The effectiveness of telerehabilitation in upper limb musculoskeletal disorders: a systematic review

Telerehabilitative services have been increasingly used in recent years, raising questions about their effectiveness. In musculoskeletal disorders, evidence supports telerehabilitation but methodological quality of evidence is limited and focused on lower limb disorders. Hence, this systematic review aimed to assess the effectiveness of telerehabilitation in upper limb musculoskeletal disorders.

We conducted electronic searches in MEDLINE, Embase, and AMED (up until 11/27/2024), complemented by hand searches. Randomized (RCTs) and non-randomized studies of interventions (NRSIs) assessing upper limb musculoskeletal disorders reporting on pain, activities of daily living (ADL), or health-related quality of life (HrQol) were included. We focused on studies from high-income countries in English or German. Risk of bias was assessed using RoB 2 and ROBINS-I. Standardized mean differences (SMDs) and 95% confidence intervals were derived from meta-analysis, where negative values favor telerehabilitation. Certainty of evidence was rated using GRADE. We grouped studies comparing telerehabilitation to standard care (subgrouped into in-person or minimal intervention) and separately examined studies with a tele-adjunct. Compared to in-person rehabilitation we assessed whether outcomes were similarly improved with telerehabilitation. For tele-interventions as adjunct or compared to minimal care we assessed whether telerehabilitation improved outcomes.

We included twenty RCTs representing 1,285 participants. All NRSIs were excluded due to critically high risk of bias. Compared to in-person rehabilitation, telerehabilitation showed similar improvements with very low certainty of evidence in pain (SMD: -0.33 [-1.16 to 0.5] VAS/NRS), moderate in ADL (SMD: -0.07 [-0.31 to 0.17] QuickDASH/DASH), and low in HrQol (SMD: -0.26 [-0.82 to 0.31]). Compared to brochure-based exercising, certainty of evidence was low for improved pain (SMD: -0.28 [-0.58 to 0.03]), moderate in ADL (SMD: -0.56 [-0.88 to -0.24]), and low in HrQol (SMD: -0.31 [-0.65 to 0.02]). Tele-adjunct yielded low certainty of evidence for improvements in pain (SMD: -0.38 [-0.71 to -0.05]) and moderate in ADL (SMD: -0.51 [-0.88 to -0.14).

Our results tend to support the effectiveness of telerehabilitation across different comparisons although certainty of evidence is inconclusive. Future studies should particularly investigate the non-inferiority of telerehabilitation compared to in-person rehabilitation and the added benefit of tele-adjunct.

Prospero registration ID: CRD42024622465.