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In addition to traditional physiotherapy, studies based on telerehabilitation programs have published the results of effectiveness, validity, noninferiority, and important advantages in some neurological, cognitive, and musculoskeletal disorders, providing an opportunity to define new social policies and interventions.
The aim of this systematic review is to investigate the effects of telerehabilitation after surgical procedures on orthopedic conditions as well as to describe how interventions are designed and to determine whether telerehabilitation is comparable with conventional methods of delivery. This systematic review summarizes the levels of evidence and grades of recommendation regarding telerehabilitation intervention (synchronous or asynchronous provided via the telerehabilitation medium, either in conjunction with, or in isolation of, other treatment interventions) after surgical procedures on orthopedic conditions.
Study quality was assessed using the Physiotherapy Evidence Database (PEDro) scores and grade of recommendation following the recommendation of the Oxford Centre for Evidence-Based Medicine.
We found 3 studies with PEDro scores between 6 and 8, which is considered as level 1 evidence (good; 20% [3/15]), 4 studies with a score of 5, which is considered as level 2 evidence (acceptable; 27% [4/15]), and the remaining 8 studies had scores of 4 or less, which is considered (poor; 53% [8/15]). A total of 1316 participants received telerehabilitation intervention in the selected studies, where knee and hip replacement were 75% of all the studies. Strong and moderate grades of evidence (grade of recommendation A–B) were found in knee and hip replacement interventions. Studies on the upper limb were 25% of the studies, but only 1 study presented a moderate grade of evidence (grade of recommendation B) and the rest were of poor methodological quality with weak evidence (grade of recommendation C).
Conclusive evidence on the efficacy of telerehabilitation for treatment after an orthopedic surgery, regardless of pathology, was not obtained. We found strong evidence in favor of telerehabilitation in patients following total knee and hip arthroplasty and limited evidence in the upper limb interventions (moderate and weak evidence). Future research needs to be more extensive and conclusive. To the best of the authors’ knowledge, this is the first attempt at evaluating the quality of telerehabilitation intervention research after surgical procedures on orthopedic conditions in a systematic review. Clinical messages and future research recommendations are included in the review.
The increasing availability of low-cost Internet and communication technologies has boosted the opportunity to apply technology-based solutions to provide health services during hospitalization and after discharge from hospital [
The growing demand for rehabilitation can result in increased costs and longer waiting lists, becoming a threat to the sustainability of health care services [
The scientific community believes that telerehabilitation will play an important role in improving, or at least maintaining, the continuity of rehabilitation care and services as they are reorganized, as it is able to increase the efficiency of the services while containing costs [
Early systematic reviews have pointed out that, despite the growing number of telerehabilitation experiences worldwide, evidence of clinical and economic effectiveness is still lacking [
Musculoskeletal injuries are frequent events in routine care and are the most common source of chronic pain and disability [
Recently, a systematic review concluded that telerehabilitation is promising and highlighted the fact that for those individuals who are unable to attend traditional face-to-face services, particularly following elective orthopedic surgical procedures [
Despite the existence of systematic reviews on telerehabilitation interventions, none of them has explored post-surgical rehabilitation in musculoskeletal injuries. Therefore, the aim of this paper is to investigate the effects of telerehabilitation after surgical procedures on orthopedic conditions, as well as to describe how interventions are designed and to determine whether telerehabilitation is comparable with conventional methods of delivery within this population. We have considered all forms of interventions that use telecommunications technology to telerehabilitation interventions.
This review has been carried out following the PRISMA 2009 guidelines [
As with most of the recent systematic reviews on the topic [
The initial search was carried out in June 2016, and was completed with a new search to update the review in October 2016. The following combinations of keywords were used: telerehabilitation, telerehabilitation physiotherapy, post-surgery telerehabilitation, musculoskeletal disorders, systematic review, telemedicine (mobile health or health, mobile or mHealth or telehealth or eHealth), telemedicine physiotherapy program. The limits of searches were studies published between 2000 and 2016.
The main steps related to the search phase are reported in
Two authors (JMPB and RMV) independently screened the titles and abstracts of all records retrieved using the database search strategy. The full text was obtained if further information was required to determine eligibility, or if uncertainty prevailed between authors. For trials published in a language other than English or Spanish, a translated version of the abstract was sourced to determine eligibility.
Disagreements between authors were initially resolved via discussion, and then by consultation with a third reviewer (FJBL).
Flowchart.
Eligibility criteria were based on the PICOS framework [
Adults (≥18 years) with telerehabilitation services after surgical procedures as a result of a primary orthopedic condition. Trials in which the participant’s condition was secondary to a diagnosed health condition that was not primarily musculoskeletal in nature (eg, hand or shoulder dysfunction following stroke) were excluded.
Any treatment intervention, synchronous or asynchronous, provided via a telerehabilitation medium, phone counseling, interactive virtual system, or gaming, either in conjunction with, or in isolation of, other treatment interventions was included.
All trials were required to have a comparison group (of the same condition), where options included (but were not restricted to) face-to-face treatment or usual care. The comparison group could not be an alternative form of telerehabilitation. A pilot clinical trial without a comparison group was included if a telerehabilitation intervention had been carried out among participants.
Any clinical outcome, including measurements based on pain, quality of life, disability or function (physical, social, or psychological), was analyzed. Economic and cost-utility outcomes were not analyzed, nor were patient and clinician satisfaction or those outcomes measuring adherence to, or compliance with, rehabilitation programs.
All types of study designs were considered: randomized clinical trials (RCT), clinical trials (CT), case reports, controlled clinical trial, and pilot study. Articles that were limited to describing the feasibility and fit-out of telerehabilitation interventions were excluded.
For all eligible trials, data extraction was independently completed by 2 authors (JMPB and MJEP), and was cross-checked for consistency by a third author (RMV). The primary authors of eligible trials were contacted when information was considered to be missing for either the quality assessment or data extraction process.
An important step in conducting a systematic review is to assess the methodological quality of each included trial. In addition, reporting methodological quality provides clinicians with information about whether the results of clinical trials should influence their clinical practice. A valid way of assessing the methodological quality of clinical trials is therefore essential [
Two independent reviewers [JMPB and RMV] completed the checklist based on the PEDro scale. The methodological quality and risk of bias were evaluated using the PEDro scale [
The PEDro scale scores 10 items: random allocation, concealed allocation, similarity at baseline, subject blinding, therapist blinding, assessor blinding, >85% follow-up for at least one key outcome, intention-to-treat analysis, between-group statistical comparison for at least one key outcome, and point and variability measures for at least one key outcome. Items are scored as either present (1) or absent (0) and a score out of 10 is obtained by summation [
According to Moseley et al, studies with a PEDro score ≥5 will be considered at low risk of bias and high methodological quality [
A study with a PEDro score of ≥6 is considered to have level 1 evidence (6-8=good, 9-10=excellent) and a study with a score of ≤5 is considered to have level 2 evidence (4-5=acceptable, <4=poor) [
Levels of evidence help us target the search at the type of evidence that is most likely to provide a reliable answer. They have been designed so that they can be used as a shortcut for busy clinicians, researchers, or patients to find the likely best evidence [
Based on evidence-based medicine working group [
Grades of recommendation | Strength of evidence | |
A | Strong Evidence | A preponderance of level I and/or level II studies support the recommendation. This must include at least 1 level I study. |
B | Moderate Evidence | A single high-quality randomized controlled trial or a preponderance of level II studies support the recommendation |
C | Weak Evidence | A single level II study or a preponderance of level III and IV studies including statements of consensus by content experts support the recommendation |
D | Conflicting Evidence | Higher-quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studies |
E | Theoretical/Foundational Evidence | A preponderance of evidence from animal or cadaver studies, from conceptual models/principles, or from basic sciences/bench research support this conclusion |
F | Expert Opinion | Best practice based on the clinical Experience of the guidelines development team |
Based on grades of recommendation and levels of evidence for therapy or prevention. Material adapted from the recommendations at the center for evidence-based medicine in oxford [
Level of evidence | Strength of evidence |
1a | Systematic review of (homogeneous) randomized controlled trials |
1b | Individual randomized controlled trials (with narrow CIs) |
2a | Systematic review of (homogeneous) cohort studies of “exposed” and “unexposed” subject |
2b | Individual cohort study / Low-quality randomized controlled trials |
3a | Systematic review of (homogeneous) case-control studies |
3b | Individual case-control studies |
4 | Case Series, low-quality cohort or case-control studies |
5 | Expert opinion based on non systematic reviews of results or mechanistic studies |
The main findings of this review are presented in
Studies included in the review had PEDro scores of 2-8, as shown in
We found 3 studies [
A total of 1316 participants received telerehabilitation intervention. Strong and moderate grades of evidence (grade of recommendation A-B) were found in knee and hip replacement interventions (80% of all the studies). Studies in the upper limb were 20% of the studies included but only 1 study presented a moderate grade of evidence (grade or recommendation B) and the rest were of poor methodological quality with weak evidence (grade of recommendation C).
The subgroup analysis by population shows us 8 articles focused on a total knee replacement population (50% of articles), 4 on total hip replacement (25% of articles), 1 on shoulder joint replacement (6% of articles), 1 on proximal humerus fractures (6% of articles), 1 on carpal tunnel release surgery (6% of articles), and 1 on rotator cuff tear (6% of articles). Another 3 telerehabilitation publications in the upper limbs (hand transplantation [case study]) [
In the subgroup analysis by telerehabilitation intervention (
We found great heterogeneity among the included studies. Sample size ranged between 5 [
Compared interventions also range between clinical protocol face-to-face physiotherapy [
Intervention duration ranged from 2 weeks [
We found some homogeneous aspects in clinical outcomes primarily in the areas of function, quality of life, and specific daily life activities [
Evaluation of methodological quality of the 15 selected studies.
PEDro scale criteria | Moffet et al [ |
Russell et al [ |
Bini et al [ |
Piqueras et al [ |
Tousignant et al [ |
Hørdam et al [ |
Fung et al [ |
Li et al [ |
Russell et al [ |
Eriksson et al [ |
Eisermann et al [ |
Antón et al [ |
Tousignant et al [ |
Heuser et al [ |
Macias et al [ |
Eligibility criteriaa | Yb | Y | Y | Y | Y | Y | Y | Y | Nc | Y | Y | Y | Y | Y | Y |
Randomization | Y | Y | Y | Y | Y | Y | Y | N | Y | N | Y | N | N | N | N |
Allocation concealed | Y | Y | Y | N | Y | Y | N | N | N | N | N | N | N | N | N |
Baseline comparability | Y | Y | Y | Y | Y | Y | Y | Y | N | Y | N | N | N | N | N |
Subject blinding | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
Therapist blinding | N | N | N | N | N | N | N | N | N | N | N | N | N | N | N |
Evaluator blinding | Y | Y | N | Y | N | N | Y | N | Y | N | N | N | N | N | N |
Appropriate continuation | Y | Y | Y | N | N | Y | Y | Y | Y | Y | N | Y | Y | Y | Y |
Intention to treat | Y | Y | Y | N | N | N | N | N | N | Y | N | N | N | N | N |
Comparison between groups | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | N | N | N |
Specific measurements and variability | Y | Y | Y | Y | Y | N | N | Y | N | N | Y | Y | Y | Y | Y |
Total PEDro Score | 8 | 8 | 7 | 5 | 5 | 5 | 5 | 4 | 4 | 4 | 3 | 2 | 2 | 2 | 2 |
aThe eligibility criteria do not contribute to the total score.
bY is Yes.
cN is No.
Subgroup analysis by population.
Population | Authors and reference | Number of articles | Participants (n) |
Articles with grade of recommendation A |
Articles with grade of recommendation B |
Articles with grade of recommendation C and D |
Level of evidence 1 (% of total articles) |
Level of evidence 2 or 3 (% of total articles) | Level of evidence >3 (% of total articles) | ||||
Total knee arthroplasty | Moffet et al 2015 [ |
8 | 718 | 3 (19) | 5 (31) | 0 |
Total Hip Replacement | Hørdam et al 2009 [ |
4 | 543 | 3 (19) | 0 | 1 (6.25) |
Shoulder joint replacement | 1 | 22 | 0 | 1 (6.25) | 0 | |
Proximal humerus fractures | 1 | 17 | 0 | 0 | 1 (6.25) | |
Carpal tunnel release surgery | Heuser et al 2007 [ |
1 | 5 | 0 | 0 | 1 (6.25) |
Rotator Cuff Tear | Macías-Hernández et al 2016 [ |
1 | 11 | 0 | 0 | 1 (6.25) |
Total % | 16 (Eisermann et al included knee and hip population) | 1316 | 38.00 | 37.25 | 25 |
Subgroup analysis by intervention.
Intervention | Authors and reference | Number of articles | Participants (n) | Articles with level of evidence 1 and grade of recommendation A (% of total articles) | Articles with level of evidence 2 or 3 and grade of recommendation B (% of total articles) | Articles with level of evidence >3 and grade of recommendation C and D (% of total articles) |
Videoconferencing (real-time) | Moffet et al 2015 [ |
5 | 357 | 3 (21.4) | 1 (6.6) | 1 (6.6) |
Asynchronous videos program | Bini et al 2016 [ |
3 | 336 | 2 (14.3) | 0 | 1 (6.6) |
Education sessions by telephone | Hørdam et al 2009 [ |
2 | 398 | 2 (14.3) | 0 | 0 |
Interactive virtual TR system & gaming | Piqueras et al 2013 [ |
5 | 225 | 2 (14.3) | 1 (6.6) | 2 (13.3) |
Total % | 15 | 1316 | 60 | 13.33 | 26.67 |
This review confirms the strong evidence in favor of telerehabilitation among patients undergoing total knee and hip arthroplasty and the limited evidence in the upper limb (moderate and weak evidence).
To the best of our knowledge, this is the first review focused on telerehabilitation research after surgical procedures on orthopedic conditions. This systematic review applied a qualitative evaluation to provide a wider picture of currently available evidence.
First, we will discuss the contributions of the first systematic reviews on the topic. Second, we discuss the generalizations, previous results, and future recommendations. Third, we discuss if results are extrapolated to the upper limb (the results of this review show poor-quality methodology and moderate and weak evidence). Finally, we discuss about the inherent difficulties in conducting telerehabilitation research and future research recommendations.
Regarding the first aspect noted in the discussion, the first systematic reviews, contributions concluded that better-quality studies are needed as well as studies on the use of telerehabilitation in routine care. Telerehabilitation research is generally not very good and there are many reviews that criticize this [
Regarding the second aspect noted in the discussion, the most recent systematic reviews provide statements on the effects of telerehabilitation interventions. Two recent studies provide statements such as, “there is a strong positive effect for patients following orthopedic surgery” [
Regarding the third aspect noted in the discussion: does this statement transfer to upper limb such as shoulder arthroscopy, carpal tunnel release surgery, hand surgery, or shoulder arthroplasty? Could this be extrapolated to the rehabilitation process in fractures or surgery interventions in upper and lower limbs? These unresolved clinical questions reaffirm the need to identify the available evidence in post-surgical rehabilitation with telerehabilitation interventions.
For this systematic review, we seek to find evidence of post-surgical telerehabilitation programs, with special emphasis on programs that can be integrated into clinical practice.
In our review, telerehabilitation research in the upper limb (shoulder joint replacement, proximal humerus fractures, carpal tunnel release, and cuff rotator tears) presents moderate and weak levels of evidence. Notable is the judgment that none of the telerehabilitation studies in the upper limb included in this review present a high level of evidence and recommendation. There is still a very small database for telerehabilitation studies after a musculoskeletal surgery that provides useful data on clinical outcomes, especially in conditions other than the replacement of joints in the lower limb. Therefore, conclusive evidence on the efficacy of telerehabilitation for treatment after an orthopedic surgery, regardless of pathology, was not obtained.
Research background has been used to discuss the strengths of telerehabilitation and the opportunities for future interventions and policies. Regarding the final aspect noted in the discussion, what are the inherent difficulties in conducting telerehabilitation research?
During the search, we observed a number of studies that provide descriptions of telerehabilitation interventions of low methodological quality. No validated clinical outcomes, too small a sample size, and a lack of comparison group are frequently found. Moreover, differences in telerehabilitation interventions, treatment period, and follow-up, create doubts in identifying whether the telerehabilitation gives comparable or better results.
A frequent problem in studies of telerehabilitation is the lack of blinding of therapists and patients. There is evidence that in clinical trials where allocation is not concealed and assessors, therapists, and participants are not blinded, a larger effect of intervention is reported than in higher quality trials with adequate blinding procedures [
It may be that there are good-quality studies the publication of which has been delayed; however, our findings are aligned and consistent with the most recent revisions regarding the need for future research needs to have stronger and more solid studies.
One of the biases identified is that telerehabilitation groups have more frequent contact with health professionals and with the intervention (especially in videoconferencing and phone contact), so they are likely to receive additional services. This creates biases whether the positive results are related to a more elaborate program than really with the interventions method.
How could this be addressed in future research? As blinding of patients and therapists is not possible in telerehabilitation interventions, several methodological aspects are fundamental for future research.
Telerehabilitation interventions should be conceptualized, coded, classified, and grouped in a similar way to physiotherapy technique codes, enabling identification in detail when the effect is due to the type of intervention. Comparison group must be the actual best evidence treatment for the same condition that allows identification of whether telerehabilitation offers better or comparable outcomes. Telerehabilitation frequency must be the same as the control group to avoid biases related to a more elaborate program. Greater homogeneous is needed especially in terms of type, duration, and intervention follow-up for each specific pathologies. Studies that show negative results should be published, avoiding publication biases. Large sample size and improvement in study quality (allocated and evaluator blinding) must be addressed. Orthopedic conditions and musculoskeletal injuries different to replacement joints in lower limbs need quality research.
High-methodological-quality studies should be conducted to confirm that telerehabilitation shows clinically relevant outcomes after surgery in orthopedic and musculoskeletal injuries, especially in upper limbs. Telerehabilitation appears to be an effective alternative to face-to-face service delivery after hospital discharge of patients following total knee arthroplasty and hip replacement. Clinical outcomes are comparable and not inferior. Despite some limitations, there seem to be clear benefits from physiotherapy at a distance regardless with the telerehabilitation technique it offers (videoconferencing, phone intervention, asynchronous video exercise programs, or gaming). Future challenges include identifying whether positive results are due to the type of intervention or the increased frequency and intensity that telerehabilitation allow.
Future research recommendations for telerehabilitation should include high-quality studies with clear conclusions and statements that could improve health interventions and health policies.
Characteristics of the included studies.
Excluded articles.
clinical trials
randomized controlled trial
None declared.