had no scope for progressing to higher levels of exercises as patients did not return for follow-up and there was no monitoring mechanism, especially for those living in regional or rural locations.
there are several learnings from these findings that can improve the rehabilitation care model practiced in the public health care system in india and similar contexts.Firstly, there is a need for remote monitoring mechanisms for enabling a continuum of care.to reduce out-of-pocket expenses incurred by seeking private care, a remote communication mechanism that can provide support and reassurance to patients might help.Remote monitoring of the progress can also facilitate early detection of impaired range of movement, poor wound healing, or inadequate pain management.secondly, education about what can be expected, and the importance of progressive exercise is crucial.
Further, technology should also bridge the gap between the surgical and the rehabilitation care team within the hospital.
the mhealth intervention package we are envisaging should consist of a knowledge repository accessible for patients and family member that provides relevant information about the recovery pathway and living with the artificial knee joint.a video-based exercise repository to facilitate physiotherapist to modify the therapy plan would be crucial, instead of a static repository or an exercise booklet.Mobile health (mhealth) including wearables are being increasingly used as a solution for promoting self-management and remote monitoring (a scoping review done by the same authors to map the features and functionalities of mobile and computer-based applications, under review for publication).however, the use of wearables in the aged population across socio-economic strata is low [41,42].to promote self-management and remote monitoring, an e-diary of pain, knee function and activity levels with asynchronous communication with health care providers may be an alternative for wearables.however, any mhealth-based intervention package will need to be evaluated for acceptability, clinical-and cost-effectiveness compared to conventional care.

Limitations
this study was conducted at a single large referral hospital catering to several number of states of Northern india.however, this may not be a representative population to all regions of india.the study finding is more representative of a population availing care in public hospitals and may not be generalizable to those seeking care at private hospitals.

Conclusion
We identified several modifiable factors that can improve rehabilitation care and exercise adherence following discharge from the hospital after knee replacement.any intervention that aims to address the gaps should use behavioural models to educate the patients about the recovery process, providing skills to perform the exercises, and enabling access to health care providers.
ND, aK, and RM conceptualised the study, shP and Ps collected data, sP and ND analysed the quantitative data, sP, shP, Ps and ND analysed the qualitative data, sP wrote the first draft of the manuscript.RMd provided expert comments.all authors agreed to the final version of the manuscript.
participated in the iDis (mean age, 35 years, and Female = 5, Male = 8) with professional experience ranging between 0.5 years and 35 years.three respondents were surgeons and 10 were physiotherapists.

Figure 2 .
Figure 2. Rehabilitation adherence.the response categories to each of 22 items (item numbers are represented within parenthesis) were coded as 1-4. the responses were either strongly agree to strongly disagree or always to never.these responses were recoded to represent best to poorest adherence

Figure 3 .
Figure 3. summary of barriers and facilitators in adhering to rehabilitation program in capability, opportunity and motivation-behavior (CoM-b) framework.

Figure 4 .
Figure 4. Perception of healthcare providers about the challenges experienced in providing care to the knee replacement patients.

Table 1 .
sociodemographic profile of the patients.

Table 2 .
socio-demographics of the participants participated in in-depth interviews (n = 9).

Table 3 .
themes, and exemplary quotes from the patient and healthcare providers interviews.
theme 1: exercise recall and ability to exercise (capability)