The Era of Technology in Healthcare—An Evaluation of Telerehabilitation on Client Outcomes: A Systematic Review and Meta-analysis

Abstract

Purpose

This systematic review and meta-analysis aimed to synthesize the evidence and examine the effect of telerehabilitation interventions compared to face-to-face rehabilitation interventions on physical functioning, mental health, and pain reduction among employed individuals, 18 years old and older.

Methods

Following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search syntax was created and inputted into Ovid Medline, APA PsycINFO, Ovid Embase, CINAHL, and Scopus. Critical appraisal of the included studies was conducted by two researchers to assess the risk of bias. A meta-analysis was completed for the randomized controlled trials and GRADE was used to determine the certainty of the evidence.

Results

A total of 16 out of 4319 articles were included in this review. This systematic review and meta-analysis found no significant differences between telerehabilitation interventions for physical functioning, mental health, and pain reduction outcomes compared to traditional rehabilitation interventions.

Conclusion

The study findings indicate that telerehabilitation is less effective than in-person care for occupational therapy and physical therapy services. Future research may look at addressing the limitations of the current study to produce more conclusive results, such as exploring the length of the intervention, knowledge and confidence of intervention application, and follow-ups.

Systematic Review Registration

This systematic review has been registered with PROSPERO under registration number CRD42022297849 on April 8th, 2022.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10926-024-10237-4.

Introduction

On March 11, 2020, the population entered uncertainty as the World Health Organization declared Coronavirus disease 2019 (COVID-19) a global pandemic [1, 2]. The emergence of the COVID-19 pandemic has led to a dramatic shift among various sectors across the globe. Many measures and mandates have been implemented to reduce the rapid spread of the infectious COVID-19 disease [3]. Such measures and mandates have influenced major sectors that drive society and work. The healthcare system has been heavily and negatively affected by the COVID-19 pandemic; however, despite the existence of telemedicine and telehealth for over two decades, its prevalence has heightened over the last few years [3].

To limit the outbreak of Covid-19, mandates such as social distancing were enforced. However, challenges arose to enforce social distancing within the healthcare field and many frontline workers were at risk of exposure to Covid-19 [4]. Additionally, individuals seeking rehabilitation services to aid with mental and physical health were negatively affected. Thus, the implementation of telerehabilitation services as an alternative mode of healthcare delivery was favored by many rehabilitation specialists and clients to prevent the transmission of Covid-19[4, 5]. The application of telerehabilitation services uncovered additional benefits such as increasing accessibility, limiting costs of travel and hospital expenses, and enhancing the outcome of treatment plans [4].

Telehealth is an umbrella term referring to the use of technologies and telecommunications to provide and deliver clinical and non-clinical healthcare services remotely [6, 7]. Telehealth has been an established, but lesser-known practice within the healthcare field, as it presents limitations and restrictions on specific examinations and procedures [8].Telerehabilitation is a branch of telehealth, a clinical rehabilitation service utilizing telehealth technologies and services to increase accessibility, improve care, and maximizes functionality [9]. Telerehabilitation has leveraged the care and services provided by occupational therapists (OTs) and physical therapists (PTs), and speech-language pathologists (SLPs) during the COVID-19 pandemic.

Within the literature, there has been growing interest in the benefits provided by implementing telerehabilitation practices among health professionals and clients. The foundations of occupational therapy focus on client-centered services and programs. OTs provide care for diverse populations; however, this presents a challenge in delivering care for clients in rural areas, experiencing challenges limiting travel, and costs of intensive care [10].To combat this challenge, telerehabilitation has been implemented as a service delivery model and recognized as an appropriate delivery model in 2014 by the World Federation of Occupational Therapists [10]. Telerehabilitation assistive technologies and care has accumulated success in OT across different age groups. Gibbs and Toth-Cohen (2011) demonstrated improvements in carryover strategies by parents with children with autism spectrum disorder (ASD). The families were provided with telerehabilitation education via online sessions across six weeks. With implementation of telerehabilitation techniques, the parents were successful in carrying out home-based tools and interventions for their children with ASD [11]. Seron and colleagues (2021) conducted a rapid review of the effectiveness of telerehabilitation in PT. The results demonstrated that telerehabilitation is an effective intervention for various PT practices (musculoskeletal, neurological, and cardiopulmonary areas).

There has been an increase in pain ratings, physical and mental health impairments due to multiple causes such as disabilities, environmental factors, and genetic factors [12] Physical functioning has been defined as “the restriction in the performance of an individual, such as difficulty getting up out of bed, getting up from a chair, walking, and climbing stairs” [13].PTs have argued that face-to-face interventions are necessary to provide care and improve physical functioning [10]. However, in a recent systematic review, Sharififar and colleagues (2023) demonstrated equivalency in improving physical functioning using telerehabilitation methods compared to face-to-face interventions. The researchers found that telerehabilitation effectively improved physical functioning outcomes such as self-care, mobility, dexterity, and pain reduction in lower and upper extremities [14]. Telerehabilitation methods have also extended to mental health care and services. Multidisciplinary teams have been encouraged to collaborate [15]. The interaction of telerehabilitation and telepsychiatry has been indicated to be effective in treating mental health disorders [15].In a literature review by Bashshur and colleagues (2016) found “telemental health” as an effective and feasible intervention in enhancing drug efficacy, reducing aversive symptoms, and improving positive mood across children and adolescents, adults, and elderly populations [16].

The International Classification of Health Interventions (ICHI) was developed and introduced by the World Health Organization [17]. The ICHI covers all divisions of the healthcare system in providing a tool to report and analyze health interventions. The ICHI includes multiple extension codes, including telehealth. ICHI Telehealth outlines the various forms of telehealth interventions that can be delivered by a healthcare provider [17]. ICHI Telehealth classification was utilized to organize and classify the included studies and greater details on the categorization will be provided in the methodology.

Previous systematic reviews have examined the feasibility of telerehabilitation interventions [18–20], however, there have been limited systematic reviews reporting on the effectiveness of telerehabilitation interventions in comparison to face-to-face interventions in improving the physical functioning and mental health well-being of clients and patients. Additionally, limited meta-analyses were conducted to examine the effectiveness of telerehabilitation interventions. Despite the dominance of telerehabilitation within the past decade, specifically during the COVID-19 pandemic, the effectiveness of telerehabilitation compared to face-to-face interventions has yet to be determined. How effective are telerehabilitation methods on clients' physical and mental outcomes? Are these methods more effective than face-to-face interventions? Thus, the objective of this systematic review and meta-analysis is to evaluate the effectiveness of telerehabilitation on client physical and mental health outcomes interventions compared to face-to-face rehabilitation interventions on physical functioning, mental health, and pain reduction among employed individuals 18 years and older.

Methods

Overview

The present systematic review and meta-analysis was registered with PROSPERO under registration number CRD42022297849. Additionally, the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. To create and refine the research question, and facilitate the search strategy, the Population/Intervention/Comparison/Outcome (PICO) framework was developed.

Search Strategy and Study Selection

The search strategy and syntax for this review were established with the support of an occupational therapy and rehabilitation science librarian at the University of Toronto and have been published [1]. The full-text search was conducted on June 13, 2023, and articles were collected from Ovid Medline, APA PsychINFO, Ovid Embase, CINAHL, and Scopus databases. The search strategy was modified according to each database's requirements and can be found in Appendix table 5. The search strategy examined telerehabilitation interventions delivered or assigned by OTs, PTs, and/or SLPs. Furthermore, the inclusion of relevant assessment and key terms associated with each discipline as well as the initial outcome variables identified [1], mental and physical functioning, were included.

The inclusion of studies within the systematic review will follow the PICO framework. Specifically, this systematic review included studies that examined a population of employed individuals (18 years of age or older) who are/are not absent from work due to a mental/physical disorder. This population was selected to examine the effectiveness of telerehabilitation on client health outcomes impacted by work. Participants recruited to the intervention group would receive a form of telerehabilitation treatment from a professional healthcare provider (e.g., OT, PT, or SLP), whereas participants in a control group would receive face-to-face traditional rehabilitation interventions from a professional healthcare provider (e.g., OT PT, or SLP). Studies included would report one of the following outcomes: mental health (e.g., depression, anxiety, stress), physical functioning (e.g., physical performance), quality of life and pain ratings.

Once the search was computed into each database, articles were collected and stored in Covidence. Covidence automatically removed duplicates that were found before the screening process. However, additional duplicates found by the reviewers during the screening process were removed. Two reviewers screened the pool of studies in two phases. In the first phase, the title and abstract phase, the reviewers read and reviewed each article's title and abstract and determined eligibility based on relevance to study aims and the eligibility criteria presented in Table 1. Table 1 also provides a brief explanation of the roles of OTs, PTs, and SLPs. The articles determined to be eligible in the title and abstract phase were then moved to the second phase, full-text screening. During this phase, the two reviewers thoroughly reviewed the full text of each article to ensure the outcome variables and eligibility criteria were met. Any disagreements during the screening process were discussed and resolved among the reviewers to achieve consensus, however, a third senior researcher was consulted when the two reviewers could not reach a consensus. This systematic review aimed to include studies examining telerehabilitation interventions delivered to the specified population of interest by SLPs on outcomes such as distress/well-being outcomes, participation rates, and patient satisfaction. However, during the first phase of screening, no studies including SLPs met our inclusion criteria, as the populations were outside the population of interest.

Table 1.

The inclusion and exclusion criteria used during article screening

Inclusion criteria	Exclusion criteria
• Peer-reviewed articles	Incomplete studies
• Studies reported in English
• Population: workers 18 years of age or older who are absent from work due to a work-related physical injury or mental health condition
• Mental health conditions are diagnosed by a psychiatrist and/or related health professional using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or the International Classification of Diseases, 11th revision	• Any article that is a knowledge synthesis (e.g., literature review, systematic review, scoping review, rapid review, meta-analysis, meta-synthesis); any article that is an opinion piece/editorial/commentary piece
• Interventions for mental health conditions may include drug therapy
• Studies that implement and examine a telerehabilitation intervention, and intervention(s) must be delivered by a licensed OT/PT/SLP in their respective jurisdiction
• Studies that report the effectiveness of the intervention on mental or physical outcomes
• Study designs that will be considered for inclusion are randomized controlled trials, non-controlled trials with pre-post treatment, cohort studies, cross-sectional studies, mixed-method studies, longitudinal studies, observational studies, and retrospective studies
• Occupational Therapist (OT): An OT is responsible for providing occupation therapy assessments and treatments to attain outcomes to aid the participation of clients in everyday occupations • Physical Therapist (PT): The role of a PT is to improve and optimize a client's ability to move and function when they have been impacted by disease, injury, and movement dysfunction • Speech-Language Pathologist (SLP): An SLP is a trained professional who provides evaluations and interventions to

Outcomes

The present systematic review and meta-analysis identified and explored physical functioning, mental health functioning, and pain ratings as the main outcome variables. Physical functioning was defined as any physical disability or impairments individuals experienced such as arthritis, chronic neck stiffness, or hand injury [13]. Mental health functioning is referred to as reductions to DSM-5 or equivalent diagnostic criteria scores. Mental health functioning was defined as any declines in emotional and psychological well-being [16]. Additionally, it was measured through reductions in symptoms scores reported by studies. Pain reduction was assessed through pain reduction inventories and self-reports on pain ratings.

Critical Appraisal and Risk of Bias of Included Studies

To evaluate the methodological rigor of each study the Critical Appraisal Skills Programme (CASP) Checklist [21] was utilized for randomized controlled trials (RCT) and cohort studies. The CASP checklist for RCTs consists of 11 questions across four domains. The CASP checklist for cohort studies includes 12 questions across three domains. Proceeding screening, two independent reviewers analyzed and scored each study on its risk of bias. Questions from each checklist for the individual studies were rated on a 3-point scale, from − 1 to + 1. A score of − 1 was assigned for high risk of bias, a score of + 1 was assigned for low risk of bias, and a score of 0 for unclear bias. A score of 10 indicates a low risk of bias score, whereas a score of five or lower demonstrates high risk of bias. The mean scores for each intervention classification were above five, thus indicating a low risk of bias.

Once reviewers individually completed their risk of bias scoring, the reviewers discussed their scoring and resolved any disagreements. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework will be implemented to assess the quality of evidence from included studies [1]. It allows to examine the transparency of evidence and clinical practice recommendations. The two reviewers independently used this framework with the pooled RCT studies. Disagreements were resolved first between the two reviewers.

Data Extraction

To retrieve the relevant information and data from each article, the Cochrane data extraction form for systematic reviews of interventions provided in the Cochrane handbook was utilized [22]. Two reviewers extracted each article’s study characteristics (type of study, type of telerehabilitation intervention,), methodological characteristics (intervention details), participant characteristics (e, physical and/or mental diagnosis..

Meta-analysis

The PRISMA guidelines were implemented to organize and perform the meta-analysis [23]. Effect sizes were calculated for each study and pooled using using standardized mean difference (SMD) for each outcome variable. Furthermore, mean age and percentage of female participants was collected to examine these variables as moderators on rehabilitation outcomes analyzed. SMDs were calculated and random effects meta-analysis modeling was computed to analyze the impact of telerehabilitation interventions on physical functioning, mental health, and pain reduction as outcome measures. Heterogeneity was calculated using the I² statistic to examine the variation between studies [1]. The Cochrane Handbook outlines a guide to for heterogeneity estimates [22]. Heterogeneity was considered low for an I² statistic between 0% and 40%, moderate between 40% and 69% and high heterogeneity reflected an I² statistic between 70% and 99%. A random effects model was selected as it controls for unobserved heterogeneity and to provide statistical generalization beyond the included studies in the meta-analysis [1, 24]. Meta-analyses were performed and tabulated using R version 4.3.2, “meta” package 7.0–0, and “metafor" package 4.4–0 [25]. Forest plots were created to visualize the effects of the interventions. Three meta-analyses were conducted to examine the effectiveness of telerehabilitation interventions on physical functioning, mental health functioning, and pain reduction. Further, two more meta-analyses were done to examine the ICHI Telehealth intervention-specific effectiveness on the specified outcome variables. Hedge’s g was calculated for each meta-analysis to account for small sample sizes. Heterogeneity between the studies was calculated and reported using I² statistic.

Intervention Categorization

The studies and interventions included in this systematic review were organized and classified into three large domains using the International Classification of Health Interventions—Telehealth [26] [The ICHI Telehealth identifies three classifications of interventions: (i) Intervention performed with advice or assistance provided from a distant location, (ii) Intervention provided to recipient/s in a distant location, and (iii) Interventions delivered via technology, without direct involvement of a human provider. Interventions performed with advice of assistance from a distant location were further described as interventions with assistance provided via robotic care and should be recorded or provided at the health care facility. Providing an intervention to an individual directly (e.g., telephone counseling) described interventions provided to recipient/s in a distant location. Finally, interventions delivered via technology, without direct involvement of a human provider depict asynchronous health interventions, delivered from via websites and/or apps.

Results

Search Outcomes

The search compiled 4319 studies which were stored in Covidence, and 823 duplicates were removed. Two reviewers screened the title and abstracts and determined 3456 to be irrelevant. The reviewers analyzed 39 full-text articles and excluded 23 for the following reasons: patient population outside inclusion criteria (n = 7), non-comparative study design (n = 8), non-telerehabilitation interventions (n = 5), and studies that do not report physical functioning, mental health or pain rain ratings (n = 3). A total of 16 studies were included in this review (Fig. 1). The included studies consisted of randomized controlled trials (n = 10), cohort studies (n = 2), descriptive studies (n = 2), retrospective design (n = 1), and a mixed methods study (n = 1). The publication of the included studies ranged from 2010–2022, with most studies published in 2022 (n = 7).

Fig. 1.

Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) diagram. ** These studies were excluded during title and abstract screening as they did not align with rationale and inclusion criteria of the current systematic review

Study Characteristics

The studies’ characteristics including methodological and participant details, and risk of bias scores are outlined in Table 2 and organized based on ICHI Telehealth categorization.

Table 2.

Study characteristics of included studies, organized by ICHI classification

Author, Year, country	Study design; sample size	Diagnostic criteria	Telerehabilitation intervention	Intervention administrator	Intervention duration	CASP grade	Physical functioning effect size (CI 95%)	Mental health effect size (CI 95%)	Pain ratings (CI 95%)
Intervention provided to recipient/s in a distant location
Palacìn-Marìn et al., 2013, Spain	Descriptive repeated measures crossover design; n = 15	Chronic LBP	“TPLUFIB-WEB” assessment	PT	n/a	9	n/a	n/a	n/a
Özden et al., 2023, Ireland	Two-armed RCT; n = 50	Chronic LBP	Video exercise-based telerehabilitation	PT	8 weeks	8	1.14	n/a	− 0.95
Adhikari et al., 2020, Nepal	Retrospective pre-post design; n = 15	LBP, neck and ankle pain	Telephone-based telephysiotherapy (TPT)	PT	4 weeks	9	n/a	n/a	n/a
Worboys et al., 2018, Australia	Cohort study, n = 18	Hand-injury	telehealth therapy	OT	8 weeks	8	n/a	n/a	n/a
Yosef et al., 2022, Israel	Pilot RCT, n = 16	Aquired Brain Injury	The Cognitive Orientation to Daily Occupational Performance (CO-OP) tele co-op	OT	3 months	4	0.66	n/a	n/a
Gianlanella et al., 2017, Italy	Prospective RCT; n = 94	Chronic non-specific neck pain	Home-based telemedicine program (HBT)	PT	6 months	8	n/a	n/a	− 0.64
Interventions delivered via technology, without direct involvement of a human provider
Toelle et al., 2019, Germany	RCT; n = 86	Non-specific LBP	mhealth app "Kaia app"	PT	3 months	6	0.25	0.13	− 0.44
Coulter et., 2017, United Kingdom	Pilot RCT, n = 21	Spinal cord injury	Web-based physiotherapy	PT	8 weeks	9	1.00	− 1.38	n/a
Zheng et al., 2022, China	Pilot parallel-group RCT; n = 39	Chronic LBP	m-health-based exercise via guidance, plus education	Rehabilitation Physician	6 weeks	10	− 0.45	− 0.26	0.19
Kloek et al., 2019; Netherlands	Descriptive repeated measures design; n = 41	Non-specific LBP	e-exercise LBP	PT	12 weeks	6	n/a	n/a	n/a
van Tilburg et al., 2020, Netherlands	Mixed methods study; n = 14	Non-specific LBP	e-exercise LBP	PT	12 weeks	1	n/a	n/a	n/a
Sarig-Bahat et al., 2014, Australia	Pilot RCT; n = 20	Prolonged neck pain	Kinematic training w/VR	PT	5 weeks	7	0.25	n/a	− 0.04
Koppenaal et al., 2022, Netherlands	Cluster RCT; n = 42	Non-specific LBP	Stratified blended e-exercise LBP	PT	3–12 weeks	7	− 0.10	− 0.13	0.16
Juhlin et al., 2021, Sweden	RCT; n = 109	Chronic widespread pain	digital e-health support	PT	6 months	9	0.00	0.29	0.24
Blanquero et al., 2020, Netherlands	RCT; n = 74	Hand and/or finger injury	ReHand Tablet application	PT	4 weeks	9	n/a	n/a	− 0.48
Janela et al., 2022, United States	Single-arm cohort study; n = 234	Chronic Shoulder Pain	Digital care program w/CBT education and therapeutic exercise	PT	12 weeks	10	n/a	n/a	n/a

“TPLUFIB-WEB” assessment: a recommender web-based system that provides person

Video exercise-based: exercises presented via web-based telerehabilitation platform, which provides detailed exercise instructions and monitors activity. TPT Telephone-based Telephysiotherapy: utilizes telecommunication technology (e.g., video conferencing, phone-calls) to provide physiotherapy services

Telehealth Therapy: live video conferencing sessions in which on the patient’s end was controlled by an allied health assistant

Tele CO-OP: Web-based metacognitive approach which focuses on strategy training and problem solving to improve participation in daily activities

HBT: consisted of scheduled and unscheduled calls (requested by patient) in which information on disease status, pain, exercises performed, and use of drugs were collected

Kaia app: an m-health smartphone app including three therapy modules providing education, exercises, and therapeutic techniques

Web-based physiotherapy: website which delivers individualized exercises, exercise diaries, and education

m-health-based exercise via guidance, plus education: web-based platform which provides guidance and education on exercises and activities and patient performance

e-exercise LBP: web-based application consisting of information sessions, video-supported exercises, and activity module

Kinematic Training w/VR: included kinematic training (active neck and head movements) and VR training (use of VR system that presented targets and obstacles for clients to overcome

Digital e-health support: communication and interaction with health professional via digital platform and participated in a pain educational programme

ReHand Tablet application: application which provides and guides clients with exercises performed on a touch screen tablet with feedback and monitoring

Digital care program w/CBT: provided monitored exercise sessions via tablet application and an online interactive CBT module

ICHI International classification of health interventions, RCT randomized controlled trial, LBP lower back pain

Interventions and Comparator

As outlined in Table 1, studies included in this review had telerehabilitation interventions performed, delivered, assisted, or instructed by an OT or PT. Although the study initially aimed to also examine interventions delivered by SLPs, the final pool of included studies did not include SLPs. Majority of the studies (13/16 studies) had a PT provide the telerehabilitation intervention. Face-to-face interventions or waitlist controls were considered appropriate comparators for traditional in-person rehabilitation interventions.

Critical Appraisal of Included Studies

Table 3 provides the specific critical appraisal averages for each ICHI Telehealth classification. Furthermore, the mean CASP score for the RCTs included in this systematic review demonstrated a low risk of bias, reflecting validity and reliability (M = 7.7; SD = 1).

Table 3.

ICHI Telehealth-specific classification of critical appraisal averages and standard deviations

ICHI classification	Sample size	CASP mean (SD)
Intervention provided to recipient/s in a distant location	6	7.66 (1.69)
Interventions delivered via technology, without direct involvement of a human provider	10	7.4 (2.57)

Meta-analytic Findings

The first meta-analysis examined the effects of telerehabilitation interventions from eight studies on physical functioning. The random effects model found an improvement in physical functioning (Fig. 2) using telerehabilitation interventions, however, the effects were not significant (g = 0.33 [95% CI − 0.08; 0.73] k = 8 (p = 0.11)). Figure 3 presents mental health functioning which was reverse coded, with lower scores indicating improvement. Telerehabilitation had no significant effect on mental health functioning across the five studies (g = − 0.10 [95% CI − 0.50; 0.29] k = 5 (p = 0.61)). The third random effects model (Fig. 4) found no significant effect on pain reduction from telerehabilitation interventions (g = − 0.26 [95% CI: − 0.58; 0.05] k = 8 (p = 0.11)) across the eight studies. Overall, the heterogeneity was moderate to high across all outcomes: physical functioning (I² = 70%, τ² = 0.2248, χ²₇ = 23.58 (p < 0.01)), mental health functioning (I² = 60%, τ² = 0.1148, χ²₄ = 10.02 (p = 0.04)), and pain reduction (I² = 66%, τ² = 0.1316, χ²₇ = 20.88 (p < 0.01). Thus, it is unclear whether the results are strictly due to the telerehabilitation itself or other intervention or participant-level variables.

Fig. 2.

Forest Plot for Telerehabilitation interventions on Physical Functioning

Fig. 3.

Forest Plot for Telerehabilitation interventions on Mental Health

Fig. 4.

Forest Plot for Telerehabilitation interventions on Pain Reduction

Intervention-Specific Findings

Four additional meta-analyses were conducted to evaluate the effectiveness of the ICHI Telehealth interventions on physical functioning and pain reduction. Mental health functioning was excluded from the analyses as there was no sufficient data. Due to a small data sample, conclusions could not be drawn from interventions provided from a distant location for physical functioning, as the weight distribution was skewed (g = 1.14 [95% CI 0.44; 1.84] k = 2, (p < 0.01))[see supplementary material Fig. 5]. However, there was a small but non-significant effect of telerehabilitation interventions without direct human involvement on physical functioning (g = 0.07 [95% CI − 0.21; 0.36] k = 6 (p < 0.01)) [see supplementary material Fig. 6]. Furthermore, the heterogeneity for both analyses was low, suggesting that the effect examined may be due to the intervention itself (I² = 34%, τ² = 0.0954, χ¹₂ = 1.52 (p = 0.22)) and (I² = 30%, τ² = 0.0374, χ⁵₂ = 7.19 (p = 0.21)). Similarly, due to a small data sample conclusions could not be drawn from telerehabilitation interventions provided from a distant location on pain reduction (g = − 0.74 [95% CI − 1.08; − 0.40] k = 2 (p < 0.01)) [see supplementary material Fig. 7]. Additionally, there was no significant effect on pain reduction from interventions delivered without human involvement (g = − 0.08 [95% CI − 0.38; 0.22] k = 6)) [see supplementary material Fig. 8]. The heterogeneity for both analyses was low indicating that effects of the intervention may be due to the intervention itself (I² = 0%, τ² = 0, χ¹₂ = 0.68 (p = 0.41)) and (I² = 48%, τ² = 0.0654, χ⁵₂ = 9.71 (p = 0.08)). The forest plots for each analysis can be found in the supplementary material.

Age and Gender

Overall, age did not have a significant effect on the outcome's variables. The gender (female) of the participants as a moderator was examined and this had a significant effect on mental health functioning (g = 1.73 [95% CI 0.25; 3.20], (p < 0.05)). However, it did not influence physical functioning and pain reduction. The interaction of gender and age was examined on each outcome variable. There were no moderation effects of gender and age on the outcome variables.

Certainty of Evidence

GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework was utilized to assess the quality of evidence of the RCTs included in the meta-analysis [27]. The GRADE comprises five criteria, risk of bias, imprecision, inconsistency, indirectness, and publication bias [27]. Two reviewers examined the quality of evidence from the pooled RCT studies and the results are presented in Table 4. The GRADE assessment was conducted based on the outcome variables, physical functioning, mental health, and pain reduction. Overall, the studies included in this systematic review were found to have very low to low quality of evidence. This suggests that future RCTs and quasi-experimental designs should aim to utilize precise and consistent measures of outcome variables and rigor for intervention conditions.

Table 4.

GRADE evidence profile of RCT studies included in meta-analysis

Question: How do telerehabilitation interventions compare to traditional interventions in health-related outcomes
Certainty assessment							No. of patients		Effect		Certainty	Importance
No of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Telerehabilitation	Tradition	Relative (95% CI)	Absolute (95% CI)
Physical Functioning
8	randomised trials	seriousa	very seriousb	not serious	not seriousc	none	195/383 (50.9%)	188/383 (49.1%)	not estimable		⨁◯◯◯ Very low
Mental Health
5	randomised trials	not serious	seriousb	seriousd	not serious	none	151/279 (54.1%)	146/279 (52.3%)	not estimable		⨁⨁◯◯ Low
Pain Reduction
8	randomised trials	seriousa	very seriousb	not serious	not serious	none	259/514 (50.4%)	255/514 (49.6%)	not estimable		⨁◯◯◯ Very low

CI confidence interval

^aLack of blinding and incomplete follow-up from patients

^bHigh heterogeneity

^cSmall number of studies

^dDifferences in intervention setting

Discussion

This systematic review aimed to analyze the combined impact of telerehabilitation interventions, and the effect of these interventions based on the ICHI Telehealth categorization of physical functioning, mental health functioning, and pain reduction. This study found no significant effect of telerehabilitation interventions on the specified outcome variables, suggesting that traditional, face-to-face rehabilitation interventions may have a similar effect on improving health-related outcomes for rehabilitation clients.

Previous studies support these findings that the efficacy of telerehabilitation interventions is not greater than or equivalent to traditional rehabilitation interventions. Werneke and colleagues (2022) examined the association between the frequency of telerehabilitation and functional status in individuals with low back pain. The results demonstrated that although synchronous telerehabilitation had a similar effect to in-person care, asynchronous telerehabilitation interventions (interventions delivered without direct human involvement) correlated with worse functional outcomes [28]. Similarly, a systematic review and meta-analysis investigating the effects of telerehabilitation on physical functioning and pain found no significant effect that these interventions were better than face-to-face interventions [29]. The study demonstrated a similar and thorough methodology to this systematic review, however had a larger number of included studies. Furthermore, the study outlined conclusions regarding the efficacy cannot be drawn due to the low-quality evidence and limited number of trials.

Most of the studies included in this systematic review had physiotherapists implement and deliver telerehabilitation interventions compared to occupational therapists. Both the OT and PT studies examined outcomes such as pain ratings, pain triggers, and patient satisfaction. Although the OT study included in this systematic review was not an RCT, the researchers concluded that OTs favored hybrid models (combination of telerehabilitation and in-person care) [30]. Additionally, from most PT studies included, mixed results were found, ultimately, authors concluding that telerehabilitation produces similar effects of in-person care. OTs focused on restoring function and meaning clients experience from day-to-day activities and occupations; whereas PT aims to restore movement and functioning in clients [31]. Therefore, a PT greatly benefits from in-person assessments to provide manual therapy depending on the severity of the individual’s dysfunction [31]. Furthermore, the treatment techniques of PT include exercise, massages, and balance-strengthening techniques to improve motor impairment and physical function. OT utilizes techniques which focus on coping skills, manipulating environments, and implementing tools and equipment to complete activities of daily living [31]. Thus, the current findings and discussion propose that telerehabilitation is more effective in a hybrid model rather than as a primary intervention.

Due to the high heterogeneity and non-significant effects of the meta-analysis, it is reasonable to suggest that the impact of telerehabilitation interventions varies across situations or populations. Given limited studies reported the mean age of participants, age was not examined as a moderator variable. A major methodological limitation of the included studies was the incompletion of follow-ups. Some RCTs outlined short-term and long-term follow-up measures to be collected to evaluate the effectiveness of telerehabilitation interventions. However, due to attrition rates and unreachable clients, long-term follow-up measures were affected. The incompletion of follow-up measures impacts the validity of the studies as the long-term effects of telerehabilitation are inconclusive. Also, studies that completed long-term follow-up measures for telerehabilitation interventions included a smaller sample, thus, the validity of results were low. Although blinding is not mandatory when conducting RCTs, it is critical to the validity of the study. The absence of blinding of participants was detected in some studies included in this review. This may have increased participant’s positive subjective responses toward their well-being in the telerehabilitation intervention, thus compromising the validity of the studies. However, previous literature has suggested that older populations experience greater difficulty with telerehabilitation interventions. In one study, researchers found the effectiveness of telerehabilitation in elderly clients was dependent on their level of computer literacy, the simplicity and complexity of the telerehabilitation intervention, and the specific health condition being treated [32]. Furthermore, most of the studies in this systematic review were conducted in developed countries including, the United States, Netherlands, Australia, and China. Despite such countries' greater technological advances, challenges arise to utilize telerehabilitation interventions successfully. For example, the accessibility of greater quality and advanced technological infrastructure is dependent on individual income.

Telerehabilitation is considered an effective alternative to traditional rehabilitation interventions as it can be implemented into pain management for those who face difficulties in travel. In analyzing the effectiveness of telerehabilitation on pain reduction in populations with shoulder pain, Gava and colleagues (2022) found no statistically significant effect of this intervention in improving pain. Thus, although telerehabilitation is viewed as an alternative treatment to improve pain reduction, it should not be considered the primary treatment [33]. These findings translate to telehealth for mental health outcomes as well. A systematic review and meta-analysis assessing the effectiveness difference between telehealth psychotherapy interventions and face-to-face psychotherapy did not find a significant effect to support telehealth interventions [34]. Given the meta-analysis found no significant differences between telerehabilitation and face-to-face interventions, telerehabilitation can be considered as effective as in-person rehabilitation. As mentioned earlier, it is important to consider the population and context in which telerehabilitation is delivered and the differences in the way it is delivered. The majority of the studies included in this systematic review were organized under interventions delivered via technology, without direct human involvement. Current literature has explored the differences between synchronous and asynchronous deliveries of telerehabilitation. Costa and colleagues (2021) conducted a study comparing synchronous and asynchronous tele-exercise in individuals with spinal cord injury. The results demonstrated no significant differences between either mode of telehealth delivery; however, greater weekly training loads were found for synchronous tele-exercise [35]. Similarly, an RCT led by Timurtas and colleagues examining the effectiveness synchronous and asynchronous telerehabilitation interventions in individuals with non-specific lower back pain found that both synchronous and asynchronous telerehabilitation methods produced similar results [36]. Although, there appears to be no significant difference between synchronous and asynchronous models of telerehabilitation, one scientific review found that the majority of studies providing asynchronous telerehabilitation have been conducted with low-moderate risk patients [37]. Whereas synchronous telerehabilitation has predominantly been delivered to moderate-to-high risk patients. Therefore, the efficacy of asynchronous telerehabilitation interventions among higher risk patients has yet to be explored. In contrast, Cottrell and colleagues (2017) performed a systematic review and meta-analysis to determine the effectiveness of synchronous telerehabilitation interventions for musculoskeletal conditions among 13 studies. The authors found that both synchronous telerehabilitation and in-person care significantly improved physical functioning and disability [20]. However, a moderate effect in favor of synchronous telerehabilitation for post-intervention care was found (SMD 0.45, 95% CI 0.20–0.70, I² = 56%)[20]. As mentioned before, it is important for future studies to consider and analyze various moderator variables that can impact the effect of results, this includes age, country, income, computer knowledge, and session duration.

Telerehabilitation should be considered as a supplement to in-person care or traditional rehabilitation through a hybrid model. Previous literature has demonstrated the positive effects of the utilization of a hybrid model among multiple populations. Ganeshan and colleagues (2022) conducted a non-randomized study to evaluate and compare the clinical outcomes of cardiac rehabilitation patients receiving in-person, hybrid, and virtual rehabilitation. The hybrid model included in-person clinical assessments, 9 in-person sessions, and 7 weekly phone and video sessions (synchronous and asynchronous) across the program. The results revealed the hybrid model had similar improvements to in-person care [38]. In addition, both clients and therapists had positive attitudes and perceptions of the hybrid model. Similarly, a population-based study by Brehon and colleagues (2024) examined the effectiveness of telerehabilitation, in-person care, and a hybrid model of care in improving return to work outcomes among injured Canadian workers. The findings demonstrated that the hybrid model had the highest number of workers return to work (75.8%), and physical functioning and vitality were most improved by hybrid care [39]. Taking these findings together, as well as the results of the current systematic review, it is reasonable to conclude that telerehabilitation is as effective as in-person care. However, the gold standard of care in rehabilitation science for low-to-moderate risk patients would be a hybrid model of care to increase accessibility and frequency of care.

Several studies have also examined the effects of hybrid telerehabilitation models among patients with heart and cardiac problems. One RCT examined the heart failure patient’s quality of life and emotional health undergoing hybrid telerehabilitation treatment, including telehealth psychological counseling [40]. The results demonstrated that heart failure patients experienced greater quality of life, significant improvements in physical domains, physical functioning, vitality, and pain reduction in the hybrid telerehabilitation group compared to the usual care (in-person treatment). Yang and colleagues conducted a systematic review and meta-analysis examining the efficacy of hybrid telerehabilitation interventions among patients with cardiovascular disease. The review included eight RCTs with a little over 1500 patients. The researchers concluded that hybrid cardiac telerehabilitation interventions were as effective as conventional care in readmission rates and mortality [41]. In addition, the study found greater improvements in peak oxygen intake and the 6 min walking test for patients in the hybrid cardiac telerehabilitation group compared to the conventional care group. Thus, current research has supported the effectiveness of hybrid telerehabilitation models among heart failure patients and patients with cardiovascular disease in improving quality of life, physical domains, and psychological domains. Further research is required to establish the feasibility of hybrid telerehabilitation models among other populations such as pediatric and geriatric persons.

Hybrid models consisting of initial in-person assessment as well as synchronous and/or asynchronous telerehabilitation treatment have found to be most effective. In a matched case-controlled study, researchers compared patients who had received telehealth hybrid interventions, consisting of an average of three in-person and two telehealth sessions, to treat hand and upper limb injuries [42]. The results from the study found the hybrid groups demonstrated no differences in adverse clinical outcomes (p = 0.741) and patients had less withdrawals from service (p = 0.031). Additionally, patient participation was higher in the hybrid groups compared to in-person treatment, where seven patients withdrew. Furthermore, patient satisfaction was positive regarding usefulness, ease, and quality of care. Therapists have expressed satisfaction with hybrid models of telerehabilitation, as initial in person assessments support the development of rapport, trust, and therapist-client alliance [43, 44]. However, barriers such as limited ability for physical examination, equipment set-up, and on-going telehealth support are important to consider for time and resources [43, 44]. Despite such barriers, therapists have recognized improvements in the functional use of upper limbs in daily activities and the quality and efficiency of telehealth hybrid care [43, 44]. Implementation of hybrid models should be considered depending on the client population and severity of the impairment and/or disease. For example, therapists with client populations that require extensive and consistent physical examinations may benefit from utilizing hybrid models that include greater in-person sessions than telerehabilitation sessions.

The results of this systematic review and meta-analysis and the findings from previous studies provide evidence for the efficacy of face-to-face interventions on clinical health outcomes. Although the efficiency, cost-effectiveness, and patient satisfaction of telerehabilitation are favorable among various patient populations, improvement in physical disabilities, pain reduction, and mental health is effectively captured through traditional interventions. Two critical elements of receiving rehabilitation care are the degree of client commitment and the therapist-client relationship [45]. In comparison to telerehabilitation, in-person rehabilitation offers a therapeutic alliance in which the client and therapist can effectively communicate and agree on the treatment and establish an affective bond [46]. A systematic review analyzed the influence of therapist-client relationships on clinical outcomes in physical rehabilitation among patients with multiple health conditions. The study found a positive correlation between clinical health outcomes (i.e. physical functioning, pain, and mental health) and therapist-client alliance [46]. Therefore, it is important to recognize the factors that increase the effectiveness of in-person rehabilitation compared to telerehabilitation. Although, telerehabilitation is a viable option to aid in improving client outcomes among adults in remote locations, additional services and methods (e.g., synchronous telerehabilitation, follow-up appointments, technology education) needs to be provided to enhance treatment effects.

Limitations

This systematic review and meta-analysis identified three limitations. First, the completed meta-analyses found high levels of heterogeneity across the studies. Therefore, the study cannot confidently conclude that the effects are strictly due to the intervention itself. However, categorization of the included studies based on the ICHI Telehealth classification yielded low levels of heterogeneity. Thus, future studies are encouraged to explore additional third variables that can impact the delivery and effectiveness of telerehabilitation interventions. Examples of these variables are discussed in the next section. Secondly, the studies included in this systematic review had small sample sizes, with the largest RCT sample size being 109 participants [47]. It is possible that due to the small sample sizes the data may have been skewed. Furthermore, small sample sizes are likely to result in false positives, effecting the internal validity of the studies. Lastly, the specific characteristics of the interventions were not examined. The specific characteristics of the studies' interventions should have been examined to control confounding variables. Furthermore, examining such characteristics would provide insight into unique characteristics of telerehabilitation interventions that work well and unique characteristics that posit challenges.

Implications and Future Directions

Despite the findings of this systematic review, telerehabilitation is a promising tool for increasing health delivery services. This study suggests that the effectiveness of face-to-face interventions is difficult to replicate through telerehabilitation interventions, and more research needs to be conducted to explore the possible reasons for such differences. The delivery of high-quality rehabilitation treatment is often met with barriers for vulnerable client populations such as travel distance, costs, efficiency, and management [1]. Thus, telerehabilitation should not be disregarded as a primary intervention, but as part of supplementary intervention plan among occupational and physical therapists, and other healthcare fields. However, the efficacy of telerehabilitation in enhancing health outcomes across multiple client populations is low. Thus, future studies are encouraged to assess and consider additional factors when investigating the effects of telerehabilitation include frequency of appointments, follow-up times, client confidence, client satisfaction, and subjective improvement.

Conclusions

This review set out to evaluate the literature on the effectiveness of telerehabilitation compared to in-person services for OT and PT treatment. Our findings suggest telerehabilitation interventions do not significantly affect client physical and mental health outcomes. With the increase in physical and mental impairments, it is important to improve the accessibility of healthcare through solutions such as extending telerehabilitation services. Thus, ongoing research is necessary to identify whether telerehabilitation can serve as an alternative to in-person services for OT and PT. Future studies may consider additional factors such as client satisfaction and subjective improvement.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Appendix

See Table 5.

Table 5.

Appendix A

Database	Search strategy
Ovid MEDLINE	(e-health or ehealth).tw, kf exp speech therapy/ exp occupational therapy/ telemedicine/or telerehabilitation/or telehealth/ or telepsychiatry/ (telemedicine or tele medicine or tele-medicine or telerehab* or telepsychiatr*).tw,kf (text messag* or video conferenc*).tw,kf ((online or web or remote* or virtual or digital) adj1 (intervention* or therap* or aftercare or rehab* or consult*)).tw,kf occupational therapist/or physical therapist/or speech therapist/ exp physical therapy/ 1 or 4 or 5 or 6 or 7 2 or 3 or 8 or 9 10 and 11
Embase	(e-health or ehealth).tw,kw exp speech therapy/ exp occupational therapy/ telemedicine/ or telerehabilitation/or telehealth/or telepsychiatry/ (telemedicine or tele medicine or tele-medicine or telerehab* or telepsychiatr*).tw,kw (text messag* or video conferenc*).tw,kw ((online or web or remote* or virtual or digital) adj1 (intervention* or therap* or aftercare or rehab* or consult*)).tw,kw occupational therapist/or physical therapist/or speech therapist/ exp physical therapy/ 1 or 4 or 5 or 6 or 7 2 or 3 or 8 or 9 10 and 11
APA PsycINFO	(ehealth or e-health).ti,ab,id exp speech therapy/ exp occupational therapy/ telemedicine/or telerehabilitation/or telehealth/or telepsychiatry/ (telemedicine or tele medicine or tele-medicine or telerehab* or telepsychiatr*).ti,ab,id (text messag* or video conferenc*).ti,ab,id ((online or web or remote* or virtual or digital) adj1 (intervention* or therap* or aftercare or rehab* or consult*)).ti,ab,id occupational therapist/or physical therapist/or speech therapist/ exp physical therapy/ 1 or 4 or 5 or 6 or 7 2 or 3 or 8 or 9 10 and 11
CINHAL	S1: (MH "Telemedicine + ") OR (MH "telerehabilitation") OR (MH "telepsychiatry")OR (MH "telehealth") OR (MH "text messaging") OR (MH "videoconferencing") S2: “ehealth” S3: “e-health” S4: (virtual N2 (therapy or care or rehab* or consult* or intervention)) OR ( online N2(therapy or care or rehab* or consult* or intervention)) OR (remote N2 (therapy or care or rehab* or consult* or intervention))OR ( web N2 (therapy or care or rehab* or consult* or intervention)) OR ( digital N2(therapy or care or rehab* or consult* or intervention)) S5: (MH "rehabilitation") OR (MH "occupational therapy") OR (MH "occupational therapy service") OR (MH "home occupational therapy") OR (MH "occupational therapy practice") OR (MH "occupational therapy assistants") S6: S1 OR S2 OR S3 OR S4 S7: (MH "physical therapy") OR (MH "physical therapy assessment") OR (MH "physical therapist assistants") OR (MH "home physical therapy") OR (MH "physical therapy service") S8: physical therapist or occupational therapist or speech therapist S9: (MH "speech and language assessment") OR (MH "speech therapy") OR (MH" language therapy") OR (MH "alternative and augmentative communication") OR (MH" rehabilitation, speech and language") S10: S5 OR S7 OR S8 OR S9 S11: S6 and S10
SCOPUS	“Telemedicine” OR “telerehabilitation” OR “telehealth” OR “ehealth” OR “e-health” OR “telepsychiatry” (online or web or remote* or virtual or digital) w/1 (intervention* or therap* or aftercare or rehab* or consult*)) “occupational therap*” OR “physical therap*” OR “speech therap* #1 AND #2 #3 AND #4

Author Contributions

Behdin Nowrouzi-Kia and Gobika Sithamparanathan contributed to the study conception, research scope, and design. Sharan Jaswal and Joyce Lo completed the data collection, critical analysis, and manuscript composition and preparation. Yifan Hao and Shangkai Zhu completed the meta-analyses. Aaron Howe and Sharan Jaswal completed the interpretation of the results. The first draft was written by Sharan Jaswal, and all authors commented and revised previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The authors declare no funds, no grants, or other support received during the preparation of this manuscript.

Data Availability

The protocol for this systematic review can be found in the BMC—Journal of Systematic Reviews. Link: https://link.springer.com/article/10.1186/s13643-023-02248-8.

Declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical Approval

Not applicable.

Consent to Participate

Not applicable.

Consent for Publications

Not applicable.