Contactless services in medical and occupational rehabilitation – a systematic inventory and critical evaluation

Status:

completed

Aims:

The range of telemedicine applications for rehabilitation has been continuously expanded in recent years. New possibilities also arise for statutory accident insurance in this context – both for rehabilitation following occupational accidents and for the treatment and prevention of occupational diseases. The present study focuses on musculoskeletal disorders of the upper extremity. Shoulders, arms, and hands are, on the one hand, particularly frequently affected by occupational accidents, and on the other hand, mechanical strain gives rise to a number of occupational diseases of the upper extremity, including the comparatively recently recognized occupational disease No. 2117 (lesion of the rotator cuff of the shoulder).

The aim of this systematic review was to examine the effectiveness of telemedical rehabilitation interventions for musculoskeletal disorders of the upper extremity. The focus was on the effect of telerehabilitation measures on the outcome measures of pain, activities of daily living, and health-related quality of life.

Activities/Methods:

For this systematic review, a literature search was conducted in three databases (MEDLINE, Embase, AMED) and supplemented by a hand search. Randomized (RCTs) and non-randomized intervention studies on musculoskeletal disorders of the upper extremity were included if they reported on pain, activities of daily living (ADL), or health-related quality of life (HrQoL). Only English- or German-language studies from high-income countries were considered. Risk of bias was assessed using RoB 2 and ROBINS-I. The standardized mean difference (SMD) with 95% confidence interval (CI) served as the effect measure and was pooled by meta-analysis; negative values indicate an advantage in favor of telerehabilitation. The certainty of evidence was assessed according to GRADE.

Three comparison constellations were analyzed with respect to telerehabilitative treatments:

(1) in-person rehabilitation as the comparator,
(2) minimal intervention as the comparator, and
(3) telerehabilitation added to standard care.

Compared with in-person rehabilitation, we examined whether telerehabilitation achieves similar outcomes. For add-on telerehabilitation interventions as well as for the comparison with minimal intervention, we examined whether the use of telerehabilitation leads to an improvement in the outcome measures.

Results:

A total of 20 RCTs with 1,285 participants were included. Compared with in-person rehabilitation, telerehabilitation showed similar results: SMD -0.33 [-1.16 to 0.50] for pain (VAS/NRS; GRADE: very low), SMD -0.07 [-0.31 to 0.17] for ADL (QuickDASH/DASH; GRADE: moderate), and SMD -0.26 [-0.82 to 0.31] for HrQoL (VR-12; GRADE: low). Compared with a minimal intervention (paper-based exercise program), telerehabilitative interventions showed slight to moderate improvements: SMD -0.28 [-0.58 to 0.03] for pain (VAS/NRS), SMD -0.56 [-0.88 to -0.24] for ADL (QuickDASH/DASH), and SMD -0.31 [-0.65 to 0.02] for HrQoL (EQ-5D-5L; GRADE for all outcomes: low). Telerehabilitation interventions used in addition to standard care also led to slight to moderate improvements: SMD -0.38 [-0.71 to -0.05] for pain (VAS/NRS; GRADE: low) and SMD -0.51 [-0.88 to -0.14] for ADL (QuickDASH/DASH; GRADE: moderate).

These findings indicate that telerehabilitation is effective across different application contexts. However, effect sizes were partly small, and the certainty of the evidence remains overall limited.

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