Telerehabilitation for musculoskeletal pain – An overview of systematic reviews

Abstract

Background

Alternative measures for minimizing musculoskeletal pain, such as telerehabilitation, can be implemented in the context of the COVID-19 pandemic.

Objective

The aim of the present overview was to examine evidence from systematic reviews of telerehabilitation for managing musculoskeletal pain.

Methods

This study was conducted following the PRISMA recommendations. Searches were conducted of the Pubmed/Medline, Scopus, Cochrane Library, Web of Science and Embase databases for review articles published from the inception of the database to July 2022. To be included, the studies needed to be a systematic review, include any type of telerehabilitation and present any outcome related to musculoskeletal pain. Studies not available in English were excluded. Theses, dissertations, letters, conference abstracts and narrative reviews were also excluded. The methodological quality of the reviews was appraised using the Assessing the Methodological Quality of Systematic Reviews criteria. Data extraction was performed by two reviewers and included the characterization of the clinical condition and telerehabilitation program, main outcomes, method for appraising the methodological quality of the primary studies, results and quality of evidence.

Results

The search led to the retrieval of 390 potentially eligible studies and 16 systematic reviews were included in this overview. Eleven reviews had meta-analyses and most had high methodological quality. Five of six systematic reviews reported evidence supporting the telehealth intervention for chronic pain conditions; and two of three high-quality systematic reviews reported the absence of evidence for non-specific low back pain.

Conclusions

This overview of systematic reviews enables a better understanding of the characteristics of telerehabilitation programs, provides information for use in clinical practice and describes gaps in the research that need to be filled.

Keywords

telemedicine mobile applications pain systematic review quality of life

Introduction

Musculoskeletal pain is common and is treated with a combination of pharmacological, non-pharmacological and complementary therapies.^1–4 If acute and subacute pain are treated properly, chronic pain can be avoided, with less of a negative impact on quality of life and productivity.^3,4 Treatment based on self-management has been recommended for such patients.³

The telehealth model emerged as an alternative to assist patients with difficulties in gaining access to health services and consists of different approaches involving information and technology systems that can vary greatly between and within countries.⁵ Musculoskeletal pain can be managed using telehealth.⁵

Telerehabilitation is defined as therapeutic rehabilitation provided at a distance or offsite using telecommunication technologies.⁶ It is a branch of telehealth used to control or monitor rehabilitation remotely and has been used in different fields of physiotherapy.^7–9 Telemedicine is the exchange of medical information using electronic communication to provide clinical care at a distance.¹⁰ This modality facilitates accessibility to health services and improves the continuity of care regardless of geographic location, with considerable potential in terms of saving time and resources.^7–9,11,12 Telerehabilitation consists of an intervention, which may be education, exercise or a pain control strategy, with or without the direct care of a specialist.^13–16

In 2019, World Physiotherapy issued a position statement on the use of telerehabilitation for improving accessibility to rehabilitation care, offering the community of physiotherapists the opportunity to reflect on this new method of care delivery.¹⁷ However, this approach took on added importance during the COVID-19 pandemic and consequent imposition of social isolation.^18,19

Social isolation and confinement to the home resulted in an increased risk of musculoskeletal pain,^20–23 which may be explained by the increase in a sedentary lifestyle, reduction in the performance of moderate to vigorous physical activities, worse sleep quality, symptoms of depression/anxiety, etc.^24–29

The use of telerehabilitation for the management of musculoskeletal pain has gained prominence in this context, as many patients could not visit their therapists due to the restrictions imposed by the pandemic.^18,19 Numerous systematic reviews addressing the effects of telerehabilitation on pain outcomes are available, which justifies an overview on this topic to synthesize evidence for therapists who currently use telerehabilitation in their clinical practice. It is, therefore, relevant to perform an overview of systematic reviews to gain a better understanding of the characteristics of telerehabilitation programs, provide information for use in clinical practice and describe research gaps. Therefore, the aim of the present overview was to examine evidence from systematic reviews on telerehabilitation for managing musculoskeletal pain in adults.

Methods

Search of literature

This study was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA statement).³⁰ The study protocol “Telerehabilitation for musculoskeletal pain – an overview of systematic reviews” was registered in the International Prospective Registry of Systematic Reviews (PROSPERO) under number CRD42021219911.

Electronic searches were performed in the Pubmed/Medline, Scopus, Cochrane Library, Web of Science and Embase databases for review articles published from the inception of the database to July 2022. The reference lists of articles included were also checked in an attempt to find additional relevant studies.

The following combinations of keywords were used: (“Telerehabilitation” OR “Telemedicine” OR “Mobile Applications”) AND (“Musculoskeletal Pain” OR “Low Back Pain” OR “Chronic Pain” OR “Neck Pain” OR “Back Pain” OR “Pain Management”).

Selection of articles

Article selection was performed based on the analysis of titles and abstracts. When title and abstract did not enable identifying whether the criteria were met, the full text was read so that no relevant studies were excluded. The selection and evaluation of the articles was performed using the State of the Art through Systematic Review (StART, v.1.06.2) software. The search and selection of articles were performed by two reviewers (LMSMAV and MAA) independently. Divergences of opinion between reviewers were resolved by consensus or the decision of a third independent reviewer (TOS).

Systematic review studies with and without meta-analysis that investigated the use of telerehabilitation on musculoskeletal pain were selected. To be included, the studies needed to meet the following criteria: (1) be a systematic review; (2) include any type of telerehabilitation; and (3) present any outcome related to musculoskeletal pain. No restrictions were imposed regarding the sex or age of the participants or the study setting. Studies not available in English were excluded. Theses, dissertations, letters, conference abstracts and narrative reviews were also excluded.

Data extraction and analysis

Data extraction was performed by two reviewers (LMSMAV and MAA) and included the characterization of the clinical condition and telerehabilitation program, main outcomes, method for appraising the methodological quality of the primary studies, results and quality of evidence. Primary study overlap within the systematic reviews was assessed using a citation matrix, and the number of overlapping primary studies was described.

The methodological quality of the reviews included in the present overview was appraised using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR 2 scale).³¹ This scale comprises 16 items that address the inclusion criteria, databases searched, characteristics of studies included, likelihood of publication bias, etc. Implications for practice were categorized as follows: evidence supports benefits of intervention; evidence sustains harm/risk of intervention; absence of sufficient evidence for a recommendation.³² Recommendations for future studies provided by the authors of each study were also collected.

Results

The search of the databases and additional sources led to the identification of 390 potentially eligible articles. After screening the titles and abstracts, 41 articles were submitted to full-text analysis, 16 systematic reviews which met the eligibility criteria were included in the present overview. Figure 1 displays the flow chart of the study.

Figure 1.

Flow chart of the systematic review.

The citation matrix is displayed in Table S1. A total of 145 primary studies were included in the systematic reviews. Ninety-eight primary studies (67.6%) were included in only one systematic review; 24 (16.6%) were included in two systematic reviews; eight (5.5%) in three systematic reviews; seven (4.8%) in four systematic reviews; three (2.1%) in five systematic reviews; three (2.1%) in six systematic reviews; and two (1.3%) in eight systematic reviews.

Among the 16 systematic reviews included in this overview, ten involved meta-analysis^{13–15,33–39} and one involved network meta-analysis¹⁶ (Table 1). All systematic reviews were published between 2013 and 2022.

Table 1.

Characteristics of systematic reviews on telerehabilitation (n = 16).

Author	Type of study	Objective	Databases (period)	Types of studies included	Appraisal of methodological quality	Outcomes	Health condition	Types of intervention
Chronic pain
McGeary et al.¹³	Systematic review with meta-analysis	Assess the efficacy of telehealth pain management programs	Ovid MEDLINE, PsycINFO, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, ACP Journal Club, DARE, CCTR, CMR, HTA, NHSEED 2000–2011	RCT	Yates scale	Pain intensity (VAS and NRS)	Adults with pain (chronic musculoskeletal pain, migraine headache, fibromyalgia and arthritis)	Technology-based intervention (video tele- conference, interactive website, telephone)
Adamse et al.¹⁵	Systematic review with meta-analysis	Assess the effectiveness of exercise-based tele-medicine in chronic pain	Cochrane, PubMed, MEDLINE, EMBASE, CINAHL and PEDRO databases 2000–2015	RCT and CCT	Adapted list of criteria consisting of 11 items	Pain intensity (VAS, NRS, CPG, WOMAC, BPI), physical activity, quality of life, barriers, facilitators, satisfaction, usability	Adults (aged 18 years and over) with chronic pain (back pain, rheumatoid arthritis, fibromyalgia, migraine, bowel diseases)	Use of internet-based technology to provide physical rehabilitation remotely, carried out in with a professional, alone, in addition to or as substitution of usual face-to-face care
Slattery et al.¹⁶	Systematic review with network meta-analysis	Evaluate and compare the effectiveness of eHealth modalities used to deliver interventions for adults living with chronic noncancer pain	CENTRAL, MEDLINE, EMBASE, PsycINFO from inception – November 2017	RCT	Cochrane Collaboration tool	Pain (VAS, BPI, MPI, PDI, Survey of Pain Attitudes), disability, physical functioning, pain severity, psychological distress, quality of life	Adults with noncancer-related chronic pain	Interventions for managing chronic pain delivered via an electronic health (eHealth) modality
Moman et al.³⁴	Systematic review with meta-analysis	Investigate the effects of eHealth and mHealth on pain-related outcomes in adults with chronic pain	MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, SCOPUS 2000 – January 2018	RCT, cross-over and clinical trials	Cochrane Collaboration tool	Pain intensity (NRS, VAS, BPI), physical/emotional functioning, satisfaction	Adults with chronic pain	eHealth or mHealth applications
Pfeifer et al.³⁶	Systematic review with meta-analysis	Investigate the efficacy of mobile application-based treatments of chronic non-cancer pain	PubMed, PsycINFO, Web of Science from inception – April 2019	RCT, cohort, observational	Cochrane Collaboration tool for RCT, Newcastle-Ottawa Scale for cohort/ observational studies	Pain intensity (VAS, NRS, BPI)	Patients suffering from chronic non-cancer pain aged 6–80 years	Mobile application-based interventions
Heapy et al.⁴⁰	Systematic review	Present and summarize studies discussing efficacy of technology-assisted interventions	Ovid MEDLINE (1966-March 2014), PsycINFO (1967-March 2014), Cochrane Database of Systematic Reviews 1996 – September 2014	RCT and non-RCT	Yates scale	Pain intensity (BPI, MPI, MPQ), physical, emotional functioning	Adults with pain (chronic, noncancer, non-headache pain)	Technology-assisted self-management interventions
Acute or chronic pain
Martorella et al.³³	Systematic review with meta-analysis	Determine the effect of tailored web-based pain management interventions for adults on pain intensity	MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science and the Cochrane Library 2000–2015	RCT	Cochrane Collaboration tool	Pain intensity (NRS, VAS, BPI), disability, anxiety, depression, pain catastrophizing	Adults experiencing any type of pain (acute or chronic)	Web-based interventions for pain management including: personalization, feedback, adaptation
Martin et al.⁴²	Systematic review	Assess the efficacy of mHealth apps on persons with pain	Ovid Medline, Ovid Embase, Cochrane, CINAHL, Scopus 2010 – April 2019	RCT and CCT	Joanna Briggs Institute	Pain intensity (VAS, NRS, BPI, faces scale, verbal rating scale)	Participants with acute or chronic pain who received an mHealth intervention	mHealth application (use of mobile and wireless devices to improve health outcomes)
Acute, subacute or chronic pain
Hewitt et al.⁴⁴	Systematic review	Assess whether digital health interventions are effective at reducing pain and functional disability in patients with musculoskeletal conditions	MEDLINE, EMBASE, CINAHAL, SCOPUS 2000 – November 2019	RCT	Cochrane Collaboration tool	Pain (WOMAC, NRS, MPI, PDI), physical functioning, disability, knowledge, self-efficacy, catastrophizing, empowerment	Adults (older than 18 years) with musculoskeletal conditions (acute, subacute and chronic)	Interventions for clients, personal health tracking and on-demand information services delivered by apps, web-based software or websites
Non-specific low back pain
Dario et al.¹⁴	Systematic review with meta-analysis	Determine whether telehealth-based interventions are effective for reducing pain and disability and for improving function and quality of life for people with LBP	MEDLINE, EMBASE, Web of Science, Scopus, CINAHL, PEDro, Cochrane from inception – August 2015	RCT	PEDro scale	Pain (NRS, VAS), disability, function, quality of life	Non-specific LBP	Telehealth strategies: health education, exercise prescription or goal-setting delivered via telecommunication technologies
Du et al.³⁵	Systematic review with meta-analysis	Assess the efficacy of e-Health based self-management programs on chronic LBP	PubMed, Cochrane, Web of Science, CINAHAL, Elsevier, PEDro, ProQuest from inception – April 2019	RCT	Cochrane Collaboration tool	Pain intensity (NRS, BPI, VAS), pain related disability	Adults (older than 18) with chronic LBP	e-Health based self-management programs
Chen et al.³⁷	Systematic review with meta-analysis	Evaluate the efficacy of mHealth interventions for patients with LBP	PubMed, EMBASE, Web of Science, Cochrane from inception – October 2020	RCT	Cochrane Collaboration Tool	Pain intensity (NRS), disability	Adults (40–68 years) with LBP	mHealth (mobile phone, computer, motion sensor biofeedback, network-based game consoles)
Lara-Palomo et al.³⁹	Systematic review with meta-analysis	Analyze the effectiveness of e-health interventions in the treatment of chronic LBP	PubMed, Web of Science, PEDro from inception – January 2022	RCT	Cochrane Collaboration Tool	Pain symptoms (VAS, NRS, Korff Scale)	Adults (older than 18) with chronic LBP	eHealth
Nicholl et al.⁴¹	Systematic review	Synthesize published evidence concerning the characteristics, components and effects of interactive digital interventions to support patient self-management of LBP	CINAHL, Cochrane Database of Systematic Reviews, CENTRAL, Cochrane Library, Database of Promoting Health Effectiveness Reviews, EMBASE, MEDLINE, PsycINFO, TRoPHI, Web of Science 2000 – March 2016	RCT	Cochrane Collaboration tool	Disability, pain intensity (NRS, VAS), quality of life, depression, fear avoidance, catastrophizing, physical activity, medication, costs, self-efficacy	Adults (18 years or above) with nonspecific LBP	Digital intervention: any intervention accessed through a computer, mobile phone or hand-held device, web-based or desktop computer programs or apps
Tabacof et al.⁴³	Systematic review	Assess and systematically describe current and future RCTs that use mHealth interventions to treat LBP	EMBASE, Medline, Web of Science March 2016 – March 2021	RCT	Cochrane Collaboration Tool	Pain intensity (NRS, Korff Scale)	Adult patients with LBP	mHealth solution
Knee pain
Chen et al.³⁸	Systematic review with meta-analysis	Examine the effects of technology-supported exercise programs on knee pain, physical function and quality of life	MEDLINE, EMBASE, CINAHL, Cochrane from inception – August 2020	RCT	Cochrane Collaboration Tool	Knee pain (WOMAC), physical function and quality of life	Adults (18 years of age) with knee osteoarthritis and/or chronic knee pain	Technology-supported exercise programs

VAS: visual analogue scale; NRS: numeric rating scale; CPG: chronic pain Grade; BPI: Brief Pain Inventory; MPI: Multidimensional Pain Inventory; PDI: Pain Disability Index; MPQ: McGill Pain Questionnaire; WOMAC: Western Ontario and McMaster Universities Arthritis Index; LBP: low back pain; RCT: randomized controlled trial; CCT: controlled clinical trials; eHealth: electronic health; mHealth: mobile health.

The published articles used different terms to refer to telerehabilitation, such as technology-based interventions,¹³ technology-assisted self-management interventions,⁴⁰ telehealth,¹⁴ web-based interventions,³³ digital interventions,⁴¹ internet-based technology,¹⁵ electronic health (eHealth),^16,34,35,39 mobile health (mHealth)^36,37,42,43 and technology-supported exercise programs.³⁸ The content of telerehabilitation was also diverse, including health education,¹⁴ exercises,^14,15,38 feedback³³ and self-management.^35,40,41

The study populations were mainly composed of adults with chronic musculoskeletal pain,^{13,15,16,34,36,40} acute or chronic musculoskeletal pain,^33,42 acute, subacute or chronic musculoskeletal pain,⁴⁴ non-specific low back pain^{14,35,37,39,41,43} and knee pain³⁸. Chronic pain conditions were diverse, including adults with chronic musculoskeletal pain, migraine headache, fibromyalgia, arthritis, back pain, rheumatoid arthritis and bowel diseases. Acute or chronic pain conditions were poorly defined as any type of pain (acute or chronic), as well as acute, subacute or chronic pain conditions. Non-specific low back pain and knee pain were more clearly defined in the studies.

Most systematic reviews included only randomized controlled trials.^{13,14,16,33,35,37–39,41,43,44} All systematic reviews involved an appraisal of the methodological quality of the primary studies, for which the Cochrane Collaboration tool was the most frequently used instrument.^{16,33–39,41,43,44}

The main outcomes were pain intensity,^{13–16,33–44} physical functioning,^{14,16,34,38,40,44} emotional functioning,^{16,33,34,40,41} pain-related disability^{14,16,33,35,37,41,44} and quality of life.^{14–16,38,41} A detailed description of the systematic reviews is presented in Table 1. Pain intensity was measured using several types of patient-reported outcomes measures, such as visual analogue scale, numeric rating scale; chronic pain grade; brief pain inventory; multidimensional pain inventory and pain disability index, among others.

Based on the AMSTAR 2 criteria, most systematic reviews had high methodological quality (Table 2). The most neglected item was #10 (report on sources of funding for studies included in review), which was not reported in 12 studies. The most critical neglected items were #13 (risk of bias consideration when interpreting results) and #15 (publication bias investigation and its impact on results), which distinguished high (62.5%), moderate (12.5%) and low (25.0%) quality systematic reviews.

Table 2.

Methodological quality of systematic reviews included using AMSTAR 2 scale.

Author	AMSTAR 2
Author	1	2	3	4	5	6	7	8	9 RCT	9 NRSI	10	11 RCT	11 NRSI	12	13	14	15	16	Quality
Chronic pain
McGeary et al.¹³	yes	yes	yes	yes	yes	yes	yes	yes	yes	only RCTs	no	yes	only RCTs	yes	yes	yes	yes	yes	high
Adamse et al.¹⁵	yes	p yes	no	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	low
Slattery et al.¹⁶	yes	yes	yes	yes	yes	yes	yes	yes	yes	only RCTs	no	yes	only RCTs	yes	yes	yes	yes	yes	high
Moman et al.³⁴	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	no	yes	yes	yes	yes	yes	high
Pfeifer et al.³⁶	yes	yes	yes	yes	yes	yes	yes	yes	yes	yes	no	yes	yes	yes	yes	yes	yes	yes	high
Heapy et al.⁴⁰	yes	no	yes	p yes	yes	yes	yes	yes	p yes	p yes	no	no MA	no MA	no MA	no	no	no MA	yes	low
Acute or chronic
Martorella et al.³³	yes	yes	yes	yes	yes	yes	yes	yes	yes	only RCTs	no	yes	only RCTs	yes	yes	yes	yes	yes	high
Martin et al.⁴²	yes	p yes	yes	p yes	yes	yes	yes	yes	p yes	p yes	no	no MA	no MA	no MA	yes	yes	no MA	yes	moderate
Acute, subacute or chronic
Hewitt et al.⁴⁴	yes	yes	yes	yes	yes	yes	yes	yes	yes	only RCTs	yes	no MA	only RCTs	no MA	yes	yes	no MA	yes	high
Non-specific low back pain
Dario et al.¹⁴	yes	yes	yes	yes	yes	yes	yes	yes	yes	only RCTs	no	yes	only RCTs	yes	yes	yes	yes	yes	high
Du et al.³⁵	yes	p yes	yes	yes	yes	yes	yes	yes	yes	only RCTs	yes	yes	only RCTs	no	no	yes	no	yes	low
Chen et al.³⁷	yes	yes	yes	p yes	yes	yes	yes	p yes	yes	only RCTs	no	yes	only RCTs	yes	yes	yes	yes	yes	moderate
Lara-Palomo et al.³⁹	yes	yes	yes	yes	yes	yes	yes	yes	yes	only RCTs	no	yes	only RCTs	yes	yes	yes	no	yes	high
Nicholl et al.⁴¹	yes	Yes	yes	yes	yes	yes	yes	yes	yes	only RCTs	no	no MA	only RCTs	no MA	yes	yes	no MA	yes	high
Tabacof et al.⁴³	yes	p yes	yes	p yes	no	no	no	yes	yes	only RCTs	no	no MA	only RCTs	no MA	yes	yes	no MA	no	low
Knee pain
Chen et al.³⁸	yes	Yes	yes	yes	yes	yes	yes	p yes	yes	only RCTs	no	yes	only RCTs	yes	yes	yes	yes	yes	high

p yes: partial yes; no MA: no meta-analysis; AMSTAR 2: Assessing the Methodological Quality of Systematic Reviews.

Implications for clinical practice were proposed in each systematic review and are presented in Table 3. Among the chronic pain conditions, five systematic reviews reported evidence supporting the telehealth intervention^{13,16,34,36,40} and one reported evidence against the intervention.¹⁵ Among the acute or chronic pain conditions, one systematic review reported evidence against the telehealth intervention³³ and one reported an absence of evidence.⁴² The unique systematic review about acute, subacute and chronic pain conditions reported evidence supporting the telehealth intervention.⁴⁴ Four non-specific low back pain studies showed evidence supporting the telehealth intervention^35,37,39,43 and two studies reported an absence of evidence.^14,41 The unique systematic review about knee pain conditions reported evidence supporting the telehealth intervention.³⁸

Table 3.

Implications for practice of systematic reviews included in overview on telerehabilitation (n = 16).

Author	Evidence supporting intervention	Evidence against intervention	Absence of sufficient evidence to suggest benefit or harm
Chronic pain
McGeary et al.¹³	Telehealth interventions resulted in greater improvements in pain management relative to treatment-as-usual or waitlist control	–	–
Adamse et al.¹⁵	–	Exercise-based telemedicine interventions do not seem to have added value to usual care	–
Slattery et al.¹⁶	Internet interventions can improve pain interference, whereas more novel modalities (i.e., mobile apps and virtual reality) are most likely to be effective	–	–
Moman et al.³⁴	eHealth and mHealth applications had a significant effect on short- and intermediate-term pain intensity, a significant and small effect on short- and intermediate-term depression, a significant effect on short-term pain catastrophizing and a significant and small effect on short-term self-efficacy	–	–
Pfeifer et al.³⁶	Small significant effect of mobile apps on reducing pain intensity in non-cancer patients	–	–
Heapy et al.⁴⁰	Technology-assisted interventions are efficacious for the treatment of chronic pain	–	–
Acute or chronic pain
Martorella et al.³³	–	Tailored web-based interventions did not prove to be more efficacious than standardized web-based interventions in terms of pain intensity, pain-related disability, anxiety or depression	–
Martin et al.⁴²	–	–	The efficacy of mHealth interventions could not be established due to the sparse literature and heterogeneity of findings
Acute, subacute or chronic pain
Hewitt et al.⁴⁴	Some evidence to support the effectiveness of digital health interventions in improving pain Stronger evidence to support the role of digital health interventions in improving functional disability. Positive results for catastrophizing and coping strategies	–	–
Non-specific low back pain
Dario et al.¹⁴	Acute and sub-acute LBP: telehealth intervention, when used as an adjunct to usual care, appears to optimize the effects of usual care in patients with recent onset of LBP symptoms	–	Chronic LBP: moderate quality evidence that telehealth-based interventions are not superior to minimally based interventions for reducing pain and disability
Du et al.³⁵	e-Health self-management programs improve pain intensity and disability	–	–
Chen et al.³⁷	Significantly positive effect of the simultaneous use of mHealth and usual care compared with usual care alone in reducing pain intensity and disability	–	–
Lara-Palomo et al.³⁹	Moderate evidence that e-Health interventions are as effective as face-to-face treatment in patients with chronic LBP	–	–
Nicholl et al.⁴¹	–	–	Evidence has not yet proven the wider utility of digital interventions for self-management of LBP for the population
Tabacof et al.⁴³	mHealth solutions may positively impact people with LBP	–	–
Knee pain
Chen et al.³⁸	Technology-supported exercise programs showed significant and clinically important improvements in knee pain and quality of life, but not in knee function	–	–

LBP: low back pain; RCT: randomized controlled trial; CCT: controlled clinical trials.

Discussion

Sixteen systematic reviews were included in the present overview, eleven of which had meta-analysis and most of them had high methodological quality. Eleven studies reported evidence supporting the telehealth intervention, two reported evidence against the intervention and three reported an absence of evidence. Among the chronic pain conditions, five systematic reviews reported evidence supporting the telehealth intervention^{13,16,34,36,40} and one reported evidence against the intervention.¹⁵ Few studies focused on acute, subacute or chronic pain conditions, and knee pain. Four non-specific low back pain studies showed evidence supporting the telehealth intervention^35,37,39,43 and two studies reported an absence of evidence.^14,41 None systematic reviews investigated shoulder, neck, hip and foot pain.

Considering the studies that did support telehealth interventions, one study that evaluated chronic pain concluded that exercise-based telemedicine interventions do not add value to usual care; this review tested the use of internet-based technology to provide physical rehabilitation remotely, and included several chronic pain conditions (back pain, rheumatoid arthritis, fibromyalgia, migraine and bowel diseases).¹⁵ The variability of pain conditions could explain the lack of positive effects.

For non-specific low back pain, two high-quality studies^14,41 reported an absence of evidence for chronic low back pain. One study investigated the effects of health education, exercise prescription or goal-setting delivered via telecommunication technologies¹⁴ and the other⁴¹ investigated any intervention accessed through a computer, mobile phone or hand-held device, web-based or desktop computer programs or apps. In this case, the variety of telerehabilitation modalities could explain the lack of positive effects.

Considering the studies that have shown positive results of the intervention, for chronic pain conditions five systematic reviews supported the use of telerehabilitation, among them, four have high quality^13,16,34,36 and one low quality.⁴⁰ Thus, there appears to be robust evidence to support the use of telerehabilitation for chronic pain conditions. For non-specific low back pain, four systematic reviews support the use of telerehabilitation, however, three of them have moderate³⁷ or low^35,43 quality. These findings suggest the need for high-quality systematic reviews to determine the evidence supporting the use of telerehabilitation for non-specific low back pain.

The systematic reviews included in this overview were published recently (between 2013 and 2022). We expect the number of primary studies and systematic reviews on this subject to increase in the upcoming years due to the context of the pandemic. The social, economic and behavioral changes related to social distancing have lasted for almost two years and the use of digital resources has been essential to maintaining health care services.⁴⁵ A study carried out in the United States reported that physical therapy through remote access technologies during the COVID-19 pandemic was well accepted by patients, who, in addition to being able to participate in sessions, considered the results satisfactory and stated they would continue with remote sessions after the pandemic.⁴⁶

The present findings also showed that the studies used different terms to refer to telerehabilitation, such as distance technology-based interventions, technology-assisted self-management interventions, telehealth, web-based interventions, digital health interventions, exercise-based telemedicine, electronic health (eHealth) and mobile health (mHealth) applications. Telehealth regards healthcare services provided remotely through electronic means of communication¹⁴ using information and communication technologies to exchange information for diagnoses, treatment, prevention, research and continuing education¹⁵ accessed through a computer, cell phone or portable device that provides self-management information or materials.⁴¹ There are numerous modalities of telehealth interventions and it is vital for such interventions to be designed in an accessible engaging way.¹⁶ The broad definition (videoconferencing, interactive website and telephone) was chosen to maximize the inclusion of studies. As telehealth evolves and expands, it will become easier to perform systematic examinations of specific modalities.¹³

One relevant aspect of the present overview was the poor description and absence of standardization of the content delivered. The content, intensity, frequency and duration of the interventions were not completely described. Another relevant aspect was the lack of description of the implementation processes, including the health assessment of users, the definition of treatment goals as well as the feasibility and progression of the proposed interventions and adherence to treatment.

Pain-related outcomes were also diverse, including pain intensity, physical and emotional functioning, pain-related disability and quality of life. The most used pain scales were numeric rating scale and visual analogue scale. Thus, we recommend the use of these scales and suggest the standardization of the outcomes used to evaluate the effect of telehealth interventions, including cost–benefit analysis.

Most systematic reviews included only randomized controlled trials and all reviews involved an appraisal of the methodological quality of the primary studies. This indicates that the conclusions of the systematic reviews are based on high-quality primary studies. The most neglected AMSTAR 2 item was the report on sources of funding for the studies included in the review and risk of bias consideration when interpreting results and publication bias investigation and its impact on results. These aspects should be addressed in systematic reviews to enhance their methodological quality.

The study populations were mainly composed of adults with chronic pain. Most studies did not distinguish among pain sites or causes, whereas six studies were designed for adults with non-specific low back pain. Studies including neck, shoulder, hip and foot pain are needed, especially in the occupational context, as musculoskeletal pain is one of the most prevalent health conditions in the working population.

Limitations and perspectives

Based on the findings of this overview, implications for practice and recommendations for future studies can be provided. These recommendations refer to the study design, participants, outcomes and description of the intervention.

The overviewed systematic reviews suggest that RCTs should have larger sample sizes, long-term follow-up (>one-year post treatment), detailed information on costs and cost savings (healthcare and medication use), focus on outcomes other than pain intensity, an analysis of the relative efficacy of technology-assisted interventions compared to in-person treatment, treatment engagement and participation, patient satisfaction and influence on outcomes, patient factors (pain severity, type of pain and comorbid mental health diagnoses) in treatment engagement and outcomes, intervention content and type of telehealth delivery that could most benefit subgroups of patients, detailed descriptions of the interventions (modalities and dosage) and adequate blinding of study participants and personnel responsible for assessing outcomes.

Considering the implications for clinical practice, most systematic reviews of chronic pain conditions reported evidence supporting the telehealth intervention. The high methodological quality of the included studies, the high number of participants and the high quality of the primary randomized controlled trials are relevant strengths of the included publications. Thus, telerehabilitation has the potential to facilitate access to health care. However, studies are needed to promote clinical applicability focusing mainly on the implementation process.

Conclusion

Sixteen systematic reviews were included in the present overview, 10 of which had meta-analysis and all had high methodological quality. Five of six systematic reviews reported evidence supporting the telehealth intervention for chronic pain conditions; and two of three high-quality systematic reviews reported the absence of evidence for non-specific low back pain. Thus, this overview of systematic reviews enables a better understanding of the characteristics of telerehabilitation programs, provides information for use in clinical practice and describes gaps in the research that need to be filled.

Supplemental Material

sj-xlsx-1-dhj-10.1177_20552076231164242 - Supplemental material for Telerehabilitation for musculoskeletal pain – An overview of systematic reviews

Supplemental material, sj-xlsx-1-dhj-10.1177_20552076231164242 for Telerehabilitation for musculoskeletal pain – An overview of systematic reviews by Ludmilla Maria Souza Mattos de Araújo Vieira, Marcela Alves de Andrade and Tatiana de Oliveira Sato in Digital Health

Footnotes

Acknowledgements

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) – Finance Code 001.

Contributorship

LMSMAV, MAA and TOS researched the literature and conceived the study. MSSMAV and TOS were involved in protocol development. LMSMAV, MAA and TOS wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version. Registration: PROSPERO (CRD42021219911 – “Telerehabilitation for musculoskeletal pain – an overview of systematic reviews”).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

Ethical Committee approval was not required due to the study design (overview of systematic reviews).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Finance code 001.

Guarantor

TOS.

ORCID iD

Tatiana de Oliveira Sato

Patient consent

Patient informed consent was not required due to the study design (overview of systematic reviews).

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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