Effectiveness of telerehabilitation in patients with post-COVID-19: a systematic review and meta-analysis of randomised controlled trials

Main findings

16 RCTs24–30 37–45 with a total of 1129 participants were included in this systematic review. Among them, 15 RCTs25–30 37–45 (involving 1095 participants and 16 comparisons) were included in this meta-analysis. The primary pooled analysis revealed that, compared with control groups (ie, placebo, sham, waiting list or usual care), telerehabilitation significantly enhances physical function (measured by 30STST, 6MWD and physical function of SF-36). However, it appears to be ineffective in improving clinical symptoms, pulmonary function, psychological function and QoL. Moreover, given the limited number and information of included trials, as well as substantial heterogeneity among trials, it is essential to approach these findings with caution.

Table 3 presents the characteristics of previous systematic reviews48–51 and/or meta-analyses21–23 on telerehabilitation in patients with COVID-19 and post-COVID-19. The results of included outcomes in the original trials are demonstrated in online supplemental material 9. The high methodological rigour and inclusion of additional RCTs have strengthened our confidence in the obtained results.

Concerning clinical symptoms, dyspnoea was the most frequently reported, followed by fatigue and exercise intolerance.52 Regarding dyspnoea, it is noteworthy that although our meta-analysis found a reduction in dyspnoea following telerehabilitation, this reduction was not statistically significant. This finding is inconsistent with previous meta-analyses,21–23 which reported statistically significant improvements. Possible reasons for this discrepancy include studies by Huang et al
22 and Seid et al
23 including patients in the acute phase, while our meta-analysis only included post-COVID-19 patients, resulting in a substantial clinical difference between the populations. In the meta-analysis by Calvache-Mateo et al,21 the only intervention examined was respiratory telerehabilitation, which showed significant improvement in dyspnoea. However, it is important to note that despite using standardised mean differences (SMD) across five trials39–41 44 45 employing three different scales (MD-12, mMRC and TDI) to assess dyspnoea, certain errors were present. For instance, the means of the two trials41 45 were positive but were mistakenly inputted as negative; additionally, the experimental and control groups were mislabeled in the forest plot. These errors compromise the rigour of their meta-analysis.21 Furthermore, the clinical symptoms in the included trials were reported using self-rating scales, lacking objectivity and potentially introducing reporting bias. Therefore, further validation is needed to confirm the effects of telerehabilitation on clinical symptoms.

In terms of physical function, currently, most post-COVID-19 patients lack effective self-management, and their exercise behaviour level is low, creating a vicious cycle with dyspnoea and decreased physical function.53 In line with a previous meta-analysis,21–23 48 51 we observed that telerehabilitation significantly improves the 30STST, 6MWD and physical function of SF-36. This indicates that telerehabilitation could be an excellent therapeutic alternative for promoting early intervention to re-establish the pre-infection functional status. Regarding pulmonary function, the results of our meta-analysis suggest that telerehabilitation appears to be ineffective for pulmonary function, consistent with previous findings. Only in the trial by Okan et al,39 patients who developed dyspnoea 2 months post-treatment, after undergoing a 5 week telerehabilitation programme mainly focused on respiratory training, showed significant improvement in FEV1 and FVC compared with the control group. Possible factors include participants primarily consisted of mild to moderate COVID-19 patients during the acute phase, with relatively mild impairment in pulmonary function. The timing of telerehabilitation may have been inappropriate, as it did not account for the physiological recovery process of patients’ pulmonary function. As inflammation resolves and lung tissue heals, patients’ pulmonary function may recover spontaneously, even without telerehabilitation.

Regarding psychological function, in line with the findings of Calvache-Mateo et al,21 we observed that telerehabilitation appeared to be ineffective in addressing the psychological function of post-COVID-19 patients. Only in the study by Huang et al,22 which included patients in the acute phase, were improvements in depression observed. This suggests that the time elapsed from the diagnosis to the baseline may be a significant factor for anxiety and depression outcomes.

Although assessments of QoL were recurrent in the RCTs included in this systematic review, the presence of missing data and the high heterogeneity of the outcomes used prevented us from conducting a meta-analysis. Only in the study by Calvache-Mateo et al,21 the pooled SMD showed a significant overall effect of respiratory telerehabilitation compared with the comparator groups (8 RCTs, n=669, SMD=0.59, 95% CI 0.09 to 1.09; p=0.02), but the effect values of the results were small and showed a high heterogeneity. Therefore, further exploration is needed to understand the impact of telerehabilitation on the QoL of patients with post-COVID-19.

For subgroup analysis, the insufficient quantity and information of included trials prevented us from obtaining reliable results. Consequently, the minimum exercise dose is not well defined for our population, and further research is needed to determine whether more sessions, longer durations or larger exercise doses lead to greater improvements, as these issues remain unresolved in previous systematic reviews or meta-analyses. Additionally, regarding the comparison between telerehabilitation and face-to-face rehabilitation, the meta-analysis conducted by Oliveira et al
54 showed that telerehabilitation (5 RCTs, n=246) was similarly effective as face-to-face rehabilitation programmes (2 RCTs, n=99), and the duration of 4–8 weeks delivered similar outcomes as programmes greater than 8 weeks. However, by reviewing the forest plots produced by them, we found that, compared with conventional care, the differences in most outcomes (such as handgrip, mMRC and fatigue severity scale) in the telerehabilitation group were not statistically significant, whereas the differences in the face-to-face rehabilitation group were statistically significant. Additionally, due to the small sample size per a single meta-analysis, the low quality of the included trials (five trials had high bias risk, and two had moderate bias risk), as well as heterogeneity in the duration and intensities of telerehabilitation, this conclusion should be interpreted with caution.

Strengths and limitations

Although several systematic reviews on post-COVID-19 have emerged, our findings add to the literature on post-COVID-19 telerehabilitation in several ways. First, some of the limitations of the currently published evidence are the synthesis of data from both acute care patients and post-COVID-19 patients in the same analysis22 23 and the lack of a meta-analysis component.48–51 This study is the first, to our knowledge, to conduct a systematic review with a meta-analysis on telerehabilitation for patients with post-COVID-19. Second, our review applied a rigorous methodology including a comprehensive literature search, an independent screening process and a standard of reporting in line with international recommendations. We identified seven additional trials,24–30 examined a full range of outcomes and conducted meta-analyses on both absolute and change values. The GRADE approach was used to evaluate the quality of evidence, increasing the confidence in our findings. Finally, we summarised the main findings of published systematic review and/or meta-analysis, analysed the similarities and differences and attempted to identify the causes.

Despite its significant findings, this meta-analysis has several limitations. First, while we employed a robust search strategy across four databases, our restriction to only include studies in English, which may have language bias. Second, although efforts were made to minimise bias and heterogeneity, differences in eligibility criteria and telerehabilitation interventions may have contributed to the variability in the results. Third, the lack of blinding of outcome assessors and participants were key issues raised in the risk of bias assessment, and we acknowledge the implications this has on the quality of evidence in this review. Fourth, at present, there is no criterion standard measurement tool for assessing clinical symptoms, physical function, psychological function and QoL in post-COVID-19 patients. Consequently, while some improvements in outcomes might have occurred, the selected measurement tools may not have been capable of detecting these changes, potentially leading to an underestimation of treatment outcomes. Additionally, some trials included estimates from a per-protocol analysis only, which might have also led to an overestimation of the treatment outcomes. Finally, the diverse definitions of outcome measurements have resulted in a limited number of trials per single meta-analysis, which prevents the assessment of potential publication bias via funnel plot analysis. Furthermore, the insufficient quantity and information of included trials may limit the generalisability of the results.

Implications

In light of the existing shortcomings of telerehabilitation and its anticipated high demand in the future, we propose several suggestions. Regarding clinical research, (1) participants, based on the research objectives, establish eligibility criteria for patients (such as the number and duration of symptoms, presence of mental health issues, etc.) to avoid resource wastage and identify potential beneficiaries of telerehabilitation. (2) Sample size: included trials were predominantly single-centre with small sample sizes, affecting the reliability of their results. It is recommended to conduct trials across multiple healthcare centres and different geographical regions, increasing sample size and diversity, thereby enhancing the external validity of the findings. Additionally, some studies have indicated that elderly and female patients with post-COVID-19 conditions may require more personalised support and comprehensive care.55 56 The studies completed covered all age and gender groups; thus, future studies focusing on specific age groups (eg, minors, adults, or elderly, males or females) might be necessary. (3) Random allocation and blinding: during randomisation, stratified randomisation can be employed based on patients’ baseline characteristics (such as age, severity and duration of symptoms) to ensure balance between groups. Both participants and assessors should be blinded to the group assignments (telerehabilitation or control group) to reduce bias. (4) Control: it is crucial to establish an appropriate control group, such as one receiving no treatment or one receiving face-to-face rehabilitation, to compare the effectiveness of telerehabilitation. Additionally, head-to-head trials57 or multi-arm trials58 can be considered to directly compare different telerehabilitation interventions and better understand the optimal implementation methods. (5) Outcomes: develop assessment tools specifically designed for post-COVID-19 patients to quantify the effects of telerehabilitation. These tools should cover clinical symptoms, physiological functions, psychological functions and QoL indicators to comprehensively evaluate the efficacy and influencing factors of telerehabilitation. Furthermore, when interpreting results, potential biases and limitations should be considered to provide objective and truthful conclusions. (6) Long-term follow-up: consider incorporating long-term follow-up (eg, 6 months to 1 year) to evaluate the enduring effects and sustainability of telerehabilitation, which will help understand the long-term impact of the treatment and potential relapse risks. (7) Cost-effectiveness analysis: assess the economic feasibility of telerehabilitation interventions, which is crucial for policymakers and healthcare providers, and can provide a basis for future promotion and implementation. (8) Others: pre-register trials and make trial protocols publicly available, adhering to the CONSORT59 reporting guidelines to ensure research transparency and reproducibility.

In terms of clinical practice, (1) multidisciplinary team collaboration: researchers involved in included trials often come from a single field, leading to shortcomings in addressing patients’ mental health issues or telerehabilitation technologies. Therefore, we recommend that research teams include experts from various disciplines, such as pulmonologists, rehabilitation therapists, psychologists, nutritionists and information technology specialists. This multidisciplinary approach will help comprehensively assess and address the diverse needs of patients. (2) Personalised treatment plans: most included trials provide the same telerehabilitation plan to all patients in the experimental group, which may not meet the individual needs of some patients and could underestimate the effectiveness of telerehabilitation. Developing personalised rehabilitation plans based on patients’ symptoms, disease severity, functional status and rehabilitation goals can ensure the precision and efficacy of telerehabilitation interventions. (3) Education for patients and their families: during the eligibility assessment phase, a large proportion of patients refused to participate in the trial. Additionally, all included trials excluded individuals unfamiliar with information and communication technology equipment, and some patients often felt frustrated and overwhelmed when facing technical difficulties. Therefore, it is essential to develop and provide detailed educational resources to help patients and their families understand the importance of the telerehabilitation process and teach them how to correctly use telerehabilitation tools and technologies. (4) Using advanced remote-monitoring technologies: among the 16 trials included in this meta-analysis, only six trials26 38–42 assessed adverse events, which were solely based on patient self-reports. However, this approach may result in missing substantial information since many adverse events necessitate the observation of a professional. Therefore, using wearable devices and mobile health applications to monitor patients’ physiological parameters (such as heart rate, blood oxygen saturation, respiratory rate and blood pressure) and telerehabilitation progress, and transmitting this data in real-time to the research team, can not only monitor adverse events but also help adjust treatment plans promptly and encourage patients to complete their telerehabilitation training on schedule. (5) Psychological support: post-COVID-19 patients often experience mental health issues such as anxiety and depression.60 Research designs should include remote psychological counselling and behavioural health management to help patients cope with psychological stress and improve mental health. (6) Interaction and social support: consider adding an online communication platform to the existing telerehabilitation equipment, allowing patients in the same group to interact, share their experiences or encourage and support each other. At the same time, telerehabilitation managers and therapists can also upload telerehabilitation demonstration videos and operation procedures to the platform, set up discussion areas to receive patients’ opinions and suggestions, understand their needs and answer their questions in a timely manner, which may help enhance patients’ motivation and compliance.