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The efficacy and safety of telerehabilitation for patients following total knee arthroplasty: a overviews of systematic reviews | BioMedical Engineering OnLine

Literature screening process and results

A total of 1019 studies were preliminarily retrieved, of which 853 remained after removing duplicates using EndNote X9. A total of 821 studies were excluded after reading the titles and abstracts; 32 were read in full text, of which 19 were excluded, and 13 were finally included. The literature screening process is shown in, and the reasons for exclusion are shown in Additional file 2: Appendix Table 2.

Basic features of the included studies

Of the 13 systematic reviews, one was published in Chinese and 12 were published in English between 2017 and 2022. The number of original studies ranged from 4 to 28, and the sample size ranged between 230 and 6418 participants. All systematic reviews included randomised controlled trials (RCTs); some included prospective, observational and case–control studies. The Cochrane bias risk assessment tool was used in five studies, the Physiotherapy Evidence Database (PEDro) scale was used in four, the Joanna Briggs Institute RCT assessment tool was used in two, the Jadad scale was used in one, and the quality assessment tool was not specified in one. The intervention groups underwent remote rehabilitation, including videoconferencing and virtual reality rehabilitation, whereas the control groups underwent conventional rehabilitation and routine nursing (Table 1).

Table 1 Basic characteristics of the included studies (n = 13)

Results of methodological quality evaluation

Among the 13 systematic reviews included, seven [20, 22, 26,27,28,29,30] had low methodological quality, and six [18, 19, 21, 23,24,25] had very low methodological quality. Among the key items, item 2 in four reviews [22, 23, 28, 29] had been registered on a website before commencing the systematic review. Concerning item 4, four reviews [18, 19, 21, 26] did not provide a comprehensive search strategy. For item 7, none of the reviews [18,19,20,21,22,23,24,25,26,27,28,29,30] provided a list of reasons for excluding an article. For item 9, regarding whether appropriate tools were used to assess the risk of bias of each included study, one review [18] was assessed as ‘partially yes’, one review [25] only included RCTs, and the remainder were assessed as ‘yes’. For item 11, one review [25] did not specify the statistical methods used, and three reviews [18, 20, 29] did not conduct a meta-analysis. For item 13, four reviews [19, 22, 26, 28] considered the risk of bias when interpreting or discussing the study results. For item 15, seven reviews [19, 22,23,24, 26, 28, 30] did not evaluate publication bias. Among the noncritical weaknesses and in relation to item 10, none of the reviews [18,19,20,21,22,23,24,25,26,27,28,29,30] described the funding source (Table 2).

Table 2 Quality evaluation results of AMSTAR 2 included literature (n = 13)

Literature report quality evaluation results

The PRISMA scores of the 13 systematic reviews ranged from 17.5 to 26.0. No systematic review reported serious defects, three reported some defects [18, 26, 30], and 10 reports were relatively complete [19,20,21,22,23,24,25, 27,28,29]. The title, abstract, introduction, source of information, study selection, study characteristics, study risk of bias and discussion have been fully reported in all reviews [18,19,20,21,22,23,24,25,26,27,28,29,30]. Nine reviews [18,19,20,21, 24,25,26,27, 30] did not register protocols; five [18,19,20,21, 26] did not provide the availability of data, code and other materials; three [18, 24, 30] did not provide certainty assessment, five [18, 22, 28,29,30] did not report the certainty of evidence; and four [18, 20, 24, 28] did not report study bias (Table 3).

Table 3 PRISMA evaluation results of the included literature (n = 13)

Biased risk assessment results

According to the ROBIS scale domain 1, the inclusion criteria, all the reviews (100%) were low risk. Regarding domain 2, research identification and selection, all reviews (100%) were high risk. In terms of domain 3, data extraction and quality assessment, two reviews (15.4%) were high risk. Regarding domain 4, data synthesis and results presentation, 10 reviews (76.9%) were high risk; in stage 3, all reviews (100%) had a high risk of bias, as shown in Table 4.

Table 4 Bias risk assessment results of included literature (n = 13)

Evidence quality evaluation results

The evidence quality evaluation results showed that among the 59 outcome indicators in the 13 reviews, there was no high-quality evidence, and there were 14 medium-quality and 33 low-quality indicators. The main reason for downgrade was the limitations of the original study, followed by publication bias and inconsistency, as shown in Table 5.

Table 5 Summary of evidence and grade evidence quality evaluation results of included studies (n = 13)

Evaluation results of main outcome indicators


Thirteen reviews [18,19,20,21,22,23,24,25,26,27,28,29,30] evaluated pain. Two reviews [19, 21] showed statistically significant pain improvement in telerehabilitation groups compared with control groups, whereas 10 reviews [18, 20, 22,23,24,25,26,27, 29, 30] showed that telerehabilitation had no statistically significant effect on pain in patients who underwent TKA. Subgroup analysis in one review [28] showed that virtual reality rehabilitation could improve pain within 1 month after TKA surgery (SMD = − 0.44, 95% CI − 0.79–0.08, P = 0.02) but did not improve pain 2–3 months after surgery (SMD = − 0.35; 95% CI − 1.02–0.32, P = 0.31).

Knee function

Regarding the WOMAC indices, nine reviews [18,19,20,21, 23, 24, 26,27,28] evaluated the effect of telerehabilitation on WOMAC scores, six reviews [18,19,20,21, 23, 24] showed that the effects of telerehabilitation in terms of WOMAC scores were similar to those for standard care and three reviews [26,27,28] showed statistically significant effects of telerehabilitation in terms of WOMAC scores.

In terms of KOOS, five reviews [18, 20, 21, 24, 27] reported the effects of telerehabilitation on KOOS. Three reviews [18, 21, 27] showed that the telerehabilitation groups had improved KOOS compared with the control groups. In contrast, two other reviews [20, 24] showed no significant difference in KOOS between the telerehabilitation and control groups.

Regarding knee flexion and extension, six reviews [20, 21, 24,25,26, 30] evaluated knee flexion and extension and joint flexion, and the results showed that the effect of telerehabilitation on knee flexion was not statistically significant. In terms of joint extension, four reviews [21, 24,25,26] showed that telerehabilitation had a statistically significantly improved joint extension (P < 0.01), and two reviews [20, 30] showed that there was no statistically significant difference in joint extension between the two groups.

In terms of walking ability, six reviews [18,19,20,21, 23, 28] used the TUG test to evaluate the effect of telerehabilitation on walking ability. Three reviews [18, 21, 23] showed that telerehabilitation shortened the TUG test compared with standard rehabilitation, and two reviews [19, 28] showed no significant difference in TUG scores between the two groups. One review [20] conducted a descriptive analysis and reached no conclusions.

In terms of quality of life, three reviews [20, 28, 30] evaluated the effect of telerehabilitation on quality of life, and a meta-analysis of one medium-quality review [30] showed no significant difference in terms of changes in quality of life between the intervention and control groups.

Evaluation results of secondary outcome indicators

Adverse events

Two reviews [20, 24] reported the influence of telerehabilitation on adverse events. Jansson et al. [20] showed that telerehabilitation had no significant effect on the occurrence of adverse events. Tsang et al. [24] reported that the rehospitalisation rate in an intervention group within 12 weeks was significantly lower than in a control group. However, the evidence quality was low.

Patient satisfaction

Four reviews [18, 19, 29, 30] evaluated the intervention effect of telerehabilitation on patient satisfaction. One review [18] showed that the telerehabilitation and control groups had similar patient satisfaction levels. Three reviews [19, 29, 30] showed that the changes in patient satisfaction were not statistically significant in either group.


Four reviews [18, 20, 24, 27] evaluated the effects of telerehabilitation on costs, and the results showed that telerehabilitation could reduce patient medical costs compared with expenses incurred in the control groups.

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