Cost-Effectiveness of Telerehabilitation Compared with Usual Care in Chronic Musculoskeletal Disorders: Systematic Review

Chichaeva Julija¹, Janhunen Maarit², Vuoskoski Pirjo³, Hautala Arto³, Aartolahti Eeva¹

1 Institute of Rehabilitation, Jamk University of Applied Sciences,

2 Health and Wellbeing, Master School, Turku University of Applied Sciences,

3 Faculty of Sport and Health Sciences, University of Jyväskylä

Systematic Review Registration number: CRD42022373376

Abstract

Musculoskeletal disorders affect various populations, reducing well-being and limiting functioning and participation. The increasing prevalence of chronic conditions, especially in the aging population, intensifies this burden, demanding increased resources. Telerehabilitation offers a solution to improve access to rehabilitation while addressing rising healthcare costs. This systematic review aimed to compare resource use, costs, and cost-effectiveness of telerehabilitation versus usual care for individuals with chronic musculoskeletal disorders.

A systematic search of six databases was conducted through May 2024. Screening was performed by two researchers independently. The quality of the included studies was assessed using the JBI Critical Appraisal of Economic Evaluations Checklist. Due to study heterogeneity and a small number of included studies, a meta-analysis could not be performed. Data analysis was performed narratively and using the JBI Dominance Ranking Matrix.

Three RCTs comprising 2504 participants were included. The participants were diagnosed with osteoarthritis or upper limb, lower limb, or back problems. Telerehabilitation methods varied from telephone contact to the use of various mobile and web applications. Clinical outcomes included health, functioning, and health-related quality of life, and the economic outcomes were costs, resource use, and incremental cost-effectiveness ratio.

Telerehabilitation was found to be the same price and equally effective compared to usual care in two studies and cheaper and more effective in one study. The results varied across all outcomes, while resource use decreased in the telerehabilitation groups.

Telerehabilitation appears promising in terms of being as effective as usual care while maintaining a similar cost. However, the limited number of studies, inconsistencies in findings, and heterogeneity make it difficult to draw definitive conclusions regarding its cost-effectiveness for chronic musculoskeletal disorders. Further high-quality and appropriate economic evaluations are required.

The findings of this study may have significant implications for rehabilitation, particularly in addressing the growing challenges of rehabilitation availability, accessibility, and allocating the optimal use of health care resources.

Keywords: Telerehabilitation, cost-effectiveness, musculoskeletal disorders, chronic conditions, healthcare resources

Introduction

Musculoskeletal health refers to the proper functioning of the locomotor system, the dysfunction of which may lead to over 150 different musculoskeletal disorders (MSDs) or conditions, leading again to acute, temporary, chronic, or even lifelong limitations of functioning and participation (Musculoskeletal Health, 2024).A chronic disorder is commonly defined as lasting more than three months (Nicholas et al., 2019). Chronic musculoskeletal disorders have a significant impact worldwide, affecting up to 30% of the global population (James et al., 2018), burdening individuals, the health care system, and the whole society. For an individual, MSDs appear as decreased well-being and limited ability to participate in work and in society and live fulfilling lives (Hartvigsen et al., 2018; Palazzo et al., 2014).

Although rehabilitation is a fundamental human right (Skempes et al., 2015), its availability is even more threatened in the future due to the change in the age structure of the population, the increase in non-communicable diseases (Kamenov et al., 2019), and the fact that rehabilitation is not necessarily prioritized (Cieza et al., 2020). MSDs impose a significant burden on healthcare systems, requiring extensive allocation of workforce and financial resources (Musculoskeletal Health, 2024). Chronic MSDs further amplify this burden by increasing costs associated with prolonged medical care and frequent healthcare service use, while also leading to substantial indirect costs such as lost productivity, absenteeism, and early retirement due to work limitations (Waters & Graf, 2018). While the prevalence of MSDs typically increases with aging (Briggs et al., 2016; Lewis et al., 2019), they also significantly impact younger individuals, particularly those in their prime working years. This not only reduces their ability to work but may also result in early retirement (Bevan, 2015; Hartvigsen et al., 2018).

Telerehabilitation (TR) is a rehabilitation service delivered through information and communication technology (ICT), either in real time (synchronously), non-real time (asynchronously), or a combination of both (Shem et al., 2022). The utilization of telerehabilitation to provide rehabilitation services has become more common over the past decade (Sarfo et al., 2018; Seron et al., 2021). TR makes different stages of rehabilitation more available and accessible to individuals (Shem et al., 2022), benefiting individuals with diverse circumstances and disabilities, while also addressing challenges tied to increasing health care costs and workforce demands (Grigorovich et al., 2022; Shem et al., 2022).

Health care interventions aim to produce health effects aligned with specific goals, requiring often already limited resources (Aluko et al., 2024). Health economic evaluation systematically assesses, analyzes, and compares the health effects, resource use, and costs of alternative interventions and provides decision-makers with valuable information to optimize resource allocation (Aluko et al., 2024; Sintonen & Pekurinen, 2006). The types of study designs for economic evaluation include cost minimization analysis (CMA), cost-benefit analysis (CBA), cost-effectiveness analysis (CEA), and cost-utility analysis (CUA), each with its own strengths and limitations (Sintonen & Pekurinen, 2006; The Joanna Briggs Institute, 2014). While these designs share similarities in the conceptualization, definition, and measurement of costs, they differ in their approach to evaluating health effects (Sintonen & Pekurinen, 2006). Although the economic impact of telerehabilitation for MSDs has been studied (Marks et al., 2022; Molina-Garcia et al., 2024), its cost-effectiveness specifically for chronic conditions, remains unclear. This review seeks to address this gap by systematically reviewing existing evidence to clarify the economic value of telerehabilitation as a sustainable option for managing chronic musculoskeletal disorders. This review aimed to compare the resource use, health care costs, and cost-effectiveness of telerehabilitation compared to usual care in individuals with chronic musculoskeletal disorders.

Methods

This systematic review of economic evaluations was conducted and reported in accordance with the Joanna Briggs Institute (JBI) guidance for systematic reviews of economic evaluations (The Joanna Briggs Institute, 2014) and the PRISMA 2020 checklist for reporting systematic reviews (Page et al., 2021), to ensure accuracy, reliability, and transparency in the literature search, analysis, and reporting processes. The objectives, inclusion criteria, and methods of analysis were specified in advance and documented in a registered protocol (PROSPERO register number CRD42022373376).  Prior to specifying the research question and writing the research plan, preliminary searches were conducted in the MEDLINE and CINAHL databases and the PROSPERO register to prevent review duplication. To determine the clear and meaningful review questions and as the basis of the inclusion criteria and search strategy, the PICOS mnemonic (Table 1) was used. It highlights the participants/population (P), intervention (I), comparator (C), outcomes (O), and study design (S) of the research.

The JBI Sumari software was used to support the processes of the review, for example, screening, appraising, extracting, and analyzing the data from economic evaluations.

Inclusion Criteria

To identify which knowledge was relevant and to set the boundaries of the review, inclusion and exclusion criteria were predefined (Table 2).

Table 2. Inclusion and exclusion criteria using PICOS mnemonics.

	Inclusion criteria	Exclusion criteria
Population	- people, with any chronic musculoskeletal condition of any severity - adults (>18 year) - any sex, socio-economic status, or ethnic origin	- children and adolescents (<18 years) - non-musculoskeletal conditions - musculoskeletal conditions related to another medical comorbidity (e.g., stroke, depression, cancer, obesity) - people who had acute trauma or surgery or other acute musculoskeletal condition
Intervention and comparator	- physical telerehabilitation delivered remotely via ICT, in real time or asynchronously, in group or individually or as a combination of these - interventions may comprise exercise training, or just guidance or counseling - telerehabilitation delivered or supported by telephone or SMS messages only - combination of telerehabilitation and in-person physical rehabilitation Comparator: - usual care (physical rehabilitation in-person)	- only face to face rehabilitation - postoperative rehabilitation - rehabilitation after acute trauma - self-management program/app without the intervention of a rehabilitation professional - interventions related to immediate medical care - medical/ physiological monitoring - psychological intervention only Comparator: - studies with no control group - waitlist / no intervention/ no active treatment
Context/ setting	- physical telerehabilitation in any health care setting
Outcomes	- Cost analysis - Relative resource use - Direct or indirect costs - Incremental Cost-Effectiveness Ratio (ICER) - Quality Adjusted Life Years (QALYs) - Disability Adjusted Life Years (DALYs)	- transaction costs
Study design	- Full (cost-effectiveness, cost-utility, cost-benefit, and cost minimization analyses) and partial economic evaluation studies (i.e., cost analysis, cost description studies, and cost outcome descriptions - randomized and non-randomized control trials - cohort or pre-post designs providing there are both an intervention and control group - full text published in Finnish/ English/ Spanish - No date restrictions	- research protocols - modeling studies - dissertations if not peer-reviewed

Data Sources and Searches

As instructed in the JBI manual (The Joanna Briggs Institute, 2014), the search was conducted in three phases. In the first phase, a preliminary limited search was conducted using the MEDLINE (Ovid) and CINAHL databases. Preliminary search results were analyzed using titles and abstracts to determine the search terms and keywords for the actual search. In the second phase, identified and specified terms and keywords were implemented in the MEDLINE (Ovid), CINAHL, Eric, PsycINFO (Ebsco), and PEDro electronic databases, as well as in a database specialized in economic evaluation; the NHS Economic Evaluation Database (NHS EED). Before implementing the search strategy in search December 17, 2022, an informaticist was consulted. An updated search conducted on May 17, 2024, yielded no new articles. The third phase includes identifying additional sources by examining the lists of references of already selected studies, hand-searching, and searching for gray literature. In economic evaluation studies, gray literature search is particularly important, as this type of study is frequently conducted by and for decision-makers (The Joanna Briggs Institute, 2014). The complete search strategy is reported in Appendix 1. Sources published in Finnish, English, or Spanish were included in the review, and searches were conducted without any time limit. The search results were exported to Zotero Reference Manager software, where duplicates were merged. 

Study Selection

The screening of the articles was executed with the JBI Sumari software. The articles were screened by two researchers (JC, MJ, EA) independently, first based on the title and abstract, followed by a full text examination. Selection was accomplished based on predefined inclusion criteria (Table 2). Disagreements were resolved by discussion or, if needed, with a third party. The excluded studies at full-text appraisal and reasons for exclusion are characterized in the Appendix 2.

Quality Assessment

Methodological quality was assessed using the JBI Critical Appraisal Checklist for Economic Evaluations (Appendix 3) by two researchers independently (JC, MJ, EA). Disagreements were discussed or, if needed, resolved with a third party.  

Data Extraction

Data were extracted from the included studies using the JBI standardized data extraction tool for economic evaluation (Appendix 4). The data were extracted by one researcher (JC), and included descriptive data about the study population, intervention, comparator(s), outcomes, study methods, study context, results for the resource use and/or cost and/or cost-effectiveness measures, and author conclusions. Authors of the studies were contacted to request missing or additional data where required.

Data Synthesis and Analysis

The data extracted were analyzed and summarized to answer the review question using the JBI Dominance Ranking Matrix (DRM), narrative, and tables. The data analysis considers what the data on the characteristics, cost-effectiveness results, and authors’ conclusions suggest about the circumstances in which the intervention is likely to be more cost-effective than the comparator. The DRM matrix has three possible classification options: strong, weak, or non-dominance.

Role of the Funding Source

Only three studies met the inclusion criteria, and they were heterogeneous in terms of populations, settings, perspectives, interventions, comparators, and reported outcomes. Due to both the small number of studies and this substantial heterogeneity, conducting a meta-analysis would have resulted in a large standard error. Furthermore, the studies did not consistently demonstrate strong dominance of one approach over another. Therefore, a narrative synthesis was deemed more appropriate for summarizing the evidence.

The funders had no role in the design, conduct, or reporting of this study.

Results

Search result and study selection

A total of 374 potentially relevant studies were identified. After removing duplicates and screening titles and abstracts for irrelevant material, 26 full‐text studies were selected for full-text assessment and 23 articles were excluded because they did not meet our inclusion criteria. The exclusion reasons were mostly ineligible intervention or comparator (55%) and ineligible participant characteristics or duplicate (see appendix 2). In total, three studies were included in the systematic review. The flow diagram in Figure 1 shows the full search and study selection process.

Figure 1. PRISMA flow diagram of the search and study selection process. 

Methodological quality

Table 3 summarizes the methodological quality of the studies. One study totaled 8/11 points and two studies 10/11 points. Question 7 (Are   costs   and   outcomes   adjusted   for   differential timing?) was not applicable in any of the three studies.

_{Y – Yes, N – No, N/A – Not applicable}

Findings of the review

Three RCT studies were included in this review; two cost utility analyses conducted in Nigeria (Fatoye et al., 2020) and England (Hollinghurst et al., 2013) and a cost-effectiveness analysis conducted in Holland (Kloek et al., 2018). The perspectives varied between health care perspective (Fatoye et al., 2020; Hollinghurst et al., 2013; Kloek et al., 2018) to patients and careers (Hollinghurst et al., 2013) and societal (Kloek et al., 2018) perspectives. See appendix (5) for complete details of the characteristics of the included studies.

Participants

The included studies comprised a total of 2504 participants, with sample sizes ranging from 47 to 2249. Hollinghurst et al. (2013) had 1506 and 743 participants in the intervention and control groups, respectively; Kloek et al. (2018) had 108 and 99; and Fatoye et al. (2020) had 21 and 26. The diagnoses were lower limb problems (27%), lumbar problems (24%), upper limb problems (21%) (Hollinghurst et al., 2013), hip and/or knee osteoarthritis (8%) (Kloek et al., 2018), and nonspecific chronic low back pain (2%) (Fatoye et al., 2020). The mean age of the participants ranged from 49 to 63 years. The proportion of female participants ranged from 60% to 68%.

Interventions and comparisons

Two studies described telerehabilitation interventions as blended physiotherapy (Hollinghurst et al., 2013; Kloek et al., 2018) and one as purely telerehabilitation without any face-to-face contact (Fatoye et al., 2020). In all studies, interventions were delivered to individual participants using mobile app (Fatoye et al., 2020), telephone, and face-to-face, if needed (Hollinghurst et al., 2013) and a web-application combined with face-to-face contact (Kloek et al., 2018). Telerehabilitation interventions included mobile-based McKenzie therapy (Fatoye et al., 2020), initial assessment, and advice of physiotherapist by telephone (Hollinghurst et al., 2013) and face-to-face half-hour sessions with a physiotherapist, which are integrated with a web-application consisting of a graded activity module, exercises, and information modules (Kloek et al., 2018). When reported, the duration of the interventions varied from 8 (Fatoye et al., 2020) to 12 weeks (Kloek et al., 2018). In the comparator group, participants received equivalent face-to-face physiotherapy (Fatoye et al., 2020) or usual physiotherapy care (Hollinghurst et al., 2013; Kloek et al., 2018).

Outcomes

Clinical effectiveness included health, functioning, and health-related quality of life outcomes. Health-related quality of life was assessed to generate quality-adjusted life years (QALYs). Economic outcomes included direct costs such as health care expenses, intervention costs (Fatoye et al., 2020; Hollinghurst et al., 2013; Kloek et al., 2018) and sports-related costs (Kloek et al., 2018) as well as indirect costs encompassing productivity losses, earnings reductions, and care and support expenses. (Hollinghurst et al., 2013; Kloek et al., 2018). The incremental cost-effectiveness ratio (ICER) was calculated in each study (Fatoye et al., 2020; Hollinghurst et al., 2013; Kloek et al., 2018). Table 4 summarizes the details of the effectiveness and economic outcomes.

_{CGI = Clinical Global Improvement Score, HOOS = Hip Osteoarthritis Outcome Score, ICER = incremental cost-effectiveness ratio, KOOS = Knee Injury and Osteoarthritis Outcome Score, MYMOP = Measure Yourself Medical Outcomes Profile, ODI = Oswestry Disability Index, OMERACT OARSI = Outcomes Measures in Rheumatology Clinical Trials-Osteoarthritis Research Society International initiative, PCS = Physical component summary, PRODISQ = Productivity and Disease Questionnaire, QALYs = quality-adjusted life years, SF36v2 Health Survey = Health Related Quality of Life Questionnaire, SF-6D = The six-dimensional health state short form, measure for valuing health and assessing the cost- effectiveness of health care interventions, EQ-5D = European Quality of Life 5 Dimensions, EQ-5D-3L = European Quality of Life 5 Dimensions 3}

Duration of follow-ups

The follow-up times varied between the studies. In the study of Fatoye et al. (2020) health outcomes were assessed at baseline, 4 weeks, and 8 weeks of the study. Hollinghurst et al. (2013) measured all outcomes except the global improvement score and waiting time to first treatment advice at baseline, 6 weeks, and 6 months, and Kloek et al. (2018) measured all outcomes at baseline, 3, 6, and 12 months.

Effects, costs and resource use

A summary of the main results is presented in Table 5. Fatoye et al. (2020) found a significant difference in changes in health outcome (p<0.001) within each group over time (baseline to weeks 4 and 8); however, the mean difference in ODI was not significant or clinically relevant (p>0.05) between the groups. Similarly, there were no differences between groups in the physical component summary of the SF36v2 at 6 months (Hollinghurst et al., 2013) or in health-related quality of life (ΔE = 0.01; 95% confidence interval (CI) -0.03 to 0.04), physical functioning (ΔE = 1.49; 95% CI -4.70 to 7.69), and physical activity (ΔE = −3.46; 95% CI -11.66 to 4.73) at 12 months (Kloek et al., 2018). Intervention groups in two studies showed minor additional health benefit of 0.001 QALY (95% CI 0.001 to 0.002) (Fatoye et al., 2020) and 0.009 QALY (95% CI −0.000 to 0.018) (Hollinghurst et al., 2013).

A reduction in the total health care cost in the intervention group compared to the control group was reported as US$ 44.26 (Fatoye et al., 2020). Hollinghurst et al. (2013) found no evidence of a difference between the groups in the cost of physiotherapy, other The National Health Service (NHS), personal costs, value of time off work, the costs incurred from health care use or travel to physiotherapy appointments. Although Kloek et al. (2018) reported significantly lower intervention, medication, and sport costs in the intervention group, total societal and total health care costs (intervention costs + primary health care costs + secondary health care costs + medication costs) did not significantly differ between groups. Primary and secondary health care, informal care, absenteeism costs, presenteeism, and unpaid productivity costs did not significantly differ between groups (Kloek et al., 2018). Resource use was reported in two studies. The control group had, on average, 0.38 (95% CI 0.12 to 0.63)(Hollinghurst et al., 2013) to 7 (Kloek et al., 2018) more physiotherapy visits and they were 20 min longer (95% CI 12 to 28) (Hollinghurst et al., 2013) than in intervention group.

_{+ = positive change in favor of the intervention group/ costs increase in intervention group, – = negative change in favor of the intervention group/ reduction of costs in intervention group, 0 = no difference between groups, * = not significant result, ** = large uncertainty, PA = physical activity, NHS = The National Health Service, PT = physiotherapy, Societal perspective = total societal and health care costs (intervention costs + primary health care costs + secondary health care costs + medication costs), Health care perspective = health care costs}

Cost-effectiveness

The Dominance Ranking Matrix (DRM) classification tool suggests weak dominance for the intervention in two studies and strong dominance in one study, meaning that the intervention was equally costly and effective (Hollinghurst et al., 2013; Kloek et al., 2018) or less costly and more effective (Fatoye et al., 2020) (Table 6). In conclusion, according to the results of Hollinghurst et al. (2013) and Kloek et al. (2018), it is unclear whether the intervention is preferable from an efficiency perspective without detailed information on the priorities and preferences of decision-makers in the decision-making context.

Table 6. Three-by-three matrix dominance classification for cost-effectiveness findings.

_{+ = implies the intervention has a greater cost, or greater health effect than the comparator, 0 = the intervention has equal cost or health effect/benefit as comparator, – = that the intervention is less costly or less effective than comparator.}

The estimated ICER varied from favoring telerehabilitation being less costly and more effective (Fatoye et al., 2020) than usual care to reaching similar results in terms of effectiveness and costs (Hollinghurst et al., 2013; Kloek et al., 2018). Fatoye et al. (2020) reported ICER as dominant in the intervention group but did not report the exact numbers. Hollinghurst et al. (2013) discovered a small extra cost in the intervention group, which was compensated by the extra QALY gain, and the estimated ICER was £2889. At the threshold level of willingness to pay (WTP) of £20 000/ QALY, there was a positive net monetary benefit of £117 (95% CI −£96–£310), and the estimated probability of cost-effectiveness of intervention was 0.88 (Hollinghurst et al., 2013).

Kloek et al. (2018) examined QALY, physical functioning (HOOS/KOOS), and physical activity (min/day) in primary analysis from a societal perspective (total costs) and in secondary analysis from a health care perspective (health care costs). The results for ICER per QALY were −52,900€/ QALY and −79,200€/ QALY, and for ICER per HOOS/KOOS point (physical functioning) −355€/ point and −532€/ point, indicating dominance of telerehabilitation compared with usual physiotherapy. However, the cost-effectiveness acceptability curves (CEACs) indicated large uncertainty from both perspectives. The probability of telerehabilitation being cost-effective was 0.68 at a WTP of 10,000€/ QALY gained and 0.70 at a WTP of 80,000€/ QALY gained from a societal perspective, and 0.84 at a WTP of 10,000€/ QALY gained and 0.80 at a WTP of 80,000€/ QALY gained from health care perspective. For physical activity, the point estimate of the ICER was 153€/ point from societal and 229€/ point from health care perspective, indicating dominance of usual physiotherapy over telerehabilitation. According to CEAC, decision makers are not willing to pay anything per 1-point improvement on the HOOS/KOOS (physical functioning) or per 1-min/ day improvement of physical activity. The probability of telerehabilitation being cost-effective compared with usual physiotherapy was 0.67 from a societal perspective and 0.82 from a health care perspective. In terms of physical functioning, a higher WTP had no effect probability In terms of physical activity, higher WTP decreased probability from a societal perspective and kept probability the same from health care perspective (Kloek et al., 2018).

Discussion

According to the results of this review, telerehabilitation has comparable health benefits and cost-effectiveness to usual care, demonstrating its potential as an alternative or complementary approach for individuals with chronic musculoskeletal conditions.

The economic impact of telerehabilitation for musculoskeletal disorders has been previously observed in three systematic literature reviews(Grigorovich et al., 2022; Marks et al., 2022; Molina-Garcia et al., 2024), in which searches were carried out in July 2021, November 2021 and November 2022. In these systematic reviews, all kinds of musculoskeletal disorders, also post-operative, were included. To the best of our knowledge, there is no synthesized evidence on the economic impact of telerehabilitation versus face-to-face usual care in chronic musculoskeletal disorders. Nonetheless, these previous studies support the results of this review, showing the great potential of telerehabilitation as well as a great need for additional evidence on the cost-effectiveness of telerehabilitation for individuals with musculoskeletal conditions.

While the total number of participants in the review was considered acceptable, the three included studies varied considerably in their sample sizes. The study by Fatoye et al. (2020) had the lowest sample size (n = 47) and indicated the strongest cost-effectiveness of the intervention, which should be noticed when drawing conclusions. Furthermore, the variation in diagnoses of participants increases the heterogeneity between studies.  However, the included diagnoses, such as chronic low back pain, chronic lower or upper limb problems, and osteoarthritis, are described as the biggest contributors to the disease burden of musculoskeletal disorders (Musculoskeletal Health, 2024).

One of the three studies included in this review was conducted in low- and middle-income country (Fatoye et al., 2020) contexts, which adds valuable diversity to the data and broadens the applicability of the findings. However, it is important to consider that healthcare infrastructure, socio-economic conditions, and cultural differences in these settings can influence both the delivery and effectiveness of interventions, which may affect the generalizability of the results to higher-income countries.

In this and several other studies (Seron et al., 2021; Suso-Martí et al., 2021) and definitions (Shem et al., 2022) telerehabilitation covers interventions conducted through phone calls or audio conferences only. However, the effects of telephone-based interventions may differ from those of interventions that extensively utilize modern technologies. For instance, interventions that utilize virtual reality for exercise training or mobile apps for clients’ personalized goal setting, progress monitoring, and real-time feedback may offer special benefits. As technology rapidly develops, the current definition of telerehabilitation may be outdated and necessitate reformulation to further explore and understand the potential benefits that can be achieved using modern technology in rehabilitation.

The outcome variables measuring clinical effectiveness seemed relevant considering the diagnosis and intervention; however, their meaningfulness to the individual cannot be assessed. For example, although the quality-adjusted life year (QALY) is a commonly used outcome in economic evaluation studies, it has been criticized for its ethical, methodological, and contextual flaws (Pettitt et al., 2016). The QALY has been described as unequal, as it assumes that a person’s health status and length of life determines the value of their life. A decision based on the QALY may reduce the right to maintain treatment for those with lifelong conditions. The QALY has also been criticized for its quantitative and overly utilitarian approach, which does not consider different scenarios of human life (Pettitt et al., 2016). Among the outcomes measuring cost-effectiveness, the incremental cost-effectiveness ratio (ICER) was calculated for all the studies, which increased the comparability of the studies in this review.

The cost-utility analysis, which was conducted only from a health care perspective and did not consider indirect costs, indicated the strongest cost-effectiveness (Fatoye et al., 2020). This should be noticed when interpreting the results of this review and overall social significance. A significant portion of the costs in society are associated with indirect costs, such as productivity loss (Fautrel et al., 2020), with musculoskeletal diseases often being the cause (Bevan, 2015; Hartvigsen et al., 2018).

Access to rehabilitation has been identified as a significant factor in enhancing individuals’ quality of life and participation (Skempes et al., 2015). Since the global need for rehabilitation is only increasing due to the changing age structure and rising incidence of non-communicable diseases (Briggs et al., 2016; Kamenov et al., 2019), alternative ways of delivering rehabilitation services should be evaluated and implemented. The evaluation should cover both the effectiveness and cost-effectiveness. This review, along with other reviews (Seron et al., 2021; Suso-Martí et al., 2021), provides evidence supporting the potential of telerehabilitation as an alternative or complementary approach to traditional face-to-face rehabilitation methods.

As this study also confirmed for individuals with chronic musculoskeletal disease, telerehabilitation  may be as effective as in-person rehabilitation (Seron et al., 2021) and has the potential to reduce health care and individual costs (Grigorovich et al., 2022) in various diagnosis groups. However, it may not be suitable for everyone, or its implementation may require different approaches with different individuals. For instance, in the qualitative study by Anttila et al. (2019) four subcategories of telerehabilitation-related perceptions were identified. These subcategories reflected users’ attitudes towards technology and the support they needed in using it. Thus, it could be significant that the professional, for example, based on the initial interview, is able to identify different users, choose digital solutions suitable for them, and offer the necessary support. Rehabilitation options, whether telerehabilitation or face-to-face, should be equally available, and the choice should be based on individual preferences and capabilities.

Furthermore, accessibility factors, such as internet connectivity, the availability of technology, and digital literacy should be considered essential for the successful implementation of telerehabilitation. These factors can influence its feasibility and effectiveness, particularly in diverse socio-economic contexts.  In future studies, the cost-effectiveness of telerehabilitation could also be evaluated among individuals with different telerehabilitation-related perceptions, considering the impact of these accessibility factors on the implementation and outcomes.

Strengths and Limitations

There are some limitations that should be considered when interpreting the findings of this study. Only three studies met the inclusion criteria, and they were heterogeneous in terms of populations, settings, perspectives, interventions, and reported outcomes. The small number of studies, conducting a meta-analysis would have resulted in a large standard error. Therefore, a narrative synthesis was deemed more appropriate for summarizing the evidence. The findings of this review need additional support before they can be generalized to different populations or settings. Another limitation is related to the follow-up times of the included studies, which varied from 8 weeks to 12 months. Both the treatment response and costs may differ when measured over a longer period. The strengths of this economic evaluation are the good methodological quality of the included studies and the clear and precisely described and implemented methodology of the review.

Conclusions

Based on the findings of this review, telerehabilitation has shown potential for comparable health benefits and cost-effectiveness to usual care in persons with chronic musculoskeletal conditions, indicating its potential as an alternative or complementary approach. However, due to inconsistencies in study results, limited sample sizes, and heterogeneity, drawing conclusions regarding the superiority of telerehabilitation over usual care in musculoskeletal disorders remains uncertain.

The results can be utilized in the health care decision-making process to solve upcoming challenges of availability and accessibility of rehabilitation at the societal and individual levels. This review shows the lack of economic evaluation studies, highlighting the high demand for methodologically high-quality and appropriate economic evaluation of telerehabilitation in individuals with chronic musculoskeletal disorders. Additionally, there is a significant lack of cost-effectiveness studies on different populations and contexts.

Conflicts of interest:

None

Role of the Funding Source:

The funders had no role in this study’s design, conduct, or reporting.

Data availability statement:

Data supporting the findings of this review were obtained from published articles included in the systematic review. The data extraction sheets, search strategies, and other materials are available in the supplementary materials. Supplementary materials are available upon request from the journal’s editorial office.

Supplementary materials:

1. Search strategy
2. Articles excluded at full text appraisal with reasons
3. JBI critical appraisal instrument
4. JBI data extraction instrument
5. Characteristics of Included Studies

Contact person:

Julija Chichaeva, Jamk University of Applied Sciences, Rehabilitation Institute, firstname.lastname@jamk.fi

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URN: http://urn.fi/urn:nbn:fi:jamk-issn-2954-1069-14