Application of Telerehabilitation for Older Adults During the COVID-19 Pandemic: A Systematic Review

Abstract

Introduction:

The use of telerehabilitation in different disciplines, particularly in the rehabilitation of older adults, has grown significantly across the world. In the wake of the coronavirus disease 2919 (COVID-19) outbreak, a chance has arisen to improve the user experience and to draw attention to the advantages of using this service. The current research aimed to evaluate the investigations that used telerehabilitation to assist elderly people during the COVID-19 pandemic.

Methods:

Systematic searches of papers published between September 1, 2019, and December 1, 2021, were conducted in PubMed, Cochrane Library, Web of Science, Scopus, Science Direct, and ProQuest databases. The author narrowed down the list of articles by using search terms. Ultimately, publications from the COVID-19 period were studied for their perspectives on the use of telerehabilitation among the elderly population. The whole process was supervised by 2 investigators at the same time.

Results:

In total, 2529 articles were included in the first search. Five articles were chosen for further assessment based on the careful consideration of their titles, abstracts, and full texts. Cross-sectional, feasibility, case, and interventional studies comprised 20%, 20%, 20%, and 40% of the papers, respectively. The studies were carried out in Brazil, the United States, Germany, Japan, and South Korea and involved using telerehabilitation for elderly individuals, identification of crucial manifestations and impairments, improving physical function in this population, and ensuring their happiness.

Conclusions:

Using a digital strategy for rehabilitation should be regarded as a means of overcoming the field’s obstacles. As a result, legislators and rehabilitation groups should consider the use of telerehabilitation for the elderly population during the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) has been considered a significant problem in health care across the world, causing particular problems for elderly individuals. Indeed, age is the single most crucial variable affecting the odds of surviving against this illness, with people aging 65 y and above being the most susceptible. ¹ Senescence, on the other hand, is a normal occurrence that has varied connotations in different cultures and has long been regarded as a risk factor for infection with COVID-19. ² In general, chronic illnesses result from aging, which reduce individuals’ ability to do their daily tasks. Another element that drives the request for rehabilitation programs is a rise in comorbidities and acute diseases (cardiovascular disease, stroke) as well as the aging population’s expectations. ³

During the pandemic, health precautions such as wearing masks, keeping a safe distance from sick people, and quarantining infected people helped to keep the outbreak under control. Quarantine, on the other hand, caused individuals to spend more hours at home, sleep more, and consume more food and alcohol. Among elderly adults with physical and functional insufficiencies, these were the root causes of physical and mental deterioration, making rehabilitation services even more critical. ² Nonetheless, face-to-face counseling, time, and money are required for most rehabilitation treatments. In rural regions, rehabilitation professionals are poorly trained and there is an imbalance in access to rehabilitation services. ⁴ There were many elderly individuals who were unable to get rehabilitation treatments prior to the outbreak, because they had a variety of clinical limitations and situations. Nevertheless, throughout the pandemic, access has grown increasingly restricted owing to a reduction in face-to-face contacts and other societal initiatives aimed at reducing the disease prevalence. ⁵ Hence, telerehabilitation has become more important in these situations. ⁶ As the term suggests, “telerehabilitation” is the practice of providing medical services across long distances without physically bringing the patient and the caregiver together. ⁷ People who adhere to “social distancing” concepts in the pandemic will find it appealing. Patient assistance, different rehabilitation services, management of individuals with impairments and chronic diseases, comprehensive remote care, and nursing home care for patients in acute sickness have all been made possible by means of the use of this service. ⁸ Before COVID-19, evidence had revealed the usefulness of telerehabilitation for the older adults. ^9,10 Nevertheless, adoption of the service was restricted for a variety of reasons including patients’ and caregivers’ worries about its use, security difficulties, unavailability of face-to-face assessment, data privacy, legal obstacles, lack of connection to technology, insurance strategies, ⁷ misunderstandings about older adults and their preferences, technological knowledge, ⁵ resource restrictions, complicated medical situations, patient care considerations, linguistic barriers, low health awareness, chronic diseases, cultural and psychological considerations, ¹¹ difficulties with the suitability and adaptability of these services, and cognitive, behavioral, and attentional issues. ⁶ However, the exceptional numbers, complexity of COVID-19, and significance of continuous care have compelled health-care systems throughout the world to rethink how they deliver present and future health-care services to their populations. The eligibility, availability, and possible use of telerehabilitation for the elderly population have been hastened as a result of epidemics. ¹² During the COVID-19 pandemic, countries have started to remove legislative limits on its use, and insurance firms have broadened the extent and breadth of the services they provide to customers. ⁷ Likewise, the pandemic has placed a strong emphasis on “appropriate comprehension and use” notwithstanding the difficulties associated with adopting telerehabilitation ¹²

To date, telerehabilitation has been chiefly used for middle-aged individuals with multiple sclerosis, cardiovascular problems, and stroke. As a result, it is unclear whether this treatment would be effective in the elderly population. ⁴ The rehabilitation of elderly people, in particular, is expected to witness an increase in the global use of telerehabilitation. Insurance companies have also expended their coverage of telerehabilitation services during the COVID-19 pandemic. ⁷ To assist older adults during the COVID-19 pandemic in 2022, the present systematic research aims to discover and assess the publications involving telerehabilitation.

Methods

Eligibility Criteria and Search Strategy

Initially, the protocols for this investigation were submitted to the PROSPERO ^a database under the identification number CRD42022314866. PRISMA ^b search guidelines were followed for this systematic review. The study question, that is, what are the publications associated with the use of telerehabilitation for the elderly population throughout COVID-19, was answered by conducting a systematic search for peer-reviewed and English-language papers published between September 1, 2019, and December 1, 2021. First, to determine that no previous systematic reviews existed on the issue, a rapid and comprehensive search was done in the Cochrane Library, and no matching publications were found. The databases searched were PubMed, Web of Science, Cochran Library, Scopus, Science Direct, and ProQuest. Gray literature, such as books, websites, conference articles, and dissertations, was searched as well. When searching between the sets of words each of which was regarded to be a different notion, the “AND” operator was used. The “OR” operator was also used between synonymous terms. Titles, abstracts, and keywords of the documents were searched for the relevant results. It should be noted that Mesh Terms were used to search for publications in the PubMed database.

The search approach used in this study has been presented in Table 1. Because there was no comparison group, C (the identical comparison group) was not taken into consideration in PICO analysis. Furthermore, the researcher chose the terms for the search, and the variables were retrieved from the publications chosen for the study. In the following phase, the investigators created a comprehensive reference collection for all the papers and assessed the titles. The publications that were not related to the study objectives were subsequently excluded. All search procedures were repeated to ensure accuracy. To manage the references, ENDNOTE edition X9 program was used.

Table 1.

Search method for the application of telerehabilitation among elderly individuals during the COVID-19 pandemic

PIO	#1 AND #2 AND #3	Strategy
P	Elder OR older OR older adult OR senior OR geriatric OR aging OR aging OR age-old OR aged OR old age OR eldest	#1
I	Telerehabilitation OR Telerehabilitation OR Tele-rehabilitation OR Remote Rehabilitation OR Virtual Rehabilitation OR Telerehab OR Tele rehab OR Telemedicine OR rehabilitation	#2
O	COVID-19 OR COVID19 OR Severe acute respiratory syndrome coronavirus 2 OR Coronavirus OR SARS-Cov-2 OR New coronavirus OR Corona	#3

Inclusion Criteria

Several publications were chosen since telerehabilitation for the elderly population during the COVID-19 pandemic was mentioned in their titles, keywords, or abstracts. Then, the abstracts were assessed before reading the complete manuscripts using assessment tools.

To conduct this study, a comprehensive search was conducted among the publications recovered from 2019 to the first day of December of 2021. Unreported documents (gray literature), procedures, conference papers, directions, recommendations, and reports from respectable institutions were reviewed, as well. Review publications were chosen on the basis of both quantity and quality. Titles, abstracts, and keywords all had to include the relevant search terms. Additionally, papers had to be relevant to the study topic. Peer-reviewed articles were also included during the selection procedure.

Exclusion Criteria

Variables irrelevant to the research topic were omitted from the study findings.

Screening

First, the titles of all the papers in the database were checked and those that matched the inclusion criteria and were related to the study objectives were selected. Then, the abstracts were reviewed and the papers that were consistent with the study objectives and inclusion criteria were chosen. After that, the full text of each paper was reviewed and analyzed. This was followed by a selection of the publications discussing the use of telerehabilitation in the elderly population during the COVID-19 pandemic. The papers were then assessed in accordance with the PRISMA benchmarks. Citation and printing prejudice were also taken into consideration, and papers with a large number of citations were given special attention. Each of the preceding stages was carried out twice. There was no conflict of interest between the reviewers of the articles (Figure 1).

Figure 1.

PRISMA diagram for the article screening procedure.

Data Extraction

The relevant data were gathered from the papers after being thoroughly read using the summary and collecting form. This form included title, corresponding author, study sampling(s), country(ies), study duration(s), study design(s), method(s), result(s), and conclusion(s), and was completed for each of the papers. Following a thorough analysis of all the publications, the forms were assessed by 2 authors and were organized in a single table. Finally, other researchers involved in the investigation provided their comments on the publications. It is worth mentioning that the summary forms were created using the Microsoft Office Word 2016.

Results

A total of 2529 documents were gathered from the databases. Nevertheless, due to their duplication across many databases, 625 papers were excluded. Additionally, 29 of the 40 original publications were excluded, because their titles did not align with the study objectives. After reviewing the abstracts of the remaining 11 publications, 1 was ruled out for the lack of relevance to the research. Among the remaining 10 full texts, 5 were found to be totally in accordance with the study objectives. The process of selecting papers for the study has been depicted in Diagram 1 (Figure 1).

The types of the papers that were extracted have been shown in Table 2. Accordingly, cross-sectional, feasibility, case, and interventional studies comprised 20%, 20%, 20%, and 40% of the papers, respectively.

Table 2.

Types of the selected papers

Study	Percentage (%)	Number	References
Feasibility	20	1	(13)
Cross-sectional	20	1	(14)
Case	20	1	(15)
Interventional	40	20	(1, 2)

The findings obtained after reading all the 5 publications have been presented in Table 3. The data include title, corresponding author, country, period of study, study objectives, study sampling, research plan, methodology, findings, and conclusions.

Table 3.

Summary form of the ultimately selected papers

No.	Corresponding author/title	Study aim	Study sample	Country	Study period	Method	Results	Conclusion
1	Danielle Bianchini Rampim et al. / Persistent symptoms and disability after COVID-19 hospitalization: Data from a comprehensive telerehabilitation program (14)	After being hospitalized for COVID-19, this research aimed to gather data on older patients’ manifestations, disabilities, and rehabilitation referrals.	Older adults hospitalized at the Sao Paulo Prevention Center for the Elderly as a result of COVID-19	Brazil	2020	As a component of a complete telerehabilitation program for the elderly individuals who had been hospitalized owing to COVID-19, a remote surveillance program (i.e., telephone follow-up) was established. Following discharge, a physiotherapist contacted to ascertain the patients’ complaints and limitations and to send them to appropriate rehabilitation providers. Using sports-themed materials like booklets and films, telerehabilitation programs were made available to the public. The Barthel indicator and the Lawton scale were used to measure manifestations and impairment, as well as the differences in consequences between the groups studied.	Both the intensive care unit (ICU) and the general ward were overflowing with elderly patients who were being treated due to COVID-19 in this trial. Based on the findings of the remote surveillance program’s assessment of the elderly patients (telephone follow-up), those hospitalized in the ICU required a greater reliance on activities of daily living (ADL) and Instrumental Activities of Daily Living (IADL). An increased demand for oxygen treatment, breathing problems, abnormal activity, and standing difficulties were all more common among the older patients hospitalized in the ICU. Referrals to psychologists, physiotherapists, nutritionists, and speech therapists were the most common rehabilitation prescriptions. The use of remote monitoring and telerehabilitation services allowed for the early diagnosis of symptoms and deficits upon discharge during this research. Exercise booklets and movies were provided as a part of the rehabilitation therapy program. A camera-equipped telerehabilitation device was used by those who required further rehabilitation (smartphone, tablet).	The older adults were shown to have a higher than average incidence of disability following hospitalization owing to COVID-19, according to this research. It was more common to find patients in the ICU with disabilities than in the general ward.
2	EBUBEKIR AKSAY. / Live online exercise programs during the COVID-19 pandemic – are useful for elderly adults? (2)	The purpose of this research was to determine the influence of live online sporting content on the physical effectiveness of older adults surviving during the COVID-19 period.	To get rehabilitation treatment, candidates aging 84-60 years were chosen from the German Department of Medical Sports.	Germany	2021	375 older adults were included in the research, which was carried out at the German Department of Medical Sports for Rehabilitation Treatment. The individuals were separated into an intervention group (getting 60 minutes of live online exercise treatment at home on a weekly basis) and a control group (getting normal daily life education under the therapist surveillance). Each group underwent pre-and post-testing to assess the degree to which their physical effectiveness had improved.	Exercise therapy had a beneficial impact on flexibility, physical endurance, dynamic balancing abilities, and dexterity according to comparison of the pre-and post-treatment evaluations in both groups. Additionally, females were more adaptable than their male counterparts. On the other hand, men’s endurance and dexterity were higher than those of women. Owing to personalization in the contexts of treatment, disease intensity, relaxation time between workouts, age, and sex, the use of online live exercise treatment programs is suggested During the COVID-19 epidemic as a manner to assist elderly individuals to enhance their physical function, because physical function reduces with age.	Using a virtual rehabilitation program for the elderly population, this research found that therapeutic exercise treatments for the COVID-19 pandemic may be accomplished. Flexibility, strength, endurance, and dynamic balance were shown to be significantly linked to the use of virtual rehabilitation activities. Elderly people in both the intervention and control groups had significantly different physical abilities before and during the intervention. Exercise treatment increased the physical abilities of both groups.
3	Austin Kang et al. / Home-based rehabilitation in patients over 60 years with stabilized ankylosing spondylitis during the COVID-19 pandemic. (1)	The purpose of this research was to develop a therapeutic exercise for elderly patients experiencing Ankylosing Spondylitis (AS) during the COVID-19 pandemic.	A team comprising 10 rehabilitation experts	South Korea	2021	For the elderly who have AS, a Delphi approach was used, and 10 specialists were consulted to gain information about the conditions and problems of home rehabilitation education. Email invitations were sent to experts who were then provided with the appropriate instructions. For a period of 1 mo, 3 Delphi cycles were held to establish an agreement on a home rehabilitation program.	The opinions of the specialists in the categorization of rehabilitation concepts and procedures, methodologies, and rehabilitation content were reviewed over the course of 3 Delphi cycles. Rehabilitative programs had to begin with objectives that would allow patients to execute activities without assistance, according to the experts. In fact, relieving manifestations like pain and stiffness while also increasing joint range of motion should be the objective of these programs. In addition, the patient-therapist interaction should be emphasized in these programs to ensure that home exercises are carried out correctly.	Because of COVID-19, it is imperative that elderly people suffering from AS continue with their therapeutic exercises to maintain their current level of health and stave off further disease development. Supervised, unsupervised, and group physiotherapy are a few options available. Clinical recommendations, on the other hand, do not provide particular guidance for sports schedules. Exercise treatment during the COVID-19 pandemic should thus be evaluated. This research used the Delphi approach to look at home rehabilitation for this particular group of people. Home rehabilitation was even advocated as a way to avoid needless journeys during the COVID-19 pandemic.
4	Addie Middleton et al. / COVID-19 Pandemic and beyond: considerations and costs of telehealth exercise programs for older adults with functional impairments living at home—Lessons learned from a pilot case study. (15)	The study aimed to show how much physiotherapy for older people with functional problems cost and how it was delivered through a remote health program.	A 67-year-old man having a stroke background	USA	2020	A remote physiotherapy program was developed and implemented in this research, which outlined the stages required. The results of a 36-session feasibility study on a distant health program for a single participant were analyzed. Patients’ and providers’ viewpoints on the software development cycle were considered in the documentation, as were expenses.	The steps of the software production process were evaluated including choosing the program platform, system documentation, identifying the needed assets, designing approaches, assessing the patient’s pre-and post- interventional functional conditions, pre-program education, implementing the appropriate settings, purposeful connection with the participant, beginning of each session based on security considerations, patient surveillance, and recording the substance of workout treatments, technical, and safety aspects. In addition, estimates were made for both fixed and changeable assets and expenses.	As a result of the pandemic, new rehabilitative technologies have emerged, providing a chance for advancement. This research gave perspective into the phases and expenses associated with planning and implementing a distant exercise treatment program regarding the elderly individuals experiencing functional disabilities.
5	Yohei Otaka et al. / An affordable, user-friendly telerehabilitation system assembledusing existing technologies for individuals isolated with COVID-19: Development and feasibility study (13)	The purpose of this research was to create and assess the use of telerehabilitation among individuals who were quarantined owing to COVID-19 using commercialized equipment and computing software.	Adults and the elderly people suffering from COVID-19 who were hospitalized in Fujita Health University Hospital, Toyoake.	Japan	2020	Telerehabilitation was recognized as a potential technique to be developed by a panel of experts. Doctors, engineers, and physiotherapists made up this team. The patients’ hospital rooms were equipped with telerehabilitation technologies. Patients had access to the information they needed, thanks to the instruments at their disposal. Skype and Zoom were used by the physiotherapist to interact with the patients. Prior to beginning an exercise regimen, the patients’ critical symptoms and movements were evaluated and the results were discussed with the doctor. Patients’ critical indications and movements were reviewed following the exercise regimen. The viability of telerehabilitation was then assessed using questionnaires.	Telerehabilitation was shown to be a great success in this research, because of the meticulous implementation of the exercise regimen. A telerehabilitation system should be user-friendly, cost-effective, and safe for quarantined individuals. Having a reduced starting investment is also advantageous from a commercial standpoint.	Individuals in quarantine with QOVID-19 may benefit from the establishment of a telerehabilitation system. The findings of this research help us better understand the usefulness of telerehabilitation.

Discussion

The present systematic review was conducted on the studies that used telerehabilitation to assist elderly individuals during the COVID-19 pandemic. According to the findings, telerehabilitation was used to identify ² and enhance elderly people’s physical performance, ¹³ which resulted in a rise in their level of satisfaction. ¹⁴

The proportion of individuals aging 60 y and above is expected to grow by 2050, making the issue of aging a major concern for the world. ³ Comorbidities, weakness, incapacity, reduced physical activity, lower quality of life, increasing public demands, and a rise in the need for rehabilitation services are all related to senescence. To satisfy their needs for lifespan, excellence, and independence, this endangered population presents difficulties to health-care systems, which in turn affects the systems’ long-term viability. To address the rehabilitation needs of the elderly population, it is vital to use effective solutions. Rehabilitative services for these individuals have been useful in both health and financial aspects. In numerous low- and middle-income nations with restricted resources, distance, economic constraints, lack of rehabilitation staff, and epidemic circumstances have prohibited older adults from receiving rehabilitation treatments. Telerehabilitation that uses the Information and Communication Technology (ICT) to deliver high-quality, low-cost, and adaptable treatments to elderly people is a novel approach to meeting the rehabilitation needs of this population. Individuals suffering from COVID-19, in particular, can conveniently make use of these services. An alternative to standard treatment during a pandemic is to use telemedicine to deliver services without the requirement for in-person visits in health centers and to reduce the spread of the virus. It is also effective in the early diagnosis and management of infected individuals. Telerehabilitation has been highlighted for the elderly population during the COVID-19 pandemic. ^{3,6,7,9,15–20} Accordingly, immediate presence and rescue operations are essential for the effectiveness of disaster management. Disaster rehabilitation methods have improved as a result of the adoption of innovative ways. ^21,22 In the majority of research conducted on the issue, telerehabilitation has proved helpful to the elderly population and has been linked to increased contentment. ^2,13,14 However, only 2 projects were focused on the obstacles and circumstances of the telerehabilitation system for elderly people ¹ and the expenses and progression procedures of the system. ²³ To properly apply this technology and maximize patient satisfaction, such factors as safety, ease of access, cost-effectiveness, user-friendliness, and conformity with rehabilitation objectives are recommended to be taken into account. To provide telerehabilitation services, 2 of the research pappers included in this study ^2,14 used Zoom video, a widely used and freely accessible video conferencing program, while 3 studies used tablets. Tablets can connect to a pulse oximeter and other medical services by means of Bluetooth. Pre-installed physical therapy applications are also available for patients with limited or no Internet access. ^13,14,23 Furthermore, 2 investigations used telerehabilitation to evaluate critical manifestations and impairment, ^13,14 and 1 research used this technology to enhance patient efficiency by means of exercise therapy. ²

The majority of the included studies in the current systematic review were carried out in developed countries such as the United States, Germany, Korea, and Japan. ^1,2,14,23 Developed nations’ interest in this technology seems to be mostly due to such factors as a well-developed infrastructure of hardware and software, a high level of computer knowledge, and specific governmental legislations. ^3,16 However, only 2 of the papers were interventional in nature and used exercise treatment for older adults’ rehabilitation. ^1,2 According to clinical principles, nonsurgical and nonpharmacological approaches with an emphasis on active care are recommended in the first line of rehabilitation. To alleviate discomfort, improve performance, and enhance the quality of life, exercise therapy is essential. Physiotherapists often suggest exercise treatment during face-to-face consultations. Nonetheless, face-to-face rehabilitation treatments are heavily affected by factors such as expense, duration, and location.

Due to the social isolation caused by the pandemic, various channels of communication have been severely restricted. ^24–27 Manifestations and impairments caused by COVID-19 among elderly individuals were only explored in 1 Brazilian cross-sectional research. ¹³ As a component of a telerehabilitation approach, they used distant surveillance by means of phone and evaluated the signs using Barthel and Lawton markers. Considering the absence of computer knowledge and practicality concerns in poor nations, telephone conversations have become a popular alternative to Internet-based telerehabilitation services. ^16,28 In the United States, an investigation was done as a case study. The study findings shed light on the methods and expenses associated with aged and functionally impaired patients undergoing distance exercise treatment. ²³ Mukaino et al. also conducted a study on the elderly individuals experiencing coronary heart disease in Japan in 2020. In that study, remote management of the patients’ computers was carried out by means of the TeamViewer software by a physiotherapist using Skype and Zoom software. TSQ and FIM questionnaires were used to gather information on the capability of the software to provide sports workouts and monitor critical manifestations as well as the degree of user happiness. ¹⁴ Overall, telerehabilitation procedures (simple or complicated) have been used to treat elderly people in a broad variety of ways during the COVID-19 pandemic. The availability of care services at any moment and from any location has been made possible in part through asynchronous platforms (offline). To the best of our knowledge, telerehabilitation for the elderly population had not been investigated during the COVID-19 pandemic.

One of the main limitations of the present research was the selection of publications in English language. Additionally, Embase database were not accessible. As a result, the following recommendations are given to improve telerehabilitation for elderly people during the COVID-19 pandemic. First, during the initial stages, telerehabilitation programs and systems for sensitive populations, including elderly and physically and functionally impaired individuals, shoud be implemented. Second, in developing nations, the installation of this technology should be made as easy as possible, so that it may be used to address the fundamental requirements of handicapped and elderly individuals, allowing them to gain autonomy and improve their overall living standards. Third, attempts should be undertaken to instruct and persuade older adults to use this technology. Fourth, in accordance with rehabilitation objectives, telerehabilitation procedures should be as uncomplicated and user-friendly as possible. Fifth, telerehabilitation platforms and applications are suggested to be developed in compliance with standards and evidence-based practices.

Conclusions

The older adults are a vulnerable group for whom receiving timely and adequate rehabilitation services is very important. Before COVID-19, this people faced challenges in responding to their rehabilitation needs, but COVID-19 exacerbated the situations. Thus, telerehabilitation can considered as a complementary option to traditional treatments during pandemic and beyond. In fact, COVID-19 should be a chance for rehabilitative service organizations to be strengthened. Our findings showed that telerehabilitation can work equally or sometimes even more effectively than traditional treatments. Also, health-care organizations and policy makers can gain new insight in to the potential benefits of this technology and plan future uses.

Author contributions

Milad Ahmadi Marzaleh and Fatemeh Sarpourian were responsible for the study conception and design. Milad Ahmadi Marzaleh and Fatemeh Sarpourian searched the relevant databases and selected the appropriate articles according to the study objective. At the same time, Milad Ahmadi Marzaleh supervised the whole thesis. All authors prepared the first draft of the manuscript. All authors did the data analysis, made critical revisions to the study for important intellectual content, and supervised the study. All authors have read and approved the final manuscript.

Funding statement

None declared.

Conflict of interest

The authors have no conflict of interests to declare.

Informed Consent

Nil.