The number of knee replacement surgeries performed in Canada keeps rising as our population ages—even if many are being postponed during the COVID-19 crisis. Surgeons have perfected the procedure but research show that 80 percent of older adults don’t follow through on their rehab.

Physiotherapist Nirtal Shah has seen this in his 15 years at the University of Toronto’s David L. MacIntosh Sport Medicine Clinic. And he’s seen it in his own family.

 Nirtal Shah

Nirtal Shah

“My mother had a total knee replacement and I saw her struggle,” says Shah (whose sister is also a physiotherapist). “And she had two kids calling her up every day, making sure she’s okay, giving her more exercises, helping her

Shah’s mother had other advantages: extended health benefits and a physiotherapy clinic nearby. “That’s not the norm. Many people have issues in terms of being able to afford care or having ready access to care.”

Shah is making it his mission to break down barriers to full recovery. With a grant from AGE-WELL, he has developed an app to help older adults recover from knee surgery. The app provides six months of video-guided rehabilitation exercises as well as checklists, weekly goals and daily reminders to keep people motivated.

“There is a misconception that older adults do not use technology,” says Shah. “But the research shows that if there is an inherent benefit for them, they will access it.”

Shah’s interest in mobile health began nine years ago with a graduate course that paired him with an engineering student. “I started thinking: How can we take what these mobile devices in our pockets do and make it useful for my patients?”

He formed a company, Curovate, and in 2016 developed his first app for people recovering from surgery to repair a torn knee ligament, the anterior cruciate ligament (ACL). “I gave it to my patients and they really liked it.”

ACL patients tend to be young adults but with AGE-WELL’s help, Shah was able to make the shift to an older demographic. “The funding was integral in starting this journey to develop an app for total knee replacement. It was great to have AGE-WELL believe in us early on,” says Shah, who collaborated with U of T professor Jonathan Rose.

Gus Falcioni (left) has a history of knee injuries and provided feedback to Nirtal Shah (right) as the app was developed.

Gus Falcioni (left) has a history of knee injuries and provided feedback to Nirtal Shah (right) as the app was developed.

Shah’s evidence-based workout program is designed for home use, with tables and chairs replacing traditional physiotherapy equipment like balance bars and workbenches. Exercises start slowly and build gradually, with time built in for icing and elevation. “Every exercise is done t the rate and pace that would be appropriate for that person at that stage post-surgery.”

The app counts down reps and sets, and even allows users to measure their knee’s range of motion with the smartphone’s accelerometer (the internal device that allows users to rotate images). “Patients have said ‘it’s fantastic that I can track my progress at home when prior to this, I had to wait to see my physiotherapist.” Patients still have routine checkups with their orthopedic surgeon, and with their physiotherapist, as needed.

Shah wanted an age-appropriate exercise model in his videos, as motivation for users. Enter Gus Falcioni, an avid basketball player with a history of knee injuries. “I have arthritis in both knees,” says Falcioni, 74. “I can’t jog or walk quickly. I haven’t played basketball for about three years”. In addition to performing all the exercises in the videos, Falcioni offered feedback as the app was developed.

“It’s a much better version of what you usually get, which is two sheets of paper, a photograph and a two-line explanation of what to do. This is much more helpful.”

Curovate launched in January 2020, with apps for ACL, knee and hip replacement patients. Shah is now building his user base, with the aim of improving outcomes for as many people as possible.

“It’s not just enough to not have pain,” he emphasizes. “You should be able to go up and down stairs without pain, you should be able to walk the distance that you want without limitation or having to sit down. That to me is the goal of the surgery.”