PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2021;101:1–18

DOI: 10.1093/ptj/pzab053
Advance access publication date February 9, 2021
Review

Effectiveness of Telerehabilitation in Physical Therapy:

A Rapid Overview
Pamela Seron, PT, PhD, MSc1 ,* , María-Jose Oliveros, PT, MSc1 ,
Ruvistay Gutierrez-Arias, PT, MSc2 , Rocío Fuentes-Aspe, PT, MSc1 ,
Rodrigo C. Torres-Castro, PT, MSc3 , Catalina Merino-Osorio, PT, MSc4 ,
Paula Nahuelhual, PT, MSc5 ,6 , Jacqueline Inostroza, PT, MSc7 , Yorschua Jalil, PT, MSc8 ,9 ,

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Ricardo Solano, PT, MSc10 , Gabriel N. Marzuca-Nassr, PT, PhD7 , Raul Aguilera-Eguía, PT, MSc11 ,
Pamela Lavados-Romo, PT, MSc12 , Francisco J. Soto-Rodríguez, PT, MSc13 ,14 ,
Cecilia Sabelle, PT, MSc15 ,16 , Gregory Villarroel-Silva, PT, MSc17 ,18 , Patricio Gomolán, PT, MSc19 ,
Sayen Huaiquilaf, PT20 , Paulina Sanchez, PT21
1 Internal Medicine Department and CIGES, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
2 Instituto Nacional del Tórax and Escuela de Kinesiología, Facultad de Ciencias de la Rehabilitación, Universidad Andres Bello, Santiago,
Chile
3 Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile
4 Carrera de Kinesiología, Facultad de Medicina, Clínica Alemana- Universidad del Desarrollo, Santiago, Chile
5 Departamento de Evaluación de Tecnologías Sanitarias y Salud Basada en Evidencia, Ministerios de Salud, Santiago, Chile
6 Facultad de Medicina, Clínica Alemana de Santiago – Universidad del Desarrollo, Santiago, Chile
7 Internal Medicine Department, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
8 Escuela de Kinesiología, Facultad de Ciencias de la Rehabilitación, Universidad Andres Bello
9 Programa de Doctorado Ciencias Medicas, Pontificia Universidad Católica de Chile, Escuela de Medicina, Santiago, Chile
10 Medical Specialties Medicine Department, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
11 Departamento de Salud Pública and Carrera de Kinesiología, Facultad de Medicina, Universidad Católica de la Santísima Concepción,
Concepción, Chile
12 Departamento Ciencias Preclínicas, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
13 Internal Medicine Department, Faculty of Medicine, Universidad de La Frontera
14 Facultad de Ciencias de la Salud, Carrera de Kinesiología, Universidad Autónoma de Chile, Temuco, Chile
15 Universidad Santo Tomás, Temuco, Chile
16 Servicio de Salud Araucanía Sur, Temuco, Chile
17 Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
18 Hospital Josefina Martínez, Santiago, Chile
19 Escuela de Medicina, Universidad de Santiago de Chile, Santiago
20 Pediatrics and Child surgery Department, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
21 Hospital Dr. Hernán Henríquez Aravena, Temuco, Chile

*Address all correspondence to Dr Seron at: pamela.seron@ufrontera.cl

Abstract
Objective. The purpose of this article was to summarize the available evidence from systematic reviews on telerehabilitation
in physical therapy.
Methods. We searched Medline/PubMed, EMBASE, and Cochrane Library databases. In addition, the records in PROSPERO
and Epistemonikos and PEDro were consulted. Systematic reviews of different conditions, populations, and contexts—
where the intervention to be evaluated is telerehabilitation by physical therapy—were included. The outcomes were clinical
effectiveness depending on specific condition, functionality, quality of life, satisfaction, adherence, and safety. Data extraction
and risk of bias assessment were carried out by a reviewer with non-independent verification by a second reviewer. The
findings are reported qualitatively in the tables and figures.
Results. Fifty-three systematic reviews were included, of which 17 were assessed as having low risk of bias. Fifteen reviews
were on cardiorespiratory rehabilitation, 14 on musculoskeletal conditions, and 13 on neurorehabilitation. The other 11 reviews
addressed other types of conditions and rehabilitation. Thirteen reviews evaluated with low risk of bias showed results in

Received: October 31, 2020. Revised: December 20, 2020. Accepted: January 11, 2021
© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommo
ns.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is
properly cited. For commercial re-use, please contact journals.permissions@oup.com
2 Telerehabilitation: An Overview

favor of telerehabilitation versus in-person rehabilitation or no rehabilitation, while 17 reported no differences between the
groups. Thirty-five reviews with unclear or high risk of bias showed mixed results.
Conclusions. Despite the contradictory results, telerehabilitation in physical therapy could be comparable with in-person
rehabilitation or better than no rehabilitation for conditions such as osteoarthritis, low-back pain, hip and knee replacement,
and multiple sclerosis and also in the context of cardiac and pulmonary rehabilitation. It is imperative to conduct better quality
clinical trials and systematic reviews.
Impact. Providing the best available evidence on the effectiveness of telerehabilitation to professionals, mainly physical
therapists, will impact the decision-making process and therefore yield better clinical outcomes for patients, both in these
times of the COVID-19 pandemic and in the future. The identification of research gaps will also contribute to the generation
of relevant and novel research questions.
Keywords: Digital Health, E-Health, Remote Physical Therapy, Telehealth, Telemedicine, Telerehabilitation

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Introduction available that many systematic reviews have summarized the
Rehabilitation is necessary to improve people’s ability to live, scattered and contradictory findings.15–23
work, and learn as much as possible and to maximize their To provide support to rehabilitation professionals, mainly
functionality and quality of life. The impact extends to the physical therapists, with the best evidence available, this study
community, society, and the economy.1,2 While rehabilitation aims to summarize the available information from systematic
is a comprehensive, multicomponent, and multidisciplinary reviews on telerehabilitation in physical therapy in terms of
intervention, the specific health condition and other determi- clinical effectiveness, functionality, and quality of life. Addi-
nants of the health system or resources available determine the tionally, adherence, satisfaction, and safety outcomes are eval-
minimum components required, which often include physical uated.
therapy.
Physical therapist interventions are required when move- Methods
ment and function are threatened to develop, maintain, and
reestablish movement and functional capacity under the con- An overview was conducted in a rapid review format
sideration that functional movement is fundamental to health adhering to the PRISMA declaration for systematic reviews.24
and an optimal quality of life.3 The protocol is registered in PROSPERO under number
Despite the knowledge of the benefits of rehabilitation and CRD42020185640, and the methodology has already been
physical therapy, these services are under-used.4 If to this is extensively described elsewhere.25 Likewise, the critical
added, on the one hand, that services or patient resources methods aspects of the overview are described below.
are scarce,5 and on the other that high demand leads to the
saturation of services and the generation of waiting lists,6 the Data Sources and Searches
limitation of access becomes a reality. A systematic search was carried out in electronic databases
In this scenario, where rehabilitation is necessary but (Medline/PubMed, EMBASE, Cochrane Library) up to May
insufficiently implemented, alternative rehabilitation models 4, 2020. The search strategy is available in Supplementary
have been created using new resources such as digital practice Table 1. In addition, the records in PROSPERO and the
to improve coverage. Thus, telerehabilitation, considered a filtered databases Epistemonikos and PEDro were consulted.
branch of telehealth, is set up as a system for the control No restriction on language or date was applied.
or monitoring of remote rehabilitation using telecommu-
nications technologies, the purpose of which is to increase
accessibility and improve continuity of care in vulnerable, Study Selection
geographically remote populations with disabilities with Systematic reviews about several conditions of interest
the potential for saving time and resources in health (musculoskeletal, neurological, respiratory, cardiovascular,
care.7,8 etc), populations (infants, children, adults, and the elderly),
In the context of infection by SARS-CoV-2 and the spread and contexts (primary, secondary, and tertiary or specialist
of the COVID-19 pandemic, health services have had to adapt attention) were considered eligible if they included an explicit
and prioritize safe delivery of care, limiting outpatient care. systematic review methodology and the primary studies
Thus, in addition to finding a way to address patients affected included were clinical trials. If a systematic review included
by COVID-19, an innovative method had to be found to studies with other designs, they were considered only if they
provide rehabilitation or physical therapy.9,10 Although the contained disaggregated data from clinical trials.
main task is to contain the spread of the infection and treat Systematic review protocols and conference proceedings
patients affected by COVID-19, health systems cannot ignore were excluded if the full text was not available.
other health problems that will inevitably require attention in The intervention must have been telerehabilitation by phys-
the future. This crisis will undoubtedly impact the way health ical therapy, defined as the provision of rehabilitation with
services work, and telerehabilitation could become a standard interventions in any area of physical therapy carried out
way of working since the previously identified barriers have remotely or outside a usual session by a therapist distant
had to be quickly overcome.11,12 from the patient and using telecommunications technologies.
There are several telerehabilitation models implemented A systematic review was included if it considered comprehen-
globally.13,14 There are also many studies that have examined sive telerehabilitation with at least 1 component of physical
its effectiveness. To date, so many telerehabilitation trials are therapy or if it contained a physical therapy treatment only.
Seron et al 3

Physical therapy had to be therapeutic exercises, functional Results

training, manual therapy, respiratory techniques and exer- Study Selection
cises, integumentary repair and protection techniques, elec- In the initial search of electronic databases, 3298 potential
trotherapy and physical agents, or education as defined by the studies were identified. Additionally, 8 records were identified
World Confederation for Physical Therapy.3 through searches of filtered databases. After elimination of
Reviews were excluded if they focused on physical activity duplicates, 3089 unique entries were obtained, which were
without considering clinical outcomes (eg, blood pressure screened by title and abstract, excluding 2830 studies because
control) and on self-management of health conditions (eg, they did not meet at least 1 of the eligibility criteria of our
hypertension) where exercise and its effect on a clinical out- overview. Of the 259 studies reviewed in full text, 206 were
come were not included. Similarly, reviews were excluded that excluded, with 53 systematic reviews finally being included.
considered mobile applications and monitors (eg, pedometer) Supplementary Figure 1 shows the PRISMA flowchart and
without involving the active action of a physical therapist. the reasons for excluding studies at the full-text stage are
Finally, systematic reviews assessing virtual reality, without presented in Supplementary Table 2.
remote supervision by a therapist and not performed outside

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the health center, were also excluded.
Regarding comparisons, reviews were included if the tel- Characteristics of Included Studies
erehabilitation was compared with usual rehabilitation (in- Twenty-one reviews were performed in Europe, 12 in Oceania,
person rehabilitation or center-based rehabilitation) or no 11 in North America, 7 in Asia, 1 in Africa, and 1 in South
rehabilitation (including usual care and waiting list). America. All 53 reviews included 754 studies, of which 425
Primary outcomes that had to be included in the reviews were included because they were clinical trials and considered
were clinical effectiveness for each condition (eg, decreasing outcomes of interest. Regarding synthesis, 26 were systematic
low-back pain). Functionality was defined as the physical reviews with qualitative synthesis only and 27 included a
abilities that enable functional independence and enhance meta-analysis.
health-related quality of life (HRQL). Secondary outcomes The most common areas of physical therapy included were:
were satisfaction with the care, adherence, and adverse cardiorespiratory rehabilitation (15 studies), musculoskeletal
effects. rehabilitation (14 studies), and neurorehabilitation (13 stud-
The selection process was performed in the Rayyan soft- ies). The other 11 reviews addressed other or mixed types of
ware26 by 2 investigators, first screening by title and abstract conditions and rehabilitation.
and then by reviewing full texts of the relevant records. The Most of the studies included adults (n = 41), older people
discrepancies were resolved by a third reviewer with more (n = 2), the infant population (n = 2), and others (n = 8).
than 10 years of experience. In addition to physical therapists, other professionals par-
ticipated, including psychologists (24 reviews), nurses (15
Data Extraction and Quality Assessment reviews), physicians (13 reviews), occupational therapists (8
The relevant information from each eligible document was reviews), and speech therapists (4 reviews).
extracted through the REDCap platform (Research Electronic
Data Capture software).27 The risk of bias of the included Characteristics of Interventions
reviews was assessed with the Risk of Bias in Systematic The most common interventions were therapeutic exercises
Reviews (ROBIS) tool.28 ROBIS was applied in 3 consecutive (48), functional training (27), and education (25). Three
phases. First, the relevance of the review for the research reviews included only synchronous interventions, and 1
question was assessed. Then, concerns with the review pro- included solely asynchronous interventions. Most of the
cess were identified for 4 domains: study eligibility criteria, reviews (49) included mixed interventions. The majority
identification and selection of the studies, data collection of the platforms implemented to deliver the rehabilitation
and study appraisal, and synthesis and findings. Finally, a were webpages in 43 reviews, phone calls in 37 reviews,
judgment of overall bias in the review was generated. Both the teleconference software in 31 reviews, and messaging services
data extraction and the appraisal with ROBIS were performed in 14 reviews. Virtual reality, understood as its use with remote
by 1 investigator, and a non-independent verification was assistance by the therapist, was also used and reported in 9
carried out by a second experienced investigator. Additionally, reviews.
information related to the methodological quality or risk of
bias of the primary studies contained in the reviews assessed
as having a low risk of bias was extracted to consider this Comparisons
aspect in formulating the conclusions of the overview. The comparisons evaluated were telerehabilitation versus in-
person rehabilitation (or usual rehabilitation) in 24 reviews,
Data Synthesis and Analysis telerehabilitation versus no rehabilitation (or usual care or
A qualitative report of the characteristics and effectiveness waiting list) in 27 reviews, and mixed comparisons (eg, tel-
findings is summarized in the figures and tables by clinical erehabilitation plus in-person intervention versus in-person
area of rehabilitation or physical therapist interventions. In intervention alone) in 22 reviews.
the design and presentation of the tables and figures, the risk
of bias of the included reviews is considered. Outcomes
The most-reported outcomes were clinical effectiveness in
Role of the Funding Source 48 reviews, functionality in 35 reviews, quality of life in 32
The funder played no role in the design, conduct, or reporting reviews, user satisfaction and adherence in 15 reviews each,
of this study. and adverse events in 13 reviews.
4 Telerehabilitation: An Overview

Characteristics by Area The ratings for each of the 4 domains in the ROBIS
Specific characteristics of included reviews are presented in tool and the overall evaluation for the included reviews
Table 1 for musculoskeletal, neurological, cardiopulmonary, by clinical area are presented in Table 2. Complementarily,
and other health conditions. Supplementary Table 1 shows the reported assessment of the
methodological quality or risk of bias of the primary studies
Musculoskeletal Rehabilitation included, specifically in the systematic reviews evaluated as
having a low risk of bias.
Musculoskeletal rehabilitation was reported in 14 systematic
reviews,16,22,29–40 including 6 reviews that reported meta-
analyses. The majority of conditions included were low- Effect of Interventions
back pain, hip arthroplasty, total knee arthroplasty, and Supplementary Tables 4–7 show specific findings for several
osteoarthritis, and the most common outcomes reported comparisons in each review included with the specification of
were pain intensity as an expression of clinical effectiveness, outcomes and their measurements, source of results, conclu-
functionality—mostly measured by the WOMAC tool—and sion of the review authors, and risk of bias overall evaluation.

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HRQL.
Musculoskeletal
Neurorehabilitation A summary of results is presented in Figure 1. Only 1 low
Neurorehabilitation was reported in 13 systematic reviews,17, risk of bias review compared telerehabilitation with in-person
20,41–51 including 7 reviews that reported meta-analyses. The rehabilitation. This review reported the effectiveness of tel-
majority of conditions included were stroke, multiple sclero- erehabilitation for clinical (pain intensity) and functionality
sis, and physical impairment in children. The most common outcomes and no difference between groups for HRQL in
outcomes reported were motor function, mobility, balance, unspecified musculoskeletal conditions.29
activities of daily living, and HRQL. Seven low risk of bias reviews compared telerehabilitation
with a control group without rehabilitation. Of these, 6, 4,
Cardiorespiratory Rehabilitation and 1 reviews reported no difference between groups for
clinical effectiveness evaluated as pain intensity,29–31,33–35
The cardiorespiratory rehabilitation was reported in 15 functionality,29,30,34,35 and HRQL,34 respectively. On the
systematic reviews,15,19,21,52–63 including 9 reviews that other hand, 2 reviews showed differences between groups
reported meta-analyses. The majority of conditions included in all primary studies included in favor of telerehabilitation
were coronary artery disease, heart failure, and chronic for functionality in patients with osteoarthritis of knee31 and
obstructive pulmonary disease (COPD). The most common with low-back pain.32 Another 5 reviews reported better
outcomes reported were related to clinical effectiveness as results of telerehabilitation for HRQL, specifically in low-
exercise capacity and HRQL. back pain,30,32 symptomatic osteoarthritis of the knee,31
total knee,33,35 and hip arthroplasty.35 Additionally, 1 review
Others Health Conditions reported clinical effectiveness for pain in 1 of 3 primary
Other types of rehabilitation were reported in 11 studies and for pain-related disability in non-specific low-
reviews,8,18,64–72 of which 5 included meta-analyses. The back pain.32 Only 1 review considered the other outcomes,
majority of conditions covered were associated with metabolic reporting no differences for satisfaction and adherence but
disorders (such as obesity or diabetes) and cancer. The most more adverse effects for the intervention group.35
common outcome reported was physical or exercise capacity. Another 6, 3, and 3 reviews evaluated as having a high risk
of bias, reported no differences between telerehabilitation
Risk of Bias and in-person rehabilitation groups for clinical effec-
Of the 53 reviews included, 35 were relevant for the research tiveness,22,36–40 functionality,36,37,39 and HRQL,22,37,38
question while the other 18 were partially relevant. Regarding respectively. For the same comparison, 3 reviews reported
the overall review process, 17 (32%) reviews were assessed as better functionality in the telerehabilitation group,16,38,40
having a low risk of bias, 24 (45%) as having a high risk of and 1 review showed same result in some primary studies
bias, and 12 (23%) as having an unclear risk of bias in the included.22 On the other hand, for the telerehabilitation ver-
evaluation with the ROBIS tool. sus no-rehabilitation comparison, 1 high-risk-of-bias review
By clinical area, there were 7 of 14 (50%) musculoskele- showed better health status with telerehabilitation,36 and
tal,16,22,36–40 4 of 13 (31%) neurological,17,20,50,51 and 7 of another high-risk-of-bias review reported better effectiveness
15 (46%) cardiovascular15,19,21,60–63 reviews considered to for pain and functionality in some primary studies included.16
be at high risk of bias, while 5 of 11 (46%) also had a high
risk of bias assessment in reviews covering other health condi- Neurorehabilitation
tions.68–72 On the other hand, musculoskeletal, neurological, A summary of results is presented in Figure 2. Three low-risk-
cardiovascular, and other health conditions were evaluated as of-bias reviews compared telerehabilitation with in-person
being at low risk of bias in 7 (50%),29–35 3 (24%),41–43 4 rehabilitation. One, 2, and 1 reviews reported no difference
(27%),52–55 and 3 (27%)18,64,65 reviews, respectively. between groups for clinical effectiveness evaluated as bal-
The domain with the greatest concerns was synthesis and ance,42 functionality,42,51 and HRQL,42 respectively. Two
findings, with 22 (42%) reviews assessing it as being at high reviews showed better results in telerehabilitation groups for
risk of bias, and 12 (23%) reviews as being at an unclear risk balance41 and physical activity51 in patients with multiple
of bias. Meanwhile, the domain with the best rating was that sclerosis. Two reviews considered other outcomes showing no
of data collection and study appraisal, with 37 (70%) reviews adverse effects41 and no differences for satisfaction42 in the
being evaluated as at low risk of bias. telerehabilitation group.
 Seron et al
Table 1. Characteristic of Included Reviewsa

No. of
No. of

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Studies
Specific Studies Physical Therapist Characteristics of Type of
Author/Year Search Date Included in
Population/Ages Included in Intervention Telerehabilitation Synthesis
Original
Overviewb
Review
Telerehabilitation in musculoskeletal conditions
Cottrell et al, November 2015 Any diagnosed primary 13 7 Therapeutic exercises, Mixed (synchronous and Qualitative
201729 musculoskeletal functional training and asynchronous) phone, and
condition/>19 y education internet quantitative
Dario et al, August 2015 Non-specific low-back 11 8 Therapeutic exercises Mixed (synchronous and Qualitative
201730 pain/>19 y and education asynchronous) phone, and
internet quantitative
Heapy et al, September 2014 Chronic, noncancer, 44 4 Therapeutic exercises Mixed (synchronous and Qualitative
201536 nonheadache pain/> and functional training asynchronous) phone,
19 y internet
Jansson et al, February 2020 Total hip arthroplasty 9 7 Therapeutic exercises, Mixed (synchronous and Qualitative
202022 and total knee functional training, and asynchronous) phone,
arthroplasty/>19 y education internet, devices
Jiang et al, May 2016 Total knee 4 4 Therapeutic exercises Synchronous internet, devices Qualitative
201840 arthroplasty/>65 y and
quantitative
Joice et al, 1996 to May 2016 Total knee 17 3 Therapeutic exercises Mixed (synchronous and Qualitative
201737 arthroplasty/19 y or asynchronous) phone,
more internet
Grona et al, December 2016 Chronic 17 2 Therapeutic exercises Synchronous internet Qualitative
201838 musculoskeletal and education
disorders (>3 mo
duration)/>19 y
Schäfer et al, July 2017 Symptomatic unilateral 7 6 Therapeutic exercises Synchronous phone, devices Quantitative
201831 or bilateral
Osteoarthritis of
knee/all ages
Nicholl et al, 2000 to March Non-specific low-back 9 3 Therapeutic exercises, Mixed (synchronous and Qualitative
201732 2016 pain/19 y or more manual therapy, asynchronous) phone,
physical therapy, and internet
education
Pastora-Bernal 2000 to October Surgical procedures as 15 9 Therapeutic exercises Mixed (synchronous and Qualitative
et al, 201739 2016 result of orthopedic asynchronous) phone,
condition/>19 y internet
Pietrzak et al, November 2011 Osteoarthritis/>19 y 5 3 Therapeutic exercises Mixed (synchronous and Qualitative
201316 and use of physical asynchronous), internet
agents

(Continued)

5
 6
Table 1. Continued

No. of
No. of
Studies
Specific Studies Physical Therapist Characteristics of Type of
Author/Year Search Date Included in
Population/Ages Included in Intervention Telerehabilitation Synthesis

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Original
Overviewb
Review
Shukla et al, 2014 Total knee 6 2 Therapeutic exercises Mixed (synchronous and Qualitative
201733 arthroplasty/>65 y and functional training asynchronous) phone, and
internet quantitative
Srikesavan et al, January 2016 Clinical diagnosis of 4 3 Therapeutic exercises, Mixed (synchronous and Qualitative
201934 rheumatoid functional training, asynchronous) phone,
arthritis/>19 y manual therapy, and internet, devices
education
Wang et al, November 2018 Total hip arthroplasty 21 14 Therapeutic exercises Mixed (synchronous and Qualitative
201935 and total knee and functional training asynchronous) phone, and
arthroplasty/>19 y internet, devices quantitative
Telerehabilitation in neurological conditions
Appleby et al, November 2019 Stroke survivors/> 18 y 13 10 Neurorehabilitation Mixed (synchronous and Qualitative
201944 asynchronous)
Videoconferencing, virtual
reality, messaging, phone,
devices
Camden et al, March 2018 Children with 23 4 Neurorehabilitation Mixed (synchronous and Qualitative
201947 disabilities/>12 y asynchronous) webpage,
videoconferencing, virtual
reality, phone, devices
Chen et al, March 2015 Stroke survivors/> 18 y 11 8 Neurorehabilitation Mixed (synchronous and Quantitative
201545 asynchronous) phone,
videoconferencing,
robot-assisted rehabilitation,
virtual reality
Di Tella et al, December 2018 Multiple sclerosis/all 10 5 Integrated rehabilitation Mixed (synchronous and Quantitative
202050 ages approach (ITA) asynchronous) phone, email,
web platform
Johansson et al, November 2009 Stroke survivors/> 18 y 9 2 Neurorehabilitation Mixed (synchronous and Qualitative
201117 asynchronous) webpage,
videoconferencing, devices

Telerehabilitation: An Overview
Khan et al, July 2014 Multiple sclerosis/> 9 7 Neurorehabilitation Mixed (synchronous and Qualitative
201541 18 y asynchronous).
Videoconferencing, virtual
reality
Laver et al, June 2019 Stroke survivors/all 22 9 Neurorehabilitation Mixed (synchronous and Quantitative
202042 ages asynchronous) webpage,
videoconferencing, virtual
reality, devices, phone

(Continued)
 Seron et al
Table 1. Continued

No. of
No. of
Studies
Specific Studies Physical Therapist Characteristics of Type of
Author/Year Search Date Included in

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Population/Ages Included in Intervention Telerehabilitation Synthesis
Original
Overviewb
Review
Rintala et al, December 2015 Multiple sclerosis/> 11 7 Integral rehabilitation Mixed (synchronous and Quantitative
201843 18 y asynchronous) devices, virtual
reality, web platform, phone
Rintala et al, May 2018 Stroke survivors/all 13 7 Neurorehabilitation Mixed (synchronous and Qualitative and
201951 ages asynchronous) devices, virtual quantitative
reality, web platform, phone
Sarfo et al, June 2017 Stroke survivors/not 22 18 Neurorehabilitation Mixed (synchronous and Qualitative
201820 reported asynchronous) phone, devices,
webpage, educational
platform, virtual reality
Schröder et al, January 2018 Stroke survivor/> 18 y 7 4 Motor training, balance Mixed (synchronous and Qualitative
201946 training asynchronous) devices, virtual
reality
Tchero et al, January 2018 Stroke survivors/> 18 y 15 7 Integral rehabilitation Mixed (synchronous and Qualitative and
201848 asynchronous) web platform, quantitative
videoconferencing, devices
Xiaoyan et al, January 2019 Stroke survivors/> 18 y 11 7 Therapeutic exercise Mixed (synchronous and Qualitative and
201949 asynchronous) devices, virtual quantitative
reality, videoconferencing
Telerehabilitation in cardiopulmonary conditions
Almojaibel et al, September 2014 COPD/>19 y 7 2 Pulmonary Mixed (synchronous and Qualitative
201619 rehabilitation (aerobic asynchronous) internet, devices
and resistance exercise,
incentive of physical
activity)
Brørs et al, January 2003 to Coronary artery 24 9 Physical activity and Mixed (synchronous and Qualitative
201956 March 2018 disease/>19 y exercise management asynchronous) internet,
through exercise plans, devices, other
supervision, and
counselling
Chan et al, July 2015 COPD and with 9 8 Cardiac and pulmonary Mixed (synchronous and Qualitative and
201662 cardiovascular rehabilitation asynchronous) phone, internet, quantitative
disease/>19 y devices
Cristo et al, Not reported Cardiovascular 7 3 Cardiac rehabilitation Mixed (synchronous and Qualitative
201821 diseases/>19 y (videogames, incentive asynchronous) devices
of walking, Nordic
training,
cycle-ergometer)
Frederix et al, Not reported Cardiac patients/not 37 13 Cardiac rehabilitation Synchronism not reported Qualitative and
201563 reported and telemonitoring phone, internet, devices quantitative

(Continued)

7
 8
Table 1. Continued

No. of
No. of
Studies
Specific Studies Physical Therapist Characteristics of Type of
Author/Year Search Date Included in
Population/Ages Included in Intervention Telerehabilitation Synthesis
Original

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Overviewb
Review
Hamilton et al, August 2016 Acute coronary 9 2 Cardiac rehabilitation Mixed (synchronous and Qualitative
201860 syndrome and at least 1 asynchronous) phone
coronary risk
factor/>19 y
Huang et al, April 2014 Myocardial infarction, 9 9 Cardiac rehabilitation Mixed (synchronous and Qualitative
201552 angina, or underwent asynchronous) phone, other and
vascularization/>19 y quantitative
Hwang et al, August 2013 Cardiopulmonary 11 11 Integral rehabilitation Mixed (synchronous and Qualitative
201561 diseases/>18 y asynchronous) phone
Jin et al, April 2018 Coronary heart disease 29 26 Cardiac rehabilitation Mixed (synchronous and Qualitative
201957 with at least 3 mo asynchronous) phone, and
follow-up/>19 y internet, devices, other quantitative
Lundell et al, August 2013 COPD according to 9 7 Cardiovascular Mixed (synchronous and Qualitative
201553 GOLD, ERS, ATS, or exercises, pedometer, asynchronous) phone, and
BTS/>40 y pursed lips, relaxation internet, devices quantitative
exercises
McCabe et al, November 2016 COPD according to 3 3 Incentive of physical Mixed (synchronous and Quantitative
201758 GOLD 2016 and at any activity (pedometer, web asynchronous) internet
stage of illness/>19 y incentive, and digital
coaching)
Munro et al, May 2013 Cardiac patients/>19 y 9 7 Cardiac rehabilitation Mixed (synchronous and Qualitative
201315 asynchronous) phone,
internet
Neubeck et al, December 2008 Coronary heart disease 11 11 Cardiac rehabilitation Mixed (synchronous and Qualitative
200959 with at least 3 mo asynchronous) phone, and
follow-up/>19 y internet quantitative
Rawstorn et al, May 2015 Coronary heart 11 8 Cardiac rehabilitation Asynchronous phone Qualitative
201654 disease/>19 y and
quantitative
Su et al, April 2019 Coronary heart 14 7 Cardiac rehabilitation Mixed (synchronous and Qualitative
202055 disease/>19 y asynchronous) website, and
mobile application, email, quantitative

Telerehabilitation: An Overview
text message, phone
Telerehabilitation in other health conditions or mixed reviews
Adamse et al, 2015 Chronic pain in 16 9 Exercise, physical Mixed (synchronous and Qualitative
201866 adults/>19 y activity, or training asynchronous) phone, and
prescription internet quantitative
Agostini et al, January 2014 Different conditions 12 12 Motor training Mixed (synchronous and Quantitative
201568 with impaired motor asynchronous) phone,
function/all ages internet, devices

(Continued)
 Seron et al
Table 1. Continued

No. of
No. of
Studies

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Specific Studies Physical Therapist Characteristics of Type of
Author/Year Search Date Included in
Population/Ages Included in Intervention Telerehabilitation Synthesis
Original
Overviewb
Review
An et al, 200969 April 2009 Children and 8 8 Physical activity Mixed (synchronous and Qualitative
adolescents with incentive within asynchronous) internet
overweight/6–18 y comprehensive
rehabilitation
Connelly et al, March 2013 Type 2 diabetes in 15 5 Physical activity, Mixed (synchronous and Qualitative
201370 adults/>19 y training or exercise asynchronous) internet
prescription, education
van Egmond et al, November 2016 Cardiac, orthopedic 23 23 Physical exercise Mixed (synchronous and Qualitative
201872 surgery, and training within asynchronous) phone calls, and
oncological comprehensive internet platform, quantitative
surgery/>19 y rehabilitation videoconference and devices
Geraedts et al, July 2012 Older adults/>19 y 32 25 Structured physical Mixed (synchronous and Qualitative
201367 activity or exercise asynchronous) phone,
internet platform and devices
Huang et al, August 2014 Adults/>19 y 25 25 Exercise or physical Mixed (synchronous and Quantitative
201965 activity incentive, asynchronous) internet-based
education system, phone, text
messaging, videoconferencing
Kairy et al, 20098 February 2007 Cardiac, respiratory, 28 4 Therapeutic exercise, Mixed (synchronous and Qualitative
musculoskeletal, or functional training asynchronous) internet,
neurological within comprehensive mobile phone, devices and
conditions/>19 y rehabilitation software
Kopp et al, 201771 November 2015 Cancer survivors/all 6 3 Cardiorespiratory and Mixed (synchronous and Qualitative
ages physical training, asynchronous) phone,
education devices, apps, webpage,
virtual reality, email, text
messaging, video games
Seiler et al, 201764 November 2016 Cancer survivors with 15 2 Resistance and aerobic Mixed (synchronous and Qualitative
fatigue/>19 y exercise training asynchronous) online
interventions or smartphone
apps
Wieland et al, May 2011 Overweight or 18 13 Physical activity and Mixed (synchronous and Qualitative
201218 obesity/>18 y exercise education asynchronous) computer- and
within a weight based intervention requiring quantitative
maintenance programs user to interact directly with
computer
a ATS= American Thoracic Society; BTS = British Thoracic Society; COPD = Chronic Obstructive Pulmonary Disease; ERS = European Respiratory Society; GOLD = Global Initiative for Chronic Obstructive
b
Lung Disease. Clinical trial including physical therapy intervention and comparison group with in-person intervention, no intervention (usual care or wait list), or mixed intervention.

9
10 Telerehabilitation: An Overview

Table 2. Risk of Bias of Systematic Reviews (ROBIS) Included by Clinical Areaa

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(Continued)

Two low-risk-of-bias reviews compared telerehabilitation reviews considered the other outcomes reporting no adverse
with a control group without rehabilitation. Of these, 1, 2, and effects41,42 and no differences42 or better satisfaction41 in the
1 reviews reported no difference between groups for clinical telerehabilitation group.
effectiveness evaluated as balance,42 functionality,41,42 and Three, 2, and 1 reviews evaluated as having an unclear risk
HRQL,42 respectively. One review about multiple sclerosis of bias reported no differences for clinical effectiveness,44–46
reported clinical effectiveness for disability in 2 of 3 primary functionality,44,45 and HRQL,44 respectively, between telere-
studies and for HRQL in 2 of 4 primary studies.41 Two habilitation and in-person rehabilitation groups. For the same
Seron et al 11

Table 2. Continued

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comparison, 1 review showed mixed results for HRQL in Finally, of 4 high-risk-of-bias reviews, 1 review about multi-
patients with stroke.45 On the other hand, for the telereha- ple sclerosis reported better results for motor disability in the
bilitation versus no-rehabilitation comparison, 1 unclear-risk- telerehabilitation group compared with the in-person group
of-bias review showed better motor function in children with and no differences for functionality.50 The other 3 reviews
disabilities in the telerehabilitation group and also reported reported no differences between groups for clinical effective-
better effectiveness for functionality in some of the primary ness in stroke survivors17,20,51 in the same comparison. Addi-
studies included.47 tionally, 1 review at high risk of bias showed no differences
12 Telerehabilitation: An Overview

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Figure 1. Summary of effectiveness results of telerehabilitation in musculoskeletal conditions by risk of bias assessment.

Figure 2. Summary of effectiveness results of telerehabilitation in neurological conditions by risk of bias assessment.

between telerehabilitation and no-rehabilitation groups for for the telerehabilitation group compared with in-person
activities of daily living in stroke survivors.51 rehabilitation in clinical effectiveness measured as all-cause
mortality.52 On the other hand, 1 review with patients
with COPD53 and 2 reviews with coronary heart disease
Cardiopulmonary Rehabilitation patients54,55 reported no differences in clinical effectiveness
A summary of results is presented in Figure 3. Four reviews between groups, regardless of the comparison group. One
were evaluated as having a low risk of bias. Only 1 review review included the HRQL outcome, reporting no differences
with patients with coronary heart disease found better results between cardiac telerehabilitation and in-person cardiac
Seron et al 13

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Figure 3. Summary of effectiveness results of telerehabilitation in cardiopulmonary conditions by risk of bias assessment.

rehabilitation,52 and another review also about cardiac Other Health Conditions
rehabilitation showed mixed results for HRQL for both telere- A summary of results is presented in Figure 4. Three low-risk-
habilitation versus in-person and telerehabilitation versus no- of-bias reviews evaluated telerehabilitation (more extensive
rehabilitation comparisons.55 Finally, 1 review showed better than telemedicine) versus usual care. One reported clinical
adherence for telerehabilitation compared with usual care.54 effectiveness to decrease body mass index,65 another found
Another 4 reviews were evaluated as having an unclear risk that an eHealth intervention was effective at managing
of bias. Two of them, comparing telerehabilitation and in- fatigue in cancer survivors,64 and the last review, about
person rehabilitation in patients with coronary heart disease, overweight or obesity, reported lower weight regain in
reported contradictory results. One review found a better the intervention group.18 Two reviews also compared
HRQL in the telerehabilitation group and no> differences telerehabilitation with an in-person intervention, 1 of
for clinical effectiveness measured as exercise capacity.56 In them reported no differences between groups for physical
contrast, the other review reported no differences between capacity but better results for HRQL in the telerehabilitation
groups for HRQL in most of the primary studies included, group,64 and the other found better clinical effectiveness with
but better clinical effectiveness measured as prevention of all- telerehabilitation.18
cause mortality.57 On the other hand, for the telerehabilitation Three reviews evaluated as having unclear risk of bias
versus no-rehabilitation comparison, 2 and 1 unclear-risk- and comparing telerehabilitation with in-person intervention
of-bias reviews showed better clinical effectiveness56,59 with reported no difference between groups for clinical effective-
telerehabilitation and no difference between groups,58 respec- ness8,66,67 and HRQL.66 The same reviews also compared
tively. Two reviews reported better results for HRQL56,59 in telerehabilitation with no intervention, and while one found
some primary studies included. no difference for pain and HRQL,66 the other 2 reported
Seven reviews were evaluated as having a high risk of mixed results for clinical effectiveness.8,67
bias. Of these, 2 reviews60,61 presented no differences Three and 1 reviews with a high risk of bias compared
between groups for exercise capacity when telerehabilitation telerehabilitation with an in-person intervention and no inter-
was compared with in-person rehabilitation. One review15 vention, respectively. From the first comparison, 1 reported
reported better results with telerehabilitation for clinical a better result for clinical effectiveness measured as body
outcomes and same comparison, and mixed results were mass index with telerehabilitation69 and the other reported
reported for HRQL.15,60,61 For the telerehabilitation versus mixed results.68 A third review showed better functionality
no-rehabilitation comparison, 2, 1, and 1 reviews showed in patients undergoing surgery and mixed results for HRQL
better effectiveness for clinical outcomes,21,63 functionality,21 in primary studies.72 For the second comparison, 1 review
and HRQL,61 respectively. Another 2 and 1 reviews reported found better glycated hemoglobin control in adults with type
no differences between groups for clinical effectiveness19,62 2 diabetes with telerehabilitation.70
and HRQL,19 respectively. Finally, 1 review obtained mixed Finally, 1 review with no comparison identified reported
results for clinical effectiveness.61 mixed results for physical activity in cancer survivors.71
14 Telerehabilitation: An Overview

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Figure 4. Summary of effectiveness results of telerehabilitation in others health conditions by risk of bias assessment.

Discussion or pulmonary rehabilitation, such as COPD. In other health

Fifty-three systematic reviews on telerehabilitation in physical conditions, the most frequently addressed were cancer and
therapy were included in this overview, 27 of which also ageing, with these being observed as emerging areas.
included meta-analyses. These reviews covered different areas With respect to the means by which telerehabilitation is
of the practice of physical therapy, mainly in the musculoskele- implemented, the most frequently studied is the use of the
tal, neurological, and cardiopulmonary areas. mobile telephone with its messaging services and telephone
Although there are global reviews and overviews that assess calls, with knowledge emerging of the effectiveness of the
the effectiveness of telerehabilitation in some specific con- applications available on smartphones as a digital practice
ditions,7,13,73–75 to our knowledge this is first comprehen- tool. The internet, including web pages mainly with educa-
sive overview that compiles results on the effectiveness of tional content, videos, or interactive gaming, is also frequently
telerehabilitation, including various clinical areas in the remit studied. Studies have investigated electronic devices that are
of the physical therapist. This makes the available evidence basically used as remote monitors with physical therapy inter-
so widely applicable in different areas of rehabilitation even ventions. Also studied were specialized platforms (eg, for
more so today where, in addition to having greater access videoconferencing), especially when synchronous communi-
to various technologies, it has been made urgently necessary cation is required. Finally, and especially in the neurological
for such rehabilitation services to reach users without them area, virtual reality has been positioned as an intervention
having to leave the home because they are geographically tool, also within telerehabilitation, and was included in this
remote and due to the COVID-19 pandemic. This latter global work only if reviews explicitly stated that virtual reality was
situation has clearly produced a collateral damage to the used outside a health center.
users of rehabilitation and physical therapy services.76,77 The Other factors must be considered in the extrapolation of the
reported experiences in this scenario, although scarce,78 reveal results. One is the fact that the reviews generally include stud-
opportunities and challenges that must be faced, such as ies from the past 2 decades, during which there has been great
technological barriers, ethical and legal regulations, health technological growth at the same time as the widespread use
insurance coverage, and cultural difficulties that preclude the of these media by the population, which makes the first studies
understanding that telehealth and digital practice can be an in the area very different from the most recent. The other
effective means of rehabilitation.79 factor is that most of the reviews and their primary studies
The population for which there is effectiveness data is were concentrated in Europe, North America, and Oceania,
mainly adult, with few studies on children or adolescents. In with little information originating from low-resource settings,
the musculoskeletal area, the conditions they address include which could affect the feasibility of using the technologies
chronic musculoskeletal pain, arthroplasties, osteoarthritis, on a more global scale because these may be the places that
and low-back pain in addition to surgically treated orthopedic have the least access as well as conventional rehabilitation and
conditions. On the other hand, in the area of neurorehabilita- would benefit most from its implementation and reduce health
tion, the evidence focuses on stroke and multiple sclerosis. In disparities.
the cardiopulmonary area, the conditions are those typically Although the knowledge available with these systematic
included in cardiac rehabilitation, such as coronary disease, reviews is broad and up to date, care must be taken in the
Seron et al 15

interpretation of the results, basically due to the risk of bias Another limitation to consider in the extrapolation of the
present in the design process, conducting and analysis of the results is the fact that physical therapy can be delivered
results from the systematic reviews, as well as the risk of alone or within a more comprehensive rehabilitation program.
inherent bias in the primary studies included in them. Only Although this distinction was not specifically considered in
one-third of the reviews were assessed as having a low risk the selection criteria of most reviews or in the description of
of bias, from which interpretations and extrapolations can be interventions, it could be observed that physical therapy was
established with more certainty. Of these, however, in almost often provided with other rehabilitation interventions.
one-half of the clinical trials included, the evaluations of the Although the aim of this overview was broad, it was pos-
quality or the risk of bias were deficient, which is why the sible to cover, but it must be clearly understood that the
uncertainty about the conclusions of the reviews continues to scope of the interventions included are about physical therapy
be high. and related with therapeutic or secondary prevention and not
Although the establishment of the eligibility criteria, iden- those of assessment or primary prevention.
tification of primary studies, and data collection were not
elements of great concern, the main issue with the systematic Implications for Clinical Practice

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reviews included in this overview has to do with the pro- The available evidence shows that telerehabilitation could
cess of synthesizing and interpreting the results. A specific be comparable or better than the conventional methods of
aspect identified regards the results being synthesized in many rehabilitation to reduce pain and improve physical func-
reviews with no consideration as to which comparison groups tion in musculoskeletal conditions generally. Additionally,
were included in the clinical trials (eg, no rehabilitation or telerehabilitation could improve functionality in patients with
in-person or usual rehabilitation in a health center, an aspect osteoarthritis in the knee and non-specific low-back pain in
that is a significant source of heterogeneity). To correct this addition to improving quality of life in patients with non-
problem to some extent, efforts were made to disaggregate specific low-back pain, osteoarthritis in the knee, and total
data from the primary studies included in the reviews where it arthroplasty in the knee and hip.
was feasible to do so, because tables were available, and there In the area of neurorehabilitation, telerehabilitation seems
was a direct relation between the information they contained to contribute to balance and to increasing the levels of physical
and the information in the text and the references of the activity in patients with multiple sclerosis, but its contribution
studies, which only left a couple of reviews with a mixed in terms of balance, functionality, and quality of life in patients
comparison in results. with stroke is unclear.
Another aspect of relevance in the interpretation of the On the other hand, cardiac rehabilitation via telematic
findings was the lack of consideration of the risk of bias of means is possibly better than in-person cardiac rehabilitation
the primary studies in establishing the conclusions of some of at reducing mortality by any cause and also seems to con-
the reviews included, which may confuse readers, especially tribute to a better ability to exercise and HRQL. On the other
because the tendency in these cases is to overestimate the hand, pulmonary telerehabilitation could have results similar
effects of telerehabilitation on physical therapy. One way to to conventional rehabilitation in terms of reducing dyspnea in
be able to draw valid conclusions in systematic reviews is to patients with COPD.
associate the results of the reviews or meta-analyses, that is, Finally, the interventions performed by physical therapists
the estimator of the effect, their magnitude and accuracy, with using technological media could be effective at reducing over-
the risk of bias. This is called certainty of evidence, which can weight and obesity as well as improving the physical capacity
be addressed in the process of interpreting the findings with and quality of life in cancer survivors.
the Grading of Recommendations, Assessment, Development Clinicians must bear in mind that these conclusions come
and Evaluation (GRADE) tool,80 which was used in no more from 17 low-risk-of-bias reviews while there are another 36
than one-third of the reviews included. reviews with methodological issues and contradictory results.
Consideration must be given to interpreting the results of Regardless of this, and in a context where it is not possible
no differences between groups, a finding present in more to perform center-based or in-person rehabilitation—because
than one-half of the reviews. This may be due to the fact patients cannot access a health center, the health centers
there were effectively no differences between the groups or cannot provide services to all those who need it, or, during the
to statistical power achieved with the sum of patients in the COVID-19 pandemic, where outpatient or in-person services
studies included in the reviews being insufficient to find differ- have been reduced or suspended in many health centers—
ences. The importance here is that—although assuming that telerehabilitation seems to be a suitable and feasible strategy
telerehabilitation is not inferior to in-person rehabilitation or, to implement. On this point it must be recognized that the
on the other hand, that telerehabilitation produces the same previously identified barriers had to be circumvented quickly,
effects as not doing rehabilitation—caution should be taken in making it increasingly more likely that this form of rehabilita-
interpreting this finding in light of the accuracy of the results, tion service will become a new standard during and after this
that is, the size of the sample reached. pandemic.
This overview has some limitations related basically to
having been conducted as a rapid review, and within these Implications for Research
limitations it should be recognized that the grey literature This rapid overview provides evidence that it is necessary to
was not searched and that the data extraction process and continue research in the area of telerehabilitation. On the
evaluation of the risk of bias were not performed in duplicate, one hand, systematic reviews must improve their processes
in addition to having been conducted by a large group of of planning, execution, and synthesis of results, incorporating
reviewers, which could have affected the reliability of the data. solid methodologies such as the GRADE approach. Future
To minimize this bias, a second reviewer with experience in overviews in specific clinical areas could incorporate a global
systematic reviews extracted data and assessed the risk of bias. quantitative synthesis of results, doing new meta-analyses and
16 Telerehabilitation: An Overview

even performing analyses of indirect comparisons. On the with physical disabilities in Kampala, Uganda. A descriptive cross
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10. Turolla A, Rossettini G, Viceconti A, Palese A, Geri T.
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Writing: P. Seron, M.J. Oliveros, R. Gutierrez-Arias, R. Fuentes-Aspe, 1260–1264.
R. Torres-Castro, C. Merino-Osorio, J. Inostroza, R. Solano, 11. Quigley A, Johnson H, McArthur C. Transforming the provision
G. Marzuca-Nassr, R. Aguilera, P. Lavados-Romo, F. Soto, C. Sabelle, of physiotherapy in the time of COVID-19: a call to action for
G. Villarroel, P. Gomolán, S. Huaiquilaf, P. Sanchez telerehabilitation. Physiother Can. 2020;73:e20200031.
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R. Fuentes-Aspe, R. Torres-Castro, C. Merino-Osorio, pist practice in Portugal. Phys Ther. 2020;100:1052–1053.
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