Introduction

Orthopedic upper extremity injuries are among the most common injuries to the body, accounting for approximately 50% of all orthopedic injuries in the United States (Worboys et al., 2018). Given the high incidence of upper-extremity orthopedic injuries, the growing demand for rehabilitation can result in increased costs and longer waiting lists and threaten the sustainability of health care services (Pastora-Bernal et al., 2017). The literature shows that telerehabilitation might improve or at least maintain the continuity of rehabilitation care and services by making them more efficient and cost-effective (Pastora-Bernal et al., 2017). Telerehabilitation involves dispensing rehabilitation services from a distance, with patients and physicians using technology to communicate (Macías-Hernández et al., 2016). As of March 2020, there were no literature review on telerehabilitation exclusively for upper-extremity orthopedic disorders. To address this knowledge gap, we carried out a systematic review to compare the outcomes of telerehabilitation and traditional rehabilitation to assess and treat adults with upper-extremity orthopedic conditions. We aim to answer the following question: how does telerehabilitation compare to traditional rehabilitation in the assessment and treatment of adults with upper-extremity orthopedic conditions?

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (Moher et al., 2009).

Search 

Online databases, such as Medline, PubMed, Rehab data, Seeker, CINAHL, Google Scholar, EMBASE, and Science Direct were searched thoroughly. Initial searches were carried out in October 2019 February 2020.

Selection criteria

Studies that met the following inclusion criteria were included: (1) study was published between February 2009 and February 2020; (2) participants were 18 years and older; (3) orthopedic interventions addressed injuries of the shoulder, arm, elbow, forearm, wrist, and/or hand; and (4) all interventions involved remote physical rehabilitation.

We excluded studies (1) in which participants had comorbidities, a history of neurological injuries, or debilitating illnesses; and (2) that did not involve physical rehabilitation specialists. There were no limitations with regards to the type of outcomes that were measured. The articles were selected using the PRISMA guidelines (Moher et al., 2009) and levels of evidence were considered.

Data extraction

The following information was extracted from the included articles: article title, study design, year of publication, purpose, sample size, orthopedic condition, type of rehabilitation intervention, other traditional rehabilitation intervention, duration and frequency of the intervention, outcome measured, results of the study, conclusion, limitations, and level of evidence/critical appraisal (Tables 1 and 2 in the Appendix).

Critical appraisal and data analysis

All the selected articles were appraised according to the quantitative review form and guidelines by Law & MacDermid (2014). We classified the levels of evidence for each article based on Holm's Hierarchy of Evidence (Moore, 1995).

Results

Article selection

Figure 1 (see Appendix) shows the flowchart of our selection process.

Demographics

Table 1 (see Appendix) summarizes the studies included in this review. The 10 selected articles were published between 2009 and 2019.

Outcome Assessments

The outcome assessments used in this review measured the following outcomes: pain, function, ROM, QoL, and edema.

Statistical Analysis

Tables 2 and 3 (see Appendix) summarize the data extracted from the selected articles and the statistical significance of the outcomes of telerehabilitation platforms in comparison with those of traditional rehabilitation.

Discussion

Even though Martinez-Rico et al., had the largest sample size of all the selected articles, 71 participants is still a relatively small patient pool. Larger sample sizes may be more representative of the population and limit the influence of outliers or extreme observations. Its positive aspect is that it was a randomized controlled trial, which tends to have a high level of evidence (Level 1). Even though Eriksson et al. reported the same results, theirs was a control study with a lower level of evidence (Level 3), a very small sample size (n=22), and a non-randomized design to avoid uneven recruitment (as per the authors' explanation). Even though these studies were randomized controlled trials (Level 1 evidence), their sample sizes were small (n=18 and n=30, respectively). Moreover, Pastora-Bernal et al. (2018) reported a potential limitation of selection bias and information, while Ismail & El Shorbagy's (2014) study was single-blinded. Ramkumar et al. and Cui et al. studies also had small sample sizes (n=10 and n=25, respectively) and were single-blinded. Also, Ramkumar et al. was a cohort study with a lower level of evidence (Level 2) and Cui et al. revealed a primary limitation due to the wireless sensor hardware used; the size, weight, and "wearability" of the device influenced the participants' willingness to use the system.

Clinical implications

The statistically significant superiority of video- and phone-based telerehabilitation over traditional outpatient therapy and home exercise programs for improving pain, QoL, ROM, and function, as demonstrated by Eriksson et al. (2009) and Martinez-Rico et al. (2018) could have many implications for occupational therapy. Video conferences and over-the-phone supervision can be easily applied by occupational therapists, who can address pain, ROM, functional, and QoL of older adults at a distance while yielding results that are potentially superior to traditional outpatient therapy or home exercise programs. This could contribute to solving the issues identified by Pastora-Bernal et al. (2017), who reported that people with upper-extremity orthopedic injuries living in remote locations may not have to access in-person rehabilitation services. Along with Ismail & El Shorbagy (2014) and Martinez-Rico et al. (2018), they also demonstrated the equivalence of video and telephone interactions to traditional face-to-face therapy in terms of achieving similar outcomes. This reinforces the idea that these telerehabilitation platforms can be used without compromising patient recovery. Even though video/phone platforms, virtual reality interfaces, and mobile applications also yielded statistically significant equivalence to traditional goniometric measurements of shoulder ROM (Ramkumar et al., 2018; Cui et al., 2019), occupational therapists could experience difficulties in using these relatively more complicated technological platforms.

Limitations

There are some limitations to this systematic review, that is, 4 of 10 selected articles did not provide sufficient data to analyze the effectiveness of telerehabilitation. Macías-Hernández et al. (2016) conducted a quasi-experimental study that tested the effectiveness of a

Regardless of the limitations of the studies included in this systematic review, it is important to note that studies with a high level of evidence (randomized controlled trials) indicated that over-the-phone supervision is significantly superior to home exercise programs for improving shoulder ROM (Martinez-Rico et al., 2018). Phone/video platforms and virtual reality interfaces were shown to be equivalent to traditional home exercise programs, face-to-face therapy, and traditional outpatient therapy for improving the pain, QoL, function, and ROM (Ismail & El Shorbagy, 2014; Pastora-Bernal et al., 2018) and for measuring ROM (Cui et al., 2019). It is also important to consider that the literature on telerehabilitation and upper extremity orthopedic injuries is limited, which explains the restricted number of articles included in this review.

Conclusion

Although there were many limitations in this analysis and in the studies that were reviewed, we were able to elucidate that telerehabilitation yields equivalent or superior outcomes to traditional rehabilitation when assessing or treating patients with upper-extremity orthopedic conditions. This depends on the type of telerehabilitation platform, traditional rehabilitation setting, and the outcome measuredFurther research based on higher levels of evidence and focusing on specific telerehabilitation interventions are needed to validate its equivalence or superiority to traditional rehabilitation for assessing or treating adults with upper-extremity orthopedic conditions.