An increasing number of patients are discharged from a total hip or knee arthroplasty with a short length of hospital stay. Technologies, such as mobile applications, are used to provide remote support to patients’ postoperative rehabilitation. Patients’ experiences of receiving mobile application-based rehabilitation after total hip or knee arthroplasty have not been investigated extensively.This was a qualitative descriptive study. Twenty-five participants who had completed a mobile application-based rehabilitation programme for total hip or knee arthroplasty were recruited. Semi-structured interviews were conducted via telephone between July 2021 and January 2022 regarding the participants’ experiences using the programme. All interviews were audio-recorded and verbatim transcribed. Data were analysed using inductive content analysis. The reporting of this study followed the Consolidated Criteria for Reporting Qualitative Research.Data analysis revealed five categories: (a) improved access to health care, (b) encouraged postoperative recovery, (c) established supportive relationships, (d) facilitated learning, and (e) future directions.The theory-underpinned mobile application-based rehabilitation programme demonstrated potential value in supporting patients’ rehabilitation after arthroplasty. Nurses can consider using mobile technologies to expand their role in arthroplasty rehabilitation and improve the quality of rehabilitation care.The online version contains supplementary material available at 10.1186/s12912-023-01409-3. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are two surgeries that are widely performed worldwide . PatientThe widely accepted standard care for patients after THA and TKA is facility-based (inpatient or outpatient) rehabilitation that begins shortly after discharge from acute care . PatientWith technological advancement, information and communication technologies, such as mobile applications (apps), are used by healthcare professionals including nurses to provide remote support to patients’ rehabilitation after THA and TKA. It is referred to as telerehabilitation . PatientDespite encouraging findings in research, existing mobile app programmes that target patients undergoing THA and TKA vary significantly in quality, requiring further efforts to improve their content, interactivity, and relevance . The appPatients’ input throughout the design, implementation, and evaluation of a mobile app-based programme also influences the quality of the programme . PatientBased on Bandura’s self-efficacy theory , the IllThis study aimed to investigate patients’ experiences using a mobile app-based rehabilitation programme that was developed for patients after THA and TKA.A qualitative descriptive study was conducted. This research method aims to provide rich and authentic descriptions of participants’ experiences and perceptions of the phenomenon being investigated, whereby researchers can obtain an in-depth understanding of the phenomenon , 27. It This study used semi-structured interviews to collect data. All the interviews were conducted by the first author of this paper. She was a nurse academic who had received training on qualitative research methods and built rapport with the participants through delivering the mobile app-based rehabilitation programme. An interview guide was developed based on a review of the literature exploring patients’ experiences with arthroplasty telerehabilitation , 22 and To recruit participants who had experienced mobile rehabilitation services, the present study purposefully sampled participants from a pool of participants in a randomised controlled trial (RCT) that used a mobile app-based rehabilitation programme to support patients’ rehabilitation at home after THA and TKA . The stuThe conceptual framework of the mobile app-based rehabilitation programme is presented in Fig. ®. It included an exercise regimen aiming to improve patients’ joint mobility, muscle strength, balance, and performance in daily activities. The exercises were demonstrated in videos designed for patients after THA and TKA. Weekly goals for rehabilitation were set, and progressive rehabilitation tasks were scheduled to help the participants achieve their goals, such as gradually increasing walking time from three 5 min per day to 30 min a day. Former patients who had successfully recovered from THA and TKA were invited to share their experiences through stories and short videos. A discussion forum was held via the app so that participants could discuss their conditions with healthcare professionals , nursing researchers, and other patients in the programme. Reminders were sent to the participants every Monday to improve engagement. Psychological support measures, such as relaxation exercises and educational materials on depression, were provided via the app. The content of the programme was reviewed by an arthroplasty surgeon, an orthopaedic nurse, a physiotherapist, and two patients. To facilitate patients’ learning via the app, educational materials were provided in visual presentations with short text messages, and all content on the app was ensured to be comprehended by a sixth grader. Each participant was provided with a booklet that illustrated how to use the programme. The educational materials  were uploaded to the app, and the participants could learn via WeChat on their own mobile devices. The participants were advised to complete the rehabilitation tasks at least 5 days a week for 6 weeks. They could record their use of the programme and completion of the rehabilitation tasks in a written rehabilitation diary.The mobile app-based rehabilitation programme was a 6-week programme provided via the app WeChatnd interview, confirmed by no new codes being identified in three more interviews. The interviews ranged from 13 to 29 (mean = 19) minutes.Data collection occurred between July 2021 and January 2022. The first author contacted the participants within a week of completing the interventions of the RCT. The study objectives were explained again, and an appointment was made for a telephone interview that would be conducted in Chinese. Data saturation was used to determine the sample size for this study. Saturation occurred when no new codes and/or categories were identified in the data from additional interviews . Data saThe interview started with restating the procedure and participants’ rights. Then questions were asked within the boundary of the interview guide. When the participants were speaking, the researcher listened carefully and respectfully with the least interruption. The researcher used reflective approaches, such as making reflection statements  to facilitate the interview process. At the end of each interview, the researcher confirmed with the participant that they had no additional comments and enquired if they could be contacted for further information. All interviews were audio recorded. The first author verbatim transcribed the record in its original language immediately after the interview. Field notes were made to record the researcher’s reflective thoughts.Preparation phase: The first author read the transcripts repeatedly to achieve data immersion. It was followed by reading the data line by line and highlighting the text words that appeared to respond to the research questions.Organising phase: The first author noted down in the margins of the transcript her preliminary analysis of the description of the content. These notes were collected onto a coding sheet to create an initial coding scheme. These initial codes were sorted into groups by comparing the similarities and differences between codes. The grouped codes were listed and further grouped into subcategories and then categories, based on the relation and links. Finally, the categories, sub-categories, and codes were refined, and a general description of the research topic was formulated. Throughout the organising process, all authors of this article, including three bilinguals who are fluent in Mandarin and write Chinese, discussed coding and codes, generation of categories/subcategories, and interpretation of findings on a weekly basis.Reporting phase: The categories, subcategories, and illustrative quotes were translated from Chinese to English. All authors examined and reported the findings. Discrepancies were discussed by all authors until a consensus was reached.Participant demographics were summarised using frequencies and percentages. Inductive content analysis was used for interview data. Instead of preconceived categories, inductive content analysis derived categories and names of categories from the text data . This apThis study was approved by the Human Research Ethics Committee of the University (No: H-2021–0414) and the Ethics Committee of the hospital (No: B2021-096R). All participants were informed that they voluntarily participated in this study and could withdraw at any time without a consequence. Identification code numbers were used in data collection and analysis to ensure participants’ privacy and anonymity. Collected data were saved in a password-protected cloud system of the university and only accessible to research team members. Written informed consent was obtained for the interviews and audio recording of the interviews.The strategies described in Table n = 17). Their age ranged from 33 to 83  years. The participants had undergone TKA  or THA  procedures, and osteoarthritis was the most common reason for surgery . Most participants lived with family . The education level of the participants varied: tertiary , secondary , primary , and no education . Many participants  had concomitant diseases, and hypertension  was the most common. Table This study interviewed 25 participants, 68% of whom were women  improved access to health care, (b) encouraged postoperative recovery, (c) established supportive relationships, (d) facilitated learning, and (e) future directions. Table All participants described that the mobile app-based rehabilitation programme improved their access to health care. Three subcategories described the improvement.“The programme provided video demonstrations for all exercise movements that I was told to do for rehabilitation. ... I had read the instructional pamphlet provided by the ward nurse, but I preferred to use the app as the information provided via the app was more comprehensive, including the precautions after the surgery and relaxation exercises that could be done after surgery to help relieve stress.” Most participants described increased access to rehabilitation information through using the mobile app-based rehabilitation programme. The participants said that compared to the pamphlets provided by ward nurses, the information provided in the programme was more comprehensive, encompassing exercise demonstration videos, postoperative precautions, and other relevant content such as relaxation exercises.“If I had not participated in the programme, I might search for information on the Internet, which might not be accurate, and it would make me confused as the Internet contained many different doctors’ statements and patients’ stories. I cannot tell which one is useful. The information provided in the programme is more reliable.” The participants said they considered the rehabilitation information provided in the programme more reliable than that they searched on the Internet, and they did not need to judge what were useful suggestions from a huge amount of information.“The programme helped me to have a realistic perception of the recovery process. ... With the information in the programme, I better understood my conditions. I understood I needed to be more patient when sometimes I felt a bit of discomfort in this (operated) leg, as it was in the recovery process.” Some participants said that increased access to rehabilitation information via the app had helped them better understand their conditions and have a realistic perception of their postoperative recovery process.“I did not need to read the materials in the module on psychological support because I was fine and I had no psychological problems. … I thought they  were only for people who had the problems.” However, a few participants said that they did not need the information related to psychological support, such as relaxation exercises, as they viewed such information as only for patients who had psychological problems.“During the first few weeks postoperatively, I had many questions about precautions, exercises, self-care, and so on. By using the programme, I was able to obtain support from the healthcare professionals, such as seeking consultations immediately after I was discharged from the hospital. I felt like I had better access to healthcare professionals for support than those who were discharged from the hospital without the mobile app programme.” Many participants described they required support from healthcare professionals in the first few weeks after surgery. They said that the mobile app-based rehabilitation programme, which commenced immediately after hospital discharge, enabled them to better access healthcare professionals and obtain timely support, such as seeking health consultations.“I went to buy some groceries the third day after hospital discharge, and my operated leg was swollen severely after I came back home. I was scared so I sent a message via the app to ask about it. The healthcare professional responded quickly, messaging me to lie down and exercise on the bed and to reduce walking in the following two days. The swelling disappeared by the third day and never occurred again. I appreciated this programme as I had advice about my condition from the healthcare professionals when I needed it.” Some participants said they appreciated that the mobile app-based rehabilitation programme allowed them to seek individual consultations with healthcare professionals. The participants sent messages via the app for consultations about their condition, and the healthcare professionals replied individually through messaging.“Initially, I could not roll over in bed as I felt intense pain in my operated leg when I tried to do so. I asked about it in the discussion forum via the app. The healthcare professional suggested I roll over with the operated leg flexing a bit. It did work, so I posted my feedback in the forum as well because I thought the information might help others who had the same problem.” Other participants described posting questions in the discussion forum for health consultations. The healthcare professionals’ responses and patients’ follow-up feedback were also posted in the discussion forum. The participants said they posted their response to the healthcare professionals’ advice because they thought it might be helpful to other patients in the programme who had a similar issue.“It is of special value for patients to use the mobile programme for rehabilitation during the COVID-19 pandemic. We could access and obtain support from healthcare professionals without visiting the hospital. This would reduce the need of going to places where social distancing is difficult, such as buses, and thus reduce my chances of being exposed to the virus.” Several participants said the mobile app-based rehabilitation programme had special value during the COVID pandemic, as it allowed patients to obtain support from healthcare professionals while having fewer worries about being exposed to the virus.“Nowadays people are always having a mobile phone in their hands. Especially, I was resting at home after the surgery and had nothing else to do. I held the mobile phone in my hand for almost the whole day. It was very convenient for me to read something on the app.” “Most people of my age are familiar with WeChat as we use it every day. I have no difficulty using it. … When I felt something was wrong while I was doing the exercise, for example, I felt bad in the exercise Clamshell, the first thing I thought was to ask about it via the app.” Many participants said using the mobile app-based rehabilitation programme was convenient as the mobile phone was a device that they used every day. The programme was provided via the mobile app WeChat, which they were familiar with and had no difficulty using. This made the programme the first choice for them to seek help when they had questions about rehabilitation.“I did not need to go somewhere, like the rehabilitation centre, to learn how to conduct rehabilitation exercises. Traffic and parking issues always give me headaches. I just stayed at my home, watching the app and practising rehabilitation exercises with the support of the mobile app programme.” The participants described that using the mobile app-based rehabilitation programme was more convenient than attending rehabilitation centres. They said they were able to learn and practise rehabilitation exercises without worrying about transport and transport-related issues, such as traffic jams and parking.“I liked to use this programme, without bothering to call nurses or doctors, which could only be done during work time. I just read the educational materials whenever and wherever I wanted and got knowledge about my recovery. I like this kind of flexibility.” Some participants said that compared to the usual care provided by the hospital , they preferred to use the mobile app-based rehabilitation programme because they could flexibly access educational materials without time and place restrictions.Sixty per cent (15 out of 25) participants said that participating in the mobile app-based rehabilitation programme encouraged them in postoperative recovery. There were three subcategories.“I browsed the posts on the discussion forum twice a day during my rehabilitation. People posted questions, and the healthcare professionals provided answers quickly. The posting activities constantly reminded me of my rehabilitation. I would not forget to practise rehabilitation exercises, and I took post-surgery precautions. I felt I was more engaged in my recovery when participating in the discussion forum.” The participants described valuing the discussion forum that was held via WeChat. They said that participating in the discussion forum increased their engagement in postoperative recovery as questions and discussions were frequently posted in the forum, which reminded them of practising rehabilitation exercises.“The healthcare professionals sent messages every Monday to remind me to continue exercising, even during the holiday. With these reminders, I did better at keeping going with the practice of rehabilitation exercises.” The participants valued the messages that were sent to them every Monday reminding them to continue rehabilitation exercises. They said these reminders helped them in undertaking rehabilitation exercises.“I was wondering why my right leg was numb, so I sent a message in the evening to ask about it. The healthcare professional responded immediately, messaging me to explain the issue and encourage me to keep observation of my symptom. Through timely communication with the healthcare professional, I felt engaged to do more for my recovery.” The participants described their communication with healthcare professionals via the mobile app programme. They said timely communication with healthcare professionals engaged them more in the management of their postoperative recovery.“In the beginning, I struggled to keep up with the video demonstrations provided in the mobile programme. After some time, following the demonstrator was a piece of cake. I felt motivated in the conduction of rehabilitation exercises, and gradually I did some extra exercises according to my condition.” “If I had any questions about rehabilitation exercises, I could ask any time in the discussion forum, and the healthcare professionals and other patients would help me. Their support motivated me to be more active in rehabilitation practice as I had no worries about the exercises.” Some participants described being motivated to conduct rehabilitation exercises by using the components of the mobile app-based rehabilitation programme, such as the exercise demonstration videos and the discussion forum. They said that practising following video demonstrations and support from healthcare professionals and other patients motivated them to become more active in their rehabilitation exercises.“One of my friends underwent the same surgery at a local hospital, and she was only provided with paper instructions on rehabilitation exercises. She asked me to share with her the demonstration videos because she had some difficulties understanding the paper instructions. Compared to her, I felt I was lucky because I was able to learn many materials besides demonstration videos in this mobile programme. I worked harder on rehabilitation exercises as I appreciated the support that healthcare professionals had provided for my postoperative recovery.” One participant described her experience compared with other patients who were not provided with the mobile app-based rehabilitation programme. She said she appreciated the support provided by the healthcare professionals in the programme, and this appreciation motivated her to work harder on rehabilitation exercises.“I believed I could master the methods of rehabilitation with the support of the programme. … I did the rehabilitation at home in a more independent way. ... I knew as long as I followed the programme and persevered patiently, I could complete the rehabilitation programme and recover from the surgery.” Many participants described their confidence in mastering rehabilitation methods and recovering from surgery with the support of the mobile app-based rehabilitation programme. They said participating in the programme enabled them to undertake rehabilitation more independently.“I used to dare not try the exercise upstairs and downstairs as I was afraid something wrong would happen. I saw the video showing that we can do it and how to do it. I remembered the movements. I was more confident to try on the stairs.” The participants said that by watching exercise demonstration videos provided in the programme, they felt more confident doing exercises they were once afraid to do.“I liked the section about stories shared by former patients who had successfully recovered. I was particularly interested in what issues they encountered during recovery, and how they handled these issues. For example, I used to feel tightening in the skin at the surgical site. I read in the shared experiences that soaking the skin in warm water would help. I did so and it was much better…. Learning from former patients gave me the confidence to manage my condition.” The participants said that learning from the experiences shared by previous patients who had successfully recovered from the surgery, such as addressing issues encountered during recovery, enhanced their confidence in rehabilitation self-management.“Sometimes I dared not to do the movements demonstrated by the demonstrators. I thought they (demonstrators) were normal people, but I was patient, could I do the movements like a normal person? Would my joint be dislocated? When I saw a patient after the same surgery did these movements, I was more confident to do exercises.” The participants said that they gained the confidence to practise rehabilitation exercises when they saw the videos showing that other patients who had undergone the same surgery did the exercises.“Sometimes I was afraid to do some exercise movements as I thought they might hurt my joints. I felt relieved and confident to try them after the healthcare professionals in this programme confirmed that I could do those movements.” The participants said the reassurance from the healthcare professionals improved their confidence in conducting rehabilitation exercises.Eighty-four per cent (21 out of 25) participants described that the mobile app-based rehabilitation programme helped them establish supportive relationships with healthcare professionals and other patients in the programme. This included two subcategories.“Through talking to healthcare professionals via the app, I built a good bond with them. I regarded them as friends with whom I can talk freely. I felt relaxed sharing with them my progress and feelings, and their support eliminated my confusion and worries.” Many participants described that through the mobile app-based rehabilitation programme, they built a good bond with the healthcare professionals. This bond enabled the participants to share their feelings freely and get the support that allayed their worry about recovery.“When I was discharged from the hospital, I asked other patients who had experienced recovery for suggestions. As time went by, I became an experienced patient, and I was very happy to help new patients by sharing my experiences and knowledge about rehabilitation. Here (the discussion forum via the app) we are like a big 'family'. If someone had questions or difficulties, we would like to help. ... I would have felt very lonely without the discussion forum, a place where I felt belonging to and we could support each other.” Most participants described the experience of establishing a supportive relationship with other patients in the programme. They said the discussion forum in the mobile programme brought them a sense of belonging, allowing them to share information, experiences, and feelings. The participants said participating in the discussion forum reduced their sense of loneliness after they were discharged from the hospital.“Sometimes I was concerned about my recovery. Several experienced patients told me in the discussion forum that it was not necessary to worry too much and that everything would be fine. Their words soothed me a lot.” The participants said that the comforting words from other patients reduced their concerns about the postoperative recovery.“If someone expressed frustration during rehabilitation in the discussion forum, I tried to comfort and encourage them. I shared how I managed the issues encountered during my recovery. I demonstrated a positive attitude towards recovery. I hoped this would help them face recovery positively.” They also described that they provided support to other patients who felt frustrated during postoperative recovery by sharing successful experiences of rehabilitation self-management.A quarter (6 out of 25) of the participants described that the components of the mobile app-based rehabilitation programme facilitated their learning of rehabilitation instructions. It included two subcategories.“Compared to paper-based instructions, the videos helped me to visualize the movements. Videos were more interesting and easier to understand than the instructions on paper.” The participants said the demonstration videos facilitated their learning of postoperative rehabilitation by making exercise instructions visual, interesting, and easy to understand.“I am illiterate, and I do not understand text messages, but I understand the videos and pictures on the app. I did exactly what the videos show, one movement after another. I followed the demonstration videos and practised every day, and now I have improved a lot.” One participant described that although she could not read text messages due to her limited literacy competence, she felt significant improvements in recovery by practising exercises daily following the demonstration videos.“Doctors taught me how to conduct exercises, but I forgot as time went by. The app programme is wonderful as I could access and learn the exercise instructions frequently and repeatedly. After several weeks I memorised most of the exercises.” “Demonstration videos are easy to visualise than the instructions on paper. They are imprinted on my mind. …It seems easier for me to memorise the exercise movements after watching the videos.” The participants described that by engaging with exercise instructions on the app repeatedly and frequently, they could better memorise these instructions. Some participants specifically described that they felt easier to memorise exercise instructions after watching demonstration videos. They said the video demonstrations were imprinted on their mind because of visualisation.The participants also provided suggestions regarding the future use of the mobile app-based rehabilitation programme and room for improvement. Two subcategories were revealed.“This programme is easy to use and quite needed by patients after arthroplasty. It should be implemented in routine care in future so that more patients can access it.” A quarter (6 out of 25) of the participants said that they had recommended the mobile app-based rehabilitation programme to their relatives and friends who had received similar surgeries. They suggested healthcare professionals integrate this programme into routine care in future so that more patients could access this service.“I would like to suggest including family members or caregivers in the programme. Healthcare professionals could assign some tasks to the family members (or caregivers) to involve them. Family members can remind the older patients if they forget something. ... Family support is important to patients, not only for their physical recovery but also for psychological support. Patients' enthusiasm would be kept if the family could accompany them during the rehabilitation journey.” Several participants suggested including family members or caregivers in the mobile app-based rehabilitation programme to provide support to the patient and maintain the patient’s enthusiasm for rehabilitation. They said this is important for the patient’s recovery.“For some common questions, such as the symptoms that probably appear after hospital discharge, a frequently-asked-question section could be developed and regularly updated. Newly enrolled patients could read the question and answer, and this may answer part of their questions. Thus reduces the workload of healthcare professionals regarding the need for repeated answers to similar questions.” “A discussion schedule could be made where the healthcare professionals attend the discussion forum several times a week. There is no need for healthcare professionals to be on 24/7 standby. In this way, the workload of healthcare professionals could be reduced, and the programme may be more sustainable.” The participants also provided suggestions for improving the current programme. They suggested developing a frequently-asked-question section and regularly updating it in the mobile app-based rehabilitation programme as some common questions were repeatedly posted. They suggested a discussion schedule that would allow healthcare professionals to participate in discussions at regularly scheduled times, instead of being on standby 24/7. They said this might reduce the workload of healthcare professionals, and the programme might thus be more sustainable.“I would suggest including pain-related information in the app programme, such as why patients feel pain and how to properly manage it after discharge. The app can provide brief instructions on the painkillers commonly used after joint replacement and may provide some tips for pain management postoperatively. … The app can provide more examples of former patients, not only in rehabilitation exercises but also in pain management. It will help patients self-manage their pain while they are recovering at home.” One participant suggested including health information and examples related to postoperative pain management in the mobile app-based rehabilitation programme. He said this would better support patients’ pain self-management after hospital discharge.“Although I had been taught how to use the mobile app programme and provided an illustrative booklet, I could not remember everything and had a bit of difficulty reading the booklet. If there was a video showing the steps of how to use the programme, it might be helpful. I live alone and have nobody to help. I could use the programme better if I had a handy video to watch and learn.” Another participant suggested providing a video demonstrating how to use the programme in addition to the current oral explanation plus a take-home booklet. She said a demonstration video would be particularly helpful to those who live alone with little social support.This qualitative study evaluated a mobile app-based rehabilitation programme from the perspectives of 25 patients who had access to the programme during their rehabilitation after THA and TKA. The findings provide an in-depth understanding of patients’ perceptions of the strengths and weaknesses of the programme as well as room for improvement. The patients perceived the newly developed mobile app-based rehabilitation programme as helpful for their postoperative rehabilitation, and they recommended incorporating the programme into routine care for patients after THA and TKA. This study adds new knowledge to the field of arthroplasty telerehabilitation as it provides an authentic description of patients’ experiences of receiving rehabilitation support via a mobile app and a discussion of this knowledge as follows.Patients in this study perceived improved access to health care, such as comprehensive and reliable rehabilitation information and support from healthcare professionals, by participating in the mobile app-based rehabilitation programme. The patients described access to rehabilitation care as convenient and flexible via a familiar app on mobile devices. They could use the programme whenever and wherever they need it without time and place restrictions. This suggests that mobile app-based programmes can overcome some limitations of synchronous telerehabilitation modes , such as the need for both patients and healthcare providers to sit in front of a high-quality screen and access the programme simultaneously . These fWith the support of the mobile app-based rehabilitation programme, the patients perceived being engaged, motivated, and confident in their postoperative recovery. They highlighted the programme components, such as exercise demonstration videos, the discussion forum, reminders, and successful experiences shared by other patients, in the enhancement of their engagement, motivation, and confidence in rehabilitation practice. Such findings inform future programme developers of potentially effective components that could be included in mobile rehabilitation programmes. Patients’ experiences of improved engagement and motivation may be partially attributed to the application of Bandura's self-efficacy theory  in the dThe patients reported developing a trustful relationship with healthcare professionals, which made them relaxed and reassured. This is congruent with previous evidence that patients in telerehabilitation experienced a close and strong relationship with their therapists , 22. FurThe Illeris model for learning, which suggests facilitating individuals’ learning process by providing interesting and understandable content, reducing mental energy needed in learning, and improving interaction with the environment , was usePatients in this study perceived convenient and flexible access to health care by using the app with fewer requirements of transport, which enabled them to obtain timely support from healthcare professionals. This was particularly valuable for patients who were in the first few weeks after surgery when they needed more support but had less mobility. By participating in the mobile app-based rehabilitation programme, the patients established rapport with healthcare professionals and other patients, which reduced their worries, concerns, and sense of loneliness. They felt more confident and independent in performing the rehabilitation tasks. These findings imply that the mobile app-based rehabilitation programme may help to improve patients' satisfaction with life and physical and emotional well-being during postoperative recovery. As these are indicators of quality of life , the proGiven the benefits of the mobile app-based rehabilitation programme, patients in this study recommended incorporating the programme into routine care after arthroplasty. This implies that the patients regard the programme as helpful to others undergoing similar surgeries. In addition, the patients did not report technology-related difficulties using the mobile app-based rehabilitation programme. With an increasing number of older individuals, who are the main population receiving THA and TKA, becoming smartphone users and comfortable with digital technologies , there iThe patients provided suggestions on future use and improvement of the mobile app-based rehabilitation programme, such as involving family members or caregivers in the programme to support patients’ rehabilitation in the home setting, developing a frequently-asked-question section and a discussion schedule to reduce the workload of healthcare professionals, and including information related to pain self-management in the programme. These suggestions are considered feasible and reasonable. The needs of both healthcare providers and patients would be revisited after the trial to explore service sustainability in terms of healthcare resources. Future studies are warranted on how to effectively engage family members and caregivers in mobile rehabilitation programmes and the effect of mobile app-based rehabilitation on patients’ relationships with their family and caregivers.A few patients described not reading the educational materials on psychological support because they did not perceive a need for this type of support. They viewed that only patients with psychological problems needed psychological support. Such findings suggest that some patients after arthroplasty may lack knowledge of or have a negative attitude towards psychological support, which could be related to low mental health literacy. A survey reported that Chinese adult citizens had low to moderate levels of mental health literacy, and older populations had the lowest level compared to youth and middle-aged . Health Study participants were recruited from an RCT that was conducted at a tertiary hospital in eastern China. The nature of RCTs might reduce the diversity of the participants in this study. For instance, patients volunteering for the trial may be more familiar with technology and be positive about telehealth. Thus, the findings may not represent the perspectives of those who are not familiar with digital technology. The views of patients who receive healthcare services in other areas of China may not be fully represented, as the context of telehealth may vary across regions and health environments. This study relied on participants’ self-reported data on the completion of the mobile app-based rehabilitation programme. Future studies could include objective measures to assess the extent they complete the programme. Only patients who self-reported completing the mobile app-based rehabilitation programme were recruited, which may bias the results as motivated patients were more likely to be included. The study participants retrospectively described their experiences using a programme that lasted 6 weeks, which may have potential recall bias. All interviews were conducted via telephone to reduce physical contact during the pandemic, which impeded the collection of non-verbal information, such as the facial expressions of the participants.In the present study, nurses led a team of healthcare professionals in the design, implementation, and evaluation of a mobile app-based rehabilitation programme. This programme was found to improve patients’ access to rehabilitation care, engage and motivate patients in postoperative recovery, help them establish a supportive relationship, and facilitate their learning of rehabilitation instructions. These findings support nurses to take an active and expanded role in using mobile technologies to improve the quality of arthroplasty rehabilitation care. This study demonstrated the provision of rehabilitation information to patients in a supportive learning environment through an app-based programme that was based on a self-efficacy theory, a learning model, and patients’ needs. The patients perceived enhanced self-efficacy, good relationships with healthcare professionals and other patients, and emotional support. These outcomes are critical for patients’ effective self-management in postoperative recovery. The conceptual framework used in this study can be applied when developing new mobile app-based rehabilitation programmes for patients in other healthcare settings. A well-designed mobile app-based rehabilitation programme can deliver care in an accessible, convenient, flexible, and engaging way, which is valuable in maintaining continuity of care for patients discharged to non-medical settings, especially those who live in remote areas and who have reduced access to hospital services due to the COVID-19 pandemic or unavailability of services.Patient users reported positive experiences using the mobile app-based rehabilitation programme that was based on the self-efficacy theory and Illeris model for learning, and these included improving access to health care, encouraging postoperative recovery, establishing supportive relationships with healthcare professionals and other patients, and facilitating their learning of rehabilitation instructions. These experiences support the value of developing telehealth solutions to support patients’ rehabilitation after arthroplasty. Future studies are required to explore the implementation of mobile app-based rehabilitation in clinical practice, including incorporating the mobile app-based rehabilitation programme into routine care and expanding the scope of the programme to include more stakeholders, such as family members and caregivers.Additional file 1.


Pulmonary artery intimal sarcoma is a rare tumor with exceptionally high mortality and easily misdiagnosed as pulmonary thromboembolism pulmonary thromboembolism (PTE) due to the nonspecific clinical presentation and symptom. Misdiagnosis or untimely diagnosis makes the disease progress to an advanced stage and eventually leads to a poor prognosis.A 37-year-old Chinese female presented with chest tightness and dyspnea for 3 months. Echocardiography and chest computed tomography revealed an intraluminal obstruction of the pulmonary arteries. Tests of serum tumor makers showed slight elevation for carbohydrate antigen-125, and α-fetoprotein. PTE was suspected according to the radiological and laboratory findings.Microscopic findings of the presumed thrombus showed prominent myxoid and edematous background with atypical spindled cells and curvilinear vascularity. Immunohistochemical staining demonstrated that the atypical spindled cells were positive for vimentin but negative for CK, S100, SMA, desmin, CD68, STAT6, CD34, β-catenin, ALK-p80, p53, and MDM2. According to the radiological and pathological findings, the diagnosis of fibrosarcoma of pulmonary artery was made.The patient underwent surgical resection and the mass was excised as completely as possible.Follow-up information showed no evidence of recurrence or metastasis after 3 months postresection.Because of the low incidence rate, nonspecific clinical symptoms, and radiological findings, primary fibrosarcoma of the pulmonary artery is commonly misdiagnosed as PTE. Pathological examination is necessary to confirm the diagnosis. In 1960, Wolf et al reported the first English case fibrosarcoma involving the pulmonary trunk. Because of the rareness and nonspecific clinical manifestations and similar imaging findings, pulmonary artery (PA) sarcoma is commonly misdiagnosed as pulmonary thromboembolism (PTE) and clinician wrongly perform antithrombotic and thrombolytic therapies, which induce the development of PAIS. About 42.3% of PAIS patients were misdiagnosed as PTE and could not receive timely and effective treatment. Herein, we report a 37-year-old Chinese female wrongly diagnosed as PAIS initially and was subsequently diagnosed as PTE.Pulmonary artery intimal sarcoma (PAIS) is an exceedingly rare malignancy with poor oncological outcomes. It was first described in 1923 by Mandelstamm via autopsy.2A 37-year-old Chinese woman came to our hospital complaining of exertional chest discomfort and dyspnea on exertion for 6 months. The patient denied any significant past medical history. On admission, physical examination was unremarkable. Two-dimensional echocardiography revealed lesions in the pulmonary arteries combined with moderate pulmonary hypertension and right ventricular dysfunction. Subsequently, contrast-enhanced chest computed tomography (CT) demonstrated multiple irregular low-density soft tissue lesions in the main pulmonary artery (PA) trunk with perfusion defects in the bilateral PA branches Fig. . FollowiPathological gross examination demonstrated a multinodular mass that was adherent to the vessel wall. Microscopic examination revealed the mass was composed of a hypercellular spindle cell population with mild atypia and increased mitotic activity in a myxomatous and edematous background Fig. . The tum3,5 with only around 400 cases reported in the literature worldwide.,7 Epidemiological studies show that PAIS typically affects middle-aged adults (mean age of 48-years-old) with a slight female predominance. PAIS typically remains a localized mass with slight metastatic ability. Based on the location, it could be divided into mural and intimal sarcoma. For mural sarcoma, the most common pathological type is classic leiomyosarcoma, which develops along the medial smooth muscle of large veins, primarily the vena cava.PAIS is a rare malignancy with an incidence of 0.001% to 0.03% Such sarcomas are characterized by an endoluminal growth that progresses to vessel obstruction or embolic seeding of distal sites.,10Alternatively, intimal sarcoma commonly arises from intimal layer of large blood vessels, such as pulmonary arteries and the aorta.,12 Because the clinical presentation of PAIS is nonspecific, the diagnosis of PAIS is particularly challenging, especially to inexperienced clinicians. Among all the differential diagnoses, it is imperative that clinicians rule out life-threatening pulmonary emboli. However, unlike the acute nature of pulmonary emboli, the symptoms of PAIS are more gradual in presentation. In our case, the patient presented with a 6-month history of progressing dyspnea on exertion, which favors the diagnosis of PAIS. Additional findings of PAIS include fever, cachexia, inflammatory anemia, and increased erythrocyte sedimentation rate also indicate the diagnosis of PAIS, especially if the patient denies any risk factors for deep venous thrombosis. Little is known about how serum tumor markers can be used in the diagnosis of PAIS. Interestingly, our case showed slight evaluated level of CA-125, AFP, and CEA which indicates a tumor lesion. However, it is unclear at this point whether CA-125, AFP, or CEA could serve as the biomarkers of PAIS and more investigation is needed.The clinical symptoms of PAIS include dyspnea, cough, hemoptysis, or chest pain which shares a clinical presentation with respiratory infection, heart failure, and pulmonary embolism.,14 Typically, chest contrast-enhanced CT of PAIS demonstrates a heterogeneous, irregular low-density mass with filling defect of the pulmonary vasculature and vascular distention.,15 In addition to PA space-occupying lesions in chest CT, multiple pulmonary nodules or hilar tumors are usually helpful for the diagnosis of PAIS rather than PTE, which is usually accompanied by wedge-shaped pulmonary infarction.–18 In CT pulmonary angiography, PAIS mainly occurs in the pulmonary trunk, and could extend proximally to the pulmonary valve and even right ventricular outflow tract, extend distally to the left and right pulmonary arteries and branches. The proximal end of the mass in PAIS is mostly swollen, bulging or lobulated.–21 Hui-Li Gan et al suggested that the “wall eclipsing sign” usually occurred in PAIS, where low-density mass almost occupies the main PA and the proximal parts and distal ends as well as erodes any of pulmonary arteries. However, PTE mostly involves the left or right PA, with saddle-shaped lump on imaging, and there is no finding of “wall eclipsing sign.”,22 In addition, PAIS has increased heterogeneity compared to PTE in CT pulmonary angiography. On magnetic resonance imaging, The T2W signal intensity of PAIS is higher than that of PTE. Some researchers recently suggested that (18) F-FDG PET/CT could be useful in distinguishing PAIS from PTE based on the maximum of standard uptake value, which mostly revealed hypermetabolism in tumors,,17 but PAIS cannot not be ruled out when there is no obvious abnormality in (18) F-FDG PET/CT. In our case, the contrast-enhanced CT demonstrated multiple irregular low-density soft tissue lesions in the main PA trunk with perfusion defects in bilateral PA branches, which is consistent with previous reports.Radiological study is a useful tool in the diagnosis of PAIS and the combination of chest CT-angiography and cardiac ultrasound is helpful for ruling out PTE.,26 Histologically, the tumor is commonly composed of spindle or epithelioid cells with various atypia; myxoid and fibrosis changes are common, as noted in our case.,27 Immunohistochemical staining for PAIS shows variable expression of desmin and smooth muscle actin but negative for epithelial markers, factor VIII, CD31, CD34, and S100. It has been reported that frequent MDM2 expression could be detected in PAIS because of the high rate of amplification of MDM2 (65%), but our case showed negative expression of MDM2. Nowadays, fluorescent in-situ hybridization examination shows frequent amplification of PDGFRA (81%), MDM2 (65%), and EGFR (76%), which can be used to improve diagnostic identification of PAIS.Macroscopically, PAIS is always an intravascular mass which is closely adherent to the vascular intima, and can extend down into adjacent vessels. Postoperative adjuvant chemotherapy and radiotherapy, however, do not demonstrate statistically significant improved survival.Surgery is the main treatment of PAIS. It has been reported that the patients who undergo curative resection have a longer overall survival than those who undergo incomplete resection .In conclusion, PAIS is a rare disease which could be easily misdiagnosed due to the nonspecific indolent clinical presentation and its symptomatic similarity to PTE. It can be diagnosed preoperatively via the use of multiple radiological modalities; and postoperatively with a combination of histopathological examination, immunohistochemical staining, and fluorescent in-situ hybridization studies.Conceptualization: Hai-Chao Tong, Wan-Lin Zhang.Data curation: Ying-Chun Li.Formal analysis: Hai-Chao Tong, Shuang Ma.Funding acquisition: Shuang Ma, Lian-He Yang.Investigation: Ying-Chun Li, Shuang Ma.Methodology: Hong-Tao Xu.Project administration: Lian-He Yang.Resources: Le-Yao Li.Software: Le-Yao Li.Supervision: Endi Wang.Validation: Hong-Tao Xu.Visualization: Wan-Lin Zhang.Writing – original draft: Ying-Chun Li.Writing – review & editing: Lian-He Yang, Gina Sotolongo.


Cryptococcus. Since LNC amphotericin is a novel drug delivery mechanism, we assessed whether resistance to 5-FC develops in this context.The EnACT trial was a phase 2 randomized clinical trial conducted in Uganda, which evaluated a novel orally delivered lipid nanocrystal (LNC) amphotericin B for treatment of cryptococcal meningitis. Oral LNC amphotericin B applies nanotechnology, which hopes to improve intracellular drug delivery to affected tissues while reducing extracellular concentrations and thereby adverse events. When flucytosine (5-FC) is used as monotherapy, it can induce stable, highly resistant mutants of Results from the ACTA and AMBITION Clinical Trials10-week mortality by antifungal regimen for cryptococcal meningitis from the clinical trial by Molloy et al. (ACTA) in top section and Jarvis et al. (AMBITION) in bottom section. Mean survival for each group is represented by diamonds and 95% confidence interval represented by error bars.Encapsulation of Amphotericin B in a Lipid nanocrystal ParticleLipid nanocrystal particle encapsulates amphotericin B molecule and delivers the drug to antigen presenting cells.The trial enrolled subjects with HIV who were diagnosed with cryptococcal meningitis and randomized to receive 5-FC and either standard IV amphotericin or LNC amphotericin. Subjects had a lumbar puncture (LP) performed on screening and days 3, 7, and 14. We used broth microdilution methods, standardized by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) to assess the MIC of isolates in each arm of the trial. We tested cryptococcal isolates from the cerebrospinal fluid (CSF) on the day of screening and then on the last positive CSF to contain cryptococcal growth. Statistical analysis included chi-square to test for a difference in MIC between the control and LNC amphotericin groups; and linear regression to compare MIC with early fungicidal activity (EFA), which is a surrogate endpoint.Intervention and Control Gropus for EnACT Phase 2The EnACT trial phase 2 was completed in 4 cohorts to determine the ideal combination of IV and LNC amphotericin. The MIC analysis was completed in the 4th cohort. In the 4th cohort, participants randomized to the intervention group started LNC amphotericin B from the day of enrollment.Broth Microdilution for 5-Flucytosine Susceptibility TestingA 96-well plate was prepared with serial dilutions of 5-FC ranging from 256 µg/mL to 0.5 µg/mL in columns 1-10. Columns 11 and 12 were drug-free controls. The first and last CSF isolate from each unique participant was inoculated into rows B-D and E-G, respectively. The first row is a negative control and the last row is a positive control.50 was 4 µg/mL and MIC90 was 8 µg/mL for both the control and LNC amphotericin B groups. There was no evidence of 5-FC resistance in any Cryptococcus isolate tested after 2 weeks of therapy. 73% (n=8) of participants in the control group and 73% (n=19) in the LNC amphotericin group had no change or a decrease in MIC from the first to last Cryptococcus isolate. 27% (n=3) in the control group and 19% (n=5) in the LNC amphotericin group had a 2-fold increase in MIC. 9% (n=2) in the LNC amphotericin group had a 4-fold increase in MIC. There was no association with MIC and EFA. 5-FC CSF levels were above the MIC50.The MICDistribution of MIC for flucytosineThe MIC for each CSF isolate in the control and oral amphotericin B arms of the trial with the percents of each MIC level in each trial arm. Chi-squared statistic testing for a difference in MIC between each trial arm.Early Fungicidal Activity Compared to MIC for Each Trial ArmThe EFA is compared to MIC in the control and oral amphotericin groups. Linear regression comparing EFA and control group shows that there is no correlation between MIC and EFA.Change in MIC During Treatment with Flucytosine and Amphotericin BA) Percent of participants in each trial group who had an increase in MIC over the treatment course. B) Individual participants are represented by a line with the MIC represented by a dot on the end of each line.There is no evidence of baseline resistance to 5-FC or incident resistance during therapy in individuals presenting with cryptococcal meningitis in Uganda. LNC amphotericin B can safely be used in combination with 5-FC.All Authors: No reported disclosures


The Utrecht Scale for Evaluation of Rehabilitation is a multi-domain measurement with good content validity, structural validity and reliability for measuring physical functioning  and cognitive functioning in geriatric rehabilitation. We aimed to determine the construct validity of both Utrecht Scale for Evaluation of Rehabilitation scales and the responsiveness and interpretability of the scale for physical functioning in geriatric rehabilitation.Prospective follow-up study embedded in routine care.Four care organisations in The Netherlands.Patients admitted for inpatient geriatric rehabilitation (2021–2022).Data collection included the Utrecht Scale for Evaluation of Rehabilitation, Mini-Mental State Examination, Barthel index, and a global rating scale anchor on recovery. Hypothesis testing was used to determine construct validity and responsiveness. For interpretability, minimal important change and floor and ceiling effects were determined.n = 211) was 77 (SD 10.4). Their mean length of stay was 38.6 days (SD 26.3), and 81% returned home. The Utrecht Scale for Evaluation of Rehabilitation showed adequate construct validity, as all three hypotheses were confirmed for both scales. The Utrecht Scale for Evaluation of Rehabilitation-physical function scale showed adequate responsiveness, with all five hypotheses confirmed. The mean change for physical function  was 15.5 points (SD 17.1). The minimal important change for Utrecht Scale for Evaluation of Rehabilitation-physical function was 14.5 points difference for improvement. This scale showed no floor (2%) and ceiling effects (14%) at admission and discharge.The mean age of participants (The Utrecht Scale for Evaluation of Rehabilitation showed to be effective for evaluating physical functioning during geriatric rehabilitation as well as screening cognitive functioning. In total, 14.5 points difference has been established as a minimal important change for physical functioning. Measuring physical and cognitive function is essential to optimize treatment.5A growing number of frail or older people are in need of geriatric rehabilitation, e.g., when faced with a sudden decline in functioning due to acute illness. Patients are characterized by multimorbidity and frailty, and often decreased trainability and learnability. Also an adequate distribution of scores  and understanding of the meaning of quantitative scores or change in scores (interpretability) is important. A systematic review showed that various instruments are used for measuring physical functioning in hospitalized older patients, with no conclusive evidence of psychometric superiority for any one instrument. For physical function, the Katz index and the Barthel index are probably most often used.9 A recent study in geriatric rehabilitation showed that the Barthel index has good measurement properties except for the disadvantage of its ceiling effect. Several available instruments to screen for cognitive impairments have good psychometric properties, such as the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment.1012 However, a potential disadvantage is that both need an interview with the patient. There is a need for an observational instrument with adequate psychometric properties.It is important to use measurement instruments with adequate measurement properties for the intended population. This will ensure that an instrument measures what it is meant to measure , can do so reliably (reliability), and it can detect change over time (responsiveness). and we recently showed promising measurement properties for the setting of geriatric rehabilitation. In our previous study on the psychometric properties of the USER, the scales on physical and cognitive function showed moderate to excellent content validity, sufficient structural validity, and excellent interrater reliability. Construct validity, interpretability, and responsiveness have not been established in geriatric rehabilitation.A promising generic multi-domain instrument is the Utrecht Scale for Evaluation of Rehabilitation (USER), as it contains items for both physical and cognitive function. It is an observational instrument for an objective appraisal of functioning in daily life and as such not burdensome for patients. The USER was developed in the field of adult rehabilitation,The objective of this study is to determine the construct validity, responsiveness, and interpretability  of the observational scales of the USER in geriatric rehabilitation. For responsiveness and minimal important difference, we only examined the physical function scale, as the cognitive function scale is primarily used for screening purposes at admission.Patients were recruited from inpatient specialized geriatric rehabilitation wards at four care organizations in the Netherlands. The care organizations participate in two academic networks, the University Network of care for Older people (UNO Amsterdam) and the University Network for the Care sector South Holland (UNC-ZH). All participants received regular geriatric rehabilitation, which includes a comprehensive geriatric assessment, the formulation of patient-specific rehabilitation goals, and a multidisciplinary rehabilitation plan fitting the needs of the individual patient.The study protocol received a waiver of consent from the Medical Ethics Committee of the VU University Medical Centre, Amsterdam, the Netherlands (2020.193). Patients were informed about the study and offered an opt-out to the data being used for this study. Data were collected by health care professionals from April 15, 2021 until March 8, 2022 and passed on to the researchers anonymized and not traceable to any particular person.Newly admitted patients were all eligible for the study and no selection was applied. The following patient characteristics were retrieved from the electronic patient files: Age, sex, rehabilitation diagnosis, discharge destination, and scores for physical and cognitive function at admittance and discharge. For physical and cognitive function, either USER or Barthel index was part of standard routine care, and the other instrument was added during the study period. In one nursing home, both instruments were standard routine care. In addition, in two nursing homes, a medical student (LB) administered the MMSE during the first week of admittance. In addition to routine care, healthcare professionals registered the Global Rating Scale at discharge.www.kcrutrecht.nl/producten/user/ . It consists of 24 observational items: 7 items on mobility, 7 items on self-care, and 10 items on cognitive functioning . Items are scored on a 6-point scale from 0 to 5. Scores of items on mobility and self-care are added to a total score for USER-physical functioning , and scores of items on cognitive functioning are added to a total score for USER-cognitive function  with lower scores indicating more dependency on others.The USER is an observational instrument that measures physical function (independence in ADL-activities of mobility and selfcare) and cognitive function. The Dutch version 1.4 was used, downloaded from  and in our previous study we tested its clinometric properties in geriatric rehabilitation. We used confirmatory factor analysis to test structural validity and unidimensionality, and we confirmed that the observational scales measure two underlying independent constructs, in which the items on mobility and self-care belong to one underlying construct. We further showed sufficient content validity, internal consistency, and interrater reliability in geriatric rehabilitation. For the physical functioning scale, the standard error of measurement (SEM) is 5 and the smallest detectable change (SDC) is 14. The USER also has a set of patient-reported items  that can be left out and were not studied here.The USER was developed as a classic-test theory instrument for adult rehabilitation Items between Barthel index and USER-PF largely overlap . The Barthel Index total score ranges from 0 to 20. Higher scores indicate a higher level of independence in activities of daily life functioning. The structural validity, reliability, and interpretability of the Barthel index are considered sufficient for measuring and interpreting changes in the physical function of patients in geriatric rehabilitation. It showed high responsiveness in hospital patients with stroke and the culturally adapted Italian version (IcaBI) was responsive to the results of inpatient rehabilitation in patients with orthopedic and neurologic diseases.The Barthel index is an observational instrument that measures physical functioning in 10 basic ADL-activities, such as eating, mobility, and grooming. The test consists of 11 questions, measuring various aspects of cognitive functioning . The total score ranges from 0 to 30 and higher scores represent a higher level of cognitive functioning, with scores ≥24 classified as ‘no cognitive impairment’. The MMSE has been validated in geriatric patients, and construct validity is satisfactory.The MMSE is a widely used screening test to measure cognitive functioning.The Global Rating Scale, a generic single-item scale, was used to ask the responsible nurse the following question: ‘To what extent has the physical function of the patient changed during the rehabilitation period?’. There were five response options: (a) much deteriorated; (b) somewhat deteriorated; (c) no change; (d) somewhat improved; (e) much improved. Hypotheses are based on comparing scores between instruments or time points, or by comparing scores between meaningful subgroups.To be included in the analyses, participants should at least have data on the USER and Barthel index at admission and discharge, or data on USER and Barthel index and MMSE at admission. Because gold standards for measuring or detecting a change in physical and cognitive functioning are lacking in geriatric rehabilitation, construct validity and responsiveness can best be determined by hypotheses testing.22 Three hypotheses were formulated a priori for each USER subscale ). Although the MMSE is not an observational instrument we consider the MMSE to measure a similar (related) construct compared to USER-CF, with Pearson's correlation coefficient of R > 0.5 (deviation from protocol (R > 0.3)). We hypothesize that scores of the same scale at two-time points (admission and discharge) will be highly correlated, with Pearson's correlation coefficient of R > 0.5. Differences in USER scores between groups were analyzed using a t-test or Mann-Whitney U Test where applicable, with p ≤ .05 assuming a significant difference.Construct validity is ‘the degree to which scores of a measurement instrument are consistent with hypotheses, for instance with regard to internal relationships, relationships with scores of other instruments or differences between relevant groups’.cale see . Constru As there is no gold standard available for detecting changes in physical functioning in geriatric patients, hypothesis testing was used. Responsiveness for the USER-PF scale was considered to be adequate if four out of five formulated hypotheses . Cut-off values for correlations were chosen in the same way as previously described for construct validity.Interpretability is ‘the degree to which one can assign qualitative meaning to instruments’ quantitative scores or change in scores’. In other words, it is the degree to which it is clear what the scores or change in scores mean. First, the distribution of the scores was examined. Floor and ceiling effects were determined by calculating the percentage of patients with the lowest and highest possible scores at the beginning and end of their rehabilitation period. A significant floor or ceiling effect was considered present if the percentage exceeded 15%. Next, the minimal important change (MIC) of the USER-PF scale was estimated using predictive modelling. The MIC is defined as ‘the smallest change in score in the construct to be measured which is perceived as important’. The predictive modelling approach is based on the predicted probability that a patient belongs to the improved group given the observed change score and uses logistic regression analysis. First, the sample was divided into two groups based on the Global Rating Scale; (1) patients reported to be somewhat or much improved (improved group) and (2) patients reported to be not changed or somewhat or much deteriorated (not improved group) excluding deceased patients. Next, the MIC was estimated by following instructions on MICpredict (adjusted) in the Appendix from Terwee et al. The MICs were adjusted for the proportion of improved patients. The 95% confidence interval around the adjusted MIC was calculated using non-parametric bootstrapping (1000 samples).Responsiveness is ‘the ability of an instrument to detect change over time in the construct to be measured’.eses see  were conR version 3.6.3.  was used to calculate the MIC confidence intervals. All other analyses were performed using SPSS .A total of 225 participants were included in the study, of whom 211 participants could be included in analyses see . For theFor a subsample of 133 participants, MMSE was administered at admission, and results were used for the analysis of the construct validity of the USER-CF scale. In this subsample, the median USER-CF scores at admittance were comparable to the whole sample . For a sn = 202) improved on average by 15.5 points (SD 17.1) on USER-PF  (p < 0.001) in the group that showed important change compared to the group that did not show important change, with mean change scores on USER-PF of 19.0  and 7.4 , respectively. For the groups that did or did not return home mean change scores were 18.5  and 0.65 , respectively (p < 0.001).ge 0–70) . Improvepredict (adjusted) of the USER-PF scale was 14.5  (n = 202). Scores at admission on USER-CF and MMSE were skewed towards better functioning, as 42% and 7% (of n = 133) respectively reached the maximum score.In this study, important clinical measurement properties of the USER were studied in geriatric rehabilitation. The construct validity was found to be adequate for the observational subscales for physical and cognitive functioning, as was the responsiveness of USER-PF. The MIC for USER-PF was found to be 14.5 points, and there were no significant floor or ceiling effects at either admission or discharge. and in patients with stroke with a mean age of 62 years (SD 11.8). The latter study found comparable ESs for USER-PF and BI, 0.86 and 0.94 respectively. However, an effect size only has meaning as a measure of responsiveness if we know (or assume) beforehand what the magnitude of the effect of the intervention is. With hypotheses testing, we showed that USER-PF was valid and responsive to change in a geriatric population, with 14.5 points difference as MIC. In our previous study, we found the SEM to be 5 and the SDC to be 14. This means that a change of 14.5 points is beyond the measurement error and represents a MIC. We found no ceiling or floor effects either at admission or at discharge. At discharge, 14% of participants had maximum scores on USER-PF. The Barthel index did show a significant ceiling effect at discharge in our study (20%) which is in line with previous research among geriatric rehabilitation inpatients, where Barthel index also showed a ceiling effect of 22% at discharge.So far, the responsiveness of the USER has only been studied in hospital populations receiving adult rehabilitation. High ESs were found in rehabilitation inpatients with a mean age of 54 years (SD 14.9) it is thus important to screen for cognitive functioning in an early stage of geriatric rehabilitation. We showed that the USER-CF observation scale can be used for this purpose, as construct validity was adequate. This is in line with studies on adult rehabilitation, as the correlation of USER-CF with the functional independence measure (FIM) cognition score was high (0.8) in the development study of the USER. The USER-CF scale displayed a significant ceiling effect, but as it is used for screening purposes, we do not consider this to be a problem because we are mainly interested in cognitive disfunction. Each score below the maximum of 50 could be a trigger for additional diagnostics. In case of cognitive disfunction, successful rehabilitation is still possible, but this has to be done by changing the rehabilitation style, e.g., by offering an appropriate programme based on errorless learning. Also, the use of observation instead of interviews is a less burdensome option for both patient and healthcare professional in the research setting.As lower cognitive functioning has consequences for available treatment options and is considered to be related to unsuccessful rehabilitation, This was unintentional, and a consequence of participating wards. We did not collect data on patients who were not yet discharged at the end of the study period, inhibiting us to perform a loss-to-follow-up analysis. On the other hand, the length of stay and the proportion of participants that returned to their own home were as expected, so we do not consider this a problem that influenced the outcomes. For 14 (6%) out of 225 included patients we had missing data, which we consider to be missing at random.A possible limitation of our study is, that the study population comprised a relatively low percentage of patients with trauma and a relatively high percentage with amputations, compared to Dutch data. In fact, we changed two pre-defined hypotheses  after careful discussions.A strength of our study is, that we followed routine care as much as possible during data collection, and USER scores were registered by healthcare professionals reflecting usual care. And although it is possible that not all comparison measurements were assessed at the exact same time point as the USER, we do not think this has influenced the results. Another strength is that we assessed measurement properties by testing predefined hypotheses, which are in accordance with COSMIN criteria in the absence of a gold standard. However, we acknowledge the challenges of hypothesis testing which is widely debated in the clinometric literature and community. we established that the USER has good measurement properties for screening cognitive functioning as well as evaluating physical functioning during geriatric rehabilitation. We therefore recommend the use of the USER in geriatric rehabilitation.In conclusion, in a consecutive set of studies described in this paper and in a previous one,The USER observational subscales show adequate construct validity for physical and cognitive functioning in geriatric rehabilitation.The USER physical functioning scale is responsive to change, with 14.5 points difference as a MIC.We recommend the use of the USER for geriatric rehabilitation inpatients.Click here for additional data file.Supplemental material, sj-pdf-1-cre-10.1177_02692155231203095 for Construct validity, responsiveness, and interpretability of the Utrecht Scale for Evaluation of Rehabilitation (USER) in patients admitted to inpatient geriatric rehabilitation by Margot W M de Waal, Michael Jansen, Loes M Bakker, Arno J Doornebosch, Elizabeth M Wattel, Dennis Visser and Ewout B Smit in Clinical Rehabilitation


Several individuals with post-COVID-19 syndrome referred for pulmonary rehabilitation did not participate. This study aimed to explore individuals’ barriers to participating in posthospitalization COVID-19 rehabilitation.This was a qualitative, multicenter study performed using semistructured interviews. This study included 20 individuals hospitalized for COVID-19 who refused to participate in a pulmonary rehabilitation program at a university hospital.Individuals reported difficulties accessing the rehabilitation center, mainly due to distance, transport costs and conditions, and lack of companions. Health problems  and lack of time due to work, commuting, and household work were also reported. Another reported theme was not perceiving the need for rehabilitation due to feeling well. Minor themes included the need for more information about rehabilitation and a lack of interest, motivation, and medical encouragement.Individuals hospitalized for COVID-19 faced several barriers to participating in a pulmonary rehabilitation program. These barriers included difficulties in accessing the rehabilitation center, health problems, lack of time, and the perception that rehabilitation was unnecessary. There is a need for actions to overcome these barriers to make the program available to a larger number of individuals. Coronavirus disease 2019 (COVID-19) may cause pulmonary and systemic repercussions, leading to persistent symptoms and long-term complications. When these complications persist for more than four weeks from the onset of symptoms, the condition is named post-COVID-19 syndrome .Pulmonary rehabilitation is the most effective nonpharmacological therapy to improve functional capacity, quality of life, and exercise capacity and reduce symptoms in individuals with chronic respiratory diseases . These bTo date, there have been no studies specifically designed to investigate the participation of individuals in a rehabilitation program following COVID-19. The available data, obtained through the enrollment of subjects in randomized clinical trials, reveal that several individuals with post-COVID-19 syndrome, who were referred to rehabilitation, did not participate in the program for reasons that remain unknown –12.Hence, these reasons need to be investigated to adopt facilitating actions to increase participation and provide the benefits of rehabilitation for this population. This study aimed to explore individuals’ barriers to participating in posthospitalization COVID-19 rehabilitation.This qualitative multicenter study used semistructured interviews based on grounded theory –15. PartThe inclusion criteria were individuals aged 18 years or older who were hospitalized for COVID-19 and refused to participate in a pulmonary rehabilitation program after hospital discharge. The rehabilitation program followed a standard model, with sessions twice a week for eight weeks . Each seThe exclusion criteria included cognitive disorders that impeded understanding study procedures and failure to respond to contact attempts. A researcher not involved in the pulmonary rehabilitation program invited individuals to participate in this study via telephone. Six contact attempts were made before excluding the individual. The principle of data saturation determined the sample size , 18.Questions were developed and focused on the main theme of this study to explore perceptions regarding barriers associated with nonparticipation in a pulmonary rehabilitation program. The questions were adapted from a study investigating barriers to participation in a pulmonary rehabilitation program for individuals with chronic obstructive pulmonary disease .Why do you think you were referred to a pulmonary rehabilitation program?I understand that you chose not to participate in the pulmonary rehabilitation program. Can you tell me about this?What was the most important factor that prevented you from participating in the pulmonary rehabilitation program?What information did you receive about the pulmonary rehabilitation program?What do you think a pulmonary rehabilitation program is?Do you think that rehabilitation would provide any benefit for your health?Would you consider participating in a pulmonary rehabilitation program in the future?In the future, for you to participate in a rehabilitation program, what circumstances should change?The interviews were conducted solely by the first author of this study, a physiotherapist and a master’s student in “Rehabilitation Sciences and Physical Functional Performance”, with experience in caring for patients with chronic respiratory and renal diseases. Semistructured interviews were held face-to-face (at home) or remotely (via telephone). Face-to-face interviews were conducted in the participant’s home, with time available for the interview, seated comfortably in a quiet, closed, and confidential environment, with only the researcher and the participant present. For telephone interviews, it was confirmed that the participant was at home, with time available for the interview, seated comfortably in a quiet, closed and confidential environment without the presence of other people. The researcher was encouraged to take notes during the interviews for subsequent use during the analysis .A single researcher fully transcribed each recorded interview. Demographic data, smoking habits, use of mechanical ventilation during hospitalization, housing situation, education level, family income, distance from home to the rehabilitation center, and Charlson Comorbidity Index score were also collected .A thematic analysis of interviews was performed using line-by-line coding , and thrThe open coding process commenced concurrently with data collection to create a hierarchical coding framework. As the data collection progressed, the axial coding phase was initiated to further enhance and clarify the connections between overarching themes and their corresponding subthemes. This iterative coding approach allowed for a comprehensive and structured analysis of the data, ensuring that the relationships between different levels of coding were well defined and coherent .A theme describes the various facets of a pattern across the dataset. A subtheme exists ’underneath’ the theme’s umbrella; it shares the same central organizing concept as the theme but concentrates on a specific element , 20.Finally, selective coding explored connections among themes and selected the main category. Theoretical memos were used during analysis to reflect how findings were derived from the data –15, and A total of 104 individuals were referred to the pulmonary rehabilitation program between December 2021 and August 2022. Ninety-nine individuals declined to participate in the rehabilitation program and were considered eligible for inclusion in this study. Among these, 79 individuals were excluded . This left a final sample of 20 individuals. Twelve interviews were conducted face-to-face and eight by telephone, without differences in the identified themes. The interviews lasted ten to twenty minutes. Additionally, the sample was saturated with seventeen interviews, and three additional interviews were performed for confirmation . With thThe median age was 50 years [25–75%: 36.5–78.5], and there were 15 females and 5 males. One individual lived alone, whereas others lived with families. The characteristics of the individuals are described in The themes related to refusal to participate in the pulmonary rehabilitation program were difficulties accessing the rehabilitation center, health problems, lack of time, and not perceiving the need for rehabilitation due to feeling well . The folThe primary theme reported by participants was reaching the rehabilitation center, as mentioned by thirteen individuals. Many individuals resided at a considerable distance from the university hospital where the rehabilitation would take place, necessitating the use of multiple public transportation modes, often of poor quality.Nine individuals indicated distance as a barrier.“It is too far; I need a taxi. It would be difficult because of the commute.” (Participant 13)“For me, the problem is that it would be at the university hospital. It would be too far away.” (Participant 1)“I want to do it, but it needs to be in a closer place.” (Participant 3)Six individuals had financial difficulties commuting to the rehabilitation center.“There is no car to take me, and to pay for a vehicle, an Uber or taxi, is very expensive.” (Participant 17)“I would have to take four buses, two to go and two to return. In addition, the ticket, four tickets would be a bit expensive.” (Participant 19)Three individuals reported the lack of a companion as a barrier.“Yes, I can participate if someone takes me.” (Participant 18)Three individuals reported that transport conditions affected their decision to participate.“The bus from here to there rumbles and jumps and only God knows what else. In addition, I would get there like this, tired, I would get there feeling bad and, on the return, it is the same route, the same thing. Therefore, for me, it is very hard.” (Participant 6)Ten individuals reported difficulties in participating in the pulmonary rehabilitation program due to various health problems. Among these issues were clinical conditions that could have been caused by COVID-19, such as fatigue and dyspnea, and which could have been treated through the intervention that was declined.Six individuals reported that pain influenced their decision not to participate in rehabilitation.“It was because of the pain I feel. I feel pain, my dear, day and night.” (Participant 3)Three individuals refused to participate due to being in the preoperative period.“I have surgery scheduled.” (Participant 10)Two individuals reported mobility difficulties, which hindered access to the rehabilitation center.“For me, the most important factor is the difficulty I have due to my left leg. I use a cane, but even so, I have a great deal of trouble going out.” (Participant 17)Nine individuals reported other health problems, including anemia, dyspnea, vertigo, fatigue, depression, heart disease, hypothyroidism, overactive bladder, and chikungunya.“I cannot stand to take a bus; it bumps all the time. My bladder seems to be out of place, the doctor even said that my bladder is overactive.” (Participant 20)“Because not only my leg hurts, but now I also feel breathless.” (Participant 6)“I am going to have to do another test for hypothyroidism. I am truly discouraged.” (Participant 16)To participate in the rehabilitation program, individuals were required to attend the university hospital three times a week for eight weeks. For this reason, seven individuals reported not having the time to attend the pulmonary rehabilitation program, primarily due to their work and domestic responsibilities.Three individuals reported not having time due to work.“It is a very long time, and takes almost half a day.” (Participant 20)“I did not participate due to lack of time. When I left the hospital, I left feeling very well and went straight to work, and my job did not give me the time to do it.” (Participant 2)Three individuals reported that a long commute to the rehabilitation center influenced their refusal to participate.“I think it is more a matter of time. To stop being able to do this and to be able to go. Because it would be time spent on it.” (Participant 4)Two individuals reported a lack of time due to household work.“It takes time. In addition, there is no one to do things here at home.” (Participant 20)Five individuals did not see the need to join a pulmonary rehabilitation program because they did not have any symptoms.“I did not present any worsening in breathing. No problem about that.” (Participant 4)Other themes related to nonparticipation in the pulmonary rehabilitation program were identified. Two individuals mentioned feeling demotivated, one needed more information about pulmonary rehabilitation, one expressed no interest in participating, and one cited a lack of medical encouragement.“I received much information, but I did not want it anyway.” (Participant 5)“I think we should have more information about the program because the basic health unit does not clarify this. In addition, for us to access these programs that you offer, we must go through the basic health unit, and they do not always give us the information we need.” (Participant 7)“I am very demotivated to do things”. (Participant 13)“I did not look into this because I did not have medical encouragement.” (Participant 8)Although not reported as a reason for refusing to participate in the pulmonary rehabilitation program, ten individuals reported not receiving any information about the program. Another five individuals reported receiving but not remembering or knowing exactly how to describe the information.“I did not receive any information.” (Participant 9)“I received it but do not know how to report it to you. The girls explained it to me, but I do not know how to report it to you, I have difficulty remembering, and after COVID, I became forgetful.” (Participant 15)This was the first qualitative study aiming to understand and discuss the barriers for individuals after COVID-19 hospitalization to participate in a pulmonary rehabilitation program. The themes related to refusal to participate were difficulties in accessing the rehabilitation center, health problems, lack of time, and not perceiving the need for rehabilitation.Rehabilitation programs worldwide also reported difficulties in patient access to rehabilitation centers , 22. AltHealth problems were reported as barriers to participation in the pulmonary rehabilitation program. Although symptoms related to post-COVID-19 syndrome  were considered reasons for refusal, they should motivate participation due to the general improvements from rehabilitation –7. PhysiSome individuals reported a lack of time as a barrier to participation. Work and household activities were previously reported by individuals with chronic lung diseases, corroborating the findings in our study . Thus, aSome individuals declined to participate in rehabilitation, as they did not perceive the need for it since they were feeling well. However, it is important to note that individuals with post-COVID-19 syndrome may not experience symptoms at rest, but they may appear during exercise . This peSeveral individuals reported not receiving sufficient information on the pulmonary rehabilitation program. The lack of medical referrals and proper communication to emphasize the importance and benefits of rehabilitation after COVID-19 appeared to be decisive in some participants’ decision to take part in the rehabilitation program. In this sense, rehabilitation should be applied as a comprehensive intervention based on information and education, including actions allowing self-care, participation, and adherence to the treatment . AdditioOur results provide important information about the barriers faced by individuals after COVID-19 hospitalization to participate in a pulmonary rehabilitation program. Additionally, they may have relevant impacts and raise questions for appropriate decisions to solve and overcome the barriers. Many barriers reported in this study can be addressed with appropriate methods of education and counseling for patients, such as addressing the lack of information about pulmonary rehabilitation. Thus, further studies need to evaluate the impact of solutions adopted to increase participation.This study had some limitations. Individual assessments of the need for rehabilitation were not individually conducted. Nonetheless, all individuals were eligible due to severe COVID-19 requiring hospitalization. Individuals who agreed to participate in rehabilitation but did not adhere to the treatment were not included in this study. This decision was based on the insufficient sample size of individuals who agreed to participate in rehabilitation, and combining two different participant profiles into a single group could introduce an ’aggregation bias.’ Consequently, further studies are warranted to assess adherence to rehabilitation in this population. The sample comprised individuals from a specific social, economic, and cultural background, and therefore, caution should be exercised when interpreting the results for other populations. Nevertheless, the identified themes and subthemes were consistent with those in studies among individuals with other chronic respiratory diseases in various countries and contexts.Individuals who were hospitalized for COVID-19 presented several barriers to participating in a pulmonary rehabilitation program. These barriers included difficulties in accessing the rehabilitation center, health problems, lack of time, and the perception that rehabilitation was unnecessary. Therefore, measures to overcome these barriers are necessary to make the program available to a larger number of individuals and to convey the proven benefits of pulmonary rehabilitation to eligible patients.S1 File(DOCX)Click here for additional data file.