Evidence of Benefit of Telerehabitation After Orthopedic Surgery: A Systematic Review

1The 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. With the general ageing of the population—at least in industrialized countries—and the limited resources devoted to public health, the development of new rehabilitation models and practices seems mandatory in order to cope with the change in population needs. Telerehabilitation, one of the emerging fields of telemedicine, is defined as a set of tools, procedures, and protocols to deliver the rehabilitation process remotely. It will be increasingly important to develop scalable and sustainable telerehabilitation programs.

2The growing demand for rehabilitation can result in increased costs and longer waiting lists, becoming a threat to the sustainability of health care services. Telerehabilitation can help with this issue by discharging patients from points of care while improving their adherence to treatment. Recent telerehabilitation studies have addressed different approaches: feasibility and efficacy, patients’ and professionals’ satisfaction, and cost analysis studies. This includes neurological diseases, stroke patients, intensive care unit, breast cancer, COPD, and musculoskeletal disorders. Although trials supporting the role of telerehabilitation continue to emerge, implementation has been slow.

3The 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.

4Early systematic reviews have pointed out that, despite the growing number of telerehabilitation experiences worldwide, evidence of clinical and economic effectiveness is still lacking. In addition, these reviews have commented on the lack of methodological rigor and variability of approaches used in telerehabilitation studies. With the growing number of telerehabilitation programs and with emerging databases providing potentially useful and reliable data on clinical outcomes, it is reasonable to expect that the number of scientific publications will rapidly increase, along with the number of systematic reviews on the topic. Systematic reviews that included telerehabilitation interventions in musculoskeletal conditions yielded a few eligible trials, so efficacy remains inconclusive. Telerehabilitation shows promise in many fields, but compelling evidence of the benefit for, and impact on, routine rehabilitation programs is still limited. There is a need for detailed, better-quality studies and for studies on the use of telerehabilitation in routine care.

5Musculoskeletal injuries are frequent events in routine care and are the most common source of chronic pain and disability. Orthopedic surgeries are experiencing some of the greatest growth rates in developed nations across the world. A study from 2014 found that the most common inpatient operating room procedure in the United States involved the musculoskeletal system. Therapeutic exercises are commonly prescribed following a surgery in an attempt to maximize functional outcome. Physical therapists have been utilizing therapeutic exercises since the conception of the profession, and they have been demonstrated to be fundamental in improving function, performance, and disability. Telerehabilitation offers the possibility to develop therapeutic exercise at a distance, among others.

6Recently, 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, telerehabilitation should be considered as a viable option in the holistic management of their musculoskeletal condition.

7Despite 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.

8This review has been carried out following the PRISMA 2009 guidelines. The review protocol was registered with an international registration database [PROSPERO, Registration Number: CRD42016047846].

9As with most of the recent systematic reviews on the topic, the following literature searches were performed to identify all possible studies that could help answer the research question. MEDLINE, Physiotherapy Evidence Database (PEDro), Scopus, PsycINFO, Web of Knowledge, CINAHL, SPORTDiscus, Directory of Open Access Journals (DOAJ), Cochrane, Embase, Academic Search Complete, Fuente Académica, and Consejo Superior de Investigaciones Científicas (CSIC) were searched. In addition, the search was performed in a relevant bibliographic database from the University of Málaga.

10The 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.

11The main steps related to the search phase are reported in Figure 1 using the PRISMA flow diagram. After the application of the selected keywords, the entire set of records was analyzed to identify eventual duplication of articles retrieved from different sources; the remaining articles were then assessed in full text for eligibility so as to identify all those matching the inclusion criteria (see Multimedia Appendix 1).

12Two 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.

13Disagreements between authors were initially resolved via discussion, and then by consultation with a third reviewer (FJBL).

14Eligibility criteria were based on the PICOS framework, as follows:

15Adults (≥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.

16Any 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.

17All 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.

18Any 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.

19All 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.

20For 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.

21An 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.

22Two 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 based on the Delphi list. It is considered a useful tool for carrying out the assessment methodology in scientific research.

23The 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. The scale includes an additional item (eligibility criteria) to evaluate the external validity, but the score is not counted.

24According to Moseley et al, studies with a PEDro score ≥5 will be considered at low risk of bias and high methodological quality.

25A 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).

26Levels 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. Grades of recommendation describe the strength and therefore value of the evidence relative to how rigorous the study was (see Tables 1 and 2).

27The main findings of this review are presented in Table 3, an evaluation of the methodological quality of the 15 studies selected according to the PEDro scale. Characteristics of the included studies are listed in Multimedia Appendix 1 showing the grades of recommendation, regarding the effectiveness, results, and effect size in the different outcomes of telerehabilitation services. A subgroup analysis by population and intervention is presented in Tables 4 and 5.

28Studies included in the review had PEDro scores of 2-8, as shown in Table 3. Studies were considered of high enough methodological quality if they had a score of at least 5. This was based on the fact that studies with a score closer to 4 did not use a triple-blind methodology (subject, evaluator, and treatment provider).

29We found 3 studies with PEDro scores between 6 and 8, which is considered level 1 evidence (good; 20% [3/15]), 4 studies with a score of 5, which is considered 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]).

30A 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).

31The 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]), and hand surgery (preclinical trials and descriptive study), have been identified in addition, but as no intervention on the subject has been published, they do not match the inclusion criteria for this review (See Multimedia Appendix 2).

32In the subgroup analysis by telerehabilitation intervention (Table 5), we found strong evidence regardless of the intervention (videoconferencing, asynchronous, phone counseling, interactive virtual system and gaming, telerehabilitation system). Therefore, we may interpret that evidence level and degree of recommendation are related to studies design, and are not related to intervention.

33We found great heterogeneity among the included studies. Sample size ranged between 5 and 237. Telerehabilitation interventions included videoconferencing sessions, phone counseling, video games, asynchronous exercise videos, and interactive virtual systems.

34Compared interventions also range between clinical protocol face-to-face physiotherapy, home physiotherapy visits and usual care at home, and a physiotherapy session followed by gaming.

35Intervention duration ranged from 2 weeks to 26 weeks with follow-up periods from 13 sessions to 9 months.

36We found some homogeneous aspects in clinical outcomes primarily in the areas of function, quality of life, and specific daily life activities, and less assessment of disability (passive and active ranges of motion, balance, and muscle strength) and pain.

37This 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).

38To 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.

39First, 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.

40Regarding 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. In our review, 60% of the included studies are of poor methodological quality with weak evidence.

41Regarding 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” and “there is unequivocal evidence that the management of musculoskeletal conditions via real-time telerehabilitation is effective in improving physical function, disability, and pain”. We agree with these statements, but only and exclusively for some pathologies. Our systematic review shows that there is still insufficient evidence on upper limb surgeries’ telerehabilitation interventions.

42Regarding 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.

43For 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.

44In 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.

45Research 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?

46During 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.

47A 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.

48It 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.

49One 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.

50How 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.

51Telerehabilitation 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.

52High-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.

53Future research recommendations for telerehabilitation should include high-quality studies with clear conclusions and statements that could improve health interventions and health policies.