Real-Time Telerehabilitation in Older Adults With Musculoskeletal Conditions: Systematic Review and Meta-analysis

Abstract

Background Real-time telerehabilitation (TR) is a new strategy for delivering rehabilitation interventions to older adults with musculoskeletal conditions, to provide continuity to conventional services and mitigate travel-related barriers. Objective We aimed to examine the effectiveness of treatment delivered via real-time TR services compared to conventional services among older adults with musculoskeletal conditions, in terms of physical performance, treatment adherence, and cost-effectiveness. Methods A literature search of randomized controlled trials (RCTs) published from January 2000 to April 2022 was conducted in six online databases: Cochrane Library, PubMed (ie, MEDLINE), PEDro, ClinicalKey, EBSCO, and ProQuest. The main eligibility criterion for articles was the use of real-time TR among older adults with musculoskeletal conditions to improve physical performance. Two reviewers screened 2108 abstracts and found 10 studies (n=851) that met the eligibility criteria. Quality assessment was based on version 2 of Cochrane’s risk-of-bias tool for RCTs, in order to assess the methodological quality of the selected articles. Results were pooled for meta-analyses, based on the primary outcome measures, and were reported as standardized mean differences (SMDs) with 95% CIs. A fixed model was used, and subgroup analysis was performed to check for possible factors influencing TR’s effectiveness based on different treatments, controls, and outcome measures. Results The search and screening process identified 10 papers that collectively reported on three musculoskeletal conditions in older adults and three types of TR programs. Aggregate results suggested that real-time TR, compared to conventional treatment, was more effective at improving physical performance regarding balance (SMD 0.63, 95% CI 0.36-0.9; I2=58.5%). TR was slightly better than usual care at improving range of motion (SMD 0.28, 95% CI 0.1-0.46; I2=0%) and muscle strength (SMD 0.76, 95% CI 0.32-1.2; I2=59.60%), with moderate to large effects. Subgroup analyses suggested that real-time TR had medium to large effects favoring the use of smartphones or tablets (SMD 0.92, 95% CI 0.56-1.29; I2=45.8%), whereas the use of personal computers (SMD 0.25, 95% CI –0.16 to 0.66; I2=0%) had no effect on improving balance and was comparable to conventional treatment. Conclusions We found that real-time TR improved physical performance in older adults with musculoskeletal conditions, with an effectiveness level equal to that of conventional face-to-face treatment. Therefore, real-time TR services may constitute an alternative strategy for the delivery of rehabilitation services to older adults with musculoskeletal conditions to improve their physical performance. We also observed that the ideal device for delivering TR is the smartphone. Results suggested that the use of smartphones for TR is driven by ease of use among older adults. We encourage future studies in areas related to rehabilitation in older adults, in addition to examination of physical performance outcomes, to gain additional knowledge about comprehensive care. Trial Registration PROSPERO CRD42021287289; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=287289

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice on telerehabilitation. The European PRM position (UEMS PRM Section)

“… 112 Real-time telerehabilitation was found to improve physical performance at the same level as in-person rehabilitation in older individuals with musculoskeletal conditions. 113 …”

“…It is recommended that PRM physicians prescribe telerehabilitation for patients with health conditions for which there is already some evidence of efficacy or at least clinical positive experiences. These include neurological disorders in general [SoE: I-IV; 38 - 40 SoR: A] specifically including stroke 42 , 43 [SoE: I; 44 - 49 SoR:A], traumatic brain injury [SoE: I 51 (particularly for cognitive rehabilitation); SoR: A], Parkinson’s disease [SoE: I; 52 - 54 SoR: A], multiple Sclerosis 55 - 59 [SoE: I (low level); 55 SoR: A] and spinal cord injury [SoE: II-IV; 60 - 65 SoR: A ] and respiratory conditions 70 [SoE: I; 71 - 76 SoR: A], cardiovascular conditions [SoE: I; 77 - 84 SoR: A], musculoskeletal conditions 73 , 74 such as knee osteoarthritis [SoE: I; 87 - 89 SoR: A] and orthopedic conditions such as joint replacement surgery [SoE: I; 90 - 92 SoR: A], low back pain [SoE: I; 94 SoR: A], fibromyalgia [SoE: II; 95 SoR: A], shoulder pain [SoE: I (very low); 96 SoR: A], COVID-19 including post COVID-19 condition [SoE: I; 99 - 103 SoR:A], low vision [SoE: II (very low); 104 SoR: A] and others such as metabolic syndrome [SoE: IV; 105 SoR: A] burns [SoE: II; 106 SoR: A] and urinary incontinence [SoE: IV; 107 SoR: A] as well as rehabilitation fields such as cancer rehabilitation [SoE: (insufficient); 108 , 109 SoR: A], geriatric rehabilitation in general [SoE: I; 110 - 113 SoR: A] and specifically for those with cognitive impairment [SoE: I; 66 SoR: A] and pediatric rehabilitation [SoE: I; 114 , 115 SoR: A] (may not be limited to those as evidence emerges).…”

Managing Musculoskeletal Pain in Older Adults Through a Digital Care Solution: Secondary Analysis of a Prospective Clinical Study

“…Health equity considerations highlight the importance of developing interventions that specifically address the barriers and concerns felt by older patients. Evidence suggests that musculoskeletal digital programs are feasible in this population [ 44 - 47 ]. In this study, we observed higher adoption than previously reported for older adults [ 45 , 46 ], as well as a higher likelihood of starting the intervention than their younger counterparts, suggesting that the possible distrust phenomenon was overcome in this particular cohort.…”

A Systematic Review of the Effects of Interactive Telerehabilitation with Remote Monitoring and Guidance on Balance and Gait Performance in Older Adults and Individuals with Neurological Conditions

“…Remote monitoring and guidance through telecommunication technologies have increasingly been recognized as a viable approach to improve individualized care, facilitate timely intervention, empower individuals, and encourage self-management [18,19]. Several techniques have been employed for remote monitoring and guidance in telerehabilitation, including secure messaging and calling, mobile apps, videoconferencing, and healthcare platforms.…”

“…Although two reviews have summarized the beneficial effects of videoconferencing interventions on telerehabilitation in older adults with musculoskeletal conditions [18] and individuals with stroke [19], there is no systematic review of the effects of telerehabilitation with remote monitoring and guidance to improve balance and gait performance in different populations. Indeed, remote monitoring and guidance allow for ongoing assessment, immediate feedback, adjustment of exercise intensity, timely interventions, and improved relationships between users and healthcare professionals, which can enhance the overall efficacy and success of the telerehabilitation program.…”