key: cord-0980631-b79omhbh authors: Suso-Martí, Luis; La Touche, Roy; Herranz-Gómez, Aida; Angulo-Díaz-Parreño, Santiago; Paris-Alemany, Alba; Cuenca-Martínez, Ferran title: Effectiveness of Telerehabilitation in Physical Therapist Practice: An Umbrella and Mapping Review with Meta–Meta-Analysis date: 2021-02-22 journal: Phys Ther DOI: 10.1093/ptj/pzab075 sha: 1254d4ffc5fd5a7bbca6a3add32c14e69e544071 doc_id: 980631 cord_uid: b79omhbh OBJECTIVE: Telerehabilitation is an option that should be adapted as soon as possible in order to face the crisis caused by COVID-19. An umbrella and mapping review with meta–meta-analysis (MMA) of the available scientific evidence was performed to determine if telerehabilitation could be an effective alternative to conventional rehabilitation in physical therapist practice. METHODS: A systematic review of reviews and a synthesis of the findings of all systematic evidence published to date with a visual map and a meta-meta-analysis (MMA) were performed. A systematic search was realized in Cochrane Database of Systematic Reviews (CDSR), MEDLINE (PubMed), and Google Scholar. Two independent reviewers performed a data analysis and assessed the quality of the included reviews, assessing the risk of bias using ROBIS. RESULTS: Twenty-nine articles that met the inclusion criteria were selected and divided according to the type of patient targeted for rehabilitation (patients with cardiorespiratory, musculoskeletal, and neurological conditions). The MMA regarding physical function between telerehabilitation and usual care rehabilitation did not reveal a statistically significant difference for patients with cardiorespiratory and musculoskeletal conditions. For patients with neurological conditions, the MMA revealed a statistically significant but negligible effect size in 6 reviews in favor of telerehabilitation (standardized mean difference [SMD] = 0.18; 95% CI = 0.03–0.34). CONCLUSION: The results of the present review showed that telerehabilitation offers positive clinical results, even comparable to conventional face-to-face rehabilitation approaches. IMPACT: The advantages of lower cost and less interference by the rehabilitation processes in patients’ daily life could justify implementing telerehabilitation in clinical settings in the COVID-19 era. In the recent years, telemedicine allows health care professionals to evaluate, diagnose and treat patients in remote locations using telecommunications networks. 1,2 A sub-area of telemedicine is telerehabilitation, which consists of remotely managing rehabilitation using new telecommunication-based practices. 3 Telerehabilitation has been employed for treating neurological, cardiorespiratory and musculoskeletal dysfunctions and facilitates access to rehabilitation services, regardless of geographical location. 3 Telerehabilitation can enable individual to continue their rehabilitation in their own social/vocational setting and had a potential role in public health emergencies, like the actual pandemic era due to the limited ability for patients to seek in-person rehabilitation services. 2 A recent systematic review shows that COVID-19 disease will epidemiologically generate a high incidence of disabling functional alterations that will have to be addressed in the post-acute phases by means of telerehabilitation. 4 However, the possible benefits of telerehabilitation in this context, previous reports have already indicated the barriers to implementing e-health content, such as lack of knowledge and the uncertainty regarding the use of technology, and doubts remain as to whether these barriers limit the effectiveness of telerehabilitation and its clinical application. [5] [6] [7] Telerehabilitation is an option that should be adapted as soon as possible to the rehabilitation systems in order to face the current crisis caused by COVID-19 or other pandemics that may occur in the future. For this reason, to thereby improve clinical care in this situation, it seems necessary to determine the effectiveness of telerehabilitation in patients with neurological, cardiorespiratory or musculoskeletal pathologies. 8 In this article, an umbrella and mapping review with meta-meta-analysis (MMA) of the available scientific evidence was performed to determine if telerehabilitation could be an effective alternative to conventional rehabilitation in physical therapist practice. [H1] METHODS A systematic reviews of reviews was conducted, as well as a synthesis of the findings of The comprehensive search was combined the following key terms using Boolean operators: Intervention ("telerehabilitation", "telemedicine", "telehealth", "exercise", "Web rehabilitation", "tecnhology rehabilitation", "computer rehabilitation", "phone rehabilitation", "function") and Review type ("systematic review", "meta-analysis ", "review literature", "qualitative systematic review"). The selection criteria for this review were based on methodological and clinical factors, specifically the population, intervention, comparison, outcomes and study type (PICOS) criteria. 11 [H3] Population The participants selected for the published studies were older than 18 years and included patients with musculoskeletal, cardiac, respiratory, or neurological diseases. The patients' sex was irrelevant. [H3] Intervention and Control The intervention was the telerehabilitation approach. telerehabilitation was considered as any technology (wearable devices, Internet, virtual reality, telephone) that enabled the monitoring or execution of physical therapy rehabilitation, remotely controlled using telecommunication-based practices. Therapy could be focused on physical or cognitive ability. The intervention could be provided as an independent intervention, added to therapy or embedded in the therapy (eg, standard care or standard therapy). Comparator groups could be standard care, face-to-face rehabilitation and conventional therapy. [H3] Outcomes The measures used to assess the results and effects were any kind of variable related to clinical outcomes, especially physical functioning, as well as health-related quality of life (HRQL). [H3] Study Design Systematic reviews with or without metanalysis. First, the two independent reviewers performed a data analysis, assessing the relevance of the reviews regarding the study questions and objectives. This initial analysis was performed based on information from each study's title, abstract, and keywords. If there was no consensus or if the abstracts did not contain enough information, the full text was reviewed. The second phase of the analysis using the full text was performed to assess whether the studies met all of the inclusion criteria. Differences between the reviewers were resolved by discussion and consensus moderated by a third reviewer 12 ( Fig. 1 ). The data described in the results were extracted by means of a structured protocol that ensured that the most relevant information was obtained from each study. 13 The two independent reviewers assessed the quality of the included reviews, assessing the risk of bias using ROBIS, 14 which evaluates the quality across 4 domains: 1) study eligibility; 2) study identification and selection; 3) data collection and study appraisal; and 4) synthesis and findings. ROBIS provides an overall risk of bias for the review as high, low or unclear. The two independent reviewers examined the quality of the selected studies using the same methodology; disagreements between the reviewers were resolved by consensus with a third reviewer. The inter-rater reliability was determined using a kappa coefficient (>0.7 indicated a high level of agreement between the assessors, 0.5-0.7 indicated a moderate level of agreement, and <0.5 indicated a low level of agreement). A further quality assessment was conducted using the Quality Assessment Scale for Systematic Reviews developed by Barton et al. 15 This 13-item scale (with criteria rated from 0 to 2) was found to be a valid and reliable tool for assessing the methodological quality of systematic reviews. The developers of the scale provide a cut-off score for high-quality reviews (>20 out of a possible 26). 15 This evaluation is no longer conducted in a peer-to-peer and independent manner, and only one evaluator evaluated the methodological quality. The statistical analysis using meta-analyses with interactive explanations was performed (MIX 1.7; BiostatXL). 16 The same inclusion criteria for the review was employed, but 2 criteria were added: 1) The Results section contained detailed information on the comparative statistical data (mean, standard deviation, and/or 95% CI) of the main variables, and 2) data for the analyzed variables were represented in at least 2 studies. The summary statistics in the form of forest plots were presented, 17 which consist of a weighted compilation of all standardized mean differences (SMDs) and corresponding 95% CI reported by each study and provide an indication of heterogeneity among the studies. The statistical significance of the pooled SMDs were examined using Hedges' g to account for a possible overestimation of the true population effect size in small studies 18 . The magnitude of g was interpreted according to a 4-point scale: 1) <0.20, negligible effect; 2) 0.20-0.49, small effect; 3) 0.50-0.79, moderate effect; and 4) ≥0.80, large effect. 19 The degree of heterogeneity among the studies were estimated by employing Cochran Q statistic test (P < .1 was considered significant) and the inconsistency index (I 2 ). 20 An I 2 >25% is considered to represent low heterogeneity, while an I 2 >50% is considered medium, and an I 2 >75% is considered to represent large heterogeneity. 21 The I 2 index is complementary to the Q test, although it has a similar problem with power as does the Q test with a small number of studies. 21 A study was therefore considered heterogeneous when it fulfilled one or both of the following conditions: 1) the Q test was significant (P < .1), and 2) the result of I 2 was >75%. To obtain a pooled estimate of the effect in the meta-analysis of the heterogeneous studies, a randomeffects model was performed, as described by DerSimonian and Laird. 22 The study population will be determined from each bubble's color. 3. Effect (x-axis): The authors classified each review according to the effects found. When the intervention group showed greater benefits than the control group, the intervention was classified as "potentially better"; otherwise, the intervention was classified as "potentially worse". When there was insufficient evidence, the intervention was classified as "unclear". If there were no differences, the intervention was included as "no differences". If there were contradictory results, we included the intervention as "mixed results". determine the strength of evidence. If each article explicitly provided its level of recommendation, this was added. If it was not explicitly reported, this was inferred by the researchers of this article. If it was not possible to determine (due to lack of information) the studies were classified as "unsettled". Twenty-three articles that met the inclusion criteria were selected and divided them according to the type of patient targeted for rehabilitation (cardiac or respiratory; musculoskeletal or postoperative and neurological telerehabilitation). The characteristics of the studies from which data were extracted (sample size, demographic characteristic, intervention, outcomes, main results and conclusions) are presented in the Supplementary Table. [ A set of five reviews evaluated telerehabilitation for patients with cardiorespiratory diseases, which included mostly cardiac events, cardiovascular disease and chronic obstructive pulmonary disease. Seven reviews were included on the use of telerehabilitation for patients with musculoskeletal disorders or who had recently undergone surgery. The main conditions for the patients with musculoskeletal disorders were chronic pain, rheumatoid arthritis and osteoarthritis. The most common operations were knee arthroplasties, knee and hip replacements and orthopedic operations. Thirteen reviews were included that evaluated the efficacy of telerehabilitation for patients with neurological diseases, the most frequent of which were multiple sclerosis, stroke, acquired brain damage, Alzheimer's disease and traumatic brain injury. [H2] Interventions All interventions were based on telerehabilitation, either in isolation or combined with classical rehabilitation. Telerehabilitation was considered any technology (wearable devices, internet, virtual reality, telephone) that allowed for the monitoring or execution of rehabilitation or therapy. The aim of the interventions was to increase motor function or physical capacity using telerehabilitation-based home exercise protocols. The interventions consisted of repeated motor tasks or exercises, balance exercises and motor re-education or aerobic exercises. It was also included education-based interventions that sought to promote changes in lifestyle or health behaviors. The main variables of interest in the various reviews differed according to the types of patients included. The reviews that focused on cardiac and respiratory telerehabilitation assessed physical function and capacity, adverse events, dyspnea and HRQL. At musculoskeletal level, the main variables analyzed were physical function, pain, disability and HRQL. The reviews that analyzed patients with neurological disorders assessed motor and cognitive function, disability, independence for activities of daily living and HRQL. Many of the reviews evaluated aspects related to the implementation of telerehabilitation, such as satisfaction with therapy and cost-effectiveness. Regarding the methodological quality, the agreement between the two evaluators was high, according to the kappa coefficient (κ = 0.88). The risk of bias of the included reviews is shown in Table 1 and Figure 2 , and the methodological quality assessment is presented in Table 2 . [H2] Findings Five systematic reviews with meta-analyses evaluated the efficacy of telerehabilitation for patients with cardiac and respiratory diseases and included 34 primary studies. Regarding physical function, four reviews showed similar results between telerehabilitation and usual care interventions [24] [25] [26] [27] and one review showed better results for telerehabilitation intervention. 28 However, the strength of findings was unclear (Fig. 3 ). With regard to the quantitative analysis, the MMA of physical function did not reveal a statistically significant difference in 2 reviews (SMD = 0.03; 95% CI = -0.15 to 0.22; P = .07) without evidence of significant heterogeneity (Q = 1.31; P = .25, I 2 = 24%) (Suppl. Material 1). Seven reviews evaluated the role of telerehabilitation in patients with musculoskeletal conditions and included 71 primary studies. Regarding physical function, seven reviews showed no differences between telerehabilitation and usual care interventions, with very low to moderate-high evidence (Fig. 3) . [29] [30] [31] [32] [33] [34] [35] One review could not draw conclusions and showed unclear results in patients with rheumatoid arthritis. 36 Finally, Agostini et al., showed better results in terms of functionality for telerehabilitation compared to usual care in patients with knee arthroplasty. 28 With regard to the quantitative analysis, the MMA of physical function did not reveal a statistically significant difference in 3 reviews (SMD = 0.00; 95% CI = -0.44 to 0.44; P = .07) with evidence of significant heterogeneity (Q = 18.61; P < .01; I 2 = 89%) (Suppl. Thirteen systematic reviews, including 172 primary studies, evaluated the efficacy of telerehabilitation for patients with neurological disorders, although there was a high level of heterogeneity between the patients and between the interventions. Regarding physical function, 12 reviews showed similar results between telerehabilitation interventions and usual care, with low to moderate evidence. 28, [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] However Laver et al 46 found insufficient evidence to determine the effectiveness of telerehabilitation on functional variables (Fig. 3) . Regarding the results shown in the MMA, differences in the type of patient targeted for rehabilitation were found. In the case of neurological disorders, the main condition studied was stroke. However, the reviews that assessed cardiorespiratory and musculoskeletal telerehabilitation presented greater variability in the included conditions, which could influence the results. Therefore, it seems that telerehabilitation could be a better treatment option in patients with neurological conditions, although further research would be needed to investigate its effectiveness in other types of disorders. In this regard, some aspects of telerehabilitation may be particularly positive in patients with neurological disorders, compared to patients with cardiorespiratory and musculoskeletal conditions. Firstly, patients with neurological disorders usually require high doses of treatment to obtain functional improvements. 47 This is difficult to achieve through of face-to-face interventions due to lack of time; however, telerehabilitation would facilitate increasing the intervention time. Secondly, telerehabilitation allows the training of functional tasks in the patient's usual environment rather than in clinical settings, favouring their transfer to daily life, a fundamental aspect in patients with neurological pathology. 48 There are, however, a number of barriers and obstacles that still need to be considered. based on telephone contact or video conferencing. However, a number of these systems employed more complex technologies that required virtual reality devices or inertial sensors, requiring patients to have sufficient infrastructure to perform the therapy, which can be difficult and increase costs due to the use of more complex technologies, which limits access to telerehabilitation services. In addition, health professionals also need adequate training to properly use these technologies. Some patients targeted for this type of rehabilitation are cognitively impaired, which can also hinder the clinical transfer of telerehabilitation. Aspects such as privacy and data protection also need to be considered when applying this rehabilitation model. One of the critical thighs about telerehabilitation is that requires patients to be involved and committed to therapy to ensure compliance with the intervention. Establishing This research study received no specific grant from funding agencies in the public, commercial, or not-for-profit sector. This meta-meta-analysis was not registered. a L = low concern; H = high concern; U = unclear concern. 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Using metadata to explore doseresponse relationships in stroke rehabilitation The use of augmented reality for rehabilitation after stroke: a narrative review The authors thank the Centro Superior de Estudios Universitarios CSEU La Salle for its services in editing this manuscript. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest. Adequate number and range of databases. 3. Alternative searches 4. Adequate range of key words 5. Non-English language papers included in the search. 6. Explicitly of inclusion criteria described to allow replication 7. Excludes reviews which do not adequately address inclusion. 8. Two independent reviewers assessing selection bias. 9. Explicitly of quality assessment described to allow replication.? 10. Meta-analysis conducted on only homogenous data or limitations to homogeneity discussed 11. Confidence intervals/effect sizes reported where possible 12. Conclusions supported by the meta-analysis or other data analysis findings (effect sizes, confidence intervals, etc) in the review. 13. Conclusions address levels of evidence for each intervention/comparison Scoring: 2 = yes; 1 = in part, 1; 0 = no.