Effectiveness of Telemedicine for Musculoskeletal Disorders: Umbrella Review

Abstract

Background: Several systematic reviews (SRs) assessing the use of telemedicine for musculoskeletal conditions have been published in recent years. However, the landscape of evidence on multiple clinical outcomes remains unclear.

Objective: We aimed to summarize the available evidence from SRs on telemedicine for musculoskeletal disorders.

Methods: We conducted an umbrella review of SRs with and without meta-analysis by searching PubMed and EMBASE up to July 25, 2022, for SRs of randomized controlled trials assessing telemedicine. We collected any kind of patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs), and objective measures, including direct and indirect costs. We assessed the methodological quality with the AMSTAR 2 tool (A Measurement Tool to Assess systematic Reviews 2). Findings were reported qualitatively.

Results: Overall, 35 SRs published between 2015 and 2022 were included. Most reviews (n=24, 69%) were rated as critically low quality by AMSTAR 2. The majority of reviews assessed "telerehabilitation" (n=29) in patients with osteoarthritis (n=13) using PROMs (n=142 outcomes mapped with n=60 meta-analyses). A substantive body of evidence from meta-analyses found telemedicine to be beneficial or equal in terms of PROMs compared to conventional care (n=57 meta-analyses). Meta-analyses showed no differences between groups in PREMs (n=4), while objectives measures (ie, "physical function") were mainly in favor of telemedicine or showed no difference (9/13). All SRs showed notably lower costs for telemedicine compared to in-person visits.

Conclusions: Telemedicine can provide more accessible health care with noninferior results for various clinical outcomes in comparison with conventional care. The assessment of telemedicine is largely represented by PROMs, with some gaps for PREMs, objective measures, and costs.

Trial registration: PROSPERO CRD42022347366; https://osf.io/pxedm/.

Keywords: PREMs; PROMs; accessibility; condition; health care; meta-analyses; musculoskeletal; musculoskeletal disorder; orthopedics; osteoarthritis; patient-reported; patient-reported experience measures; patient-reported outcomes measures; rehabilitation; systematic review; telemedicine; telerehabilitation.

Figure 1

Flow diagram.

Figure 2

AMSTAR 2 (A Measurement Tool to Assess systematic Reviews 2) summary plot. Item 1: “Did the research questions and inclusion criteria for the review include the components of PICO?”; item 2: “Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?”; item 3: “Did the review authors explain their selection of the study designs for inclusion in the review?”; item 4: “Did the review authors use a comprehensive literature search strategy?”; item 5: “Did the review authors perform study selection in duplicate?”; item 6: “Did the review authors perform data extraction in duplicate?”; item 7: “Did the review authors provide a list of excluded studies and justify the exclusions?”; item 8: “Did the review authors describe the included studies in adequate detail?”; item 9: “Did the review authors use a satisfactory technique for assessing the risk of bias RoB in individual studies that were included in the review?”; item 10: “Did the review authors report on the sources of funding for the studies included in the review?”; item 11: “If meta-analysis was performed, did the review authors use appropriate methods for statistical combination of results?”; item 12: “If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?”; item 13: “Did the review authors account for RoB in primary studies when interpreting/discussing the results of the review?”; item 14: “Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?”; item 15: “If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias small study bias and discuss its likely impact on the results of the review?”; item 16: “Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?”.

Figure 3

Outcomes reported by reviews. The frequencies of each outcome category reflect the number of reviews addressing them. Inner circles represent the 3 categories defined in the methods: objective outcomes, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMs); outer circles represent the outcome domains (eg, physical function). HrQoL: health-related quality of life.

Figure 4

Bubble plot showing directions of effects and AMSTAR 2 (A Measurement Tool to Assess systematic Reviews 2) results by (A) outcomes and (B) type of population. This graphic provides information in three dimensions: (1) in the x-axis, the authors’ conclusions are rated as “beneficial for intervention,” “no effect,” or “beneficial for control” (this is further described in the Data Extraction section); (2) in the y-axis, the quality assessment (AMSTAR 2) is shown; and (3) the bubble size is proportional to the number of participants included in each systematic review. PREM: patient-reported outcome measure; PROM: patient-reported experience measure.